1. Shoulder Adductor, Extension,
and External Rotator Lengthening
indications for shoulder adductor
lengthening are usually in a child with a
quadriplegic pattern involvement who has a
severe shoulder adduction contracture
making axillary care and dressing difficult.
primary contracture is usually with
internal rotation and adduction coming from
abduction extension and elbow extension
during ambulation or while sitting in a
cosmesis and fewer problems
with injury of the hand can occur with
lengthening of the triceps and external
An incision is made over the anterior
deltopectoral groove. The inferior border of the
pectoralis major is identified (Figure S1.1.1).
The superior and inferior borders of the pectoralis
minor and major are identified and a hemostat is
passed underneath these two muscles.
Cautery is used and the muscles are transected
completely. Abduction then should increase 20° to
30°, sufficient to allow easy access to the axillary
region (Figure S1.1.2).
If the latissimus dorsi and teres minor are very
contracted, a separate posterior incision can
be made (Figure S1.1.3) and these can be
released as well (Figure S1.1.4).
The teres major and minor can also be
transected medial to the long head of the
triceps. Care has to be taken to avoid injury of
the axillary nerve coming up through the
quadrilateral space (Figure 1.1.5).
The long head of the triceps is then
identified distal to the axillary nerve and
transected (Figure 1.1.6).
The lateral head of the triceps is next
defined and transected (Figure 1.1.7).
The wounds are closed and no
immobilization is utilized.
Immediate passive range of motion is
2. Humeral Derotation
indication is usually severe external humeral
rotation or severe internal rotation.
most common patterns are children with
contractures, which make seating difficult, or
the high-functioning child with hemiplegia who
has a severe internal rotation contracture.
Incision is made along the anterior
border of the deltoid and carried down to
the midarm (Figure S1.2.1).
interval is opened to the humerus with
subperiosteal dissection distally but not
with elevation of the deltoid insertion into
An osteotomy with an oscillating saw is
made at the level just proximal to the humeral
insertion of the deltoid (Figure S1.2.2).
the humerus is to be rotated externally, the
plate is placed on the medial surface with a
minimum of two holes proximally and three
holes distally and, if possible, a six-hole plate
should be utilized (Figure S1.2.3).
compression of the
performed (Figure S1.2.4).
postoperative passive range of
motion is allowed; however, when the limb is
not being ranged, it should be immobilized in a
sling for 4 weeks to allow healing to begin.
3. Elbow Flexion Contracture
Elbow flexion contractures are common in both
children with hemiplegia and those with quadriplegia.
For the child with hemiplegia and a mild contracture,
only the bicep is released. If the child has a very
functional upper extremity, a Z-lengthening of the
biceps tendon may be performed.
For the quadriplegic child with a severe contracture,
complete transection of the biceps and brachialis is
performed with some myofascial lengthening of the
Incision is made anterior transverse just proximal
to the elbow crease (purple line, Figure S1.3.1).
It is carried down to the subcutaneous tissue with
spreading and retraction of the subcutaneous
If more proximal or distal exposure is needed the
incision can be extended in Z-plasty fashion
(Figure S1.3.1, blue lines).
2. The tendon of the biceps is palpated and
extensively cleaned. Retractors are placed
on each side and the tendon is transected
(Figure S1.3.2, purple lines).
At this point, if it is felt that the arm is
strength, a Z-lengthening of the tendon can
be performed (Figure S1.3.2, green line).
For the quadriplegic child with a severe
contracture, complete release of the biceps and
the majority of the brachialis fascia beneath the
biceps is performed as well (Figure S1.3.3).
a significant lateral contracture of the flexor still
remains, myofascial lengthening of the lateral mass
also can be performed.
active range of motion is begun if
there is no other indication for the utilization of a
cast. If the child also undergoes forearm
procedures, the elbow may be immobilized in a
cast in approximately 70° to 80° of flexion.
is utilized based on the requirements of
other procedures, not the elbow tendon
4. Pronator Release or Transfer
or transfer of the pronator teres is
indicated if there is a significant pronator
contracture, usually in the child with a hemiplegic
children with a quadriplegic pattern with
functional forearms also may need a pronator
The incision is made in the midforearm between
the brachioradialis and the extensor carpi radialis
longus muscles (Figure S1.4.1). The incision is
carried through the subcutaneous tissue and the
interval between brachial radialis and extensor
carpi radialis longus is opened.
The radius is identified and the fascia overlying
the radius is opened.
The pronator teres tendon will be identified, and
proximal dissection is extended until the full tendon
of the pronator teres can be identified. The
pronator teres has a very broad insertion onto the
A right-angle clamp is placed around the
pronator teres (Figure S1.4.2).
If a release is planned, especially for
individuals with quadriplegia and for many
children with hemiplegia, the tendon is
transected and care is taken to make sure that
no remnants of the tendon remain attached.
If a transfer is indicated, the tendon is
released with its underlying periosteum to the
distal third–middle third junction of the radius.
