PPRP MANAGEMENT
UPPERLIMB
DR.RAJESH
PG in ORTHOPAEDICS
GMC
SHOULDER MOVEMENTS
• Flexion
– Coracobrachialis
– Pect.major
– Ant. deltoid
• Extension
– Lati.dorsi
– Teres major
– Post....
• Abduction
– Deltoid (15-90o)
– Supraspinatus(15o)
– trapezius
• Int.rotation
– Subscapularis
– Lat.dorsi
– Teres major
–...
AIMS OF SURGERY
• Near normal function of
hand
• Elbow flexion and forearm
pronation
• Glenohumeral stability and
motion
•...
BIO MECHANICAL CLASSIFICATION
;SAHA
• Prime movers
– Deltoid
– Pectoralis
major(clavicular head)
– Muscles working on long...
BIOMECHANICL CLASSIFICATION
;SAHA
Steerer group
1)Supraspinatus (sup.glider)
2)Subscapularis (post.glider)
3)infraspinatus...
• According to saha 2
out of 3 stabilizer
muscles to be
functional for
trapezius transfer
• For subscapularis
– Sup.2 digi...
HENRYS FACIAL SLING OPERATION
• For paralysis of
– Trapizius
– Rhomboids or
– Levator scapulae
• Fascia lata of thigh is u...
TRAPEZIUS TRANSFER FOR DELTOID
• Sahas technique
– Entire insertion of
trapezius along with
attached
• Lat. End of clavicl...
AFTER TREATMENT
• Spica cast applied in 45o
abd.,neutral rotation,flexed
in the plane of scapula
• Cast removed at 6-8 wee...
SHOULDER ARTHRODESIS
• Pre requisites
– Presence of strong scapulo-thorasic muscles is
mandatory
– Sufficient bone stock i...
SHOULDER ARTHODESIS
• Fused in
– Abduction 25o-30o
– Flexion20o
– Int.rotation 35o-40o
• Too much flexion causes-winging o...
SHOULDER ARTHODESIS
• Extra articular arthrodesis
– Watson and jones
• Extra and intra articular
arthrodesis
– Hill
• Intr...
• Compression
technique
– Charnley and houston
• Using internal and
external fixation
• Pins and ex-fix
removed after 6wee...
AO TYPE ARTHRODESIS
• Good bone stock
should be there
• No need to apply
spica cast
• Need to remove
hardware after fusion
PPRP ELBOW MANAGEMENT
• Elbow flexors
– Brachialis
– Biceps brachii
– Brachioradialis
• Elbow extensors
– Triceps,anconeus...
ELBOW FLEXION
RESTORATION
• Methods available
– Steindler flexorplasty
– Bunnell and Carroll anterior triceps transfer
– C...
STEINDLERS
FLEXORPLASTY
• Bunnell modification
– Uses facial transplant
– Anchors proximally
and laterally
– Eliminates th...
• BUNNELL ant.
Transfer of triceps
• BROOKS-SEDDON
pectoralis major
transfer
FORE ARM
• Pronation deformity is left alone, it permits
good function
• Fixed supination deformity is disabling
• Results...
• Manual osteoclasis
– Of fore arm bones if pt
is under 12 yrs
– Pronation osteotomy
with plating in elderly
patient
PPRP HAND MANAGEMENT
• Grasp is weakned
and pinch is lost if
active thumb
opposition is lost
• Strong pinch (key
pinch) is...
BUNNELS TECHNIQUE
• Contractures at CMC joint 1st and 2nd web
spaces released
• Tendon must pass its insertion in to thumb...
THUMB OPPOSITION
• COMPONENT MOVEMENTS
– Abduction
– Flexion of MCP thumb
– Internal rotation
– Radial deviation of
proxim...
TENDON TRANSFERS
• Riordan technique
• Brand technique
• Grooves and goldner
– FCU and FDS used
• Camitz
– Uses palmaris l...
RIORDAN TECHNIQUE
• FDS to ring finger
divided
• Tendon is passed
through FCU pulley
• Tendon anchored to
abd.brevis and
c...
BRAND TRANSFER
• Uses sublimus tendon to
ring finger
• Pulley made in fat over
hamate
• Tendon split in to two
strips
• At...
RESTORATION OF ADDUCTION
OF THUMB
• Adductor pollicis is
paralysed
• Deformity-
– MCP hyper extension
– IP joint hyper fle...
BOYES TECHNIQUE
• Brachioradialis is
lengthened by
additional graft
• Palmarward through
3rd interosseous
space
• Carried ...
RESTORATION OF ABD OF
INDEX FINGER
• Second component of
pinch action
• Due to paralysis of 1st
palmar int.
• Transfer of
...
PARALYSIS OF INTRENSICS
• Leads to extension deformity of MCP joints
• Restored by BRAND technique
• ECRL or ECRB with fre...
Restoration of intrinsic function
• REORDAN
– FCR +plantaris
• Fowlers transfer
• Brand trasfer
– ECRB+ free graft
• Tenod...
