COMBINED NERVE PALSIES
Seen most commonly in leprosy and trauma
Low Median-Ulnar palsy
 Most common combined nerve palsy
 Characterised by
1. complete loss of palmar sensibility
2. intrinsic paralysis (intrinsic negative) hand
 .
Priorities
1. Improve key pinch – restore adduction
2. Restore thumb abduction for opposition – grasp
3. stronger tip pinch –thumb to index
4. improved power flexion of fingers with MP/IPJ flexion coordination
5. restore metacarpal transverse arch and correct little finger abduction
6. restore sensibility for key or tip pinch
 Treatment very similar to ulnar nerve only lesions except thumb is very weak as it
only has FPL, EPL and EPB/APL
 Before doing any transfer need at least:
1. protective sensation,
2. good passive range.
 Radial motors and long finger/wrist extrinsics are available.
 Office workers need only opposition whereas labourers need opposition and
strength.
Opposition:
 EIP opponensplasty around the ulnar border to the thumb. If scarring is excessive
then pass EIP through the FPL tunnel.
 Alternatives: ECU with graft, PL
Pinch:
 Fuse the thumb IP joint to overcome the positive Froment’s.
 EPB or EIP or APL to 1st DI for pinch.
Clawing:
 For clawing one can use ECRL/BR (ie, leaving the centrally acting ECRB) + graft
(toe extensor or plantaris) through the lumbrical canal to the lateral band of the
extensor mechanism to act as an IPJ extensor.
Sensation
 Sensation may be restored by transferring the superficial radial nerve into the
median nerve
Summary Low median/ulnar (my approach)
1. improve abduction and opposition
a. EIP transfer ulnar border in manual worker
b. EIP through interosseous membrane
2. improve finger flexion integration (optional)
a. ECRB + 4 tail graft in manual worker
b. Zancolli 4 tail FDS MF in older patient
High Median/Ulnar Nerve Palsy
 Biggest problem is total loss of volar sensibility
 If other hand is normal, best to achieve key pinch and simple grasp
 Transfers
1. Finger flexion: ECRL  FDP
2. Thumb flexion: BR  FPL
a. disadvantage is that it crosses 2 joints and weakens with elbow flexion
3. Opposition: EIP  Thumb
a. Consider 1st MCPJ arthrodesis if tip pinch unstable
4. Clawing
a. Static procedures – Zancolli capsulodesis
High Ulnar/Radial Nerve Palsy
 Surgery need to be staged as flexors and extensors affected
o Stage 1 – wrist and finger extension with thumb abduction
o Stage 2 – finger flexion
Wrist Extension
 Pronator Teres to ERCB
FDP LF/RF
 End to side to FDP MF
Clawed fingers
 FDS MF Zancolli
Finger extension
 FDS IF to EDC
Thumb extension
 PL to EPL
High Median/Radial Nerve Palsy
 Intrinsics mostly intact, but sensation only in ulnar distribution.
Wrist extension
 wrist drop is the main problem.
 Problem is that all wrist motors are lost except FCU, and can only be addressed in
2 ways:
1. radiocarpal fusion
2. Free innervated muscle transfer
 With wrist fusion, loss of tenodesis effect, thus total range of motion will be
limited
Finger flexion
 FDP sutured end to side
Finger and thumb extension
1) FCU  EDC and EPL (if wrist fusion done)
2) With a free muscle transfer, the tenodesis effect that occurs with extension will
allow some degree of finger and Th flexion.
Thumb flexion
 FPB intact
 FPL is tenodesed across IPJ
Thumb Opposition
 Generally not attempted until wrist is stabilised and there is adequate adduction of
thumb
1. Huber transfer
2. de Vecchi operation – transfer adductor pollicis insertion from adductor to
abductor tubercle.
Triple Nerve Palsy from leprosy
 Triple nerve palsy occurs in 1% of leprosy patients
 classical deformities in triple nerve paralysis are flexion of the wrist, extension of
the metacarpophalangeal joints of the fingers, clawing of the fingers and a simian
thumb.
 Extension contracture of the metacarpophalangeal joints, flexion contracture of the
wrist and interphalangeal joints, and web contracture of the thumb may be seen
when the paralysis is of long standing..
 results in loss of extension of the wrist, loss of extension of the fingers and thumb,
and loss of intrinsic muscle action in the fingers and thumb.
 The overall functional loss in most cases is almost total ; the hand is scarcely used
at all and contractures at all joints are liable to develop early.
Surgery
 In the common combination of high ulnar with high radial and low median
palsy in leprosy, the muscles supplied by the median nerve in the forearm are
normally available for transfer.
 These are pronator teres, flexor carpi radialis, flexor digitorum sublimis
(superficialis), palmaris longus, flexor pollicis longus, flexor digitorum profundus
and pronator quadratus.
 Of these the first four have been used for various reconstructive procedures.
 When paralysis was partial, no transfer was considered if the power of the affected
muscle was already over Grade 3.
 Staged:
1. Restoration of active extension of wrist, fingers and thumb
a. Wrist extension: PT to ECRB
b. Finger extension: FCR to EDC
c. Thumb extension: PL to EPL / FCR to EPL
2. Restoration of intrinsics and opponensplasty
a. Intrinsics: Zancolli capsulodesis
b. Opponensplasty: FDS MF
CONCLUSIONS
Brand offers the following tips for multiple nerve and severe deficits:
1. Don’t wait too long before embarking on tendon transfers
2. Aim for one good function rather than multiple poor functions.
3. Aim for one good type of prehension: grasp or key pinch.
4. Often it is best to use the strongest muscle as a wrist extensor.
5. It is best to use 2 muscles for one movement: one to move and one to oppose,
rather than to rely on the effect of gravity to balance the hand.