| Abstract |
Background: The flexor pronator slide is an effective treatment option for ischemic contracture and contracture related to spastic cerebral palsy, but little is known about the use of the flexor pronator slide in other non-ischemic contractures. I propose a flexor pronator slide to simultaneously correct wrist and finger flexor contractures and preserve the muscle resting length. To avoid overcorrection of the deformity, I propose the use of a wide-awake local anesthesia with no tourniquet (WALANT) procedure, in which the patient is able to continually assist the surgeon in assessing the contracture release and improvement in finger movement. Additionally, the WALANT flexor pronator slide releases the specific muscles responsible for wrist and finger contractures (i.e., the flexor digitorum profundus, flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis, and pronator teres), sparing the intact finger functions.
Description: The patient in the video received a WALANT injection of 1% lidocaine with 1:100,000 epinephrine and 8.4% sodium bicarbonate in the operating room, and surgery was started 30 minutes after the injection to obtain the maximum hemostatic effect
Alternatives: Fractional or Z-lengthening of the flexor tendons is the alternative for finger and wrist flexion contractures.
Rationale: This patient had previously undergone multiple flexor tendon surgeries in the hand and forearm. The patient developed tight ring, middle, and little finger contractures that could not be passively extended with the wrist in neutral or dorsiflexion. This patient could not extend the proximal or distal interphalangeal joints of the middle, ring, and little finger in wrist extension. Conversely, wrist flexion extended all fingers. When the surgeon tried to extend the fingers with the wrist in extension, excessive force was required and a jog in the movement was appreciated in all small joints. This denoted contractures of the long flexors and flexor tendons of the forearm. Fractional or Z-lengthening may release the flexion contracture in such cases, but leads to loss of active flexion, disrupts the muscle resting length, and causes loss of flexion strength. Because our patient had very tight finger contractures, they were deemed not amenable to fractional or Z-lengthening. Therefore, we preferred the use of a flexor pronator slide to simultaneously correct wrist and finger flexor contractures while preserving the muscle resting length. To avoid overcorrection of the deformity, we preferred to perform a WALANT procedure, during which the patient could continually assist the surgeon in assessing the contracture release and improvement in finger movement. This patient returned to her computer job after the surgery.
Expected outcomes: The flexor pronator slide is an effective treatment option for ischemic contracture and contracture related to spastic cerebral palsy. In 1923, Page described the flexor pronator slide as a surgical option for the late management of compartment syndrome
Important tips: The treatment for a non-ischemic contracture of the wrist and fingers requires flexor pronator slide surgery to simultaneously correct the deformity without losing the resting muscle length and strength.Both fractional or Z-lengthening and flexor pronator slide surgery for such contractures yield straightforward contracture release. However, maximal preservation of the flexion power and muscle resting strength when releasing these contractures is possible only by shifting the flexor pronator muscles distally without affecting its resting length, which can be achieved by flexor pronator slide.A WALANT flexor pronator slide avoids overcorrection of the deformity because the patient is able to continually assist the surgeon in assessing the contracture release and improvement in finger movement.
Acronyms and abbreviations: FCU = flexor carpi ulnarisFCR = flexor carpi radialisWALANT = wide-awake local anesthesia with no tourniquetFPL = flexor pollicis longusDASH = Disabilities of the Arm, Shoulder and HandFDP = flexor digitorum profundusFDS = flexor digitorum superficialis.
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