Michael A. Tonkin

Surgery for Cerebral Palsy: Part 1. Classification and Operative Procedures for Pronation Deformity

32 patients with cerebral palsy underwent operations for pronation deformity. The deformity is classified into four groups. Patients in group 1 are capable of supination beyond neutral. No surgery is necessary. Those in group 2 are able to supinate to the neutral position. A pronator quadratus release is advised and may be combined with a flexor aponeurotic release. In group 3, patients have no active supination. However a full range of passive supination is readily achieved. A pronator teres transfer is advised. Patients in group 4 have no active supination. Full passive supination may be present, but is tight. A flexor aponeurotic release and a pronator quadratus release may unmask active supinator activity. An active transfer for supination is possible as a secondary procedure.

Palmar cutaneous branch of the median nerve

The palmar cutaneous branch of the median nerve was dissected in 25 fresh cadavers. The origin from the median nerve, the course, termination, and variability of the palmar cutaneous nerve are described in relation to two reference lines. In no case did a branch of the palmar cutaneous nerve extend ulnar to the axial line of the ring finger. The planning of incisions around the palmar aspect of the palm and wrist should be based on this anatomical knowledge.

Lateral band translocation for swan-neck deformity☆

Lateral band translocation involves transfer of the dorsally subluxed radial lateral band to the palmar aspect of the joint where it is maintained by a sling created between the flexor superficialis tendon and the palmar plate. Thirty fingers with swan-neck deformity of differing causes and a preoperative hyperextension deformity averaging 16 degrees were treated. After operation all swan-neck deformities were corrected and the average flexion contracture was 11 degrees. The range of preoperative flexion was either regained or improved. There were no recurrences and no complications. This relatively simple procedure is an effective treatment of swan-neck deformity and an attractive alternative to previously described procedures.

Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon

We reviewed 21 patients with 22 ruptures of the extensor pollicis longus at a mean of 5.3 years after transfer of the extensor indicis proprius tendon. Of these, 19 with 21 transfers described the result as good, and two as fair. The mean deficit of extension between the operated and unoperated thumbs was 1.4 cm, and the mean flexion deficit 0.6 cm. Pressure gauge measurements showed that the strength of the transfer was 51% of that of the uninjured extensor. The two fair results had an extensor lag of over 1.5 cm. Independent extension of the index was maintained in all patients, none having a discernible lag, but the strength of index extension was reduced to 49% of that of the normal finger. There was no evidence of functional loss. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon is a simple and reliable procedure with few complications. It gives satisfactory long-term extension of the thumb.

Classification of Congenital Anomalies of the Hand and Upper Limb: Development and Assessment of a New System

The Oberg, Manske, and Tonkin (OMT) classification of congenital hand and upper limb anomalies was proposed in 2010 as a replacement for the Swanson International Federation of Societies for Surgery of the Hand classification system, which has been the accepted system of classification for the international surgical community since 1976. The OMT system separates malformations from deformations and dysplasias. Malformations are subdivided according to the axis of formation and differentiation that is primarily affected and whether the anomalies involve the whole limb or the hand plate. This review outlines the development of classification systems and explores the difficulty of incorporating our current knowledge of limb embryogenesis at a molecular level into current systems. An assessment of the efficacy of the OMT classification demonstrates acceptable inter- and intraobserver reliability. A prospective review of 101 patients confirms that all diagnoses could be classified within the OMT system. Consensus expert opinion allowed classification of those conditions for which there is not a clear understanding of the mechanism of dysmorphology. A refined and expanded OMT classification is presented.

Surgery for Cerebral Palsy: Part 2. Flexion Deformity of the Wrist and Fingers

34 children with cerebral palsy had operations to correct flexion deformities of the wrist and fingers. 30 out of 34 patients were improved functionally and cosmetically. Zancolli’s classification provides sound guidelines on which to base surgical decisions.

Pre-operative distraction lengthening for radial longitudinal deficiency

Patients treated for total radial aplasia have been reviewed. It was possible to re-align the carpus by radialization in five out of six limbs treated with pre-operative distraction, but in only one out of six treated without distraction. The average improvement in radial angulation in the non-distraction group was 19° and in the distraction group 38°. The average improvement in radial translation was 16 mm and 17 mm in the two groups respectively. Pre-operative distraction with the Kessler device permits re-alignment of the hand without skeletal resection or excessive tension on the radial neurovascular structures.

Sesamoid arthrodesis for hyperextension of the thumb metacarpophalangeal joint

Forty-two sesamoid arthrodeses performed since 1986 were reviewed. Thirty-seven cases were considered successful. Hypertension recurred in 3 of the 20 procedures performed for cerebral palsy and 1 of the 21 performed in association with basal joint arthroplasty for arthritic conditions. The single post trauma case was successful. Flexion was preserved. Prevention of hyperextension of the metacarpophalangeal joint assists in reducing metacarpal adduction in cerebral palsy and has a stabilizing effect in basal joint arthroplasty.

Acute Calcific Tendinitis in the Hand and Wrist

Three cases of acute calcific tendinitis in the hand and wrist are described. The frequent misdiagnosis of this condition is discussed in the tight of these cases and a review of the literature.

Surgery for Cerebral Palsy Part 3: Classification and Operative Procedures for Thumb Deformity

Spastic thumb deformity is the result of imbalance between intrinsic and extrinsic forces acting across unstable joints. This paper presents a classification of spastic thumb deformity based on the accurate assessment of the deforming forces, outlines methods for their correction and reviews the results of our surgery. Thumb reconstruction procedures were performed in 32 patients with 33 spastic thumb deformities. All patients were assessed pre- and postoperatively using the same functional assessment system which was performed by the same team. The thumb was maintained out of the palm in 29 patients and lateral pinch was established in 26 patients.