PARALYTIC With and Treatment Special Reference

CLAW

HAND in Leprosy of Stiles INDIA

and Hospital, Vellore, South India

to Paralysis Transfer VELLORE,

College

by the Sublimis PAUL W. BRAND,

and Bunnell

Professor

of Orthopaedic

Surgery,

Christian

Medical

It is only finger nails are cat tribe like the They but This

occasionally the essential so much mainly fight

that

the

human and

hand the

is used pulps are

for

scratching. in the way.

In

this

action

the of the

instruments, on their on their

only

Animals

who depend mole, depend probably

claws in battle, and profundus muscles their intrinsic be lost. nails has brings

animals who use them to bring their claws muscles. The spread by that the and

for digging, into action. retraction, of the texture pulp. of our

could

and

dig without

not the effectiveness, In the human hand beautiful organ

of their claws would the function of the and

been

superseded knowledge

of discrimination

power

to our

environment transform When not much at the

; it is also the means by which we impose our will on the tools that subdue and the world for our pleasure. the intrinsic muscles of the human hand are paralysed, the power of the grasp is affected. There are four 2) the main power disabilities: of abduction 1) The and fingers cannot be opened is lost; out rather rather fully than than joints; adduction 3) in grasping

interphalangeal

an object, flexion begins at the terminal joints, closing on the palm; 4) the effective part of the finger becomes the pulp. The first two disabilities have received most of the functionally, however, the last two matter most.

the fingers the tip and attention

on themselves the nail (claw) literature.

in the

Considered

ANATOMY

The

anatomy

of intrinsic

muscle

action

has others. muscles

been We

fully

and

beautifully need to attempt flexors

analysed

by Bunnell here,

(1948), Kaplan (1953), Littler but the following points need Metacarpo-phalangealfoint--The

(1949) and emphasis. intrinsic

do not

an analysis

are the only

prime

of the metacarpotheir joints

phalangeal joints. The long flexor muscles first action is on the interphalangeal joints. have no prime flexor, but retain a powerful Interphalangeal action of the joints-In intrinsic the muscles normal acting hand through

do flex these joints, In intrinsic palsy the extensor, the extensor these the joints lateral may band,

but only secondarily; metacarpo-phalangeal digitorum.

be extended by the unaided which lies just dorsal to the extensors, have provided extensor. the

joint fulcrum. They may be extended also by the action of the long intrinsic muscles stabilise the metacarpo-phalangeal joint. In the absence of the intrinsic muscles the interphalangeal joints The attempt phalangeal the residual the resistance hyperextension all joints
618

no prime the

to joints

straighten the whole until their anterior

hand leads only to hyperextension of capsules limit the backward movement.

metacarpoAt this stage

power of the long extensors may partly extend the interphalangeal joints against of the overstretched long flexors. As soon as the metacarpo-phalangeal is relaxed in beginning to close the hand, the interphalangeal joints again lose power. This means The patient that unless therefore an object always is small closes enough
THE

extensor first.

his

hand

by

closing

his by the

terminal curve
SURGERY

to be grasped
JOURNAL OF BONE

of

AND

JOINT

PARALYTIC

CLAW

HAND

623

set up in front of him and is told to imitate the pictures on the chart. The photographer also demonstrates with his own hand the position he is to attempt. The six standard positions are: 1) Hold your hand quite straight at all joints. 2) Bend at the metacarpo-phalangeal

joints

and

straighten

all

interphalangeal

joints.

3)

Close

your

fist. index finger.

4)

Hold

up

your

thumb at right angles to your hand. 5) Pinch firmly between 6) Bring your thumb across your palm to the base of the little include a card with date and number.

finger The

and thumb. photographs

FIG.

Wooden stabilised

cylinders for assessing grasp index. It is important that the cylinders should not be fixed or for the patient. Otherwise he will use the cylinders as a fulcrum and extend his fingers passively.

RESULTS

It is not intelligible Excellent, we

easy

to group

together and

a mass failure.

of figures In this

of angles study we

so that have

they grouped

mean the

something results as

in terms of success Good, Fair and Poor.

The division is bound are trying to achieve.

to be arbitrary It also depends

and to depend upon our upon what one considers

own conception it possible

to

of what achieve.

