FLEXOR MUSCLE SLIDE IN THE SPASTIC HAND. The Max Page Operation

Transcription

1 FLEXOR MUSCLE SLIDE IN THE SPASTIC HAND The Max Page Operation W. F. WHITE, UDDINGSTON, SCOTLAND Froni the Orthopaedic Department, Law Hospital, ( arh,,ke In cerebral palsy the scope for operation on the hand is much less than that for operation on the lower limb. This is determined by the intricacies of hand function (Zuck 1964). Operation is only of value in the spastic type. When done early, in carefully chosen cases, it may assist physical re-education and rehabilitation by improving muscle balance and thus correcting or partly correcting deformity. SELECTION There are many contra-indications to operation and selection is crucial. The most important single attribute called for in the patient is drive-a compelling urge or will to succeed. Usually it is associated with reasonable intelligence, but there are some children and adults of low intelligence, yet with good drive and cooperation, who become adept at using their hands. Nevertheless, on the whole, the more intelligent patients do better. Unfortunately, poor intelligence is often linked with an extensive motor disability and this combination virtually rules out operation. About three-quarters of these patients have some alteration of sensibility. Tactile cognition is poor, perhaps because of lack of experience, but more often from lack of the required manipulative facility. However, if there is marked impairment of sensibility, operation is not justified. Severe athetoid movements with poor voluntary muscle control are contra-indications. The patient must be able to put his hand to an object reasonably well. Inadequacy of training facilities prohibits operation. Age is important. The extraordinary adaptability of the young child leads to successful rehabilitation even though there are the obvious disadvantages of bone growth and recurring imbalance. Nevertheless, it is probably advisable to wait until the child is six or seven before operating. The criteria for selection are therefore stringent and the proportion of cases suitable for operation is small. After clinical assessment patients may be divided broadly into three groups. The first and largest consists of those who are too severely affected for operation. At least half fall into this category. They are so afflicted mentally and physically that they are ineducable and untrainable. In about a quarter, function is so good that it is unwise to interfere. This leaves about a fifth who are eligible for consideration. BASIC FAULTS Loss of function is due, in the main, to three basic faults. First, flexion of the wrist and fingers associated with pronation of the forearm. Secondly, flexion and adduction of the thumb causing the grip reflex. Thirdly and most important of all, inability to release the grip. This to some extent resembles the position of the hand in the normal new-born child-the first flexor stage. Use of the hand is thwarted by the powerful flexor contractions initiated by the stretch reflex (Kenney and Heaberlin 1962). The extensors are weak perhaps from pyramidal involvement. More often, long stretched and overwhelmed, they cease to function through disuse (Zuck 1964). VOL. 54 B, NO. 3, AUGUST

2 454 V. F. WHITE RATIONALE The crux of the problem is the stretch reflex. The main object is to try to control or diminish this, to relieve the spasm and thus to correct or at any rate to improve the deformity. It seems rational therefore to alter the length and tone of the flexors by releasing their origin and allowing them to slide distally, as suggested by Page nearly half a century ago (Page 1923). / Exposuriof FIG. I flexororigin. FIG. 2 Branch of median nerve preventing further descent. This might promote better muscle balance around the wrist and hand, thus enhancing extensor ability. The first muscle slide in the series was done in 1959 and preliminary reports were made in 1961 and at the meeting of the Soci#{233}t#{233} Internationale de Chirurgie Orthop#{233}dique et de Traumatologie in Paris in 1966 (White 1961). Since then selection has become even more strict. THE JOURNAL OF BONE AND JOINT SURGERY

