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Wheeless' Textbook of Orthopaedics
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High Median Nerve Lesions



- See:
      - Entrapment of Median nerve   at the Elbow and Forearm:
      - Combined Injuries of the Median and Ulnar Nerves:
      - Median Nerve
      - Nerve Repair

- Deficit:
    - loss of pronation of forearm, wrist flexors, index & long finger flexion;
    - loss of thumb flexion:
    - long term contractures:
          - adduction contractures can be prevented w/ oppenens splint;
          - fixed supination deformity may develop despite bracing (due to the deforming
                  forces of the EPL and adductor;

- Prerequisites for Tendon Transfer:
    - absence of web space contracture and supination contracture of thumb;
    - tendon transfer for the extrinsic muscles innervated by median nerve may
          be delayed, anticipating return of long flexor f(x)

- Accessory Transfers in High Median Nerve Lesions:
    - FPL is reenforced by Brachioradialis ;
    - FDP of index & long fingers are reinforced by transfer of ECRL ;
    - FDP of ring and small fingers are anchored to FDP of index and
            middle fingers using side to side repair;
    - opponensplasty:
            - w/ median nerve injury several inches above the wrist, consider early transfer;
            - treatment options:
                  - EIP transfered to APB (Burkhalter);
                  - opponens & APB   are reinfored by paralyzed FDS around distal
                          end of FCU - ECU used as a motor;
                  - paralyzed FDS of ring finger is isolated at wrist and at base of digit &
                          delivered at at wrist;
                  - distal FCU tendon is detached & anchored to ECU tendon, thereby
                          forming indirect dynamic pulley;
                  - paralyzed FDS is then passed thru this pulley & into proximal
                          phalanx of thumb, similar to a routine opponens transfer;
                  - proximal end of FCU is sutured to paralyzed FDS;
            - accessory procedures include either arthrodesis of the MP joint or the distal IP
                    joint of the thumb, depending of the stability;





Early Tendon Transfers in Upper Extremity Peripheral Nerve Injury.
      WE Burkhalter.
      COOR No 104, Oct 1974.

Restoration of strong opposition after median-nerve or brachial
    plexus paralysis.

Abductor digiti quinti opponensplasty.






Original Text by Clifford R. Wheeless, III, MD.