For example, it could be argued that it is not reasonable to expect a tendon transfer to move a joint beyond its pre-operative passive range. Therefore, an excellent result would be to produce active movement through the whole range of pre-operative passive movement. This is reasonable, but our later results have this standard. We have chosen in this study to work excellent operation. types his hand mechanics 5) the unless We full range has been obtained, have analysed separately the
Results

sometimes to absolute

shown

better-than-excellent and not to call at

results

by

standards

a result of

however bad the results of operation to show: I) The his fist fully; 4) absence of all the

contracture on different of the

the time pre-operative

of hands.

have

been

analysed

ability

patient

to open

fully; 2) the ability of the patient of closing the hand (lumbrical patients own opinion; and 6) the

to close movement); summation

3) the restoration of the correct of abnormal lateral deviation; above in an overall impression.

THE

OPEN

HAND

ASSESSMENT

To hand joint.

score

excellent straight with 1 of the

a patient, no single standard

with degree diagrams

hand for

previously flexion photographs

clawed,

must

be able

to open

his this

absolutely In position

of residual

at the proximal he is allowed

interphalangeal to attempt

movement not allowed

VOL.

freely, but to extend

NO.

in position 2 and during the metacarpo-phalangeal

1958

measurement he has the joint while extending

restriction that he is the interphalangeal

40 B,

4,

NOVEMBER

624

P. W.

BRAND

111
6 A typical photographic record. Every patient has exactly this type of photographic record. Column 1, diagrams. Column 2, before operation. Column 3, after operation. Column 4, follow-up (two years later). Notice how the results improve with time. In row 2, illustrating metacarpo-phalangeal flexion with interphalangeal extension, the post-operative result might be classed as good. In the later follow-up it would be excellent if it were not for commencing intrinsic plus deformity. In row 3, illustrating the closed fist, the post-operative photograph shows some residual stiffness. A later follow-up shows a normal fist. In row 5, the later follow-up demonstrates the intrinsic plus deformity of the middle finger. This patient has also had an abductor replacement operation for his thumb. (Action of the thumb has not been considered in this publication, and the relevant photographs are therefore omitted.)
FIG.
THE JOURNAL OF BONE

LI

__________

__________

AND

JOINT

SURGERY

PARALYTIC

CLAW

HAND

625 title to excellence is lost to straighten the finger, function, and if the or if enough

joints-that finger bends there To score to appear along the

is, it has backwards ulnar good

to be a true lumbrical ( more than straight

action. The ) on attempting of the out finger enough

is significant

or radial the hand

deviation should open

on straightening. for all ordinary be 30 degrees flexed when measured than 150 degrees of opening at the

normal dorsum.

at rest. A normal It is uncommon

resting hand may to require more

interphalangeal joints in grasping the largest objects. To score good in our series a finger must open out to at least 150 degrees unassisted. A good finger may show perceptible but not gross terminal joint flexion, or it may show slight lateral deviation if it can be fully and normally straightened, but if it shows the slightest limitation of extension and has lateral

deviation, To extend if there plus. Any as poor. Table

then it is classed as fair. score fair a finger must to 120 degrees is a definite finger that without lateral does not lateral deviation, score

show

improvement

over

pre-operative finger into before to produce

figures,

and

must

deviation. or if it even

A fully straight bends backwards if it is better transfer than

scores only fair marked intrinsic operation a fully is classed open hand

fair

II is an analysis

of the success

of the sublimis

with straight, undeviated fingers: 73 per cent of fingers have scored a good or excellent result. This may be further analysed in an attempt to understand the causes of failure and to be able to predict the degree of probable success in any given case.

TABLE
OPEN HAND

II
ASSESSMENT

Fin g Index Middle Ring Little Average

er

Excellent
(per cent)

Good
(per cent) (per

Fair
cent) (per

Poor
cent)

(130) (134) (150)

(150)

29 32 36 26 31

48 43 39 38 42

21 23 21 30 24

2 2 4 6 3

Fingers that were stiff before operation limitation after operation than the mobile

showed fingers.

a much higher proportion of extension This is not surprising. Further analysis

shows that 76 per cent of all patients achieved a post-operative unassisted angle that was as good as, or better than, the pre-operative assisted angle. Ninety per cent showed a postoperative angle that was within 20 degrees of the pre-operative assisted angle. The failures (10 per cent) as judged by this standard were further studied, and in an unselected group of five cases in which there was a post-operative contracture more gross than the pre-operative assisted sublimis angle exploration was carried out. In every case it was found that the stumps tendons left behind in the flexor sheath had grown across the interphalangeal of the joint

and attached themselves to the sheath, proximal bowstring across the joint, preventing extension. joint could be extended. This complication We have found that it has occurred less sublimis
VOL.

