Tendon Transfers

Question 1

When possible, protective sensation should be restored
prior to tendon transfer

Answer 1

T

Question 2

The timing of late tendon transfers

Answer 2

takes place 6 to 18 months following
injury

Question 3

nerve regeneration rate of
approximately 1 mm/day or 1 in/month

Answer 3

T

Question 4

sensation should be restored prior to
tendon transfer whenever possible

Answer 4

T

Question 5

Without protective sensation

Answer 5

brain will tend to
exclude the insensate limb or digit(s) from functional activities

Question 6

In the
case of radial nerve injury, the area of sensory loss is not critical to
hand function,

Answer 6

T

Question 7

A single transferred tendon should not be used to perform two distinct active functions,

Answer 7

T

Question 8

a single tendon transfer can
perform one active function combined with different passive functions

Answer 8

T

Question 9

Power transfers require a strong donor muscle whereaspositional transfers do not require strength

Answer 9

T

Question 10

Transfer of
a muscle to a new location typically results in a loss of one grade of
strength

Answer 10

T

Question 11

Boyes’s rule for tendon excursions

Answer 11

Flexors and extensors of the wrist = 3cm
the extensors of the digits=5CM
digital flexors = 7CM

Question 12

The excursion of some muscles can be increased
through proximal dissection of the muscle belly, particularly in the
case of a brachioradialis (BR) transfer

Answer 12

T

Question 13

the excursion of the
transfer can be increased by 2 to 3 cm through the tenodesis effect of
wrist flexion or extension

Answer 13

T

Question 14

wrist flexor for finger extension or wrist extensor
for finger flexion (Synergy)

Answer 14

T

Question 15

The PIN is primarily a motor nerve

Answer 15

T

Question 16

sensory component of the radial nerve need special consideration in radial nerve palsy

Answer 16

F. not a critical sensory loss and typically does
not require treatment.

Question 17

Options for radial nerve transfere

Answer 17

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

Question 18

Merle di\ubigne described a slight modification of prevous options what was that ?

Answer 18

he used the same principle except he used FCU for both EDC and EPL
and PL for EPB and APL

Question 19

Starr originally described use of the FCR instead of the FCU to
restore digital extension

Answer 19

T

Question 20

Boyes and Brand advocated using the FCR
instead of the FCU, why?

Answer 20

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)

Question 21

What is the Superficialis (Boyes) Transfer

Answer 21

■ 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

Question 22

Superficialis (Boyes) Transfer did not use the palmaris longus

Answer 22

T

Question 23

Jones advocates using FDS of the long finger in case of palmaris absent

Answer 23

F FDS of the ring finger

Question 24

Boyes later argued that neither wrist flexor was suitable to restore
digital extension

Answer 24

T

Question 25

Why Boyes not convinced with wrist flexors?

Answer 25

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

Question 26

Median nerve at the proximal forearm supply PT, FDS, FCR, and PL before giving AIN

Answer 26

T

Question 27

giving off the anterior interosseous nerve approximately 6 to 8 cm distal

Answer 27

T

Question 28

the FDP to the long finger is often mantianed with median nerve palsy by an ulnar nerve contribution

Answer 28

T

Question 29

Thumb IP joint flexion Index and long finger DIP and PIP joint flexion was lost in low palsy

Answer 29

F (high palsy only)

Question 30

Following median nerve injury, In thump MCP joint flexion, may be maintained how?

Answer 30

by the ulnar-innervated deep head of the FPB.

Question 31

A patient with a unilateral, nondominant loss of opposition may compensate quite well with MCP joint flexion alone

Answer 31

T

Question 32

How we can restore the sensation in the radial side of the hand?

Answer 32

Bertelli has described sensory transfers in an attempt to restore sensation in high median nerve injuries

Question 33

Three thenar intrinsic muscles contribute to the thumb opposition: the opponens pollicis, the APB, and the FPB wich is most important ?

Answer 33

the APB is the most important muscle in thumb opposition.

Question 34

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

Answer 34

T

Question 35

Options for pully reconstruction of the opposition reconstruction (APB)

Answer 35

loops of the FCU tendon at or near its insertion on the pisiform, the palmar aponeurosis, transverse carpal ligament, and the FCU tendon itself

Question 36

options for restoring opposition (opponensplasty)

Answer 36

Transfer of the PL tendon Camitz transfer The FDS opponensplasty The abductor digiti minimi (ADM) c the EIP opponensplasty

Question 37

Camitz transfer, is often utilized in patients with severe carpal tunnel syndrome and advanced thenar atrophy

Answer 37

T

Question 38

Advantages?

Answer 38

its ease of harvest, as it lies in the same surgical field as a carpal tunnel release, and the lack of functional deficit

Question 39

Disadvantage?

Answer 39

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

Question 40

useful in providing palmar abduction in patients with severe thenar atrophy to aid in grasp

Answer 40

T

Question 41

The FDS opponensplasty use FDS of the ring finger as part or all of it

Answer 41

T

Question 42

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

Answer 42

T

Question 43

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.