• In complete flexor paralysis
– ECRL to FPL
– ECU to deep flexor tendons used
• Carpectomy
– Used for severe flexion defo...
PARALYSIS OF WRIST
EXTENSION
• For ECRB
– Tendon of pronaror teres
– FCU
• JONES operation
– Ponator teres to radial wrist...
TENODESIS
(opponens&flexor tenodesis)
• If no finger and wrist flexors are present
• Wrist extension is present
• Thumb op...
ARTHRODESIS OF WRIST
• Smith Peterson technique
– Distal 4cms of ulna is used
as graft
• Dorsal AO DCP plate
• Capitate ra...
Take home message
• Functional ,mobile
upper limb is the
goal
• THANQ ALL
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polio upperlimb orthopedic management

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polio upperlimb orthopedic management

  1. 1. PPRP MANAGEMENT UPPERLIMB DR.RAJESH PG in ORTHOPAEDICS GMC
  2. 2. SHOULDER MOVEMENTS • Flexion – Coracobrachialis – Pect.major – Ant. deltoid • Extension – Lati.dorsi – Teres major – Post. deltoid • Adduction – Pect.major(lower&upper) – Coracobrachialis – Lat.dorsi&teres major
  3. 3. • Abduction – Deltoid (15-90o) – Supraspinatus(15o) – trapezius • Int.rotation – Subscapularis – Lat.dorsi – Teres major – Ant.deltoid – Pect.major • Ext.rotation – Infraspinatus – Teres minor – Post.deltoid
  4. 4. AIMS OF SURGERY • Near normal function of hand • Elbow flexion and forearm pronation • Glenohumeral stability and motion • Overall mobility and reach of upper limb • For shoulder surgery , – Functional elbow and – Good hand function should be there
  5. 5. BIO MECHANICAL CLASSIFICATION ;SAHA • Prime movers – Deltoid – Pectoralis major(clavicular head) – Muscles working on long lever arm – Exert maximum force for lifting of arm during abduction • Choice of muscle transfer – trapezius
  6. 6. BIOMECHANICL CLASSIFICATION ;SAHA Steerer group 1)Supraspinatus (sup.glider) 2)Subscapularis (post.glider) 3)infraspinatus -Steer the head on glenoid surface. -Exert a stabilizing force Lifting force is minimal Depressors 1)Pect.major 2)Lat.dorsi 3)Teres major Rotate humeral shaft during elevation and depress the head in late abduction
  7. 7. • According to saha 2 out of 3 stabilizer muscles to be functional for trapezius transfer • For subscapularis – Sup.2 digitations of serr. Ant – Pectoralis minor – Levator scapulae • Supraspinatus – Levator scapulae – SCM – Scalaen.ant • For infra spinatus – Lati.dorsi – Teres major
  8. 8. HENRYS FACIAL SLING OPERATION • For paralysis of – Trapizius – Rhomboids or – Levator scapulae • Fascia lata of thigh is used • Slings placed b/w – 6th and 7th cervical spine to sup. Medial border of scapula – 3rd thoracic vertebrae to lower border of scapula
  9. 9. TRAPEZIUS TRANSFER FOR DELTOID • Sahas technique – Entire insertion of trapezius along with attached • Lat. End of clavicle • AC joint • Acromion • Adjoinig part of scapula spine – Anchored to lat. Aspect of humerus distal to tuberosity by 2 screws.
  10. 10. AFTER TREATMENT • Spica cast applied in 45o abd.,neutral rotation,flexed in the plane of scapula • Cast removed at 6-8 weeks • Active exercises started • Transfer of deltoid origin for partial paralysis ;HARMON • Bateman trapezius transfer
  11. 11. SHOULDER ARTHRODESIS • Pre requisites – Presence of strong scapulo-thorasic muscles is mandatory – Sufficient bone stock in gleno-humeral joint – Good hand and elbow function • Disadvantages – Imparts strength at cost of mobility – Scoliosis may be produced – Cosmetically not good – Unsuitable in b/l cases
  12. 12. SHOULDER ARTHODESIS • Fused in – Abduction 25o-30o – Flexion20o – Int.rotation 35o-40o • Too much flexion causes-winging of scapula • Too little int.rotation-decreases ADL • Too much abduction-over stretch trapizius • There are four methods of arthrodesis
  13. 13. SHOULDER ARTHODESIS • Extra articular arthrodesis – Watson and jones • Extra and intra articular arthrodesis – Hill • Intra articular arthrodesis – Cofield – steindler • Compression arthrodesis
  14. 14. • Compression technique – Charnley and houston • Using internal and external fixation • Pins and ex-fix removed after 6weeks • Cast continued for another 6 weeks
  15. 15. AO TYPE ARTHRODESIS • Good bone stock should be there • No need to apply spica cast • Need to remove hardware after fusion
  16. 16. PPRP ELBOW MANAGEMENT • Elbow flexors – Brachialis – Biceps brachii – Brachioradialis • Elbow extensors – Triceps,anconeus • Supinators – biceps and supinator • Pronators – Pronator teres and quadratus