to the joint. They thus formed a sort of On cutting and excising the bowstring the

has been predicted by Bunnell in his writings. frequently since we have taken care to divide the

exactly
NO.

at its insertion.
4,
NOVEMBER

40 B,

1958

626 Apart full extension from this by this complication, operation

P. W.

BRAND

it appears is the presence

that

really

the

only

cause contracture

of failure

to produce

of pre-operative

or pre-operative

defect in the continuity in lepromatous cases,

of the dorsal expansion (Fig. 7). This later defect is sometimes present and also occurs as a result of old injury or infection on the dorsum of

-J
FIG.

_
7-Incomplete
This

Figure

7 extension
patient

FIG.

of the interphalangeal
complication.

joints
Figure

in a hand

contractures.

is a common

8-Imperfect

8 which had pre-operative closure of the fist after

operation the
angle

in a

who before be assumed

operation

had ulnar when

The

profundus the
defect

weakness. pre-operative
must be

finger.
is very

Such will Table

a defect
from

can
the

to be present
angle.

assisted
repaired or the

different

contracture

operation In Hypermobile

be a failure. III we have implies a good

grouped finger

our with

cases joints
TABLE

according that
III
BEFORE OPERATION

to bend

their

pre-operative slightly

mobility. on passive

will

backwards

STATE

OF

FINGERS

Contracted Hypermobile
Finger (per cent)

Mobile
(per cent)

Defective
(per

cent)
(per

Mild cent)

Marked (per cent)

Index (130)
Middle Ring Little Average (134) (150) (150)

8
14 12 4 9

44
32 30 34 35

22
34 31 35 31

17
10 17 17 15

9
10 10 10 10

pressure.

Such

fingers

are

very

common

in India

where

slim,

mobile

fingers

are

highly

prized.

Finger supple,
group

gymnastics fluid finger

includes fingers

form a common part of Indian classical movements which most westerners find
that could be fully straightened passively.
THE

dancing. impossible
The
JOURNAL

This dancing demands to imitate. The mobile defective group comprised

OF BONE AND JOINT SURGERY

PARALYTIC

CLAW

HAND

627

FIG. 9 FIG. 10 Figure 9-Radial deviation of the fingers. An occasional complication after the sublimis has been sutured to the radial side of the finger. Figure 10-Terminal joint flexion. This occurs in almost every sublimis replacement operation after a year or two.

I FIG. 11 FIG. 12 Figure 11-Moderate degree of intrinsic plus. Hyperextension of the proximal interphalangeal joint and flexion of the terminal joint. This complication is fairly common in mobile hands. Figure 12-Severe degree of intrinsic plus. This hand in the first year after operation was classed as an excellent result. In the following two years it has developed an ugly and disabling deformity. This degree of intrinsic plus is uncommon.

VOL.

40 B,

NO.

4,

NOVEMBER

1958

628 fingers defect less

P.

W.

BRAND

with a full range of passive movement but in the dorsal expansion. A mild contracture than 30 degrees.

with a failure was classed one of more

in the assisted angle-that is, as a lack of passive extension than 30 degrees. and its management here. The name hand of an ischaemic are joint, finger (as in as

A marked
intrinsic

contracture
plus

was

Complications-The

deserves

separate plus

consideration, was first used

deformity but a few

is a very interesting one, points must be mentioned the effect on the

intrinsic

by Bunnell The

to describe

contracture follows: joint even

of the intrinsic muscles. 1) the proximal interphalangealjoint

features of the is hyperextended.

condition (Figs. 10 to 12) 2) Ifthe metacarpo-phalangeal interphalangeal normal

is held in extension it becomes passively. This is the intrinsic If a sublimis tendon is removed

impossible to flex the proximal plus sign. from its insertion in an otherwise there and

cases where it is to be used as an abductor of the thumb), marked by a tendency to flexion of the terminal joint proximal interphalangeal joint. plus and the interphalangeal

often follows a slight a slight hyperextension developed with the

deformity at the intrinsic metacarpoinsertion, becomes an

This joints

deformity never goes on to a fully can be fully flexed passively, even the sublimis muscle that is transferred was previously no prime flexor. of the sublimis,

phalangeal joints extended. If, however, as for intrinsic palsy, a very powerful

to the lumbrical a flexor now

extensor of the same joint and leaves that joint with takes over the flexor function, but is now an opponent acted synergistically. the Stiles-Bunnell even though Re-education operation is very action of the difficult. sublimis In many If the

