Traitement palliatif des

paralysies:
Principes des transferts
tendineux

Christian Dumontier
Institut de la Main & hpital saint Antoine, Paris
Avec laide de Caroline Leclercq

Principes

Chaque patient est unique

Plusieurs options possibles
Beaucoup de techniques
dcrites dans les livres

Ne pas nuire !
Savoir quoi faire
Savoir ce qui peut tre
fait
Savoir ce que vous
savez faire

Principes
Indications
Pr-requis
Stratgie thrapeutique
Alternatives ?
Technique(s)

Institut
de la Main

Indications

Indications: lsions
nerveuses
Lsions nerveuses traumatiques: tronculaires, plexiques
ou spinales; non rparables ou chec de rparation
Compressions nerveuses volues

Institut
de la Main

Indications: lsions
musculaires ou tendineuses
Lsions traumatiques complexes du bras ou de l'avantbras avec perte de substance musculaire/tendineuse
Ruptures tendineuses (ex: rupture EPL)
Post-Ischmie (Volkmann)

Institut
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Indications: lsions centrales

Maladies neurologiques
Squelles AVC
Paralysies crbrales
Squelles des traumatismes crniens...

Institut
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Indications: maladies neuromusculaires

Charcot-Marie-Tooth
Myopathies

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Indications: lsions
congnitales
Hypoplasie du pouce
Arthrogrypose
...

Transfert ADM
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Pr-requis

Conditions locales
Conditions gnrales
Conditions post-opratoires

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Pr-requis

Qualit de la peau ?
Ncessit de gestes plastiques pr-opratoires ou
associs

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Pr-requis
Souplesse des articulations
Ncessit dune arthrolyse ?
Stabilit des articulations
Ncessit dune stabilisation

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Pr-requis

Sensibilit de la main ? (condition relative)

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Pr-requis: conditions
gnrales et post-op
Coopration du patient
QI (relatif), problmes comportementaux, attente
irralistes
Age: trs vieux, trs jeune
Possibilits de participer la rducation: conditions
socio-conomiques, motivation, disponibilit dun kin/
centre spcialis

Institut
de la Main

Stratgie
Un tendon ne peut rparer quune fonction
Choisir le tendon en fonction des besoins des patients
Slectionner la fonction la plus importante rparer
dabord, puis faire les techniques additionnelles
(arthrodse, tnodses,...)
Dans un avant-bras et une main normale, il y a 50 muscles pour
faire les mouvements. Le choix dpend des tendons disponibles
et de la demande

Programmation de la
chirurgie
Maladie neurologique: non volutive +++
Lsion post-traumatique
Irrparable: Plexus brachial (6-9 mois); ttraplgie (1
an)
Echec de rparation : 1 an aprs la rparation avec
absence dvolution clinique et EMG

Alternatives
Arthrodses
Tnodses
Orthses
...

Principes techniques des

transferts tendineux

Choix du moteur
Choisir un muscle de grade 4+ ou 5
Testing musculaire : BMRC
Grade 0 : aucune

rponse

Grade 1 : contraction palpable

Grade 2 : mouvement actif avec gravit
Grade 3 : mouvement contre gravit
Grade 4 : mouvement contre rsistance
Grade 5 : normal
Institut
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PRINCIPLES OF TENDON TRANSFER IN THE HAND AN

Choix du moteur

Table 1 Relative strength of muscles in the hand and forearm, taking FCR = 1
Muscle

Strength relative to FCR

Brachioradialis
2.0
Flexor carpi ulnaris
2.0
ECRL,ECRB,ECU,PT,FPL,FDS,FDP1.0 (each tendon)
EDC,EIP,EDQ
0.5 (each tendon)
APL,EPB,PL
0.1 (each tendon)
Interossei
2.7 (total/combined)
Lumbricals
0.5 (total/combined)
Reproduced from Gelberman RH. Operative Nerve
Repair and Reconstruction. Philadelphia: Lippincott, 1991;
1587, with permission.

