So let's just move on to the thumb. So I think it's the same kind of thing. It's all about balance. So we want to release what's tight, whether that's the adductor, the short or long flexor, and then augment the extensor abductors. And again, we can stabilize the joints. So it's all about this kind of balance. So we have poor volitional control of our extensors and abductors. We have spastic overpull of our flexors and adductors. And we're trying to get that better balance. So we want to release the contractures. And we can either do that through a Z-plasty with the release of the adductor at its insertion. But then you lose its function. So I would not do that for the higher level patient. For the higher level patient, I would do the adductor release off the origin, leave its nerve supply. And you can either take the transverse head, the transverse and the oblique head. Ooh, there's our next act. And you can include the flexor. And then you want to augment the weak structures. So again, I'll show this on the cadaver where we'll bring the extensor. Again, if it's around Lister's tubercle, it's going to be a secondary adductor. And if you bring it down into the first compartment, or even if it's not in the first compartment, it just has to not be dorsal to the axis of the wrist, then it's going to be an adductor. And then you can also stabilize the joint. So let me just show you that. All right, so this is our ECRB, and this is our FCU, and that's our transfer there. So I'm just going to move that out of the way. And so we'll see here in the dissection, we're looking for Lister's tubercle. So here's Lister's tubercle right here. Here's our EPL tendon right here. So we're going to use the same incision and dissect out our EPL tendon. And again, you can open up that compartment a little bit if you need to dissect it free from some of the surrounding adhesions. A lot of these spastic kids have a ton of adhesions because they don't have normal tendon excursion. Then we're going to come down here, and we're going to augment our extensor. If we have a MCP hyperextension deformity, which this cadaver does not, then you don't want to put it into the proximal phalanx because that'll just augment your MCP hyperextension deformity. Then you want to take your EPL and put it into the metacarpal neck. So here's our EPL tendon. We're going to harvest it just distal to our MP joint. Maybe we can turn that a little bit so you can see. So here's EPB right here. Here's EPL. So I've harvested, or maybe I should say Doug harvested for me, the EPL tendon. So we want to take that down so we release our extensor mechanism. Then we are going to come back up to our wrist incision, and we're going to harvest that like that. I usually put a holding stitch in here. I use a 90-90-90 stitch so I have a nice stitch in the end so I can hold it. Then I've done a subcutaneous tunnel here. So we can see here there's a tunnel, and this is going to come bowler to the axis of the wrist because, again, you want to have this augment extension abduction, and when it sits and the vector of pull is around lister tubercle, it's going to be ulnar to the metacarpal, and that's going to have a secondary AD duction, and we want to bring it down here where we have AB duction. So we'll put that through our vessel loop here and then deliver it through that incision. And, again, here I would try to not break our vessel loop. Make sure we have a big. We did not have a tendon passer as one of our instruments of choice here today. So we just want to make sure we have a good-sized incision, but you want to make this so it has a straight vector. So I would come back up here and free this up from the retinaculum so you can see the muscle belly as it comes off, then do a straight line of pull here. It doesn't have to come through the actual extensor retinaculum. Did you get it? I don't think it's going to get through. Oh, shoot. Okay. Well, then we'll open it up. Do we have a knife? Like this? Yeah. Oh, yeah. So then we'll open it up here. And I've sometimes used extensor retinaculum and made a little pulley right here if I feel like it subluxes and it doesn't stay in a straight line of pull. Obviously, we want to be careful of our radial sensory nerve in this spot. Is this on? Yeah, it's still there. Do you see it? It's really stuck. So here it is right here so here it is right here and There it is on the loop. So you can make a little loop here of extensor retinaculum to keep this so that it's bowler and then Where's it getting hung up There it is Mosquito Pull There we go, there we go All right So I think we had a little adhesion there So then your choices for insetting this as you can inset it right here on your metacarpal head And I would do this tight. I would do this pretty tight. I've used suture anchors I've used a tendon braider and just braid it through or if you need Full extension of the entire digit you can come right back out to its previous stump And now this is longer because it has a shorter line and you can do a weave right into itself right there Do we have questions about the EPL rerouting All right, I'm just gonna pretty briefly just show the incisions for the Metav and Two-minutes, how are we doing time-wise? Good are you heckling? He's heckling All right, so your adductor release is going to be done right here and You're gonna just come right down That was missed it pretty good That's why you're supposed to draw the line after your finished closure So you're gonna come through your palmar fascia and then you're gonna find your lumbar co with your digital neurovascular bundle on it and then just deep to that you're gonna find your adductor originating on your third metacarpal and Inserting and it's kind of a deep dark structure down here It's gonna be right there if you can see down in there And that's going to be the transverse head. I Don't think you're gonna be able to see it very well, but you can feel the metacarpal and then even just run a Freer down the radial side of the third metacarpal and if you come back and take off the flexor brevis as well You want to find the recurrent median nerve? You don't want to just go slashing through

balance

thumb injuries

tight muscles

extensor muscles

abductor muscles