Arvid Ejeskär

Sollerman Hand Function Test: A Standardised Method and its Use in Tetraplegic Patients

A standardised hand function test based on seven of the eight most common hand grips is reported. The test consists of 20 activities of daily living. The test procedure and the method of scoring are described as is our evaluation of the validity and reliability of the test. Fifty-nine tetraplegic patients were evaluated using the test before reconstructive surgery to their hands. The test score correlated well with the accepted international functional classification of the patients arm (r = 0.76, p < 0.001). The mean test score in the arms of patients lacking sensation was significantly lower than in those with tactile gnosis (O:1-3 compared with OCu:1-3, p < 0.001).

Elongation in Profundus Tendon Repair: A Clinical and Radiological Study

A radiographical study of 63 digits with tendon lacerations within the digital sheath is presented. 60 of these digits were evaluated clinically 6-36 months (mean 15 months) after surgery. At primary tendon repair one wire marker was placed on each side of the repair site in the profundus tendon. The distance between the markers was measured at operation and postoperatively on 3 different occasions on radiograms. The results showed that increase of the distance between the markers by more than 5 mm, considered to indicate elongation in the suture, occurred in 25 out of 59 repaired profundus tendons (42%) and in most instances this happened during the period of immobilization. The cause of elongation could be identified in 9 digits. In 5 it was due to rupture of the suture material, the tendons being repaired with 5-0 Flexon steel wire. In the other 4 digits, sutured with 4-0 Silky Polydec, slipping of the knot was revealed at reoperation. There was a strong correlation between increased distance between the markers and a poor outcome, elongation being the most frequent cause.

Flexor tendon repair in no-man's-land: Results of primary repair with controlled mobilization

Fifty-three patients with 60 injuries within the digital sheath, which were treated with primary tendon repair by the Kleinert technique, had follow-up of 6 to 36 months after operation. Seventeen digits had isolated lesions of the profundus tendon and regained an average 38° range of motion (ROM) in the distal interphalangeal (DIP) joint. Forty-three digits had injuries to both the profundus and superficialis tendons, 35 of which flexed within 2 em from the distal palmar crease (81%), and 21 had a total active motion of at least 200° (49%). The average active ROM in the DIP joint was 30°. The results were superior to our own results with primary repair by the Verdan technique. Comparison with our own results after secondary tendon repair by the Kleinert technique showed that repair of isolated profundus lesions could be done primarily or secondarily within 1 month of injury with equally good results. Primary repair of double tendon lesions gave better results than secondary repair.

Zone II flexor tendon repair in children. A retrospective long term study.

Forty-three children with 46 lacerations of the flexor digitorum profundus tendon were evaluated at a mean of five and a half years (range three to 10) after tendon repair. Postoperatively, 27 digits were treated with early controlled mobilisation as described by Kleinert and 19 digits were immobilised in plaster. Thirty-one digits were primarily repaired within 24 hours, and in 15 digits repair was delayed. The return of total active motion (TAM) in the interphalangeal joints was evaluated with the Strickland formula, and the mean was 77%. TAM correlated with the age of the child at the time of injury. Variables such as postoperative regimen, concurrent injury to the superficial tendon or digital nerve, delayed tendon repair, localisation of injury in the fibro-osseous canal, and type of trauma, had no significant effect on the final result.

Finger flexion force and hand grip strength after tendon repair

Isolated finger flexion force and hand grip strength were measured in a group of patients with flexor tendon lacerations treated by primary tendon repair. The results show that reduced isolated finger flexion force is much more common than reduced hand grip strength (66% and 26% respectively). Reduced finger flexion force is strongly correlated to elongation in tendon repair, to the range of motion in the distal interphalangeal joint, and to reduced hand grip strength in patients with lesions of both flexor tendons in one finger. Range of motion in the distal interphalangeal joint and hand grip strength in the individual patient are of little value for prediction of isolated finger flexion force, however. Hand grip strength is sufficient for evaluation of strength in many cases, but knowledge of finger flexion force is a valuable adjunct in analyzing patients with subjective and/or objective weakness in their hands after flexor tendon surgery.

Split distal flexor pollicis longus tenodesis: long-term results.

A thumb lacking intrinsic muscle function but having extrinsic flexion will hyperflex in the interphalangeal joint giving a positive Froments sign. This can effectively be prevented with split flexor pollicis longus tenodesis. The mean postoperative range of motion in the IP joint of 39 hands was 28 (18)° and 23 (20)° six and 12 months postoperatively. The procedure makes arthrodesis (temporary or permanent) superfluous. This procedure can be recommended strongly.

Flexor Tendon Repair in No Man's Land

Fifty-three patients with 60 injuries within the digital sheath, which were treated with primary tendon repair by the Kleinert technique, had follow-up of 6 to 36 months after operation. Seventeen digits had isolated lesions of the profundus tendon and regained an average 38 degrees range of motion (ROM) in the distal interphalangeal (DIP) joint. Forty-three digits had injuries to both the profundus and superficialis tendons, 35 of which flexed within 2 cm from the distal palmar crease (81%), and 21 had a total active motion of at least 200 degrees (49%). The average active ROM in the DIP joint was 30 degrees. The results were superior to our own results with primary repair by the Verdan technique. Comparison with our own results after secondary tendon repair by the Kleinert technique showed that repair of isolated profundus lesions could be done primarily or secondarily within 1 month of injury with equally good results. Primary repair of double tendon lesions gave better results than secondary repair.

Restoration of active palmar abduction of the thumb in tetraplegia by tendon transfer of the extensor digiti minimi to abductor pollicis brevis.

We describe a method to restore active palmar abduction of the thumb and report its functional impact in tetraplegia. At 54.2 (SD 42.8) months after cervical spinal cord injury (12 traumatic, 3 nontraumatic), the extensor digiti minimi (EDM) tendon was transferred to the abductor pollicis brevis (APB) through the interosseous membrane in 15 tetraplegic patients (age range 19–70 years) in addition to a mean 3.2 procedures to restore key pinch. According to International Classification, the operated upper extremities were in the OCu4 to OCu8 (1 patient X) group. The maximum distance between thumb and index finger tips during active or passive opening of the hand, maximum angle of palmar abduction, grip and key pinch strength, and active finger range of motion were measured. All patients were re-examined after 38.4 (SD 22.7) months. The active thumb-index opening increased significantly from 2.5 (SEM 1.0) cm before to 9.0 (SEM 0.8) cm after surgery. Nine patients without previous active opening of the first web space recovered a mean thumb-index opening of 9.1 (SEM 1.7) cm, whereas this distance increased by an average of 2.9 (SEM 0.8) cm in six patients who had active thumb index distance of 6.3 (SEM 1.6) cm before surgery. All but one patient were able to direct and coordinate key pinch and perform tasks using the restored APB function, including five patients whose EDM strength was rated as grade 3 before transfer. This EDM-to-APB transfer meets the theoretical requirements of architecture matching between donor and recipient muscles, the principles of tendon transfer, and our surgical expectations. We strongly recommend that an active EDM is transferred to the APB to restore opening of the hand and help in key pinch control in patients with tetraplegia.