The tendon of the pronator teres then is
membrane, wrapped around the radius distally
in the opposite direction (Figure S1.4.3), and
sutured into the periosteum or a single drillhole
placed in the distal radius with a stay suture
tied to a suture anchor (Figure S1.4.4).
Care should be taken to avoid major
bicortical drillholes because of the risk of
forearm is immobilized in full
supination in a long-arm cast for 4 weeks.
treatment includes range
of motion after cast removal, which can
occur as early as 2 weeks if no other
procedures were performed.
5. Flexor Carpi Ulnaris Transfer
for Wrist Flexion Deformity
Wrist flexion, often combined with ulnar deviation, is a
common contracture. Flexion of the fingers may be
present as well.
Transfer of the flexor carpi ulnaris is indicated when there
is dynamic wrist flexion contracture and when there is a
wrist flexion contracture with a fixed contracture on the
This procedure may be combined with lengthenings of
the extensor carpi ulnaris if there is significant ulnar
deviation, or lengthening of the flexor carpi radialis if
there is significant fixed wrist flexion contracture after
1. The incision is made across the wrist crease along
the flexor carpi ulnaris (Figure S1.5.1) and then may be
extended across the forearm in a lazy S
fashion, dependent on whether finger flexor
lengthenings are indicated (Figure S1.5.2).
The tendon border of the flexor carpi ulnaris is
identified and freed of its fascial and muscle
attachments in the distal 6-cm segment. The tendon is
detached as far distally as possible off the carpal
bones, being careful to protect the ulnar nerve on the
deep and thenar side of the tendon (Figure S1.5.3).
It is next stripped using a surgical finger or another
instrument so its fascia is stripped at least to
midforearm. A suture is place in the end of the tendon.
At this time, the wrist should easily dorsiflex
passively to 20° or 30°, and if this is not possible,
the flexor carpi radialis is identified and a
myofascial or Z-lengthening is performed
based on how much dorsiflexion is needed.
Usually, a Z-lengthening is required because
the muscle often is very short and the tendon
Flexor carpi radialis lengthening is only required
in wrists with severe flexion contractures (Figure
An incision is made in the dorsum of the wrist
from distal on the radial side to slightly proximal on
the ulnar side (Figure S1.5.5).
If the goal is to transfer the tendon into the
extensor carpi radialis longus or brevis, these
tendons are exposed to their insertion distally,
freeing the extensor hallucis longus.
If the goal is to transfer the FCU into the finger
extensors, the finger extensors are identified at
their common dorsal wrist compartment.
A tendon passer is passed through the
subcutaneous tissue from dorsal to volar, and
the tendon is grasped and pulled into the
dorsal wound, which should provide easy and
sufficient tendon length.
should be taken to make sure that the
muscle is pulled in a gentle curve and a sharp
bend is not made in the subcutaneous tissue
at midforearm (Figure S1.5.6).
then is directed back to the volar
area where further lengthenings are
performed if indicated.
With the wrist in 20° to 30° of
dorsiflexion, if there is full passive finger
extension, no finger flexor lengthenings
are indicated. If the fingers are unable to
extend with the wrist in 20° of
dorsiflexion, especially if they lack more
than 40° or 50° coming to
extension, lengthenings of the finger
flexors should be performed.
Usually, the primary contracted finger flexor is
the flexor digitorum superficialis, which then is
exposed by extending the incision across the
muscle belly in the midforearm, aiming toward
the incision of the pronator release.
flexor muscles are identified and, if good
muscle mass is present and the finger flexion
contractures are not severe, myofascial
lengthenings are performed.
lengthenings of all the flexor
digitorum superficialis muscles usually are
required (Figure S1.5.7).
8. If the finger flexion contractures are quite
severe, then the tendons of the flexor digitorum
superficialis are identified and the tendons of the
index and long finger (Figure S1.5.8, group A) are
sutured together as far distally as possible and
proximally at the level of their muscle bellies.
The tendons of the ring finger and little finger
(Figure S1.5.8, group B) similarly are sutured
The tendons then are transected, one distal and
one proximal, which allows a Z-lengthening of the
combined motor units to the index and long finger
and the ring and little fingers. Sufficient
lengthening is provided to allow finger extension
Following flexor digitorum superficialis
lengthening, if there is still significant
contracture present, the flexor digitorum
profundus tendon and muscle are identified
and, for moderate contractures, a myofascial
lengthening can be performed.
a severe lengthening is required, a similar
combined Z-lengthening is performed.
With the wrist extended 20°, the thumb
should be extended, and if it is unable to fully
extend at neutral abduction and the flexor
pollicis longus is very tight, a myofascial
lengthening of the flexor pollicis longus usually
is sufficient and can be performed through
the same incision.
severe contractures in which the muscle
belly is short, a Z-lengthening should be
performed (Figure S1.5.10).
11. If additional procedures of the thumb or fingers are
required, these next should be performed before the
tendon transfer is completed.
However, the description of this procedure will presume that
this has been done or is not needed. The volar wounds are
all closed in the appropriate fashion.
Attention is directed to the dorsum, where the tendon has
had a Kessler suture placed through its end and can be
drawn into the wound (Figure S1.5.11).
