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High Median Nerve Lesions

- See:
      - Entrapment of Median nerve  at the Elbow and Forearm:
      - Combined Injuries of the Median and Ulnar Nerves:
      - Median Nerve
      - Nerve Repair

- Deficit:
    - loss of pronation of forearm, wrist flexors, index & long finger flexion;
    - loss of thumb flexion:
    - long term contractures:
          - adduction contractures can be prevented w/ oppenens splint;
          - fixed supination deformity may develop despite bracing (due to the deforming forces of the EPL and adductor;

- Prerequisites for Tendon Transfer:
    - absence of web space contracture and supination contracture of thumb;
    - tendon transfer for the extrinsic muscles innervated by median nerve may be delayed, anticipating return of long flexor f(x)

- Accessory Transfers in High Median Nerve Lesions:
    - FPL is reenforced by Brachioradialis ;
    - FDP of index & long fingers are reinforced by transfer of ECRL ;
    - FDP of ring and small fingers are anchored to FDP of index and middle fingers using side to side repair;
    - opponensplasty:
           - w/ median nerve injury several inches above the wrist, consider early transfer;
           - treatment options:
                 - EIP transfered to APB (Burkhalter, et al);
                 - opponens & APB  are reinfored by paralyzed FDS around distal end of FCU - ECU used as a motor;
                 - paralyzed FDS of ring finger is isolated at wrist and at base of digit & delivered at at wrist;
                 - distal FCU tendon is detached & anchored to ECU tendon, thereby forming indirect dynamic pulley;
                 - paralyzed FDS is then passed thru this pulley & into proximal phalanx of thumb, similar to a routine opponens transfer;
                 - proximal end of FCU is sutured to paralyzed FDS;
           - accessory procedures include either arthrodesis of the MP joint or the distal IP joint of the thumb, depending of the stability

Early Tendon Transfers in Upper Extremity Peripheral Nerve Injury.

Restoration of strong opposition after median-nerve or brachial plexus paralysis.

Abductor digiti quinti opponensplasty.