Choisir un muscle avec une force adapte

Table 2

Excursion of musclesinthe adultforearm and hand

Puissance aire de section transversale

du muscle
Muscle
Brachioradialis
Flexor digitorum profundus (FDP)
Flexor digitorum supercialis (FDS)
Extensor pollicis longus (EPL)
Extensor digitorum communis (EDC)
Extensor indicis propius (EIP)
Flexor pollicis longus (FPL)
Flexor carpi ulnaris (FCU)
Flexor carpi radialis (FCR)
Extensor carpi radialis longus (ECRL)
Extensor carpi radialis brevis (ECRB)
Extensor carpi ulnaris (ECU)
Extensor pollicis brevis (EPB)
Abductor pollicis longus (APL)
Lumbrical
Thenar muscles
Interossei

Aire de section physiologique (PCS) = volume du

muscle / longeur moyenne des fibres
Fraction de tension= PCS / somme des PCS

Excursion (cm)
4.0
7.0
6.5
6.0
5.0
5.0
5.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.8
3.8
2.0

Reproduced from Gelberman RH. Operative Nerve

Repair and Reconstruction. Philadelphia: Lippincott,
1991;
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1587, with permission.

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Fraction de tension

Ex : BR sur FPL
PL sur les radiaux

Table 2

Choix du moteur

Excursion of musclesinthe adultforearm and hand

Muscle

Excursion (cm)

Brachioradialis
Flexor digitorum profundus (FDP)
Flexor digitorum supercialis (FDS)
Extensor pollicis longus (EPL)
Extensor digitorum communis (EDC)
Extensor indicis propius (EIP)
Flexor pollicis longus (FPL)
Flexor carpi ulnaris (FCU)
Flexor carpi radialis (FCR)
Extensor carpi radialis longus (ECRL)
Extensor carpi radialis brevis (ECRB)
Extensor carpi ulnaris (ECU)
Extensor pollicis brevis (EPB)
Abductor pollicis longus (APL)
Lumbrical
Thenar muscles
Interossei

4.0
7.0
6.5
6.0
5.0
5.0
5.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.8
3.8
2.0

Reproduced from Gelberman RH. Operative Nerve

Repair and Reconstruction. Philadelphia: Lippincott, 1991;
1587, with permission.

Choisir un muscle avec une amplitude adapte :

K

One transfer for one function. It is unreasonable to

expect a tendon transfer to carry out two dierent
functions simultaneously.
As far as possible, synergistic muscles should be used.
Muscles work in groups and patterns that are
controlled at subconscious level. For example, nger
exors tend to work at the same time as wrist
extensors, while nger extensors tend to work
simultaneously with wrist exors. Synergy should be
preferred, rather than considered to be essential.
The transfer is more readily integrated into normal
hand use if a synergistic muscle is used. In the absence
of a synergistic muscle others can be used, but the
new function will probably be more dicult to
incorporate and a longer period of rehabilitation will
Institut
be required.

Radiaux 33 mm - Extenseurs des doigts: 50 mm,

Flchisseurs des doigts: 70 mm
K

Smith, 1987

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Choix du moteur

Choisir un muscle avec une longueur suffisante (sinon

greffe)

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Choix du moteur

Ne pas entraner de dficit !

Prlvement FCR

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Choix du moteur

Idalement prendre un muscle antagoniste (relatif)

Ex: flchisseurs pour les extenseurs du poignet

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Trajet
Choisir le trajet le plus direct
Eviter les poulies (parfois ncessaires)
Ne croiser quune seule articulation
Eviter les angles aigus dans le trajet du transfert

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Fixation distale

Rsistante mais nonadhrente et non

ischmiante
Pulvertaft, fils fins non
rsorbables

Tension donner ?

Adapte ?! (Goldner 60%

longueur; Cooney;
Exprience)
Un peu suprieure la tension
physiologique

Force

Lieber & Friden 2003

50

100

150
200
Longueur

250

300

Diagnostic ?

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Paralysie radiale
Fracture de l'humrus
Paralysie de:
(Triceps)
Brachioradialis
Court supinateur
Extenseurs du poignet (ECRL+B, ECU)
Extenseurs doigts et pouce
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Paralysie radiale basse

Paralysie du nerf interosseux postrieur:

Partielle extenseurs du poignet (ECU)
Extenseurs doigts et pouce

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Stratgie
Un transfert pour une fonction
Extension du poignet
Extension des doigts
Extension du pouce

Triple transfert
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Stratgie

Adapt aux besoins du patient

Si travailleur manuel = laisser le FCU en place

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Triple transfert
Historique
Extension des doigts et abduction du pouce (FCU)
1897 Rochet
1899 Francke
Extension du poignet
1916 Robert Jones : PT
1916 Mayer : FDS
1918 Stoffel : FCR

Boyes 1960 : 58 transferts dcrits

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Triple transfert
Historique

Merle d'Aubign 1946 :

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Triple transfert
Merle d'Aubign 1946 :

Extension du poignet
Pronator teres (sur ECR)

PT sur extenseurs poignet

FCU sur extenseurs doigts + EPL
PL (ou FDS) sur EPB + APL

Extension des doigts

FCR / FCU
FDS 4
Extension pouce
variable

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Extension du poignet
Pronator teres
Force 1.2kg > tendons ECR
Course 5 cm > tendons FCR
Synergique de l'extension du poignet
Pronation reste assure par PQ
Dsinsertion du radius avec languette
prioste
trajet superf ou profond / BR
Insertion: ECRB (ou ECRL centralis)
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Wrist extension
Pronator teres to Extensor carpi radialis brevis
Need to take a strip of periosteum
Should be fixed at the end (to test finger extension
using the tenodesis effect)

FCU :

Extension
des
force 2kg Course 3.3cm

Puissant flchisseur du poignet,

dans l'axe des mvts habituels du poignet

Merle D'aubign, Zachary, Scuderi

FCR : force 0.8kg Course 4 cm

Tsuge 1969 au travers Mbrane interosseuse
Brand 1975 au bord radial du poignet

FDS : course 6.5cm

le seul qui permet ext active doigts

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Extension des
doigts
Transfr sur EDC
+/- E propre index
+/- E propre du 5
+/- EPL

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Extension du
pouce

Quel extenseur ranimer ?

-APL: stabilisateur 1er mta
et inclinateur radial
-EPB: extenseur P1 (et parfois P2)
-EPL: extenseur P2 et rtropulseur

Institut
de la Main

Extension des doigts

FCU : force 2kg Course 3.3cm.
Puissant flchisseur du poignet, dans l'axe des mvts
habituels du poignet (Merle D'aubign, Zachary,
Scuderi)
FCR : force 0.8kg Course 4 cm (Tsuge 1969 au travers
Mbrane interosseuse, Brand 1975 au bord radial du poignet)
FDS : course 6.5cm, le seul qui permet ext active doigts
en mme temps que ext poignet (Boyes : FS III (+FS IV
pouce))

Extension du poignet avec le

pronator teres
Dsinsertion du PT avec une
bandelette prioste
Passage au-dessus / en-dessous du
brachioradialis
Fixation sur lECRB (ou ECRL
centralis)

Extension du
pouce
But: ranimer l'abduction de la colonne du
pouce
-Soit deux transferts
EPL avec EDC, et EPB + APB (PL)
-Soit un seul transfert
sur EPL drout (Scuderi)

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Technique de
choix
!

Extension poignet
PT sur ECRL centralis

Extension doigts
FCU sur EDC + EIP

Extension pouce

PL sur EPL drout dans le 2e compartiment

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Median nerve

Median nerve function to

restore
Thumb abduction and opposition (low palsy)
Thumb flexion (high palsy)
Flexion of the index and middle fingers (high palsy)
(Improve sensibility over distribution of the median nerve )

Pre-requisites before opposition transfer

Long-standing palsy may
lead to first web
contracture, supination
deformity and joint stiffness
that may need surgical
release before tendon
transfer

Mobile CMC
Adequate 1st web
Passive opposition
Finger motion
Functioning EPL, FPL, APL
(Thumb and finger sensibility)

Thumb opposition
Various techniques and transfers have been described,
both passive and active and should be tailored to the
patients need
EIP to APB (and EPL) - Aguirre & Caplan
FDS (ring) but usually either severed or paralyzed and
need more force (43%) to obtain the same function
(Anderson 1992)

EIP transfer

Thumb opposition

The motor (EIP / FDS)

The pulley ?
The distal fixation ?

The pulley
Adduction is proportional to the
length of the moment between
tendons and axis of flexion (X)
Ante-flexion is proportional to
the length of the moment
between tendon and axis of TM
(Y)

Distal fixation
Along the axis of the APB
Expansion to the dorsum of the
axis if extensors are weak (Roach
2001)

FDS transfer
Loss of grip strength
Loss of PIP extension (8 in 50% of
patients North 1980)
Good to excellent results in
60-85% of patients (Bohr 1953,
Jensen 1978, Anderson 1992)

Results

Anderson 1992 (166 pts)

89% good to excellent after EIP, 85%
after FDS
EIP > FDS in their series
FDS (ring) needs more force (43%) to
obtain the same function

Ulnar nerve
TENDON TRANSFERS ! OMER, JR

221

TABLE 4
Isolated Ulnar Palsy
Needed Function
Thumb adduction for key
pinch (low palsy)
Thumb-index tip pinch

Proximal phalanx power

flexion and integration of
MCP and IP motion
(clawed fingers)
Metacarpal (palmar)
transverse arch and
adduction for small finger

Volar sensibility for ring and

small fingers
Distal finger flexionfor ring
and small fingers (high
palsy)
Wrist flexionulnar side

Preferred Motor

Alternate Transfer

ECRB, with free tendon graft between

thirdfourth metacarpals, to tendon of
APB
Slip of APL to first dorsal interosseous
tendon, and arthrodesis MCP joint of
thumb
ECRL with 2- or 4-tailed graft passed volar
to deep transverse metacarpal ligament
to either A2 pulley of flexor sheath or to
radial band of the dorsal apparatus
EDM tendon is split and ulnar half is
transferred volar to deep transverse
metacarpal ligament to radial collateral
ligament of proximal phalanx or A2
pulley of the flexor sheath (EDC of small
finger must be effective)
Proximal median digital nerve translocated
to distal ulnar digital nerve
FDP (middle) tenodesed to FDP (ring and
small), with possible tendesis of distal IP
joints in the ring and small fingers
FCR to insertion of FCU

FDS (middle) to abductor tubercle of thumb,

with palmar fascia as pully
EPB to first dorsal interosseous tendon, if
MCP joint of thumb arthrodesed
If wrist flexion contracture, FCR with 4-tailed
graft to either flexor sheath (A2 pulley) or
lateral bands of dorsal apparatus
If small finger is clawed as well as
abducted, insert ulnar half of EDM only
into A2 pulley

Free or vascularized nerve graft

From Omer 2004

PL to insertion of FCU

Function to restore after low ulnar

nerve palsy

Loss of hypothenar muscles

Wartenbergs sign
Loss of transverse metacarpal
arch

Loss of carpal arch

Bunnells technique have been
abandoned
Ranneys transfer (EDQ) is
sometimes performed

Correction of Wartenbergs

Transfer of the ulnar slip of the EDM to the radial side

In case of clawing, the radial slip is transferred volarly

Function to restore after low ulnar nerve

palsy
Loss of interosseous muscle (+
lumbricales)
Claw hand
Loss of key pinch (10% nl)
Loss of normal finger flexion
Loss of strength (70-80% loss)

Claw hand correction

Static procedures (capsulodesis and static tenodesis,
rarely bone block)
Dynamic procedures
Dynamic tenodesis (Fowler)
Tendon transfer

Capsulodesis
Stretch with time whatever
the technical variations
used in lax patients

FDS transfer
Lasso
Patients will loose 20% of
their grip strength
Bone (Burkhalter)
Stiles-Bunnell (if Bouviers
maneuver does not correct
hyperextension)

Drawbacks
Brandsma (1992) observed 15% swanneck deformity, 29% DIP flexion
contracture and 26% PIP flexion
contracture over 158 FDS transfers
North (1980) observed no
complications

Results
Ozkan 2003 (44 patients)
Lasso and ECRL-4 tail most effective for
grip strength
FDS 4-tail most successful in correcting
the claw hand deformity, especially in
long-standing paralysis in which there
was elongation of the extensor
apparatus.

1st interosseous restoration

APL accessory slip (+
graft) (Neviaser 1980)
PL (+ graft) (Hurayama
1986)
EPB (Bruner 1948)

Function to restore after low ulnar nerve

palsy
Loss of Thenar muscles
Jeannes and Froments signs
Loss of key pinch

Thumb adduction
FDS (ring) to ulnar side of the thumb
EIP (or ECRB + graft) through the
metacarpals

Results
Fischer 2003, 9 patients, ECRL to AP, APL to 1st DIO
Key pinch 73%, pulp-to-pulp pinch 72%, power grip
73%
Force of thumb adduction 63%
Force of index finger abduction 58%
Large variations between patients

Combined lesions

TENDON TRANSFERS ! OMER, JR

223

TABLE 6
Combined High (Proximal) Median and Ulnar Palsy
Needed Function
Thumb adduction
(AP)key pinch
Thumb flexion (IP joint)
Thumb abduction (APB)

Thumbindex tip pinch

Finger flexion (FDP)

Power for flexion of

proximal phalanx with
integration of MCP
and IP motion
(clawed fingers)

Metacarpal (palmar)
arch and adduction
for small finger
Wrist flexion
Median and ulnar volar
sensibility

Preferred Motor

Alternate Transfer

ECRB with free tendon graft between

third and fourth metacarpals to
APB tendon
BR to FPL in forearm
EIP with pisiform pulley to insertion
APB tendon (plus) EPL tendon

BR or EIP with free tendon graft between third and

fourth metacarpals to abductor tubercle of thumb
(APB tendon)
Tenodesis of FPL distal to MCP joint of thumb
EPL or ECU with free graft around pisiform pulley
to APB tendon (thumb MCP is arthrodesed and
no active motion at thumb IP joint)
EPB or PL to first dorsal interosseous, and fusion
of thumb MCP joint

Thumb MCP joint arthrodesis; and

APL slip with free tendon graft to
first dorsal interosseous tendon
ECRL to all 4 tendons of FDP with
possible tenodesis of distal IP of
ulnar 3 fingers
Tenodesis of all 4 digits with free
tendon graft from dorsal carpal
ligament volar to deep transverse
metacarpal ligament to lateral
bands of extensor apparatus (or)
from deep transverse metacarpal
ligament to extensor apparatus
EDM to deep transverse metacarpal
ligament (EDC of small finger must
be active)

Superficial radial innervated index

fillet flap to palm (or) first dorsal
metacarpal artery neurovascular
island pedicle flap

Biceps brachii extended with FCR tendon to

tendons of FDP
Capsulodesis of MCP volar capsule (or)
arthrodesis of PIP joints (or) arthrodesis of MCP
joints

EDM to radial lateral bands (extensor hood) of the

ring and small finger
ECU to insertion of FCU
Superficial radial nerve translocation (or) free
vascularized nerve graft

Conclusions
Nerve repair is the best technique available even if results
are still disappointing
Sensory deficit is a major complication which
reconstruction is difficult with limited results
Tendon transfer are well described for complete paralytic
hand
Indications are less described for patients with partial
recovery

Results

Amplitude: wrist flexors 3 cm, Finger extensors 5 cm

Results: Dunnett 1995

49 injury to the radial nerve (22) or brachial plexus (27).
5.6 years FU. Function improved in 84%
Impaired coordination and dexterity > 60%
Premature fatigue > 80%
Wrist power extension 22% of contralateral side (8% to
80%), power of digital extension was 31% (5% to 130%),
and power grip was reduced to 40% (5% to 86%).

