13 months after fronlifting               next 7 days after blepharoplasty

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   Before                                                After

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   Before                                                  After

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Floating thumb

Triphalangeal thumb

The 4th day after surgery

One year after reconstruction

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M.de Quervain

Needle aponeurotomy

Aponeurectomy

One year after abdominoplasty with liposuction

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One year after surgery

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3 years after surgery

Two years after augmentation – 290ml

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She was a beautiful young women depressed because of her left hand deformation. The spastic elbow flexion contracture with severe wrist deformity.

trying to wrist extension                      grip before reconstruction

A good grip after complex reconstruction

Full range of motion in the elbow, good supination, wrist extension and palm opening

She was married several years after reconstruction. Now she has a son and she is able to take care of him. She is happy.

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A 42years old man with cerebral palsy – the left hemiparesis

There are limited the elbow extension, the forearm supination and the grip.

The successful result two years after reconstruction

Just after one surgery there is better the hand grip . The patient is very satisfient and do not want to reconstruct the supination.

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A 19year old manMuž 19 let

Cerebral palsy with quadriplegia, the left upper extremity is worse

The elbow extension is limited  and  we can see involuntary contract to flexion with use of the hand. This man is not able to turn his forearm to look at his palm or to touch his face. There is an absence of active wrist extension and the “swan-neck deformity” of the fingers with  a functional problem during grip – difficulty in iniciating fingers flexion.

The quality of the grip is worse on the left side. The wrist fall down during grip of the subject and the elbow tend to flexion.

Při ovládání vozíku levé ruka pomáhá jen velmi omezeně.

We started to reconstruct in the elbow.

Tím jsme nejen uvolnili velké ohnutí lokte, ale zlepšili jsme i postavení předloktí , zápěstí a prstů.  Pacient se poprvé v životě může levou rukou dotknout obličeje, podívá se do dlaně a má velkou radost, že může pohladit maminku po tváři. Video je ze 13. dne po operaci

5 weeks after surgery the elbow is better

lépe vůlí ovládá pohyb v lokti, který je volnější, nelze jej však plně natáhnout pro velké zkrácení hlavně cév a nervů. Toto natažení je přesto výhodou. Postavení v zápěstí zatím podporujeme ortézou a plánujeme do budoucna stabilizovat při další operaci.

2 months after the first surgery the hand function is better

 je zřejmé omezení křečí v lokti, ale zůstávají v zápěstí, kde jsme zatím neoperovali. Přesto pacient díky obrovskému nasazení při rehabilitaci dokáže pracovat s tímto omezením a velmi se snaží o uvolnění spasmů.  Funkce levé ruky se již nyní podstatně zlepšila.

   Díky částečnému natočení levého předloktí pacient může pracovat oběma rukama a vyrobit i tuto krásnou dekoraci – závěs na zeď se srdíčkem. Je to obrovská radost pro všechny kolem.

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A man 20years old

The permanent position of both upper limbs in elbow and wrist flexion, he use his right hand to grip and his left hand just to subjects support with wrist dorsum. He can drink in this way.

After surgery – this man has full range of motion in his elbow – he can fully extend and touch the brake of his wheel chair for the first time in his life. He did not loose the full elbow flexion.

We performed the elbow release and also the grip reconstruction. This boy is able to grip and grasp the subject, he can eat banana…..

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17letý chlapec s ochrnutím všech 4 končetin a horšími deformitami na levé horní končetině

Stav před operacemi – levý loket se často ve stresu samovolně ohýbá, při soustředění jej chlapec nedokáže natáhnout tak jako loket pravý. Pravé zápěstí je trvale ohnuté, prsty mají malý rozsah pohybu. Pro výrazně omezenou schopnost úchopu pacient levou ruku často vyřazuje.

Trvalý výsledek po 2 operacích – při první bylo zlepšeno postavení ruky a zápěstí, při druhé byla uvolněna kontraktura lokte v ohnutí – loket pacient dokáže plně natáhnout a použít tak ruku při jízdě na vozíku, dokáže si dosáhnout pro předměty v prostoru, ruka může uchopovat a pomáhat v běžné denní činnosti.