The tendon is woven with a Pulvertaft weave through the
tendon to which it is intended to be transferred (Figure
The tension is increased until the wrist is at 20° to a maximum
of 30° of extension and the tendons are sutured together
Following a provisional fixation with one or two
sutures, tension is relaxed and the wrist should stay
in dorsiflexion of 10° to 30° when the wrist is not
If the wrist drops into flexion, the tendon repair has
to be taken down, the wrist further dorsiflexed, and
the tension of the tendon transfer increased.
If the dorsiflexion is more than 30°, the tendon
should be relaxed to prevent a hyperdorsiflexion
deformity. Suturing of the tendon is completed.
The wound is closed.
A forearm cast is applied with the wrist in 30° of
phalangeal joints extended to neutral and
interphalangeal joints flexed to 45°.
fingers should be incorporated in the cast to
the fingertips with the appropriate flexion as
thumb should be in abduction and slightly
flexed, especially avoiding hyperextension of the
metacarpal phalangeal joint of the thumb and
weeks of immobilization in a cast is
required, then the cast is removed and a dorsal
or volar wrist extension splint is worn 24 hours
per day for an additional 4 to 8 weeks, with the
splint being removed for gentle active range of
motion and bathing only.
this, the splint is gradually removed as
strength is increased.
6. Proximal Row Carpectomy
and/or Wrist Fusion
indication is primarily in individuals with
nonfunctional upper extremities and severe
fusion is to be avoided in any extremity with
substantial function, especially in hemiplegics;
however, wrist carpectomy or fusion should be
considered only in older individuals or those with
After postoperative rehabilitation and cast
removal, little therapy is indicated as these are
by definition nonfunctional upper extremities in
which the operation was done for comfort
care, improved ability for dressing, and personal
may or may not occur, but the
fibrous arthrosis is stable if the finger flexors do
not contract and claw the fingers into the palm.
7. Thumb Adductor Lengthening
Thumb adductor lengthening, by release
of the muscle in midsubstance, is
indicated for mild to moderate thumb
Postoperative management is with the
thumb in abduction in the cast for 3 or 4
Make sure the cast is not producing
thumb hyperextension at the MTP joint.
After cast removal, thumb abduction
splinting at nighttime is usually used for at
least 3 weeks.
No other treatment is indicated.
8. Webspace Lengthening and
lengthening and Z-plasty are used for
severe adduction contractures of the thumb,
especially those in which the goal is to get the
thumb out of the palm and around large objects.
thumb webspace lengthening with a more
aggressive adductor lengthening is indicated.
has to be taken to avoid excessive
lengthening because this will greatly improve
thumb abduction at the expense of
the thumb is abducted enough to hold a
drinking glass, almost always lateral key pinch
relative importance of these functions
needs to be individually considered in each
A soft bulky dressing is used for 3 weeks
until the wounds are well healed.
is then started, focusing on the
functional gains that the child hopes to
9. Metacarpal Phalangeal
Joint Fusion of the Thumb
The indication for the metacarpal phalangeal joint
fusion is severe flexion of the metacarpal phalangeal
joint or severe extension hypermobility.
The most common indication is a House type 4 thumb
deformity, also known as a cortical thumb, in which the
caretakers have difficulty in keeping the hand clean.
posture leads to sweating in the hand
and the development of a very foul odor.
with functional use of the thumb,
but severe MTP hyperextension, are the
Pin removal and cast removal can be
performed when the X-ray demonstrates
some bridging callus.
splinting or therapy is further required.
10. Extensor Pollicis Longus
Rerouting is indicated for active thumb
adduction contractures, or those in which
there is a lack of thumb abduction and
extension; rerouting of the extensor pollicis
longus is indicated for moderate
The thumb is held in an abduction cast for
4 weeks and then is allowed to have full
active range of motion.
11. Palmaris Longus or Brachioradialis
Transfer to the Abductor Pollicis
The indication to transfer the palmaris
longus or brachioradialis to the abductor
pollicis is to augment thumb abduction
due to inactive power of a moderate to
The hand is immobilized in a thumb spica
with maximum thumb abduction but
avoiding MSP hyperextension.
cast is removed after 4 weeks, and a
thumb abduction splint is worn at
nighttime for an additional 2 to 4 months.
12. Volar Plate Advancement and
Sublimis Slip Reinforcement for
Swan Neck Deformity
finger flexors with wrist flexion
deformity and contracted intrinsic muscles result
in hyperextension of the proximal interphalangeal
(PIP) joint and flexion of the distal interphalangeal
joint to cause a stretching out of the volar
capsule at the proximal interphalangeal joint.
the deformities are severe, finger PIP
joints get locked in extension and surgical
treatment may be indicated.
from hyperextension or inability to flex the
PIP joint causing functional limitation is the
typical direct indication for surgical treatment.
At 4 weeks postoperatively the pins are
splint is made to prevent dorsiflexion and
should be worn for another 2 to 4 weeks.
the splint is removed, there should be
no attempt at forceful extension stretching;
however, range of motion into PIP joint flexion
of the fingers is encouraged.