Complications

Introduction dun dsquilibre

entre les tendons restants

Prlvement FCR

Diagnostic ?

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Paralysie du nerf
mdian
Paralysie distale
-Abductor pollicis brevis

Paralysie proximale
-Flchisseurs des doigts:
FS 2-3-4-5

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Paralysie du nerf
mdian
Territoire nerf mdian
Trs invalidant

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Paralysie
distale

Transferts sensitifs : abandonns

Moteur : ranimation de l'antposition du pouce

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Tubiana 1973
Dissections cadavriques
250 paralysies du pouce

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Direction du transfert

Superficiel : antposition
Profond : opposition

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Direction du transfert

Superficiel : antposition
Profond : opposition
Radial : antposition
Ulnaire : opposition

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Direction du transfert

Superficiel : antposition
Profond : opposition
Radial : antposition
Ulnaire : opposition
Proximal : antposition
Distal : opposition

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Exempl

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Zancolli

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Thompso
n

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RoyleThompson

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Palazz
i

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AlnotMasquelet

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Summar
y

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Fixation
Bord radial du pouce
sinon effet de supination
Si MP instable (paralysie FPB)
double fixation de part et d'autre de la MP (Brand)

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Fixation
Bord radial du pouce
sinon effet de supination
Si MP instable (paralysie FPB)
double fixation de part et d'autre de la MP (Brand)

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Paralysie
distale
Thompson

-FS 4
-Poulie aponvrose palmaire
-abduction-opposition
-Intrt
-Force comparable (3.0)
-Course satisfaisante

-Probleme
-Pas utilisables dans les paralysies
hautes
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Paralysie
distale
Bunnell

-FS 4
-Poulie - FCU
-Abduction / Opposition

-Intrt
-Force comparable (3.0)
-Course satisfaisante
-Probleme
-Pas utilisables dans les paralysies
hautes

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Paralysie
Camitz
distale
Palmaris Longus
-Poulie - aucune
-Abduction

-Intrt
-Morbidit faible
-Utile dans amyotrophie
du canal carpien
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Paralysie
Camitz
distale

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Paralysie
proximale
Brachioradialis sur FPL
-Librer le muscle trs haut

-La force de flexion

dpendra de la position du coude

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Paralysie
proximale
ECRL sur FP 2
-Alternative : tnodse FP 1-2-3

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Diagnostic ?

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Paralysie nerf
cubital
Paralysie distale
Doigts
Tous les interosseux Palmaires et dorsaux
Tous les lombricaux sauf 1er and 2me
Cinquime doigt : hypothnariens (opp,ADM,FDM)

Pouce
Adducteur
+/- Flexor pollicis brevis

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Innervation Flexor pollicis brevis

70%: median et cubital
! dfaut d'adduction

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Flexor pollicis brevis

testing

Pince terminale forte

Si hyperextension MP : FPB paralys
(signe de Jeanne)
Si flexion MP : FPB intact

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Paralysie nerf
cubital
Paralysie proximale

Les mmes
+ ECU
+ Flexor Profundus 3-4-5

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Tableau
! Pouce
Signe de Froment
supination (manivelle)
instability MP

! Index
Dfaut d'abduction

! Pince 1-2
faible
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Tableau
! Pouce
Signe de Froment
supination (manivelle)
instability MP

! Index
Dfaut d'abduction

! Pince 1-2
faible
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Tableau
! Pouce
Signe de Froment
supination (manivelle)
instability MP

! Index
Dfaut d'abduction

! Pince 1-2
faible
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Tableau
! Pouce
Signe de Froment
supination (manivelle)
instability MP

