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Objective: Thumb abduction and extension is one of the most serious and complicated hand function so its absence hinders the grabbing function of other fingers so thumb operations have developed into Active Dynamic Tenodesis of Extensor Policis Longus by Palmaris Longus in deficient thumb abduction and extension rather than static bone operations in succeeding in forming mobile thumb by maintaining the muscular balance via tendon transfer of PL to EPL end to side. Patients and Methods: From 2012 to 2015 reconstructive surgery active dynamic tenodesis was performed on 30 case of deficient thumb abduction and extension. In cases of radial nerve palsy, brachial plexus palsy and spastic cerebral palsy, we use palmaris longus whenever available as it has appropriate line of pull to create abduction extension and it will not overwhelm thumb flexion. In our cases, we do not detach palmaris longus from its insertion so our aim is to use it as active dynamic tenodesis of thumb abduction and extension when extensor pollicis longus is rerouted and sutured to palmaris longus end to side. Results: In our study we succeeded in forming mobile thumb by PL transfer and tenodesis to EPL. In our patients, strong lateral pinch on the second middle finger added to maintaining sufficient radial abduction during grabbing were obtained in all patients, the assessment involves physical examination, electromyography. Radiology and diagnostic nerve blocks in CP. 100 % of cases are satisfied, as all patients have g ood and full thumb function so satisfactory results are achieved. Conclusion: Our results demonstrate that active dynamic tenodesis of extensor pollicis longus is an effective and simple procedure for restoring thumb extension and abduction in 30 patients with different etiology of deficient thumb abduction and extension. Active Dynamic Tenodesis of Extensor Policis Longus by Palmaris Longus in Deficient Thumb Abduction and Extension ARC Journal of Orthopedics Page |2 found to increase the tensile strength of tendons [4]. The extrinsic extensors of the fingers and thumb are all innervated by the posterior interosseous nerve (PIN) branch of the radial nerve .The thumb has three separate extrinsic extensors , originate from the dorsal ulna in the midforearm and are innervated by the PIN. The abductor pollicis longus (APL) inserts on the radial base of the thumb MC to produce some extension, but mostly abduction. The extensor pollicis brevis (EPB) inserts on the base of the thumb proximal phalanx, and the extensor pollicis longus (EPL) inserts on the base of the thumb distal phalanx [5]. Extension is the movement of the thumb in a lateral or coronal plane away from the palm as to maintain the plane of the thumbnail at right angles to the plane of the other fingernails, movement occurs between the trapezium and the first metacarpal bone, at the metacarpophalangeal and interphalangeal joints, produced by the extensor pollicis longus and brevis. Abduction is the movement of the thumb in an anteroposterior plane away from the palm, the plane of the thumbnail being at right angles to the plane of the other nails movement occurs mainly between the trapezium and the first metacarpal bone; a small amount of movement occurs at the metacarpophalangeal joint, produced by the abductor pollicis longus and brevis [6]. In spastic cerebral palsy, dynamic approach to thumb-in-palm deformity. A, Release of adduction contracture through Z-plasty first web incision B, Transfer of PL to EPL, which has been released from third dorsal compartment. C, Transfer of distal portion of tendon of EPL to PL end to side, socalled dynamic tenodesis. If there is no suitable donor for active transfer, divide the APL tendon and reroute its distal portion volarly, attaching it in an end-to-side fashion to the flexor carpi radialis tendon under sufficient tension to maintain metacarpal abduction, and provides a dynamic abductor tenodesis. If the flexion deformity at the metacarpophalangeal joint is significant but joint stability is normal, a similar tenodesis of the extensor pollicis brevis tendon may be performed, don't create a disabling hyperextension deformity at MCP joint [7]. Tendon transfer to augment thumb extension should be performed after good passive motion is attained; it is contraindicated when there is weak pinch , correction of contracture is the essential principle as maximum passive motion of all joints must be present before tendon transfer is performed because no tendon transfer can move stiff joint and it is impossible for a joint to have more active motion postoperatively than it had passively preoperatively , adequate strength and appreciation of the relative strength of the forearm muscles is important in selecting an appropriate motor donor [8]. Boyes stringing of EPL: Tsuge noted of bow stringing EPL across radial aspect of the wrist was prevented by hooking it around the insertion of APL. Amplitude of motion