The profundus muscle with which it previously after occurs, sublimis

and profundus to act reciprocally cases true reciprocal action never tendon transfer is made with the

lumbrical

is achieved.

at neutral tension the operation is a failure. If the sublimis is sutured at higher tension than the profundus the operation is a success in that the claw hand is corrected but there seems to be a continued tonus of the sublimis as a background to all finger movement. During closure of the fingers the profundus seems to have to overcome the resistance of the sublimis at the
proximal interphalangeal joint before that joint will bend. It succeeds because the mechanical

advantage of the flexor tendons at that joint is greater than that of the lateral band. If the finger is a stout and stable one this muscle conflict does not seem to matter, and if there is some degree of stiffness in the clawed position there may be definite advantage in this continuous corrective pull by a powerful muscle. In a flexible, mobile finger, however, we regularly see a year-by-year tendency to develop hyperextension of the proximal interphalangeal joint and flexion passive movement to flex extended. the of the terminal joint. If the patient keeps his fingers he may avoid the second feature of intrinsic joint of such the even regular intrinsic mobile by exercises and plus, the inability picture far joints are may be than

interphalangeal In the absence functionally, it has against

passively when the metacarpo-phalangeal movements, the full intrinsic plus plus hand is fairly useful, and

developed. Considered the claw especially recognised seen in

better

hand that in pinch the early third

replaced. the thumb

It is ugly, however, and a definite source of weakness, (Fig. 12). The seriousness of this deformity was not noticeable and most during the really mobile first year. The hands develop worst cases are at least a mild

because it is seldom and fourth years,

degree of it after a few years. The deformity is correctable that Littlers operation is satisfactory for these cases, but a tenodesis of the profundus tendon in the middle segment joint nearly extended, or else the deformity in the contracture cases for which Littlers Comment-As should carry completely the claw this complication the best prognosis, occurs we have will recur. operation

to some extent. We have found it needs to be supplemented by of the finger, with the terminal not be necessary those that operation

(This tenodesis would was first designed.)

in the best and most felt it right to abandon

mobile hands and the sublimis transfer is probably corrective,

OF BONE

for mobile hands hand with contracture

during the past year. because it provides

The operation a very powerful

THE JOURNAL

still the best for but for mobile

AND JOINT SURGERY

PARALYTIC

CLAW

HAND

629 operation Neither developed of these

hands unit. requires deformity. We

it should We now the are

be displaced use free grafts

by Fowlers from the extensor

operation carpi

or radialis

by a new brevis.

in this operations plus as the

removal of the sublimis An analysis of the results in a position operation The high to say,

and neither of them is followed by intrinsic of these operations will be published shortly. however, that Fowlers operation is not as good

Stiles-Bunnell after operation. under early action fairly

for the stiff hand, and it is sometimes disappointing results improve with time, however, especially if the (enough to make metacarpo-phalangeal provide digiti extension adequate minimi.

for a few months tendon is sutured difficult in the communis

tension

post-operative for the little

phase), and if care is taken to finger, after removal of the extensor

extensor

Our own operation tendon is passed from transverse metacarpal carpi The

uses the same principle as the Fowlers procedure, in that the new the dorsum of the hand through the interosseous space, anterior to the ligament and sutured to the lumbrical insertion. We use the extensor and extend its tendon with a four-tailed easily develop a natural synergism with of the hand improves to normal movements

radialis brevis as the motor muscle action of a wrist extensor can very In this operation, the most also, so far perfect

free graft. lumbrical hand followed functions these

movement. reconstructions

the action

with finger

time. action

In all our have are

approximations and an

this new procedure. Lateral deviation (Fig. of the intrinsic muscles.

9)-Abduction To produce

adduction excellent

of the fingers should perhaps

result

one

restore

movements also. In Bunnells account of his operation he suggested that the sublimis tendons might be split so that each tendon is attached only to the radial, or only to the ulnar side of adjacent fingers. In this way lateral movement might be restored. It was an ingenious suggestion, but he did not state whether he had ever actually achieved this object. We tried this method a few times some years ago and gave it up because abduction and adduction movements were not obtained. As we looked at the operative field and saw split tendon-slips criss-crossing each other in the palm without intervening soft tissue, it seemed improbable that each slip would move independently of the others. It may be that re-education was at fault. We would be glad to hear of the experience of others. Since 1951 we have been transferring only one sublimis slip to each finger and attaching it to the radial side of the dorsal expansion. We are satisfied with this method for these reasons: 1) It obviates the need for four incisions tendon another finger on which the can fingers be used and for shortens restoring operating opposition finger in case and tourniquet and abduction of profundus time; 2) it saves thumb; a sublimis 3) it allows or in the index to the weakness,

sublimis to strengthen

to be left in the little its power of pinch.

