Tendon Transfers Flashcards
When possible, protective sensation should be restored
prior to tendon transfer
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The timing of late tendon transfers
takes place 6 to 18 months following
injury
nerve regeneration rate of
approximately 1 mm/day or 1 in/month
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sensation should be restored prior to
tendon transfer whenever possible
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Without protective sensation
brain will tend to
exclude the insensate limb or digit(s) from functional activities
In the
case of radial nerve injury, the area of sensory loss is not critical to
hand function,
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A single transferred tendon should not be used to perform two distinct active functions,
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a single tendon transfer can
perform one active function combined with different passive functions
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Power transfers require a strong donor muscle whereaspositional transfers do not require strength
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Transfer of
a muscle to a new location typically results in a loss of one grade of
strength
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Boyes’s rule for tendon excursions
Flexors and extensors of the wrist = 3cm
the extensors of the digits=5CM
digital flexors = 7CM
The excursion of some muscles can be increased
through proximal dissection of the muscle belly, particularly in the
case of a brachioradialis (BR) transfer
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the excursion of the
transfer can be increased by 2 to 3 cm through the tenodesis effect of
wrist flexion or extension
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wrist flexor for finger extension or wrist extensor
for finger flexion (Synergy)
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The PIN is primarily a motor nerve
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sensory component of the radial nerve need special consideration in radial nerve palsy
F. not a critical sensory loss and typically does
not require treatment.
Options for radial nerve transfere
The pronator teres (PT) to the ECRB muscle (wrist extensors)
The flexor carpi ulnaris (FCU) is used to restore digital extension
The
palmaris longus (PL) is transferred to the EPL, which is rerouted
volarly to provide more palmar abduction. If the PL is absent, a slip
of the ring finger FDS tendon can be transferred to the EPL
Merle di\ubigne described a slight modification of prevous options what was that ?
he used the same principle except he used FCU for both EDC and EPL
and PL for EPB and APL
Starr originally described use of the FCR instead of the FCU to
restore digital extension
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Boyes and Brand advocated using the FCR
instead of the FCU, why?
FCU was more important to wrist flex.ion,
too strong
Did not provide adequate excursion
in radial nerve palsy, the FCU is the only remaining ulnar-sided wrist motor, and its sacrifice eliminates active ulnar deviation (dart-thrower’s motion)
What is the Superficialis (Boyes) Transfer
■ PT to ECRB and extensor carpi radialis longus
■ FCR to abductor pollicis longus and extensor pollicis brevis
■ Flexor digitorum superficialis of long finger (FDS-III) to EDC
■ Flexor digitorum superficialis of ring finger (FDS-IV) to EPL and
extensor indicis proprius
Superficialis (Boyes) Transfer did not use the palmaris longus
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Jones advocates using FDS of the long finger in case of palmaris absent
F FDS of the ring finger
Boyes later argued that neither wrist flexor was suitable to restore
digital extension
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Why Boyes not convinced with wrist flexors?
as their limited excursion (33 mm) leaves them reliant on tenodesis to fully extend the digits
and simultaneous wrist and finger extension is not possible
Median nerve at the proximal forearm supply PT, FDS, FCR, and PL before giving AIN
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giving
off the anterior interosseous nerve approximately 6 to 8 cm distal
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the FDP to the long finger is often mantianed with median nerve palsy by an ulnar nerve contribution
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Thumb IP joint flexion Index and long finger DIP and PIP joint flexion was lost in low palsy
F (high palsy only)
Following
median nerve injury, In thump MCP joint flexion, may be maintained how?
by the
ulnar-innervated deep head of the FPB.
A patient with a unilateral,
nondominant loss of opposition may compensate quite well with
MCP joint flexion alone
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How we can restore the sensation in the radial side of the hand?