of tendon excursion for each muscle, Boyes had suggested the use of the following values for practical purposes: Finger extensors and EPL: 50 mm, Finger flexors: 70 mm. These numbers of critical importance and significance since it is impossible for wrist flexors with an excursion of 33 mm to substitute fully of finger extensors with an amplitude of 50 mm, the true amplitude of the tendon cannot be increased. Two things can be done to augment its effective amplitude: Firstly, a muscle converted from monoarticular to biarticualr or multiarticular therapy effectively utilizing the natural tenodesis effect. Second factor is extensive dissection of the muscle, surrounding facial attachments (9). Timing of tendon transfer after radial nerve sufficient time is determined by using Seddons figures for nerve regeneration is approximately 1 mm per day, this means 5 or 6 months before PR and ACRL return following nerve repair and remaining muscles 7.5 months [9] (Table 1). Table1. Work capacity of forearm muscle (Boyes, 1964) (9). Donor muscles (MKg) Recipient muscles (MKg) BR 1.9 EPL 0.1 PT 1.2 APL 0.1 FCR 0.8 EPB 0.1 FCU 2 EDC 1.7 PL 0.1 EIP 0.5 FDS 4.8 ECRL 1.1 FDP 4.5 ECRB 0.9 FPL 1.2 ECU 1.1 2. PATIENTS AND METHODS The procedure was done in 30 patients divided into 3 groups according to the etiology of deficient extension and abduction of the thumb.12 patients with irreparable radial nerve palsy and 8 patients of brachial plexus palsy (C5– 6–7) were in need to restore a combination of thumb extension and abduction, 10 patients Active Dynamic Tenodesis of Extensor Policis Longus by Palmaris Longus in Deficient Thumb Abduction and Extension ARC Journal of Orthopedics Page |3 with spastic cerebral palsy with 7 cases absent abduction and extension thumb and 3 cases of thumb in palm. Three groups of patients was managed by active dynamic tenodesis of EPL. Group 1: 12 cases of irreparable radial nerve injury. Age: from 6–25 years, sex: 4 female and 8 male (Figure 1). Figure1. Case N2 irreparable radial nerve injury A) Preoperative photo; B) intraoperative; C&D) postoperative photos after healing. Group 2: (8 cases) of brachial plexus palsy C 5–6-7 neglected with absent MEMP in muscles of extensor pollicis brevis-longus and abductor pollicis. Age: from 4–40 years. Obstetric palsy 5 cases, sex: 2 female and 3 male. Traumatic Brachial Plexus palsy 3 cases, sex: 1 female and 2 male (Figure2). Figure2. Case No. 3: Traumatic brachial plexus palsy, K-wire Fixation to prevent hyperextension of MCP jo. Group 3: (10 cases) of spastic cerebral palsy with 7 cases type 1 Sakellarides classification of thumb in palm and 3 cases type 3 thumb in palm. Age: from 4 to 18 years. Sex: 3 female and 7 male. IQ: <80% spastic cerebral palsy unilateral disability. Type1 Sakellarides classification of thumb in palm (weak EPL and weak abduction of thumb treated by transferring of PL to EPL, 3 cases CP type 3 thumb in palm with need for first release of first dorsal web skin space, release of adductor pollicis, myotomy of flexor pollicis brevis and fractional lengthening of flexor pollicis longus to attain subtle mobile joints of the thumb, then the patient underwent extensive physiotherapy before our procedure is done (Figure 3). Figure3. Case No.1: Spastic cerebral palsy thumb in palm 2 stages procedure, second step reconstruction of EPL by PL. 2.1. Operative Technique Extensor pollicis longus rerouting: EPL rerouting (Transfer EPL from third to first extensor compartment so extensor adductor to abductor. Redirect the EPL tendon along the radial aspect of the wrist, using redirecting the tendon through third compartment, the EPL tendon is moved from dorsal forearm and rerouted to the volar forearm the EPL can be routed around the EPB and APL tendons just proximal to the compartment to fixed and wrapped around the normal PL to achieve active tenodesis of EPL as PL was still attached to its normal anatomical tendon to its deep layer to the flexor retinaculum and its superficial layer to palmar aponeurosis which creates a combination of abduction and extension force and tenodesis on the thumb Identify the extensor pollicis longus at the metacarpophalangeal joint, and dissect it out from the extensor aponeurosis for a distance of 10 mm distal to the joint. This leaves a longitudinal defect 4 mm wide in the extensor hood. Identify EPL through a longitudinal incision at the distal radius, and withdraw it into the forearm. The EPL is located at Lister's tubercle through a dorsal longitudinal incision, the retinaculum ulnar to the tubercle is released, allowing the thumb EPL is moved from Lister's canal after the tendon is cut at myotindinous junction, in most cases we don't release the canal just pull distal end of the EPL tendon is driven from the wound, small longitudinal volar incision on the ulnar side of the PL tendon, the PL tendon is Active Dynamic Tenodesis of Extensor Policis Longus by Palmaris Longus in Deficient Thumb Abduction and Extension ARC Journal of Orthopedics