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By T. Berek. Duke University. 2017.

Another option similar to the slide is excision of the proximal muscle fascia with detaching the muscle from the bone purchase 10 mg alavert with mastercard. With the limited con- trol present in spastic hands alavert 10mg mastercard, individual tendon Z-lengthening is more com- plicated and provides little gain. Transfers of flexor digitorum superficialis to flexor digitorum profundus to create a single motor unit for the fingers seem to also provide little benefit over simpler lengthening procedures. Most of the function of a hemiplegic hand is for gross finger grasp and thumb key pinch, both ac- tivities requiring power more than fine control. Complications of Treatment The major complication is overlengthening, leaving the fingers with no power in the range where individuals need power for function. This loss of function usually recovers over several years, but only partially. We have not had any individuals with such severe weakness that they desired an operative attempt to correct the overlengthening. Some individuals want ad- ditional lengthening if there is still too much flexion. Those who want addi- tional lengthening are mainly individuals in whom a decision was initially made that the finger flexors need lengthening but no or very minimal length- ening was performed. The other complication is leaving an imbalance with an excessively strong flexor digitorum profundus and extensor digitorum longus causing the swan neck deformity to develop. This deformity can be extremely dis- abling because it locks the fingers so that they cannot be used. Treatment indicated is described in the next section. Finger Swan Neck Tightening of the finger flexors secondary to the wrist flexion deformity plus spasticity of the intrinsic muscles and the extensor digitorum longus results in hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint, which causes the swan neck deformity. The volar cap- sule of the proximal interphalangeal joint becomes stretched out secondarily.

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She had no previous surgeries and currently received no physical therapy order alavert 10 mg fast delivery. She had grown rapidly in the past 2 years purchase 10mg alavert amex, and in the past year, as she had spent more time in the wheelchair, she had gained a lot of weight. A physical examination demon- strated hip abduction to 20°, almost symmetric hip rota- tion with 40° internal and 30° external rotation; popliteal angles were 70°, the knees had 10° fixed knee flexion con- tractures, and the feet had severely fixed planovalgus de- formities. The kinematics showed high knee flexion at foot contact and decreased knee flexion in swing phase, with a severely reduced knee range of motion (Figure C7. The pedobarograph showed severe planovalgus with ex- ternal foot progression of 34° on the right and 19° on the left (Figure C7. Most weight bearing was in the medial midfoot (Figure C7. The main cause of the loss of ambulation appeared to be the crouch gait caused Figure C7. Gait 365 formities, which prevented the foot from functioning as valgus with a triple arthrodesis both stabilized the foot a rigid moment arm, with the majority of the weight bear- and corrected the malalignment. Hamstrings were length- ing on the medial midfoot (Figure C7. This lever arm ened, and after a 1-year rehabilitation period, she was disease needed to be corrected by stabilizing the foot so again doing most of her ambulation as a community am- it was a stiff and stable structure, and it had to be aligned bulator using crutches. The foot pressure showed a dra- with the axis of the knee joint. Correction of the plano- matic improvement although there was still more weight Figure C7. The kinematics demonstrate a good indicating some mild residual valgus (Figure C7. Elizabeth would have become a perma- cating continued weakness in the gastrocsoleus (Figures nent wheelchair user if her feet had not been corrected.

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