Bertelli has described sensory transfers in
an attempt to restore sensation in high median nerve injuries
Three thenar intrinsic muscles contribute to the
thumb opposition: the opponens pollicis, the APB, and the FPB wich is most important ?
the APB is the most
important muscle in thumb opposition.
the ideal vector for
an opposition transfer should parallel this muscle, from the pisiform
to the insertion of the APB on the abductor tubercle at the base of the
thumb proximal phalanx
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Options for pully reconstruction of the opposition reconstruction (APB)
loops of the FCU tendon at or
near its insertion on the pisiform, the palmar aponeurosis, transverse
carpal ligament, and the FCU tendon itself
options for restoring opposition (opponensplasty)
Transfer of the PL tendon Camitz transfer
The FDS opponensplasty
The abductor digiti minimi (ADM) c
the EIP opponensplasty
Camitz transfer, is often utilized in patients with
severe carpal tunnel syndrome and advanced thenar atrophy
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Advantages?
its ease of harvest, as it lies
in the same surgical field as a carpal tunnel release, and the lack of
functional deficit
Disadvantage?
the tendon may be damaged in traumatic
median nerve palsy owing to its superficial location; it is a weak muscle; and its vector of pull is not ideal for producing true opposition
useful in providing palmar abduction in patients with
severe thenar atrophy to aid in grasp
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The FDS opponensplasty use FDS of the ring finger as part or all of it
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Royle passed the tendon through the sheath of the FPL
Bunnell, rerouting the tendon through a pulley created by a strip of FCU tendon
Thompson later advocated tunneling the tendon subcutaneously to reach the thumb
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disadvantage of the FDS opponensplasty is that it can only be used
when the median nerve injury has occurred distal to the innervation
of the FDS.
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abductor digiti minimi providing an excellent vector for opposition and restoring muscular bulk to the thenar eminence
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This transfer is synergistic to opposition and provides good
strength and excursion
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What the limitation of Huber transfer?
limited ability to produce palmar
abduction.
Indication of Huber transfer
mostly to children with hypoplastic thumb deformity or
when other options are not available
The ADM muscle belly provides improved cosmetic appearance of the thenar region in children
with hypoplastic thumb deformity
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EIP opponensplasty is an excellent option that can be
used in high or low median nerve palsy
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Although the EIP is not a strong muscle, it is sufficient
to position the thumb in opposition
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Advantage of EIP?
its ease of harvest, availability in high and low palsies, and
minimal functional deficit
In high median nerve palsy what the option to reconstract the FPL and FDP of the index ?
BR is typically selected to restore FPL function, and the ECRL is used
for index finger flexion
ECU harvest have demonstrated radial deviation wrist deformities
in these patients and severe grip weakness
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adequate index and long finger flexion can be achieved with a sideto-side transfer to the functioning ring and small finger profundus
tendons
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The lack of forearm pronation resulting from denervation of
the PT and pronator quadratus does not always require treatment Why ?
as shoulder abduction can position the forearm in a pronated position
If this deficit is a problem, or if shoulder function is abnormal
biceps rerouting can be performed, which converts the biceps from a
supinator into a pronator
in High Median Nerve Palsy (Smith and Hastings)
EIP to abductor pollicis brevis
Brachioradialis (BR) to flexor pollicis longus (FPL)
Flexor digitorum profundus (FDP) tenodesis (side to side, powered by
ulnar)
Burkhalter methods
EIP to abductor pollicis brevis
BR to FPL
Extensor carpi radialis longus (ECRL) to FDP (index and long)
Boyes
Extensor carpi ulnaris with graft to thumb proximal phalanx
BR to FDP (index and long)
ECRL or extensor carpi radialis brevis to flexor pollicis longus (FPL)
Brand
Extensor carpi ulnaris with graft to thumb proximal phalanx
FDP tenodesis
ECRL to FPL
Flexor carpi ulnaris split to flexor carpi radialis and flexor carpi ulnaris
for wrist balance
In brand tech he is the only one how useed FCU in tow slip to stabilizes the wrist
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Unlike the median and radial nerves, the ulnar nerve has very few
motor branches proximal to the hand
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anomalous innervation patterns (i.e., Martin-Gruber and Riche-Cannieu) are not uncommon
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Ulnar nerve palsy examination tests
Froment sign
Pitres-Testut test
Wartenperge sign
clawing is less severe in high ulnar nerve palsy as the FDP paralysis
lessens the flexion forces on the PIP and DIP joints
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the FCU paralysis does not result in demonstrable grip weakness
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High ulnar nerve palsy we should correct the clawing before the FDP
F extrinsic transfer should typically be performed before
correcting clawing to enable the patient to make a strong, full fist after
correcting the intrinsic paralysis
restoring active DIP joint flex.ion in
the ring and small fingers is easily accomplished with a side-to-side
tenodesis of these tendons to the functional FDP tendons of the long
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Key pinch is a combination of thumb adduction through the AP
and index finger abduction through the first dorsal interosseous
muscle
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Procedures to restore key pinch (adductorplasty) only need
to restore thumb adduction as the index finger can be stabilized
against the adjacent digits, obviating the need for active index finger abduction
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The ECRB37 and BR are both commonly used to
restore thumb adduction;
T The
FDS tendons to the long and ring fingers have also been used for
adductorplasty.
The ECRB37 and BR must be lengthened with free tendon grafts and passed from dorsal to volar in the third intermetacarpal space, using the second metacarpal as a pulley and orienting
the vector of pull in a line parallel to the AP
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FDS tendons have good independent control and excursion
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Disadvantage of FDS?
this vector does not mimic that of the AP as well
as the ECRB or BR do
the sacrifice of an FDS tendon may weaken grip who already suffer from a loss of grip strength and can sometimes lead to PIP joint hyperextension
the ring finger FDS must never be sacrificed in a
patient with high ulnar nerve palsy, as this will leave them without
an extrinsic flexor
the EIP, EDC-index, and EDQ have also been described as transfers
to restore thumb adduction, but these are often weak motors with
suboptimal vectors of pull
Physical examination iscritical in selecting the appropriate procedure to correct the clawed hand.
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The Bouvier test
passively
flexing the MCP joints and asking the patient to actively extend the
IP joints
If the patient is able to fully extend the IP joints through the
extrinsic digital extensors with the MCP joints flexed, the Bouvier
test is positive and the clawing is considered simple (static).
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If the extrinsic extensors are unable to extend the IP joints
with the MCP joints passively flexed, the Bouvier test is negative and
the clawing is considered complex (dynamic)
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IN simple clawing we treat MCP hyperextension only
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Option of MCP hyperextension treatment
osseous blocks on the dorsal metacarpal head
volar (Zancolli) MCP joint capsulodesis
free tendon grafts from the
deep intermetacarpal ligament, passed through the lumbrical canal,
and secured to the extensor mechanism.
a dynamic tenodesis procedure, where a tendon graft is looped
through the extensor retinaculum of the wrist, and each end is split
in half. The four free ends are then routed along the lumbrical canals
and inserted into the lateral bands to provide MCP joint flex.ion and
IP joint extension with wrist flexion
dynamic tenodesis procedure is best preserved for positive Bouvier test
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Transfers of the FDS can be used to correct both simple and
complex clawing
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If only MCP hyperextension is to be corrected (simple clawing), the transfers can be
inserted into the Al or A2 pulleys44 or into the proximal phalanx
itself
If a superficialis transfer must also provide
IP joint extension, the modified Stiles-Bunnell procedure describes
insertion into the lateral band
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joint hyperextension and swan neck deformity can develop from using FDS for dynamic clawing treatment
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How you can minimize the risk of swan neck deformity?
This risk can be minimized by suturing one of the distal slips of the FDS remnant across the PIP joint to act as a checkrein to prevent hyperextension or by only performing this procedure in patients with stable joints
Or use ECRL, ECRB, FCR, or BR
muscles may be used for this transfer
The primary drawback
to all superficialis transfers is that they may further diminish grip
strength
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the wrist extensors
provide a higher degree of synergy by coupling wrist extension with
grasp
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Post op
patients are immobilized in a cast or splint for 4 weeks.
removable orthosis
gentle mobilization exercises are initiated
Passiveor active-assisted exercises are continued for an additional 4 weeks,
gradually begin strengthening exercises at 8 weeks
postoperative
By 12 weeks, the tendons should be fully healed
Although the EIP is not a strong muscle, it is sufficient
to position the thumb in opposition
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