Management of Thumb Opposition
with BURKHALTER’s Procedure
TRUONG LE DAO, M.D.
Intrinsic muscles palsies of the hand
Burkhalter W.E, Cristhensen R.C, Brown P.W,
Extensor Indicis Proprius opponensplasty
J. Bone Joint Surg. 55: 725-732, 1973
This technique has been applied to restore
thumb opposition since 1990 in HCMC
Hospital of Dermatovenerology.
Tendon transfers require a multidisciplinary
team particularly physiotherapist for
preoperative as well as postoperative
assessment and useful exercise.
Department of Surgical Reconstruction
& Rehabilitation in Leprosy
HCMC Hospital of Dermatovenerolory
• Surgical Principles
• Technique of Opposition Transfer
• Surgical Stratery
• Rehabilitation after Tendon Transfer
• High median-nerve injury,
when the FDS are not available.
• Combined median-ulnar nerve injury,
either high or low .
• Which motor muscle?
• Which route?
• Which pulley?
• Which type of insertion ?
• Bunnell called tendon transfers muscle
• The EIP provides thumb mobility and full
Extensor Indicis Proprius
Choosing the Route of Transfer
• The more radial the route, the more thumb
abduction it provides to the thumb.
• The more ulnar the route, the more flexion
and pronation it provides to the thumb.
• The most effective opposition transfer
courses to its insertion on the thumb from
the directon of the pisiform, paralleling the
• The best plane for the transfer is superficial to
the palmar fascia in the subcutaneous layer.
• The more direct the route of transfer, the less
force is needed to effect thumb movement.
The EIP has a more direct route than the FDS.
• Ulnar bone is a stiff
pully. It doesn’t change
the tendon direction of
more than 45 degrees.
Double Insertions (Riordan)
• The abductor pollicis brevis tendon, the thumb
MCP joint capsule.
• And the extensor pollicis longus over the
proximal phalanx, if there is significant direct
injury to the ulnar-innervated muscles.
Technique of Opposition Transfer
• An incision is made over the
dorsum of the index MCP joint.
The EIP is harvested from its
insertion. A small portion of the
extensor expansion taken with
the tendon may ensure that it will
reach its new insertion on the
• The extensor hood must be
meticulously repaired to prevent
an extensor lag of the index MCP
• A second incision is made over the distal
aspect of the dorsoulnar forearm.
• The tendon and muscle belly of the EIP must
be freed more proximally to provide a more
direct line of pull.
• A third incision is made over the pisiform.
• A wide subcutaneous tunnel is developed
between the incisions over the pisiform and
the dorsoulnar forearm.
• The EIP tendon is passed through the tunnel
around the ulnar border of the forearm.
• A fourth incision is made over the radial aspect
of the thumb MCP joint.
• Another subcutaneous tunnel from the pisiform
to the thumb MCP joint provides the pathway
for the thumb transfer.
• The EIP tendon is attached according to
Adjusting the Tension of the Transfer
• The tension is adjusted with the wrist in 30
degrees of flexion and the thumb in full
• The thumb is casted in full opposition and
the wrist in flexion with anterior and posterior
splints for hand-lower forearm for
approximately 4 weeks.
• Preoperative care
• Thumb Web Release
• Flexion contracture of the thumb IP
Pre Operative Care
• Scar mobilization by:
– mechanical massage
– active motion
• Maximization of range of motion (ROM):
– frequent passive ROM
– dynamic splinting and serial casting aid
– static splinting
• Adequate thumb web:
– A short opponens splint with a C-bar
– Passive stretching to the thumb
• Flexion contracture of the
–Serial plaster cast
• Maximization of muscle
strength. Specifically, the
proposed donor muscle.
• Patient education:
–what the donor does,
where it is, and how to
initiate its contraction. It is
much easier to accomplish
Thumb Web Release
• If there is still a limited ROM
despite good hand therapy and
splinting, a thumb web-space
release may be necessary at
the time or before opposition
• Skin coverage for the thumb
web is obtained with a Z-plasty,
four-flap web-plasty, rotational
flap from the dorsum of the
index metacarpal and MCP
joint, or skin graft.
Fixed Flexion Contracture ot the Thumb IP
• This problem is not always solved by Burkhalter’s
• If BOUVIER test (+), the radial half of flexor pollicis
longus was cut near its insertion and attached to EPL
over the middle of the proximal phalanx of thumb.
Rehabilitation after Tendon Transfer
• During in a protective splint or cast
• After discontinued protective splint
• Postoperatively, during the first 3 to 5 weeks :
– Active and passive ROM exercises are initiated to
the joints that do not need protection. Edema is
controlled with elevation, and active ROM.
• By 4 to 5 weeks: Mobilization to all joints.
• Until 6 weeks: Continuing protective splinting to
• From 6 to 8 weeks: discontinuing protective splint and
instituting passive ROM for all joints. Light activities.
• By 8 weeks: progressive resistance exercises such as
putty gripping, weights.
• By 12 weeks: increasing strength, endurance, and
function with a home program if needed.