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BACKGROUND:
We present a novel method for using Botox for the treatment of extremity spasticity and contracture by targeting the appropriate muscles thus minimizes the risk of injecting vital structures. The procedure outlined was devised from human cadaveric dissection performed by the authors.
METHODS:
The hand should be supine; begin by identifying landmarks: the wrist and elbow epicondyles. Mark a dot on both the medial and lateral epicondyles of the elbow. Using the landmarks, 3 lines will be drawn on both the volar and dorsal forearm. The muscle bellies are located in the proximal 1/2-2/3 of the forearm. Inject with the proper length needle, keeping in mind the thickness of the subcutaneous tissue, to reach the muscle belly. Always draw back prior to injection and inject multiple sites for effective release. For the hand and proximal forearm injections, superficially identify the flexor carpi radialis (FCR) for wrist contracture, palmaris longus (PL) in the fascia of the hand, and flexor carpi ulnaris (FCU) for wrist contracture. Flexing of the proximal interphalengeal (PIP) of finger will reveal the superficial and profunda muscles. Line 1 will be a line of the FCR from the radial wrist to the medial epicondyle. Line 2 will be for the PL from the midportion of the wrist to the medial epicondyle. Line 3 will of the FCU and drawn from the medial epicondyle to the volar wrist. Inject along the 3 lines. For wrist flexion contracture, inject lines 1 and 3 superficially along proximal 2/3 of forearm. Inject lines 1, 2, and 3 deeply to release finger flex contracture in the superficial and profunda muscles. Stay away from the antecubital (AC) fossa. For the flexor Palmaris longus (FPL), identify the landmarks. Draw a line from the FCR to the AC fossa from the 1/4-3/4 marks on forearm, just to the ulnar side, to inject FPL.
For extensor surface landmarks, identify the lateral epicondyle; the landmarks are all at approximately the same level. The extensor communis (EC) runs down the center and extends the fingers. For the ECR longus and brevis, draw a line from the lateral epicondyle to the dorsal/ radial aspect of the wrist. For the ECU, draw a line from the lateral epicondyle to the ulnar aspect of the dorsal wrist. Divide the wrist into 3 lines: the ECR (line 1), the extensor communis (line 2), and the ECU (line 3). To denervate wrist extensors inject the ECR/ ECU in the proximal 2/3 of forearm and inject lines 1 and 3. For the extensor palmaris longus (EPL) follow the central part of the forearm. Inject along the central line for the communis by 1/2-1cm. For the fingers, inject superficially along line 2 and for the thumb inject deeper along line 2.
RESULTS:
This procedure will enable clinicians to maximally reduce spasticity and contracture in their patients, minimize complications,and reduce wasted Botox.
CONCLUSIONS:
Our procedure should facilitate and guide clinicians seeking to further the development of Botox as a treatment for spasticity.