  17. 17. ELBOW FLEXION RESTORATION • Methods available – Steindler flexorplasty – Bunnell and Carroll anterior triceps transfer – Clarks part of pect.major transfer – Brooks and sedon pect.major transfer – Hovanean lati.dorsi transfer – Bunnels transfer of SCM
  18. 18. STEINDLERS FLEXORPLASTY • Bunnell modification – Uses facial transplant – Anchors proximally and laterally – Eliminates the tendency of fore arm pronation
  19. 19. • BUNNELL ant. Transfer of triceps • BROOKS-SEDDON pectoralis major transfer
  20. 20. FORE ARM • Pronation deformity is left alone, it permits good function • Fixed supination deformity is disabling • Results from strong biceps and wrist extensors • Weak flexor pronators • Zancollis technique – Re-routing biceps tendon around neck of radius
  21. 21. • Manual osteoclasis – Of fore arm bones if pt is under 12 yrs – Pronation osteotomy with plating in elderly patient
  22. 22. PPRP HAND MANAGEMENT • Grasp is weakned and pinch is lost if active thumb opposition is lost • Strong pinch (key pinch) is lost if thumb adduction is lost • Loss of thumb apposition is common in polio and disabling
  23. 23. BUNNELS TECHNIQUE • Contractures at CMC joint 1st and 2nd web spaces released • Tendon must pass its insertion in to thumb in a direct manner to pisiform subcutaneously • Thumb angulated forwards and towards ulna • Tendon attached to dorsi ulnar aspect of prox.phalynx and MC head • Tendon sutured under moderate tension with wrist in flexion
  24. 24. THUMB OPPOSITION • COMPONENT MOVEMENTS – Abduction – Flexion of MCP thumb – Internal rotation – Radial deviation of proximal phalynx over MCP – Thumb towards finger • Important muscle is abductor poll. brevis
  25. 25. TENDON TRANSFERS • Riordan technique • Brand technique • Grooves and goldner – FCU and FDS used • Camitz – Uses palmaris longus – Enhances opposition • Littler and cooley – Abd.digi.mini muscle used
  26. 26. RIORDAN TECHNIQUE • FDS to ring finger divided • Tendon is passed through FCU pulley • Tendon anchored to abd.brevis and capsule • Splint for three weeks • Opponent splint for 6weeks
  27. 27. BRAND TRANSFER • Uses sublimus tendon to ring finger • Pulley made in fat over hamate • Tendon split in to two strips • Attach one strip to MCP joint • Another to tendons of abd.poll.bravis and EPL
  28. 28. RESTORATION OF ADDUCTION OF THUMB • Adductor pollicis is paralysed • Deformity- – MCP hyper extension – IP joint hyper flexion • Transfer of bra.radialis or wrist extensor – Boyes tech • ECRB transfer-smith tech • FDS for both add &apposition- – Royle thompson
  29. 29. BOYES TECHNIQUE • Brachioradialis is lengthened by additional graft • Palmarward through 3rd interosseous space • Carried across palm and anchored to tendon of add.pollicis
  30. 30. RESTORATION OF ABD OF INDEX FINGER • Second component of pinch action • Due to paralysis of 1st palmar int. • Transfer of – Ext.prop.indices or – Accessory Slip of abd.poll.longus tendon
  31. 31. PARALYSIS OF INTRENSICS • Leads to extension deformity of MCP joints • Restored by BRAND technique • ECRL or ECRB with free graft(toe extensors) used • through interosseous space • Ant. To deep transverse MC ligament • Sutured to edge of lateral band and • Extensor expansion of finger proximal to IP joint
  32. 32. Restoration of intrinsic function • REORDAN – FCR +plantaris • Fowlers transfer • Brand trasfer – ECRB+ free graft • Tenodesis – fowlers and • capsulodesis – zancollis
  33. 33. • In complete flexor paralysis – ECRL to FPL – ECU to deep flexor tendons used • Carpectomy – Used for severe flexion deformity of hand
  34. 34. PARALYSIS OF WRIST EXTENSION • For ECRB – Tendon of pronaror teres – FCU • JONES operation – Ponator teres to radial wrist ext.rs – FCU to ext.digitorum – FCR to thumb extensors&abductors
  35. 35. TENODESIS (opponens&flexor tenodesis) • If no finger and wrist flexors are present • Wrist extension is present • Thumb opposition obtained by – Opponodesis – By using free graft – Through ulnar tunnel • Combined with – Tenodesis of finger and thumb flexors – Through distal radius
  36. 36. ARTHRODESIS OF WRIST • Smith Peterson technique – Distal 4cms of ulna is used as graft • Dorsal AO DCP plate • Capitate radius arthrodesis – With proximal row carpectomy • Disadvantages – Weakness of grip,and – Holding of crutch
  37. 37. Take home message • Functional ,mobile upper limb is the goal
  38. 38. • THANQ ALL
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