Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Radial Nerve Palsy Tendon Transfers             Episode II
What is a tendon transfer?• The tendon of a functioning muscle is detached from  its insertion and reattached to another t...
What is a tendon transfer?• “Using the power of a functioning muscle unit to  activate a non functioning nerve/muscle/tend...
Indications•   Paralysed muscle     –   Nerve injury – peripheral or brachial plexus     –   High cervical quadriplegia (n...
General principles1. Only justified in restoring functional motion of the hand, not just motion• Not all patients require ...
General principles3. Recipient site• “Tissue Equilibrium” concept as per Steindler/Boyes• Tissue bed into which transfer i...
General principles4. Donor muscle factors (APOSLE)    Amplitude of the donor muscle    – Should be matched to the unit bei...
General principlesPower of the donor muscle– Any transferred muscle loses at least one grade of strength, so only Grade 5 ...
General principlesOne tendon, One function– Effectiveness reduced in transfer designed to produce multiple functionsSynerg...
General principlesLine of transfer– Should approximate pull of original tendon if possible– Acute angles should be avoided...
General principles5. Other muscle factors of secondary importance    – Innervation - Donor muscle should be independently ...
General principles8. Selected arthrodeses    – Simplify polyarticular system    – Stabilise joints    – Arthrodeses useful...
General principles9. Timing      – “The timing of tendon transfers depends upon the aetiology and prognosis of motor      ...
General principles11. Contraindications     – Age – due to joint stiffness, decreased need for power movements and        ...
Selecting donor tendons•   Based on Smith & Hastings (Principles of tendon transfers to the hand. Instr    Course Lect 29:...
Maximising Success / Surgical Technique1.   Incisions should not cross the path of the transferred tendon2.   Avoid interf...
Maximising Success / Surgical Technique5. A single insertion is best. Dual insertions tend to     provide motion to the ti...
Maximising Success / Surgical Technique7. Joint should be initially immobilised in a position that relieves tension at the...
General Post Operative Management• Rehabilitation is equally important in tendon transfer success  as surgical execution• ...
Basic Principles of Post Operative Rehabilitation• Described by Toth 19861. Protective phase• Begins at surgery and lasts ...
Basic Principles of Post Operative Rehabilitation3. Intermediate phase• Begins 5 – 8 weeks post operatively• Gradually inc...
Radial Nerve Palsy•   Need to differentiate between complete radial nerve palsy (includes    triceps) and posterior intero...
Tendon Transfers• Well defined and highly effective, aiming to  replace  – Wrist extension  – Finger extension  – Thumb ex...
Radial Nerve Palsy• Non-Operative Treatment  – Splintage     • Burkhalter observed grip strength increased 3-5 by simply  ...
Radial Nerve Palsy• Early transfers (“Internal Splintage”)   – Burkhalter believes greatest functional loss is grip streng...
Riordan TransferDonor        Insertion         Function PT          ECRB          Wrist dorsiflexionFCU       EDC IF - LF ...
PT to ECRB
FCU to EDC
PL to EPL
Donor    Insertion                Function                         ReferencePT       ECRL & ECRB              Wrist extens...
Brand transfers for radial nerve palsy
Brand transfers for radial nerve palsy• Boyes/Brand believes that finger extension is best  monitored by synergistic FCR, ...
Direct Nerve Transfers• Transfer of intact nerves to denervated  muscles.• MacKinnon and associates  – Median nerve suppli...
Post-Operatively• Long arm splint immobilisation for 4 weeks   –   15-30° pronation   –   wrist 40° extension   –   MPJ 10...
Radial nerve palsy tendon transfersw
Upcoming SlideShare
Loading in …5
×