On reviewing our cases on a long-term basis we find that 19 per cent show a significant radial deviation and 4 per cent deviate enough to give a deformed appearance. The reason we first chose the radial-side insertion was that it seemed reasonable to have the index finger stabilised on the radial-side to resist the tendency of the thumb to push it medially in pinching. muscle that It has often been stressed that transfer to the index finger finger. We have found palsy tip that is that of the one if the first dorsal interosseous muscle is weak is needed to reinforce the pinch by restoring disabilities in hands that have been separate middle a radial-side abduction to

of the

reconstructed from fingers.

after

ulnar-median The anaesthetic

the index and middle thumb slips in between index slips

fingers tend to the index and

each other. We have side of the This has thumb, The

therefore recently index finger and kept index effect

VOL.

begun all the middle

to insert the other sublimis fingers

finger sublimis into the radial and made a very

transfer into the ulnar side of the other fingers. good tripod pinch between

the index

and

together

and long fingers. It also gives of this change on the strength

40 B,
NO.

a much better appearance to the hand of the pinch will be analysed in a later

as a whole. communication.

4,

NOVEMBER

1958

630 The the results change in insertion is too recent of the

P. W.

BRAND

to affect transferred
FIST

the

results

in this

study,

which

represents

of radial-side

insertion

tendon.
ANALYSIS

CLOSED

Most patients with when profundus weakness phalanges (Fig. 8). If the Sometimes from its usual weakness An base of finger. hold a but the the palm fingers it may place. cannot be due This

claw hand can close in the ring and little

their fingers

fingers makes

fully before operation it difficult to flex the to

except terminal

close after operation the failure must be due to loss of flexion power owing to the transference is true only implies of those a tight cases fist, in which with the there finger

the operation. of the sublimis profundus into the

is an additional tips fully tucked

in two fingers. excellent category

each finger. A knitting needle must be grasped and held firmly in the curve of the A good assessment means that the finger closes fully but not tightly enough to needle in its curve. Fair means that a gap is visible between base of finger and tip tip meets the palm farther down. Poor means that the finger tip does not meet (Table IV).
TABLE
CLOSED

IV
FIST

Excellent
(per cent)

Good
(per cent) (per

Fair
cent)

Poor
(per cent) 5

39

33

23

MECHANISM

OF

CLOSING

This as follows: (even joints begin

is a vitally

important

assessment from the

so far as function position flex the of finger flexion

is concerned. maximal straightness first at the before the

Results of

were that

graded finger joints

Excellent-Starting

if that is not excellent), and can complete its to flex.

the patient can metacarpo-phalangeal

metacarpo-phalangeal interphalangeal

TABLE
MECHANISM OF

V
CLOSING

Excellent
(per cent)

Good
(per cent) (per

Fair
cent) (per

Poor
cent)

A finger movement
beginning

that is more

cannot useful

be fully than

straightened finger flexion flexion

but that begins begins

which closes just and

closes

with

the

correct joints

sequence first when flexion metacarpomechanism to reach The results

of

a straight

its interphalangeal before metacarpo-phalangeal along

to grasp.

Good-One is complete. Fair-One

in which in which

interphalangeal interphalangeal

continues

with it is the a failure

phalangeal flexion. Fair is quite used in the normal hand for grasping defined standard after operation.
Poor-Metacarpo-phalangeal flexion

satisfactory for most activity. In fact, small objects. However, it represents

is delayed

behind

interphalangeal

flexion.

are

shown

in Table

V.
THE JOURNAL OF BONE AND JOINT SURGERY

PARALYTIC

CLAW

HAND

631 gives a very recorded good mechanism the patient of

It closing.

will

be

noticed

that

the of

Stiles-Bunnell these hands

procedure which we have

A defect

in some

not

is that

cannot close his interphalangeal to (latent form of intrinsic normal situation. This defect

joints before the metacarpo-phalangeal plus ). It is associated with the loss is noticed in typing and piano playing.