Answer 43

t

Question 44

abductor digiti minimi providing an excellent vector for opposition and restoring muscular bulk to the thenar eminence

Answer 44

T

Question 45

This transfer is synergistic to opposition and provides good strength and excursion

Answer 45

T

Question 46

What the limitation of Huber transfer?

Answer 46

limited ability to produce palmar abduction.

Question 47

Indication of Huber transfer

Answer 47

mostly to children with hypoplastic thumb deformity or when other options are not available

Question 48

The ADM muscle belly provides improved cosmetic appearance of the thenar region in children with hypoplastic thumb deformity

Answer 48

T

Question 49

EIP opponensplasty is an excellent option that can be used in high or low median nerve palsy

Answer 49

T

Question 50

Although the EIP is not a strong muscle, it is sufficient to position the thumb in opposition

Answer 50

T

Question 51

Advantage of EIP?

Answer 51

its ease of harvest, availability in high and low palsies, and minimal functional deficit

Question 52

In high median nerve palsy what the option to reconstract the FPL and FDP of the index ?

Answer 52

BR is typically selected to restore FPL function, and the ECRL is used for index finger flexion

Question 53

ECU harvest have demonstrated radial deviation wrist deformities in these patients and severe grip weakness

Answer 53

T

Question 54

adequate index and long finger flexion can be achieved with a sideto-side transfer to the functioning ring and small finger profundus tendons

Answer 54

T

Question 55

The lack of forearm pronation resulting from denervation of the PT and pronator quadratus does not always require treatment Why ?

Answer 55

as shoulder abduction can position the forearm in a pronated position

Question 56

If this deficit is a problem, or if shoulder function is abnormal

Answer 56

biceps rerouting can be performed, which converts the biceps from a supinator into a pronator

Question 57

in High Median Nerve Palsy (Smith and Hastings)

Answer 57

EIP to abductor pollicis brevis Brachioradialis (BR) to flexor pollicis longus (FPL) Flexor digitorum profundus (FDP) tenodesis (side to side, powered by ulnar)

Question 58

Burkhalter methods

Answer 58

EIP to abductor pollicis brevis BR to FPL Extensor carpi radialis longus (ECRL) to FDP (index and long)

Question 59

Boyes

Answer 59

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)

Question 60

Brand

Answer 60

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

Question 61

In brand tech he is the only one how useed FCU in tow slip to stabilizes the wrist

Answer 61

T

Question 62

Unlike the median and radial nerves, the ulnar nerve has very few motor branches proximal to the hand

Answer 62

T

Question 63

anomalous innervation patterns (i.e., Martin-Gruber and Riche-Cannieu) are not uncommon

Answer 63

T

Question 64

Ulnar nerve palsy examination tests

Answer 64

Froment sign Pitres-Testut test Wartenperge sign

Question 65

clawing is less severe in high ulnar nerve palsy as the FDP paralysis lessens the flexion forces on the PIP and DIP joints

Answer 65

T

Question 66

the FCU paralysis does not result in demonstrable grip weakness

Answer 66

T

Question 67

High ulnar nerve palsy we should correct the clawing before the FDP

Answer 67

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

Question 68

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

Answer 68

T

Question 69

Key pinch is a combination of thumb adduction through the AP and index finger abduction through the first dorsal interosseous muscle

Answer 69

T

Question 70

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

Answer 70

T

Question 71

The ECRB37 and BR are both commonly used to restore thumb adduction;

Answer 71

T The FDS tendons to the long and ring fingers have also been used for adductorplasty.

Question 72

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

Answer 72

T

Question 73

FDS tendons have good independent control and excursion

Answer 73

T

Question 74

Disadvantage of FDS?

Answer 74

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

Question 75

the EIP, EDC-index, and EDQ have also been described as transfers

Answer 75

to restore thumb adduction, but these are often weak motors with suboptimal vectors of pull

Question 76

Physical examination iscritical in selecting the appropriate procedure to correct the clawed hand.

Answer 76

T

Question 77

The Bouvier test

Answer 77

passively flexing the MCP joints and asking the patient to actively extend the IP joints

Question 78

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).

Answer 78

T

Question 79

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)

Answer 79

T

Question 80

IN simple clawing we treat MCP hyperextension only

Answer 80

T

Question 81

Option of MCP hyperextension treatment

Answer 81

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

Question 82

dynamic tenodesis procedure is best preserved for positive Bouvier test

Answer 82

T

Question 83

Transfers of the FDS can be used to correct both simple and complex clawing

Answer 83

T

Question 84

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

Question 85

If a superficialis transfer must also provide IP joint extension, the modified Stiles-Bunnell procedure describes insertion into the lateral band

Answer 85

T

Question 86

joint hyperextension and swan neck deformity can develop from using FDS for dynamic clawing treatment

Answer 86

T

Question 87

How you can minimize the risk of swan neck deformity?

Answer 87

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

Question 88

The primary drawback to all superficialis transfers is that they may further diminish grip strength

Answer 88

t

Question 89

the wrist extensors provide a higher degree of synergy by coupling wrist extension with grasp

Answer 89

T

Question 90

Post op

Answer 90

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

Question 91

Although the EIP is not a strong muscle, it is sufficient to position the thumb in opposition

Answer 91

t