Radial nerve palsy tendon transfersw

1,468 views

Published on

  • Be the first to comment

  • Be the first to like this

Radial nerve palsy tendon transfersw

  1. 1. Radial Nerve Palsy Tendon Transfers Episode II
  2. 2. What is a tendon transfer?• The tendon of a functioning muscle is detached from its insertion and reattached to another tendon or bone to replace the function of a paralysed muscle or injured tendon. The transferred tendon remains attached to its parent muscle with an intact neurovascular pedicle.
  3. 3. What is a tendon transfer?• “Using the power of a functioning muscle unit to activate a non functioning nerve/muscle/tendon unit”.• Tendon transfers work to correct: – instability – imbalance – lack of co-ordination – restore function by redistributing remaining muscular forces
  4. 4. Indications• Paralysed muscle – Nerve injury – peripheral or brachial plexus – High cervical quadriplegia (needs some input to brachial plexus/hand) – Neurological disease – Nerve repair with early transfer as internal splint• Injured (ruptured or avulsed) tendon or muscle – Considerations • Graft vs. transfer (adhesions more likely in graft – 2 anastomoses) • Quality of available donors • Length of time since injury • Nature of tendon bed• Balancing deformed hand e.g. cerebral palsy or rheumatoid arthritis• Some congenital abnormalities
  5. 5. General principles1. Only justified in restoring functional motion of the hand, not just motion• Not all patients require the same functions/motions2. Patient factors• Age• Functional disabilities with poor non operative prognosis• Ability to understand nature and limitations of surgery, including aesthetic goals• Motivated to co-operate with post operative physiotherapy
  6. 6. General principles3. Recipient site• “Tissue Equilibrium” concept as per Steindler/Boyes• Tissue bed into which transfer is placed should be soft and supple• Good soft tissue coverage• Stable underlying skeleton• Full passive range of motion of joints to be powered• Area to be powered must be sensate
  7. 7. General principles4. Donor muscle factors (APOSLE) Amplitude of the donor muscle – Should be matched to the unit being replaced • Finger flexors ≈ 60 - 70mm, • finger extensors and EPL ≈ 40 - 50mm, • wrist flexors / extensors ≈ 30 - 40mm, • brachioradialis ≈ 20 - 30mm – Amplitude of motion of any tendon can be increased by :- • Increasing the number of joints its crosses eg the amplitude of a tendon crossing the wrist joint is increased by 20 – 30mm by full ROM of wrist • Tenodesis effect during active movement • Freeing fascial attachments to donor tendons • Inserting the tendon closer to the joint being moved, but this requires a motor unit of increased power (due to leverage); and vice versa
  8. 8. General principlesPower of the donor muscle– Any transferred muscle loses at least one grade of strength, so only Grade 5 muscles are satisfactory (Grade 4, or 85% normal strength, can be sufficient for some transfers). Donor muscle strength should be maximised pre- operatively.– Strongest are brachioradialis and FCU. Donor power correlated roughly with cross sectional area of muscle and fibre length– Overly powerful muscles will unbalance and, over time, deform a joint. So muscle power should be matched if possible.– Effective power of a transfer can be increased by placing the tendon insertion farther from the joint axis and as close to 90° as possible
  9. 9. General principlesOne tendon, One function– Effectiveness reduced in transfer designed to produce multiple functionsSynergistic muscle groups are generally easier to retrain– Fist group – wrist extensors, finger flexors, digital adductors, thumb flexors, forearm pronators, intrinsics– Open hand group – wrist flexors, finger extensors, digital abductors, forearm supinators– Use of synergistic muscles tends to help retain joint balance
  10. 10. General principlesLine of transfer– Should approximate pull of original tendon if possible– Acute angles should be avoidedExpendability– Transfer must not cause loss of an essential function
  11. 11. General principles5. Other muscle factors of secondary importance – Innervation - Donor muscle should be independently innervated and not act in concert with other motors (eg lumbricals) – Availability or necessity of antagonists eg brachioradialis is an effective wrist extensor only if triceps is functioning to resist its normal elbow flexor action6. Tension of the transfer – “All transfers should be sutured at the maximum tension in the position that reverses their proposed activity” (Lister’s 4th Edn)7. Location and nature of pulley if required