3 FLEXOR MUSCLE SLIDE IN THE SPASTIC HAND 455 OPERATION The operation is shown in Figures 1 to 3. It is carried out through an antero-medial incision and the displacement of the flexor orign is about three and a half centimetres (Inglis and Cooper 1966). Further descent is prevented by branches of the median and to a lesser extent the ulnar nerves. These nerve branches are stripped proximally; on a few occasions they have been divided. The ulnar nerve has been transposed on three occasions. Through FIG. 3 Extent of displacement of origin. a separate incision the insertion of pronator teres is severed and the radial origins of flexor pollicis longus and flexor superficialis are stripped. In two cases early in the series the origin of adductor pollicis was released from the third metacarpal and carpal bones. After operation a plaster slab is applied to maintain the elbow in extension, the wrist in neutral position and the fingers just short of full extension. This is kept on for three weeks. Thereafter the wrist alone is immobilised for one month. This splint is used during the night only for a further three months. TABLE I TABLE II TYPE OF OPERATION ASSESSMENT Operation Numerof Function Marks Muscle slide Muscle slide with arthrodesis 12 Arthrodesis Grip 3 Pinch 3 Release 6 Good 9 or more Total Fair 7or8 In the first year or so a compression arthrodesis of the wrist was done after the muscle slide. Position was chosen after a trial in plaster. It was usually in slight palmar flexion, and always in ulnar deviation to correct to some extent the thumb in palm attitude (Cooper 1952). The carpo-metacarpal joints were not fused. This left a little movement which might assist grip and release (Goldner 1955). Over the last nine years arthrodesis has been done much less often. VOL. 54B, NO. 3, AUGUST 1972

4 456 W. F. WHITE MATERIAL There were thirty-two patients-less than 20 per cent of those examined. The total number of procedures was seventy-one, but it is intended here to concentrate only on three groups (Table I): those who had a muscle slide-fifteen: those who had a muscle slide followed Fi;. 4 FIG. 5 FIG. 6 Figure 4-Grip. Figure 5-Pinch. Figure 6-Release. by arthrodesis-twelve: those who had arthrodesis-five. The average age of the patients was eighteen and the average follow-up was seven and a half years. It would be foolish to expect anything approaching normal function after operation in the spastic hand. The aim is to make the hand more useful. Assessment of results is difficult. ASSESSMENT (TABLE II) Function was divided into three basic elements-grip, pinch and release (Figs. 4 to 6). Grip and pinch were given three marks each. It was accepted that in the spastic hand pinch is often between the pulp of the thumb and the side of the index finger rather than its pulp- THE JOURNAL OF BONE AND JOINT SURGERY

5 FLEXOR MUSCLE SLIDE IN THE SPASTIC HAND 457 the key pinch. Since inability to open the hand is perhaps the major disability, release was given six marks. Full marks does not imply normal function. For one thing movements are almost always at slow speed. Nine or more was considered to represent good function. Seven or eight represented fair function and anything less than seven was a failure. Before operation all patients were in the failure group. TABLE III TABLE IV RESULTS GOOD AND FAIR RESULTS RELATED TO TYPE OF OPERATION Results Number:f Operation Number:f Good 10 Muscle slide..... Ii 21 Fair Muscle slide with arthrodesis.. 6 Failure 11 Arthrodesis Total 32 Total TABLE FAILURES RELATED TO TYPE OF OPERATION V 0 pe ration Number patients of Muscle slide... 4 Muscle slide with arthrodesis 6 Arthrodesis... 1 Total RESULTS (TABLE III) The results in ten patients were classed as good, in eleven as fair and in eleven as failures. The good and fair groups were considered satisfactory and were taken together to simplify the figures. These results were analysed according to operation and the means of selection were critically reviewed. ANALYSIS BY OPERATION (TABLES IV AND V) Of the twenty-one patients with satisfactory results eleven had only a muscle slide ; six had a muscle slide followed by an arthrodesis ; and four had only an arthrodesis. This conflicts with the modern view which is against arthrodesis-for sound reasons. Nevertheless, in some patients arthrodesis is still of value. In the numerous failures six patients had a muscle slide followed by an arthrodesis: four had only a muscle slide and one had only an arthrodesis. The outstanding lesson was in the last failure which was total: an arthrodesis done on demand for the sake of appearance. Any operation must have as its primary object improvement in function. A review of the factors governing selection is more significant. Emphasis was placed on the twin attributes of drive and intelligence, and on the extent of motor disability. VOL. 54B, NO. 3, AUGUST 1972