joints even if he wants of the sublimis from its

DISCUSSION

it has

In reviewing been highly

the statistics successful.

of the results Three-quarters

of the sublimis of all cases have

transfer operation given an excellent

one may feel or good result had than other

considered pre-operative 90 per cent

in terms of the open hand, contracture. The correct of cases. One may feel that

irrespective mechanism these figures

of the fact that many patients have of closing has been restored in more would be hard to better with any

operation. However, have seen after feel satisfied.

as we look operation

back on these 1 50 cases and also on the but which we were not able to re-examine

many other hands that we for this study, we do not

The reason for the remarkable success of the operation is also the source of its greatest weakness. A very powerful muscle, with a big amplitude, like the sublimis digitorum, is used to do the work of a very small muscle, the lumbrical, which has a short range of action. The sublimis transfer, therefore, nearly always achieves its purpose. As time goes on, however, it often more than achieves it and produces secondary deformities. Conversely, the absence of the sublimis from its normal situation produces a weakness in pinch and to a lesser extent in grasp for the that is significant. We feel that we are now use of the Stiles-Bunnell operation. cases in which there is a significant contracture of choice. from in a position contracture to lay down at the proximal operation, produce joints definite indications

In all

interphalangeal the results sublimis that are In stable transfer avoids this graft type from

joint and in which the transfer is the operation better hands than with could no range

cannot be fully overcome before Its powerful corrective effect may the give would the limited pre-operative of the interphalangeal a good result give a stronger sublimis transfer operation range

be predicted of passive

of movement. a sublimis

hyperextension

under moderate tension will usually the removal of the sublimis tendon For hypermobile, flexible fingers of hand better results will the extensor carpi radialis

although an operation which and more useful hand. is contra-indicated. or by the four-tailed For

be achieved by Fowlers brevis referred to earlier.

SUMMARY 1. The intrinsic paralysis that occurs in leprosy years. has been treated by the sublimis transfer upon, of Stiles and Bunnell for the past nine and 150 patients selected geographically Since 1951 300 have been followed hands have been up in this study. operated

2. The patients have been assessed by a standard method involving: 1) Measurement of range of movement of the interphalangeal joint (unassisted movement, assisted active movement and passive movement); 2) grasp index; and 3) photographs of each hand in six standard positions. 3. Assessment of the open hand-The Stiles-Bunnell procedure is effective in achieving a fully open hand: operation is that plus hand. 4. Assessment mechanism joints flex
VOL.

73 per cent it sometimes of sequence

of the fingers hyperextends of joint flexion-The in 93 per joints.

scored good or excellent the interphalangeal joint, Stiles-Bunnell cent of cases-that operation is, the

results. producing

A defect in the an intrinsic satisfactory

restores

of closure before the

NO.

of the hand interphalangeal

1958

metacarpo-phalangeal

40 B

B,

4,

NOVEMBER

632 5. The closure after closedfist assessment-About of the fist after operation.

P. W.

BRAND

30 per In 5 per

cent cent

of patients had some defect of cases the fingers did not

in the reach

complete the palm

operation.

6. Complications-The intrinsic hands. This is a late complication by Littlers operation together with Lateral deviation of fingers due to

plus defect is commonest in the best and most mobile which gets worse in succeeding years. It can be corrected a profundus tenodesis in the middle segment of the finger. radial-side attachment of the transferred tendon can be

avoided by ulnar-side attachment of the tendon used for the index finger. of the sublimis stump in the flexor sheath may be avoided by division of the insertion. Weakness of grasp and pinch from loss of sublimis may be avoided one or two in position.
7.

Bowstringing sublimis at its by using only should be left

sublimis

tendons
that the

split
sublimis

into

several
transfer

strands.
of Stiles

The
and

index
Bunnell

finger

sublimis
powerful

It is concluded

is a very

corrective

of intrinsic paralysis of the fingers. Its chief defect is that it is too the opposite deformity. For this reason the use of this operation fingers in which there is some limitation of passive extension. For operation should be selected which does not remove the sublimis from

powerful and produces should be restricted to fully mobile fingers an its normal position.

Most of these operations have been performed by a series of assistants and trainees in hand surgery. I wish to thank them for the enthusiasm and meticulous care in record keeping which has made this study possible. I also wish to record my appreciation of the sterling work of our records clerk, Mr Furness, who has travelled many miles in seeking out changed addresses. I would like to thank Mr Guy Pulvertaft for his helpful criticism of
this article.

REFERENCES

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