  12. 12. General principles8. Selected arthrodeses – Simplify polyarticular system – Stabilise joints – Arthrodeses useful in providing stable pinch grip • Thumb MPJ and IPJ • Index PIPJ and DIPJ
  13. 13. General principles9. Timing – “The timing of tendon transfers depends upon the aetiology and prognosis of motor imbalance, the neurophysiologic problems for the patient, and the constitution of the involved extremity” (Omer GE: Timing of tendon transfers to the hand. Hand Clin 4(2):317, 1988) – Usually last stage in reconstruction, after skeletal stability, soft tissue coverage, sensation and joint mobility “tissue equilibrium” – Brown suggested early transfer if expected poor results • Nerve gap>4cm • Large wound or extensive scarring • Skin loss over nerve10. Comparison to alternatives – Nerve repair or transfer – Tendon repair or graft – Tenodesis (joint stabilisation by anchoring tendons that move the joint) – Arthrodesis – Amputation – Muscle lengthening, release or denervation (in spasticity)
  14. 14. General principles11. Contraindications – Age – due to joint stiffness, decreased need for power movements and difficult rehabilitation – Motivation – patients must be concerned about disability and highly motivated to perform hand rehabilitation – Task analysis – transfers must be designed to accomplish tasks rather than just specific motions. Eg opening doors requires grasp and twist – Nature of disability – systemic and local disease factors must be controlled before reconstruction attempted12. Disadvantages – No increase in strength – Normal function of transferred muscle is lost – Transferred tendon may perform a different force, amplitude of movement and functional pattern – Transferred tendon must learn a new movement/function
  15. 15. Selecting donor tendons• Based on Smith & Hastings (Principles of tendon transfers to the hand. Instr Course Lect 29:129, 1980)1. List functioning muscles2. List which of those muscles are expendable3. List hand functions requiring restoration4. Match #2 and #35. Staging
  16. 16. Maximising Success / Surgical Technique1. Incisions should not cross the path of the transferred tendon2. Avoid interference with normal structures3. Tendon should insert into the joint of motion at 90° to maximise power and excursion. Insertion can be moved away from the joint to improve power, but this is at the expense of decreased excursion4. The transferred tendon should insert into another tendon or bone. Strong insertions allow earlier mobilisation.
  17. 17. Maximising Success / Surgical Technique5. A single insertion is best. Dual insertions tend to provide motion to the tighter insertion. Can be an advantage in complex movements, where one insertion is tighter during one phase of motion, and the other takes over during another phase. 6. Tension should be set to produce the necessary joint movement with maximal muscle contraction. Some initial over correction should be planned, as some tendon stretch is usual.
  18. 18. Maximising Success / Surgical Technique7. Joint should be initially immobilised in a position that relieves tension at the insertion of the transfer8. Reverse order – harvest grafts, prepare recipient site and tunnel before raising muscle
  19. 19. General Post Operative Management• Rehabilitation is equally important in tendon transfer success as surgical execution• Rehabilitation / physiotherapy is essential in – Regaining joint mobility lost during splinting – Training tendon to glide in new course – Teaching patients to activate a new muscle to achieve a certain function, which requires development of new neural pathways• The more that a patient notices a disability, the greater the motivation, so the easier the retraining• Children are usually managed with static protocols or longer protective phase
  20. 20. Basic Principles of Post Operative Rehabilitation• Described by Toth 19861. Protective phase• Begins at surgery and lasts 3 – 5 weeks• Objectives:- – Protective splinting – Oedema control – Mobilise uninvolved joints2. Mobilisation phase• Begins when tendon healing is adequate for activation (usually 3 – 5 weeks post op)• Objectives – Mobilise tendon transfer – Immobilise soft tissue – Continue immobilisation of uninvolved joints to prevent joint stiffness from disuse – Reinforce preoperative teaching and patient education – Continue oedema control and protective splinting – Begin home rehabilitation program• Usually day time dynamic splinting with nightly static splinting
