An Alternative to an Artificial Hand December, 1964 P H Y S I O T H E R A P Y Page 13 By M IS S J. M c G U I R E , M .C . S . P . , J a n e F u r s e H o s p i t a l , S e k h u k h u n i l a n d , T r a n s v a a l F o r th e A fr ic a n pa ti en t w h o has to h av e a n a m p u t a t i o n o f h a n d , a n artificial li m b is n ot al wa ys p ra c ti c a b le , es p ec i­ ally in th e R ese rv e area . A useful a l t e r n a t i v e has be e n fo u n d in th e K iiik e n b e r g 's o peration. T h i s divid es th e r a d i u s a n d ulna i n to s e p a r a te a n d m o bi le “j a w s " a n d so p ro vi de s an effective pin cer-lik e grip. W it h this in view, resisted m o v e m e n t s wer e en c o u r a g e d fo r th e e l b o w a n d s h o u l d e r o f th e righ t a r m , a n d p a r t i c u l a r a t t e n t i o n was paid to p r o a n d s u p i n a t i o n o f th e fo re a r m . A t th e s a m e time, I tried to o b t a i n w h a t m o v e m e n t was possi bl e in th e left h a n d , d o i n g th e exercises in itially in a sali ne b a th . I p a d d e d a s p o o n h a n d l e , a n d J a c o b u s g ri p p ed it b et w e en t h u m b a n d first m e t a c a r p e l - p h a l a n g e a l j o in t, a n d was th u s ab le to feed h im se lf a ga in. C ase H isto ry Jacob us, an A fr ic a n aged 35, suffered sev ere b u r n s o f both h a n d s d u r i n g a n ep il ep tic fit in A p r il . 1963. His right hand had been a m p u t a t e d 5 cm . a b o v e th e w ri st- jo in t, an d the left han d had been severely m a i m e d . H e was first seen here six m o n t h s later, w he n he w as c o m p l a i n i n g o f a p ar ti a l skin b r e a kd o w n o f th e left h a n d . H e had at t h a t ti m e v ir t u ­ ally n o m o v e m e n t in th e wrist o r h a n d , th e m e t a c a r p o ­ phalangeal jo in ts b ein g h y p e r -e x te nd e d a n d th e p h a la n g e a l ones flexed. T o g e t h e r wit h th e s t u m p on th e right a r m a n y self-help was severely limited, a n d s o th e K r u k e n b e r g ’s operation was dec ide d u p o n . O p e r a tio n N otes F le x o r d ig i t o r u m su b li m i s w'as d iv id ed i n to tw o halves a n d the i n te ro ss e o u s m e m b r a n e d i v i d e d ; th e e x te n s o r m usc les were di vided in to tw o g ro u p s . A large n e u r o m a on th e en d o f the m e d i a n nerve w as r e m o v e d , a n d th e nerve s h o r t e n e d . F le x o r d ig it o r i u m p r o f u n d i s a n d flexor hallucis lo n gu s wer e dissected o u t a n d re m o v e d , a n d th e belly o f e x te n s o r d i g i t o r i u m w as a l so r e m o v e d . E x t e n so rs a n d flexors o n th e ra di al h a l f w er e well a t t a c h e d to th e e n d o f th e b o n e by s c a r tissue. T h e flexor t e n d o n s were sl ack a n d neede d s h o r te n i n g . T h e skin was closed o v e r t h e ra di al digit, but ha d to hav e a skin g raft s h o r tl y af te r o ve r th e u ln a, as th er e was n ot e n o u g h skin t o co v er th e in si de o f b o t h r a d i u s a n d u ln a . D r . N o t t i d g e said he w'as g re a tl y a id e d by th e fact that th e a m p u t a t i o n was wel l-h ea le d, w it h a l r e a d y s h r u n k e n , t h o u g h h ea lt h y , f o r e a r m muscles. T re a tm e n t W it h i n a few da y s, J a c o b u s w as a b le to gen tly a b d u c t th e rad iu s. A ft e r a m o n t h , he c o u l d o p e n a n d cl ose th e ‘pi ncers' Qu ic k ly , grip a soft r u b b e r wedg e firmly, a n d was pi ck in g light o bj ect s o u t o f a box a n d p u t t i n g t h e m on th e table. T h e m u scl e w o r k in volved was inter est in g. T o open the " h a n d ” he used p r o n a t o r teres, h elp ed by b ra c h i o - ra d i a li s an d po ssi bl y e x t e n s o r c a rp i ra dial is. T o clos e th e h a n d a n d g rip he used s u p i n a t o r , help ed by b iceps, a n d b o t h m o v e ­ m e n ts c o u ld be d o n e wit h th e e l b o w ei th er flexed o r ex te n d e d . Be fo re d is c h a rg e several m o n t h s la te r, th e “ j a w s ” c o u ld be o p e n e d to a n an g le o f 23° (i.e. a d i s t a n c e o f a b o u t 2 inches be tw e en th e b o n e en ds) . O n c e th e te n d e r n e ss o ve r th e b o n e en d s ha d g o n e, th e p at i en t ha d a gr ip t h a t w as c o n s i d e ra b ly s t r o n g e r t h a n th e o n e exe rte d b et w e en th e n o r m a l t h u m b an d first m e t a c a r p e l ; it ca n be exp ec te d to incr ea se still more. H e co u ld , by usi ng a gr ip b et w e en th e k n u c k le s o f his left h a n d a n d th e ‘p in c e r ’, c o m p le t e l y lace u p a s h o e a n d tie a bow . W i t h th e ‘p i n c e r ’ onl y he c o u l d feed h im se lf wit h a p a d d e d s p o o n a n d hol d th in gs like a n a v e ra g e sized b o o k . H e w as a b le t o pick u p obj ect s as sm al l as a m a t c h , a n d c o u ld pick u p a n d hur l a 2 lb. s a n d b a g fr o m o n e en d o f th e r o o m to th e o t h e r! T h e l a tt e r t o o k t i m e to le ar n, as th e ‘p i n c e r ’ refused t o re lease at th e exa ct m o m e n t re qu ir ed at first. H a d J a c o b u s been li ter at e, he w o u ld have been a b le to write with a V - s h a p e d w o o d e n p e n ci lh o ld er . A t his d is c h ar g e he w as s upp li ed wit h tr o u s e rs wit h a zip fa st ene r, as small b u t t o n s still def ea te d him. L w ou ld like to t h a n k D r . N o t t i d g e for th e use o f his note s o n th e case, a n d fo r his c o - o p e r a t i o n t h r o u g h o u t . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )