1) Median nerve injuries can result in loss of motor function to key muscles in the forearm and hand. Tendon transfers can help restore function by transferring muscles still innervated to replace lost functions. 2) Common tendon transfers include using the superficialis or EIP tendon to restore thumb opposition. The BR or ECRL can be used to restore thumb or index finger flexion. 3) Rehabilitation after tendon transfer focuses initially on splinting the transfers and mobilizing other joints, followed by gentle active and assisted range of motion exercises to strengthen and condition the transfers.

1. MEDIAN NERVE
PALSY AND TENDON
TRANSFER
DR.N. BENTHUNGO TUNGOE
PG. M.S(ORTHOPEDICS)
CENTRAL INSTITUTE OF ORTHOPEDICS
NEW DELHI

2. Median nerve introduction
 The median nerve is derived from both the lateral and medial cords of the
brachial plexus, with the lateral cord providing mostly sensory axons from C6
and C7, and the medial cord providing motor axons from C8 and T1.
 Also called labourer’s nerve.

3. Motor Functions
 The median nerve innervates the majority of the muscles in the anterior forearm, and
some intrinsic hand muscles.
 The Anterior Forearm
 In the forearm, the median nerve directly innervates muscles in the superficial and
intermediate layers:
 Superficial layer: Pronator teres, flexor carpi radialis and palmaris longus.
 Intermediate layer: Flexor digitorm superficialis.
 The median nerve also gives rise to the anterior interosseous nerve, which supplies the deep
flexors:
 Deep layer: Flexor pollicis longus, pronator quadratus, and the lateral half of the flexor
digitorum profundus (the medial half of the muscle is innervated by the ulnar nerve).
 In general these muscles perform pronation of the forearm, flexion of the wrist and
flexion of the digits of the hand.

4. Cont:
HAND: The median nerve innervates some of the muscles in the hand via two
branches.
 The recurrent branch of the median nerve innervates the thenar muscles –
muscles associated with movements of the thumb.
 The palmar digital branch innervates the lateral twolumbricals – these muscles
perform flexion at the metacarpophalangeal joints of the index and middle
fingers

5. Innervation
•Motor
• superficial volar forearm group
• Pronator teres
• Flexor carpi radialis
• Palmaris longus
• intermediate group
• Flexor digitorum superficialis
• deep group
• Flexor digitorum profundus (lateral)
• Flexor pollicis longus
• Pronator quadratus
• hand
• 1st and 2nd lumbricals
• Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis

6. Sensory innervation:
 The median nerve is responsible for the cutaneous
innervation of part of the hand. This is achieved via two
branches:
 Palmar cutaneous branch – Arises in the forearm and
travels into the hand. It innervates the lateral aspect of
the palm. This nerve does not pass through the carpal
tunnel, and is spared in carpal tunnel syndrome.
 Palmar digital cutaneous branch – Arises in the
hand. Innervates the palmar surface and fingertips of the
lateral three and half digits.

7. Course of median nerve
 Anterior compartment of arm
 anterior compartment (anteromedial to humerus)
 runs with brachial artery (lateral in upper arm / medial at elbow)
 no branches in the arm
 Forearm
 enters the forearm between the pronator teres and biceps tendon
 travels between flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP)
 then emerges between the FDS and flexor pollicis longus (FPL)
 Hand
 the nerve then enters the hand via the carpal tunnel, along with the tendons of the FDS, FDP and FPL
 Terminal branches
 anterior interosseous branch (AIN)
 innervates the deep volar compartment of forearm except the ulnar half of the FDP
 palmar cutaneous branch
 supplies sensory innervation to lateral palm
 recurrent branch (to thenar compartment)
 digital cutaneous branches
 supply the radial 3 1/2 digits (palmar)
 can also supply the index, long, and ring fingers dorsally

8. Clinical findings:
1. Injury at the Elbow: Supracondylar fracture of the humerus.
 Motor functions: The flexors and pronators in the forearm are paralysed, with the exception of the flexor
carpi ulnaris and medial half of flexor digitorum profundus. The forearm constantly supinated, and
flexion is weak (often accompanied by adduction, because of the pull of the flexor carpi ulnaris). Flexion
at the thumb is also prevented, as both the longus and brevis muscles are paralysed.
 The lateral two lumbrical muscles are paralysed, and the patient will not be able to flex at the MCP joints
or extend at IP joints of the index and middle fingers.
 Sensory functions: Lack of sensation over the areas that the median nerve innervates.
 Characteristic signs: The thenar eminence is wasted, due to atrophy of the thenar muscles. If patient tries
to make a fist, only the little and ring fingers can flex completely. This results in a characteristic shape of
the hand, known as hand of benediction.
2. Injury at the Wrist:
 How it commonly occurs: Lacerations just proximal to the flexor reticaculum.
 Motor functions: Thenar muscles paralysed, as are the lateral two lumbricals. This affects opposition of
the thumb and flexion of the index and middle fingers.
 Sensory functions: Same as an injury at the elbow.

9. Median nerve clinical assessment:
1. Pronator teres (C6, C7) assessment: The patient’s forearm is extended and fully
pronated. The patient is then instructed to resist supination of the forearm by the
examiner.

10. 2. Flexor carpi radialis (C6, C7) assessment: The patient flexes the wrist
along the trajectory of the forearm.

11. 3. Flexor digitorum superficialis (C8, T1) assessment: To test proximal
interphalangeal joint flexion, the supinated forearm and hand are placed straight.
Each finger is tested separately. Placing your fingers between the single finger to be
tested and the remaining fingers that are immobilized isolates this movement. This
maneuver places the finger to be tested
in mild flexion at the metacarpal–phalangeal (knuckle) joint, and stabilizes the
remaining fingers in extension, a position that allows isolation of the flexor
digitorum superficialis.
 The flexor digitorum superficialis (also known as
the sublimis muscle, C8, T1) is also innervated by
the median nerve and mediates flexion of the
second to fifth digits (all except the thumb) at
their proximal interphalangeal joints.

12. 4. Flexor digitorum profundus (C8, T1) assessment: To assess the median
innervation of the flexor digitorum profundus one should concentrate on the
index finger. To do so, hold the metacarpal-phalangeal and proximal
interphalangeal joints immobile, and have the patient flex the distal phalanx
against your resistance.

13. Ochsner’s clasping test: flexor digitorum superficialis and profundus(
lateral half)

14. The Thenar Group
5. Flexor pollicis longus (C8, T1) assessment: Immobilize the thumb, except the
interphalangeal joint, and then ask the patient to flex the distal phalanx against
resistance.

15. 6. Okay” or “circle” sign with anterior interosseous
nerve weakness.
 A quick way to assess the flexor digitorum
profundus and flexor pollicis longus innervation
from the anterior interosseous nerve is to ask the
patient to make an okay sign by touching the tips
of the thumb and index finger together.
 With weakness in these muscles, the distal
phalanges cannot flex, and instead of the
fingertips touching, the volar surfaces of each
distal phalanx make contact.

16. 7.Pronator quadratus (C7, C8) assessment
 : Have the patient resist supination of a fully flexed and
pronated forearm. With full forearm flexion, pronation
by the usually dominant pronator teres is minimized.

17. 8. Abductor pollicis brevis (C8, T1) assessment: Resist movement of the thumb
away from the plane of the palm (palmar abduction), while stabilizing the
metacarpals of the
remaining fingers.

18. 9. Flexor pollicis brevis (C8, T1)
assessment
 The patient flexes the thumb at the metacarpal-
phalangeal joint against resistance placed over
both the proximal and distal phalanges.
 Make certain the distal interphalangeal joint does
not flex because in allowing this, substitution by
the flexor pollicis longus occurs.
 Use your other hand to immobilize the first
metacarpal to reduce substitution by the
opponens pollicis.
 Because of its dual innervation, even with
complete thenar motor branch palsies some
thumb flexion still occurs.

19. 10: Opponens pollicis (C8, T1)
assessment:
 Have the patient forcibly maintain
contact between the volar pads of the
distal thumb and fifth digit, while you try
to pull the distal first metacarpal away
from the fifth digit. Although thumb
opposition is only innervated by the
median nerve, a combination of thumb
adduction (adductor pollicis, ulnar nerve)
and thumb flexion (flexor pollicis brevis,
deep head, ulnar nerve) may mimic
thumb opposition even when there is
complete median nerve palsy present.

20.  11. Lumbrical of second digit (C8,
T1) assessment:
 Stabilize the patient’s index finger
in a hyper-extended position at
the metacarpal-phalangeal joint
and then provide resistance as
the patient extends the finger at
the proximal interphalangeal
joint.

21. Tendon transfer in median nerve injuries
 Median nerve palsy is perhaps the most devastating single nerve injury of the upper extremity. Not only is there a
loss of fine motor control and opposition, but sensibility is lost over the area of the hand used for precision
movements and prehensile functioning.
 Tendon transfer procedures to restore movement may be ineffective if sensibility cannot be restored.
 High median nerve palsy is defined as an injury proximal to the innervation of the forearm muscles. Although PT
and FCR functions are lost, forearm pronation and wrist flexion are compensated for by other muscles, and do not
need to be restored.
 Although the FDS to all four fingers is lost, flexion is maintained in the ring and small fingers by the functioning
ulnar-innervated FDP muscle bellies. However, even though ring and small finger flexion is preserved, grip
strength is diminished.
 More importantly, there is a loss of thumb IPJ flexion and index and middle finger DIPJ flexion due to loss of the
AIN innervated muscles. This results in a lack of fine motor control of the hand, which is normally provided by
precise movements of the IPJ of the thumb and the IPJ’s of the index and middle fingers.
 In addition to these deficits, crucial thumb opposition is lost.
 Low median nerve palsy, on the other hand, results in loss of thumb opposition and sensory loss only. The fact
that some degree of sensory reinnervation is likely when a low median nerve injury has been repaired makes this
a potentially less devastating injury than high median nerve palsy.

22. 1. Restoring thumb opposition:
 The most devastating loss of movement following high or low median nerve
injury is the loss of thumb opposition. This can be restored with an
opponensplasty, or opposition transfer.
 Thumb opposition is a complex movement that involves palmar abduction,
pronation, and flexion of the thumb metacarpal and proximal phalanx.
 The ideal insertion for an opposition transfer is the APB insertion. Insertion at
this point most reliably causes the combination of movements that result in
thumb opposition.
 The angle of pull should be from the location of the pisiform, because this
approximates the normal direction of pull of the APB.
 A pulley is often necessary to create the proper line of pull. The transverse
carpal ligament, the palmar fascia edge, a loop of the FCU tendon, and the FCU
tendon itself have all been used as pulleys

23. The superficialis opponensplasty
 described by Royle in 1938,
 involves dividing the ring inger FDS distally in the finger, retrieving the FDS
proximal to the carpal tunnel, re-directing the tendon distally through the FPL
sheath, and inserting it into the thumb.
 This transfer was later modified by Thompson by re-directing the tendon
subcutaneously to the thumb, instead of through the FPL tendon sheath.
 Bunnell recommended rerouting the tendon around a looped strip of FCU to
achieve a more effective line of pull.
 The main disadvantage of the superficialis opponensplasty is that it can only
be used in cases of low median nerve palsy, because the FDS is paralyzed in
high median nerve palsy

24. Superficialis opponensplasty using
ring finger FDS for restoration of
opposition in low median nerve
palsy.

25. The EIP(extensor indicis propius)opponensplasty:
 in cases of both low and high median nerve injury, and is the most commonly
employed opposition transfer in high median nerve palsy
 Although the EIP is a weak motor, it is sufficiently strong to move the thumb
into opposition.
 The EIP is tunneled around the ulnar aspect of the wrist, routed across the
palm from the level of the pisiform, and inserted on the APB.
 It is important to close the extensor hood of the index MCPJ after EIP harvest
to prevent postoperative extension lag at the index MCPJ.
 Functional loss with the EIP transfer is minimal, and retraining the EIP to
perform thumb opposition is not difficult.

26. EIP opponensplasty for restoration of
opposition in high median nerve palsy.

27. Camitz procedure:
 Although the use of the palmaris longus (PL) for restoring thumb opposition was first
described by Bunnell, it was popularized by Camitz.
 Although the PL transfer effectively restores palmar abduction, the pronation and flexion
components of opposition are not re-established.
 The primary indication for performing a Camitz transfer is to augment palmar abduction in
patients who have motor loss from severe carpal tunnel syndrome.

29. The Huber transfer:
 employs the ulnar nerve-innervated abductor digiti minimi (ADM) to restore
opposition.
 This transfer is usually used in cases of congenital absence of the thenar
muscles, and in cases where the FDS and EIP are not available.
 The ADM is released from its insertion, turned over 180 degrees, and inserted on
the APB insertion.
 Strength and excursion are well matched to the deficit, and the transfer is
synergistic

30. HUBER PROCEDURE:

31. Restoring Thumb IPJ flexion and index
finger DIPJ flexion
 In cases of high median nerve injury, thumb IPJ flexion and index finger DIPJ
flexion can be restored with transfer of the BR, the ECRL, or ECU.
 The most common transfers are BR to FPL and ECRL to index FDP. However, it
should be remembered that reinnervation of the FPL and FDP is common after
a high median nerve injury has been repaired.
 If a return of function is anticipated, an end-to-side transfer should be
performed.
 If recovery is not expected, an end-to-end transfer results in a more direct line
of pull.

32. Rehabilitation:
 First 4 weeks:
 splint that should take tension off the tendon transfer(s) performed. For example, if a transfer was
performed to improve clawing, the splint should keep the MCPJ’s flexed and the IPJ’s extended.
 maintain mobility in the non-immobilized joints of the upper extremity.
 After 4 weeks:
Mobilization should start with gentle active and assisted range of motion exercises. It is important to mobilize one joint at a
time to prevent placing too much tension on the transfer. For example, if an ECRB transfer to treat clawing was performed,
the therapist should mobilize the MCPJ’s while keeping the wrist and IPJ’s immobile.
 6 weeks: exercises that activate the muscles used in the tendon transfer, and should begin muscle
retraining. Electrical stimulation and biofeedback may be used to assist with retraining.
 8 weeks: At eight weeks postoperatively, strengthening exercises should be initiated, and the splint
can be weaned off over the next four weeks.
 Full activity is resumed at twelve weeks.

33. COMPLICATIONS:
 Tendon adhesions,
 transfer rupture,
 Transfer weakness
 Infection
 Neuro vascular injuries