  21. 21. Basic Principles of Post Operative Rehabilitation3. Intermediate phase• Begins 5 – 8 weeks post operatively• Gradually increases hand activity and passive range of motion exercises• Limited functional movements permitted4. Resistive phase• Beginning at 8 – 12 weeks• Tendon junctions are strong enough to withstand increasing resistance• Therapeutic objective is to increase endurance and strength of transferred muscles• Work related simulated tasks are begun to patient tolerance
  22. 22. Radial Nerve Palsy• Need to differentiate between complete radial nerve palsy (includes triceps) and posterior interosseous palsy – Brachioradialis and ECRL are innervated prior to termination into posterior interosseous and sensory branches of radial nerve• Severe impairment due to loss of extension power to the wrist, fingers, thumb and loss of radial abduction of the thumb• Wrist extension is critical for stability, which is essential for grip and assisting the function of many tendons crossing the wrist
  23. 23. Tendon Transfers• Well defined and highly effective, aiming to replace – Wrist extension – Finger extension – Thumb extension and abduction• Standard – accredited to Riordan 1964
  24. 24. Radial Nerve Palsy• Non-Operative Treatment – Splintage • Burkhalter observed grip strength increased 3-5 by simply stabilising the wrist with splintage • Tailor to needs of patient • Brand recommended that if wrist splint during day then need night finger extension splint because lose length of flexor muscle fibres making it more difficult to achieve normal balance after nerve recovery or after tendon transfers – Maintenance of full passive ROM in all joints of the wrist/hands and prevent contractures
  25. 25. Radial Nerve Palsy• Early transfers (“Internal Splintage”) – Burkhalter believes greatest functional loss is grip strength therefore advocated early PT to ECRB • Therefore eliminate need for external splint plus also restore grip strength – 3 indications: • Works as substitute during early regeneration • Works as helper by adding power to reinnervated muscle • Acts as substitute in cases which results of nerve repair are poor (eg chronic/crush injuries or elderly)
  26. 26. Riordan TransferDonor Insertion Function PT ECRB Wrist dorsiflexionFCU EDC IF - LF Finger extension PL EPL (rerouted) Thumb extension
  27. 27. PT to ECRB
  28. 28. FCU to EDC
  29. 29. PL to EPL
  30. 30. Donor Insertion Function ReferencePT ECRL & ECRB Wrist extension Jones 1921FCR EPL, EPB, APL & EDC IF Thumb & index extension, thumbFCU EDC MF – LF abduction Finger extensionPT ECRB Wrist extension Goldner 1974FDS MF EPL (re routed) Thumb extension & abductionFCU EDC Finger extensionPT ECRB Wrist extension Brand 1975PL EPL Thumb extensionFCR EDC Finger extensionPT ECRL & ECRB Wrist extension Boyes 1970FCR APL & EPB Thumb abductionFDS RF EPL & EIP Thumb & index extensionFDS MF EDC via interosseous m Finger extensionPT ECRB Wrist extension Beasley 1970PL APL Thumb abductionFDS LF EPL Thumb extensionFDS RF EDC Finger extensionPT ECRB Wrist extension Smith &FCU EDC & EPL Digit extension Hastings
  31. 31. Brand transfers for radial nerve palsy
  32. 32. Brand transfers for radial nerve palsy• Boyes/Brand believes that finger extension is best monitored by synergistic FCR, and that EPL remains motored by PL – FCU too strong and excursion too short for finger extensors – FCU function as a prime ulnar stabiliser of wrist makes it too important to sacrifice• Boyes also concluded that FDS excellent for finger extensors because of greater excursion (70mm) therefore – FDS MF to EDC – FDS RF to EPL and EI (more independent control to thumb and IF)
  33. 33. Direct Nerve Transfers• Transfer of intact nerves to denervated muscles.• MacKinnon and associates – Median nerve supplies redundant branches to FDS and therefore available for transfer – Or branches to PL and FCR (if these tendons not used for transfer)
  34. 34. Post-Operatively• Long arm splint immobilisation for 4 weeks – 15-30° pronation – wrist 40° extension – MPJ 10-15° flexion – Thumb in maximal extension and abduction – PIPJ fingers left free• ROS & change splint at 10-14 days• AROM hand therapy begins at 4 weeks• Removable short arm splint to extend fingers, thumb and wrist for further 2 weeks, only removed for exercises

×