6 458 W. F. WHITE SELECTION AND RESULTS (TABLES VI, VII AND VIII) Of the twenty-one patients with satisfactory results, nineteen had drive and seventeen were of reasonable intelligence. There were fifteen hemiplegics and five tetraplegics but it is doubtful ifthese figures really substantiate the view that hemiplegics do better than tetraplegics. In the best results-those classed as good, there were eight hemiplegics and two tetraplegics. It must be stressed that any gain in the tetraplegic is much more vital. It has to be put to use and is in no danger of being dissociated as sometimes happens in the hemiplegic (Samilson 1966). The eleven failures demonstrated the faults in selection. Only one of the eleven patients had good drive and reasonable intelligence. TABLE VI GOOD AND FAIR RESULTS RELATED TO SELECTION OF PATIENTS (TWENTY-ONE PATIENTS) Characteristics Number:f Hemiplegic Tetraplegic Triplegic Drive Good intelligence.. 17 TABLE VII TABLE VIII GOOD RESULTS RELATED TO SELECTION FAILURES RELATED TO SELECTION OF PATIENTS (TEN PATIENTS) OF PATIENTS (ELEVEN PATIENTS) Characteristics Number:f Characteristics Number:f Hemiplegic.. 8 Hemiplegic. 8 Tetraplegic.. Tetraplegic. 3 Drive Drive.. 1 Good intelligence. 9 Good intelligence 1 COMMENT It is unrealistic to expect uniform success in this field. Nevertheless there were many failures. The fault almost certainly lay in selection and it has been emphasised that the criteria for operation are strict. The most important single attribute is drive. Any operation must be simple and designed for a specific and limited purpose. Burman (1938) wrote: There is a certain sympathy in spastic hands by which an operative procedure directed at one point diminishes spasticity in another. Long before that, in 1919, Sir Arthur Keith wrote of Hugh Owen Thomas: He treated muscles as he treated his patients. He relieved the weak and oppressed, he restrained the strong. That, in effect, sums up the rationale of the muscle slide. THE JOURNAL OF BONE AND JOINT SURGERY

7 FLEXOR MUSCLE SLIDE IN THE SPASTIC HAND 459 SUMMARY 1. A study has been made of thirty-two patients who had had operations for their spastic hands. 2. In twenty-seven a flexor muscle slide was done, either by itself or in association with an arthrodesis of the wrist. The rationale of the operation is discussed. 3. The first muscle slide was done in 1959 and the average follow-up was seven and a half years. 4. Selection is crucial : drive, usually coupled with intelligence, is essential for success. 5. Operation is not a replacement for physical therapy. The object is to make rehabilitation easier. The flexor muscle slide, in carefully chosen cases, may play a significant part in achieving this. I wish to thank Mr James Garden for his help and Mr Athol Parkes for his encouragement and for referring a number of patients to me. I am also grateful to Mr John Hunter, photographer at Law Hospital, and to Miss Catherine Loudon, who did the drawings. REFERENCES BURMAN, M. S. (1938): The Spastic Hand. Journal ofbone and Joint Surgery, 20, 133. COOPER, W. (1952): Surgery of the Upper Extremity in Spastic Paralysis. Quarterly Review ofpaediatrics, 7, 139. GOLDNER, J. L. (1955): Reconstructive Surgery of the Hand in Cerebral Palsy and Spastic Paralysis Resulting from Injury to the Spinal Cord. Journal ofbone and Joint Surgery, 37-A, INGLIS, A. E., and COOPER, W. (1966) : Release of the Flexor-pronator Origin for Flexion Deformities of the Hand and Wrist in Spastic Paralysis. Journal ofbone and Joint Surgery, 48-A, 847. KEITH, Sir Arthur (1919): Menders of the Maimed, p. 60. London : Oxford University Press. KENNEY, W. E., and HEABERLIN, P. C., Jun. (1962): An Electromyographic Study of the Locomotor Pattern of Spastic Children. Clinical Orthopaedics, 24, 139. PAGE, C. M. (1923): An Operation for the Relief of Flexion-contracture in the Forearm. Journal ofbone and Joint Surgery, 5, 233. SAMILSON, R. L. (1966): Principles of Assessment of the Upper Limb in Cerebral Palsy. Clinical Orthopaedics and Related Research, 47, 105. WHrrE, W. F. (1961): Surgery of the Spastic Hand. Proceedings of the Second Hand Club and the Scandinavian Club for Surgery of the Hand, Copenhagen, May 15-19, 1961, p. 57. ZUCK, F. N. (1964): Cerebral Palsy. In Orthopaedic Surgery by Sir Walter Mercer and Robert B. Duthie. Sixth edition, p London: Edward Arnold (Publishers) Ltd. VOL. 54 B, NO. 3, AUGUST 1972