! Index
Dfaut d'abduction

! Pince 1-2
faible
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Tableau
clinique
! Doigts longs
Griffe cubitale
Manuvre de Bouvier
Wartenberg

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Tableau
clinique
! Doigts longs
Griffe cubitale
Manuvre de Bouvier
Wartenberg

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Tableau
clinique
! Doigts longs
Griffe cubitale
Manuvre de Bouvier
Wartenberg

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Tableau
Sensitif

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Moteurs
disponibles
FS ring finger (distal palsies)
Extensor indicis proprius (EIP)
Extensor digiti minimi (EDM)
Extensor pollicis brevis (EPB) + MP Az
Wrist motors +graft
Brachioradialis
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1-Le pouce
Paralysie distale

1.

FPB paralys
-

Moteur: FS4 : Royle-Thompson

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Technique
Royle-Thompson

Prlvement distal FS4

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Technique
Royle-Thompson

Prlvement distal FS4

Rcupr au poignet

Pass sous les tendons flchisseurs

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Technique
Royle-Thompson
-

Prlvement distal FS4

Rcupr au poignet

Pass sous les tendons flchisseurs

Amen vers le pouce

Sous les pdicules vasculo-nerveux

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Fixation
distale

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Technique
Royle-Thompson

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Le pouce
Paralysie distale
2. FPB actif

- Moteur:
FS4
Ou EIP travers la membrane interosseuse

- Fixation distale
Adductor (sesamoide) and MP radial

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Institut
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1-Le pouce
Paralysie

FS4 et 5 pas utilisables

EIP travers la membrane interosseuse
n'est ni assez long ni assez fort pour stabilizer la MP :
gestes associs

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Le pouce
gestes associs

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Thumb
gestes associs
capsulodse MP

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Thumb
gestes associs
capsulodse MP
arthrodse sesamodo-metacarpienne

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2- les doigts
longs

Griffe cubitale
Abduction index

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Griffe cubitale
- Capsulods
e

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Griffe cubitale
- Capsulodse

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Griffe cubitale
- Capsulodse
- Tnodse (Fowler)

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Griffe cubitale
- Capsulodse
- Tnodse (Fowler)
- Transfert tendineux
Insr en dorsal (Brand)

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Technique du
Lasso
lasso direct
Avec flexor superficialis FS4 / FS5
inutilisable dans les paralysies proximales

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Technique du
Lasso
lasso direct
avec transfert tendineux (EIP)

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Technique du
Lasso
lasso indirect
flexor superficialis paralys + transfert

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Abduction Index
- EIP drout
- EPB + fusion MP

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Rsum
paralysie cubitale

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Paralysie distale

- FPB paralys
FS4: pouce
EIP: lasso 4-5
APL (1 bandelette) + greffe : 1er IOD

(Pour une pince plus forte:

FS4: pouce
FS5: lasso
EIP: 1st DIO)

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Paralysie distale

FPB actif
EIP: pouce
FS4 : lasso + 1er IOD

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Paralysie proximale

FP 4-5 : suture latrale FP 2-3

1re option
FS3 : lasso (3)-4-5 + 1er IOD
EIP : pouce (+stabilisation MP)

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Paralysie proximale

FP 4-5 : suture latrale FP 2-3

1re option
FS3 : lasso (3)-4-5 + 1er IOD
EIP : pouce (+stabilisation MP)
2nd option (flexion forte des doigts)
ECRL : lasso indirect 2-3-4-5
EIP : pouce (+stabilisation MP)

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Paralysies
mixtes

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Conclusio
n

Pas de technique "standard":

examen clinique (FPB)
besoins du patient
exprience et crativit du chirurgien
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Alternative
Distal palsy

- Fisher & Buchler

JHS A 28:28-32, 2003
- Alternative Zancolli cf shema p 202
FS4 + FS 5: direct lasso
EIP (through IM) : thumb
FS3: 1st and 2nd DIO muscle

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Stratgie
Un transfert pour une fonction

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