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20letý muž

na invalidním vozíku s těžkými deformitami obou horních končetin – horšími vpravo. Díky vysoké inteligenci velmi dobře spolupracoval. Před operací jsme se snažili stav vylepšit dlahováním, ale marně.

Před operací je omezené natažení loktů, otočení předloktí, zvednutí zápěstí a prstů a tím je omezený úchop

After blepharoplasty

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Before surgery

After surgery

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A year after reconstruction elbow extension (release flexion contracture) and the grip reconstruction

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A 31years-old woman after brain surgery 20 years ago

The left hand function before surgery

The range of motion before

The result one year after surgery

The stabile result four years after reconstruction

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A 47 years old woman – car accident – comatose for 11 months – quadruparesis

Severe upper arm deformities – painful, no grasp, minimal range of motion

finger extension                                          finger flexion

The right hand mostly in the rest position – extreme wrist flexion – painful

The left hand grasp with severe wrist flexion and claw finger deformity

The first surgery – release elbow flexion contracture.

Better range of motion 9 month after surgery

The second surgery – just on soft tissues

Better wrist position, grasp is possible, no pain – 6 weeks after surgery

The finger stiffeness on the left hand

Better finfers position and grasp 3 months after surgery

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A 50-years old man with left handspasticity after brainstroke – 35 years ago – it means in his age of 15

No function  of his left hand

The range of motion before surgery

One year after the first stage – release of the elbow flexion contracture

The range of motion is better in the elbow, distally as well as in the shoulder

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The attempt to the wrist and fingers extension

Severe deformities – elbow, wrist and fingers flexion

contracture and forearm pronation contracture

Before surgery we consider not only the severity of deformities , but also age, IQ, motivation  and other neurologic diseases. A very important factor is family support and complex treatment.

In 70% of cases I first reconstruct the grip and the supination is also better in this phases. At the second stage I release the elbow flexion contracture and finally I correct swan-neck deformities. In 30% I start in the elbow flexion contracture with the proximal release of wrist and fingers flexors and the grip is reconstructed in the second phases.

So far I have operated on 283 patients, most of them teenagers with cerebral palsy. Similar deformities can be seen in patients after brain stroke, brain injury, brain surgery, encephalitis or with congenital anomaly of the brain.

Treatment

Preoperative therapy should be aimed at maintaining function and preventing contracture. Exercises and splinting are important and adaptive devices can be very useful to enable patients to independently perform daily activities. After conservative treatment we make a decision for surgery. 

No single method is universally successfull – we have always combined surgical methods. Operative procedures are directed at  release of skin contractures and spastic muscles as well as at augmentation of weak muscles and sometimes stabilization of MCP joint of the thumb.

I always use turniket control with the brachial block  in combination with  general anaesthesia or sedation and all sutures are absorbable to minimize stress after surgery .

After surgery we use static splinting to preserve new position in each patient for 2 or 4 weeks. After that removable splints and often dynamic splints are applied and we start exercises early or later – it depends on the type of reconstruction. The most important is occupational therapy after surgery.

All of our patients are satisfied because they considered the procedure was beneficial to the quality of their life.

One of the greatest benefit is less or none involutary movement to elbow flexion. Decrease of spasticity allows voluntary movements withouth involuntary elbow flexion which has psychological impact. Patients can willingly grasp and also place an object on the table or elsewhere in space.

Improvement of the forearm supination allows to hold a subject, better hygiene or to get dressed. 

Improvement of the wrist and fingers extension makes possible a stable grip position.  Patients can grasp small and also larger objects, they can lean against the table by their palm.

He is able to extend his wrist, but extension of his fingers is not possible, fingers are spastic.  With his wrist flexed his fingers are flexed too, and he has no ability to open his hand. That is why his grip is limited before reconstruction.

Immediately after surgical reconstruction of hand function on his left side

Prevention and treatment of edema and training after surgery – the 17th day

The result 6 weeks after grip reconstruction

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A 65years-old woman – C6/7 ischemic lesion

The funcion of both hands before surgery

Training in the splint after surgery

The funcion of both hands  6 weeks  after the left hand reconstruction and training the right hand MCP joints

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Cubital tunnel syndrome

Guyon’s canal syndrome

Pronator syndrome

Supinator syndrome