Complex Hand Injuries/Trauma/Tendon Transfers Flashcards
What are the stages of wound healing?
Inflammatory: 3-5 days
Fibroplasia: 5-28 days
Maturation: 28 days to 2 years
which muscle commonly used as a donor for wrist extension after radial nerve palsy?
pronator teres
donor muscle used for wrist extension in patients with cerebral palsy
in CP, wrist is typically postured in pronation and wrist flexion due to increased flexor tone.
FCU can be transferred to EDC or ECRB
which transfers are part of the “superficialis transfer” (“Boyes transfer”) for radial nerve palsy?
FCR or FCU to EDC
PT to ECRB
FDS of MF to EDC
FDS of RF to EPL
FCR to APL/EPB
*the wrist flexors have less amplitude of excursion than finger extensors, so active extension of the fingers can only be achieved with wrist is in volar flexion, relying on tendodesis
what sequence of repair is followed in a replantation?
- bony fixation
- extensor tendon repair
- flexor tendon repair
- nerve repair
- arterial anastomoses
- venous anastomoses
- skin coverage
after repair of a completely transected nerve, how long should you wait to perform stretching and nerve gliding exercises?
3 weeks
what is Jeanne’s sign?
seen in a low ulnar nerve palsy
hyperextension of the thumb MCP with key pinch or gross grip due to loss of adductor pollicis, which helps thumb adduct, flex at the MP, and extend at the IP
what constitues a low median nerve injury?
an injury at the wrist
this wouild include a majority of the thenar muscles
loss of OP and APB render thumb in an adducted position
lumbricals to IF and MF are also impacted
what constitutes a high median nerve lesion?
at or near the elbow
loss of FDP to IF/MF and FDS to all fingers robs the hand of grasp
active pronation also lost due to pronator teres and pronator quadratus
what constitutes a low radial nerve lesion?
injury to PIN and occurs distal to the elbow
wrist extension preserved b/c ECRL innervated more proximally, as is brachioradialis
what constituates a high radial nerve lesion?
injury is proximal to the elbow
wrist, finger, and thumb extension lost as well as thumb abduction
what constitues a low ulnar nerve palsy?
injury at the level of the wrist
loss of all hypothenars, palmar and dorsal interossei, and lumbricals to RF and SF, resulting in clawing
what constitutes high ulnar nerve lesion?
at or near the elbow
in addition to all muscles from a low ulnar nerve lesion, also lose FDP to RF and SF, which makes clawing much less severe
loss of FCU as well
what are common radial nerve tendon transfers?
- PT to ECRB
- FCU to EDC
- FCR to EDC
- middle finger FDS to EDC
- PL to EPL
- ring finger FDS to EPL
- middle finger FDS to EIP
- ring finger FDS to EDM
what are common median nerve tendon transfers?
- RF FDS transferred via constructed pulley at the pisiform, across the palm, & inserted to dorsal ulnar thumb metacarpal for opposition
- EIP to APB
- neurovascular pedicle of ADM to APB
- ECRL to APB
- PL to APB
- BR to FPL
- ECRL to FPL
- RF/SF FDP tenodesis to IF/MF FDP
- ECRL to a synchronized FDP
what are common ulnar nerve tendon transfers?
- ECRB to AP
- ring finger FDS to AP
- accessory slips of EIP to thumb and FDI insertion for IF abduction
- accessory slip of APL to FDI
- ECRB to lateral bands to restore MCP flexion
- MF FDS to lateral bands of RF/SF to reduce clawing
- ECRL through lateral bands for MP flexion
- zancolli lasso: FDS to A1 pulley anti-claw
- BR to MCP flexion
- RF/SF FDP tenodesis to IF/MF FDP
following trauma, typical posturing of edematous hand is:
MCPs in extension
wrist and PIPs in flexion
thumb in adduction
how many degrees is one radian?
1 radian = 57.29 degrees
used to calculate tendon excursion for each joint
why is a radian clinically relevant?
it refers to the amount of joint motion equal to the amount of tendon excursion
what are the 2 most important goals of thumb reconstruction?
restoration of opposition
restoration of sensation
what % of hand functional is the thumb responsible for?
40-50%
what 3 movements make up thumb opposition?
palmar abduction
flexion
and pronation
what 3 movements make up thumb retroposition?
abduction
extension
supination
what is the position of the MCPs of RF/SF in an anti-claw orthosis for low ulnar nerve palsy?
30-45deg
what are common tendon excursions in the hand?
wrist = 3cm
common finger extensors = 5cm
long finger flexors = 7cm
what is the Camitz procedure?
PL to APB to restore thumb opposition
common with severe carpal tunnel
what is the Steindler flexorplasty?
Used following brachial plexus injury. Transposes flexor-pronator origin proximally on the humerus, given a greater moment arm and allowing elbow flexion. Strength will always be severely limited (5#)
what is the single most imporant motion to restore UE function?
elbow flexion
what is a Huber tendon transfer?
ADM to APB
common for reconstruction of congenital hypoplasia of the thumb
what is the Zancolli Lasso
used after ulnar nerve injury
use FDS and pass through a window between A1 and A2, and suturing back onto A1. Creates a statis tenodesis causing MP flexion and allowing PIP extension
what is a Bunnell tendon transfer?
an opponensplasty running RF FDS through a constructed pulley at the pisiform and inserting to thumb to create opposition
what is an L’Episcipo tendon transfer?
latissimus dorsi and teres major are moved to a new posterior and lateral insertion on humerus to turn them into external rotators instead of internal. Common for brachial plexus palsy
what is a Boyes tendon transfer?
ring finger FDS to EDC
what’s the best transfer to replace FPL after high median nerve injury?
BR
what’s the most common brachial plexus lesion?
An upper plexus lesion at C5 and C6, aka Erb’s palsy
what is the Mallet classification system?
a standardized assessment for shoulder motions used in evaluation of brachial plexus palsy
after radial nerve injury, how soon can a tendon transfer be considered?
radial nerve palso should resolve in 3-4 months. If there has been no clinical improvement in 3 months, surgery can be considered
In general, after tendon transfer, how should ROM proceed?
start gentle PROM 3 days to 1 week post-op
at 3-4 weeks, start NM Re-ed
Follow with functional training and progress to AAROM, slowly incorporating resistance
at 6-8 weeks, add LLLD stretch
what are 3 standard sets of tendon tranfers for radial nerve palsy?
- PT to ECRB
FCU to EDC
PL to EPL - PT to ECRB, ECRL
Middle FDS to EDC
Ring FDS to EPL and EIP
FCR to EPB and APL - PT to ECRB
FCR to EDC
PL to EPL
