FLEXOR CARPI ULNARIS TRANSFER TO IMPROVE

FUNCTION AND COSMESIS OF HAND IN

PATIENTS WITH CEREBRAL PALSY
Gulzar Saeed Ahmed1
ABSTRACT
Objective: Function and appearance of the involved hand in patients with cerebral palsy can be
improved by orthopedic surgery especially in spastic hamiplegia. Flexor carpi unlnaris transfer to
extensor carpi radialis longus or bravis is a procedure commonly used for correction of flexion
pronation deformity of hand in patients with cerebral palsy.
Patients and Methods: Twenty patients with the mean age 7.5 years were selected for the
procedure. Eight patients were in Zancolli class I, and 12 were in Zancolli class II. Green & Banks
technique was used.
Results: Seventeen out of twenty patients had good functional improvement and cosmetic
appearance. There parents were satisfied with the results. In three patients functional
improvement and cosmetic appearance was fair but parents were not satisfied with the results.
Conclusion: Green and Banks procedure is good for cerebral palsy patients with moderate flexion
pronation deformity at wrist. Functional and cosmetic appearance of hand improves considerably
with this procedure.
KEY WORDS: Flexor Carpi Ulnaris, Transfer, Cerebral Palsy.
Pak J Med Sci April 2007 Vol. 23 No. 2 242-244

INTRODUCTION palm and swan neck deformity. Although only

Cerebral Palsy is non progressive, non heredi- a small number of children’s with cerebral
tary encephalopathy that occurs in the prena- palsy have indication for surgical treatment of
tal or perinatal period, and is characterized by upper extremity deformities, orthopedic sur-
altered motor sensory and often intellectual gery does improve function and appearance
function. It can be classified as pyramidal of the involved hand especially in spastic
which includes spastic hemiplegia diplegia, hemiplegia. Flexor carpi ulnaris transfer to ei-
paraplegia and quadriplegia or as extra pyra- ther extensor carpi radialis longus or extensor
midal which includes athetoid and ataxic carpi radialis bravis has become a standard
patterns. A third is a mixed variety in which procedure to improve function of hand in
patient has both spasticity and athetosis. patients with cerebral palsy.1
Hand is involved in almost all type of cere- When flexor carpi ulnaris is transferred to
bral palsy. The function of hand is usually im- radial wrist extensor, it removes a deforming
paired. The other common deformities of up- force that pulls the hand into ulnar deviation
per limb are adduction and internal rotation and flexion and provides a force that promotes
deformity of shoulder, elbow flexion, forearm supination of the forearm and extension of the
pronation, wrist and finger flexion, thumb in wrist. This is a retrospective study in which
pre and postoperative position of wrist has been
1. Dr.Gulzar Saeed Ahmed
Associate Professor of Orthopedic Surgery, compared and function is assessed by objec-
Isra University/Hospital, Hala Road, tive and subjective measures.
Hyderabad, Sindh – Pakistan.
PATIENTS AND METHODS
Correspondence:
Dr. Gulzar Saeed Ahmed. Twenty patients were selected for this study
A-9, Block C, Unit-6, Latifabad, with the age range between six to nine years,
Hyderabad, Sindh – Pakistan.
E-mail: gulzarsaeed@yahoo.com (mean 7.5 years.) Twelve patients were male.
* Received for Publication: July 1, 2006 Right hand was involved in 12 patients and
* Accepted: October 4, 2006 left in eight. The surgeries were performed be-

242 Pak J Med Sci 2007 Vol. 23 No. 2 www.pjms.com.pk

tween June 1998, and June 2002. The minimum and a tourniquet applied to the upper arm.
follow-up was three years. TECHNIQUE: (Green & Banks).3 Anterior lon-
Careful repeated evaluation was made be- gitudinal incision was made over flexor carpi
fore offering surgery. Children who have com- ulnaris (FCU). The FCU tendon was detached
pletely ignored the hand were not offered sur- from pisiform insertion and muscle was dis-
gical treatment. All the patients had good con- sected proximally off ulna. Small longitudinal
trol of shoulder and elbow. Children with athe- incision was made on the dorsum of wrist on
toid pattern were also excluded. The patients extensor carpi radialis bravis (ECRB), proximal
selected for surgery had dynamic deformities to first extensor compartment. FCU tendon
which were spastic and slowly correctable. was passed subcutaneously around ulnar bor-
Active extension of fingers was present in all der of forearm. Button hole was made in ECRB
patients. In all patients selected for surgery, tendon and FCU was passed through button-
flexion pronation deformity was passively cor- hole and sutured to itself under appropriate
rectable. Patients with static contractures were tension with the forearm in full supination and
not included in the study. the wrist in 45 degree of extension. Wound was
Muscle examination was done to determine dressed and cast extending from axilla to the
the degree of spasticity, strength and tips of fingers was applied with wrist held in
coordination’s. Childs ability to pinch and extension and forearm in supination and
grasp and release the object was also deter- thumb in abduction. One week after surgery
mined. It was also assessed that patient should cast was bivalved and exercises were started
have sufficient proximal control of the extrem- with arm out of cast. This was continued for
ity to voluntarily place the hand on top of the four to six weeks with cast remaining in place
head and then on the opposite knee within five between exercises periods. After that the cast
seconds. Sensitivity pattern of the hand was was worn at night only for six weeks.
determined. The child was blindfolded and
RESULTS
was asked to differentiate between sphere and
a cube, recognition of familiar objects egg coins, The procedure was successful in majority of
or to indicate the position of the hand when the patients, adequate dorsiflexion was
the palm has been placed by the examiner fac- achieved in most of the cases, grasp and re-
ing upward or downward. For flexion defor- lease was enhanced and cosmetic appearance
mity of the wrist and finger, the classification also improved. There was superficial wound
system of Zancolli and Zancolli was used.2 infection in two patients which was treated
Class-I Mild: Involvement, in which the patient with antibiotics according to culture and sen-
demonstrates full finger extension with sitivity. Preoperatively in all patients the hand
theWrist flexed to less than 20 degrees. There- was in about 30 to 50 degrees of flexion, pr-
fore, reasonable dorsal motor strength is present. onation and ulnar deviation. All the patients
Class-II Moderate: Involvement, in which full were able to move fingers and thumb but pinch
finger extension is possible, only when the wrist and grasp was severely impaired due to flexed
is flexed to more than 20 degrees. Patients in position of wrist. After surgery range of move-
Subgroup A demonstrate weak extension of ment at wrist, and grasp and release was im-
the wrist with the fingers flexed, while those proved in all patients. In seventeen patients
in Subgroup B lack any wrist extension. range of movement at wrist was between fif-
Class-III: Severe involvement where in the pa- teen degrees flexion and forty degree extension,
tient has great wrist and flexion deformity with- and ten degrees of pronation and fifty degrees
out active extension of the wrist or fingers. of supination. In three patients range of
Eight patients were in Class one and twelve movement at wrist was between twenty de-
patients were in Class II. The surgery was grees of flexion and thirty degrees of extension
carried out under general anesthesia with the and thirty degree of pronation and thirty
patient supine, the upper limb on a hand table degree of supination.

Pak J Med Sci 2007 Vol. 23 No. 2 www.pjms.com.pk 243

Gulzar Saeed Ahmed

Parents of seventeen patients were satisfied extension at fingers. Lengthening of multiple

with the cosmetic appearance and improve- flexor tendons may result in scarring and ad-
ment in grasp and release mechanism of hand. hesions resulting in loss of function.
Parents of three patients were not satisfied with Flexor pronator release at elbow is effective
the function but were satisfied with the in correction of wrist and elbow correction but
cosmetic appearance. is not indicated in those patients in which wrist
flexion deformity is passively correctable.6 In
DISCUSSION
our study all the patients were benefited by
Flexion pronation deformity at wrist in single tendon transfer. Beach WR et al,7 pub-
patients with spastic cerebral palsy makes the lished their 17 years experience with Green’s
hand almost nonfunctional and cosmetically procedure and showed tremendous success.
unacceptable. Patients with good IQ and well Eighty-eight percent of their patients had cos-
controlled proximal part of limb have as rea- metic improvement, & 79% improved function-
sonable chance of improving function as well ally. None had a decreased functional rating.
as cosmetic appearance. Flexor carpi ulnaris Winner SM, Johnson KA,8 also published
transfer to either extensor carpi radialis lon- their successful results with the transfer of FCU
gus or extensor carpi radialis bravis has become and concluded that in majority of patients; wrist
a standard procedure to improve function of arc of motion was improved and grasp and
hand in patients with cerebral palsy. The best release was enhanced after operation.
time for intervention is between the ages of four Our study results are comparable with the
and eight years.4 above mentioned studies. Seventeen out of
Van Heest AE et al,5 studied the the supina- twenty patients (85%) in our study showed
tion effect of tendon transfer of the flexor carpi improved function and cosmetic improvement
ulnaris to the extensor carpi radialis brevis or was seen in all patients.
longus on cadaver model. The ability of this
CONCLUSION: Green and Banks procedure
wrist extension transfer which also provide
is good for cerebral palsy patients with mild to
forearm supination was investigated. Releas-
moderate flexion pronation deformity at wrist.
ing the distal two thirds of the FCU ulnar ori-
Functional and cosmetic appearance of hand
gin resulted in a mean supination that was sig-
improves considerably with this procedure.
nificantly greater than the mean supination
achieved with releasing the distal one third of REFERENCES
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244 Pak J Med Sci 2007 Vol. 23 No. 2 www.pjms.com.pk