Pre and post operative Physiotherapy management in Tendon Transfer of Hand

1. Pre and Post Operative
Physiotherapy Management In
Tendon Transfer of Hand
By Dr. Rajal Sukhiyaji
(M.PT. in Sports Science)

2. Contents
• Definition
• Principles of tendon transfer
• Prerequisites for tendon transfer
• Treatment goals
• Indications, Contraindications, Precautions
• Radial nerve palsy ( Purpose, Preoperative requirements,
Tendon transfer, Post operative Management, Different
splint)
• Ulnar nerve palsy
• Median nerve palsy
• Post operative complication
• Evaluation time
• Recent advances
• References

3. Definition :-
• Tendon transfer is a surgical procedure that
involves moving the insertion of a tendon muscle
unit from one location to another location.
• A tendon transfer can be used to restore grasp,
improve the position of the hand in space, and to
prevent deformity, dislocations and contractures.

4. General Principles Of Tendon Transfer
Three important principles should be emphasized
1) The transfer should not significantly decrease
the remaining function of the hand.
2) The transfer should not create a deformity if
significant return of function occurs following
a nerve repair.
3) The transfer should be phasic or capable of
phase conservation.

5. Fundamental principles of muscle-
tendon units include the following:
1) Correction of contracture
2) Adequate strength
3) Amplitude of motion
4) Straight line of pull
5) One tendon, one function
6) Synergism
7) Expendable donor
8) Timing of tendon transfer

6. Prerequisites for tendon transfer
• The patient must be a suitable candidate.
• All joints must be fully passively mobile.
• All skin and soft tissue in the vicinity of the
transfer must be pliable and mobile.
• The muscle-tendon unit to be transferred must
be sufficiently strong to perform its new function
in its altered position.

7. Treatment Goals
 Preoperative goals
A) Achieving and maintaining full PROM and AROM if
possible.
B) Achieving maximum strength of the donor muscle and
antagonist muscles
C) Maintaining supple, soft tissue by minimizing scar,
edema, and adhesions and resolving intrinsic/extrinsic
muscle tightness. Use gel, elastomer molds, kinesiotape,
and so on.

8. D. Complete comprehensive evaluation, including sensory
testing, functional assessments, ROM measurements,
strength testing, and photographs for postoperative
comparison.
E. Educate the patient about the therapy process, splinting
demands, and realistic postoperative expectations.
F. Establish good communication with the surgeon,
schedule postoperative therapy. Review operative report
when available.

9. Postoperative goals
A.Protect transferred tendon.
B. Maintain ROM of uninvolved joints and involved joints.
C. Control postoperative edema and pain.
D. Control scar tissue (skin and subcutaneous) and prevent
adhesions to decrease drag on transfer.
E. Progress patient to functional use of hand.

10. Indications
• Poliomyelitis
• Paralysis of muscle
• Nerve injury (peripheral or brachial plexus)
• Injured (ruptured or avulsed) tendon or muscle
• Balancing deformed hand e.g. cerebral palsy or
rheumatoid arthritis
• Some congenital abnormalities

11. • Prompt consideration of tendon transfers is indicated if,
(a) The prognosis for neurologic recovery is poor even with
nerve repair,
(b) Muscles have been destroyed, or
(c) Nerve grafts have been required to restore nerve continuity.

12. Contraindications
1. Contracture of joints or skin that would limit movement.
2. Lack of a suitable muscle or muscles for transfer.
3. A progressive neuropathy, e.g. nerve damage following
radiation therapy.
4. Complicating medical conditions, e.g. muscle spasm or
circulatory inadequacy.

13. Precaution
A. Acceptance of less than full PROM before transfer.
B. Overestimation of donor muscle strength
C. “Drag” along transfer route secondary to scar
D. Technical failures (e.g., rupture of juncture, too loose or
too tight)
E. Be mindful of stretching out transfer. Wait until 6 weeks
after surgery before addressing tightness of transfer.

14. Radial Nerve Palsy
• The classic ‘wrist drop’ result.
• When the wrist cannot be stabilized in extension, the power
of the long flexors is minimized, thereby seriously
impairing grip function.
• Where the radial nerve is irreparable, the following
functions will need to be restored:
1. Wrist extension.
2. Finger extension (at the MCP joints).
3. Thumb extension and abduction.

15. Purpose
• It is impossible for the patient with this condition to
open the hand to grasp objects; therefore, the transfer of
normally functioning muscle–tendon units is frequently
used to overcome the deficit.
• The radial nerve supplies all of the wrist extensors and
finger extensors, including the thumb.

16. Preoperative requirements
1. The wrist must be passively mobile in extension.
2. The MCP joints must be passively mobile in extension.
3. The thumb web space must be normal.
4. There must be a full range of forearm supination/pronation
and also elbow flexion/extension.
5. Minimize edema if present.

17. Tendon transfer for radial nerve palsy
1)Flexor carpi radialis transfer
• PT to ECRB for wrist extension
• Flexor carpi radialis (FCR) to EDC for finger MP
extension
• Palmaris longus (PL) rerouted to EPL for thumb
extension

18. 2)Flexor carpi ulnaris transfer
• PT to ECRB for wrist extension
• FCU to EDC for finger MP extension
• PL to rerouted EPL for thumb extension
3)Boyes transfer (Superficialis transfer)
• PT to ECRL and ECRB
• Flexor Digitorum Superficialis (FDS) III to EDC
• FDS IV to Extensor Indicis and EPL
• FCR to APL and EPB

19. Flexor carpi ulnaris (FCU) transfer for radial nerve
palsy using pronator teres (PT), FCU and palmaris
longus (PL) as motors.

20. Post operative Management
Splint position
1. Elbow in 90 degrees of flexion.
2. Forearm in about 30 to 90 degrees of
pronation.
3. Wrist in 30 to 45 degrees of extension.
4. MCP joints in 10 to 15 degrees of
flexion; PIP joints free or at 20 to 45
degrees flexion. The splint extends just
proximal to the PIP joints which are
left free to move.
5. Thumb in maximum extension and
abduction.

21. • Week 0 to week 3 or 4: Splint/cast.
A. Maintain ROM of uninvolved joints
B. Protective ROM of individual joints
C. Avoid composite wrist and digit flexion.
D. Edema management
E. Scar management
F.Desensitization techniques
• Week 3 or 4: Splint. Fabricate splint, according to
surgeon’s guidance, which may or may not include the
elbow. Position the hand and wrist in same positions as in
the original cast.
A. ROM: as above.
B. Scar management

22. • Weeks 5 to 6: Muscle reeducation.
• Week 7: Begin dynamic flexion splinting if extrinsic
extensor tendon tightness is present.
• Week 8: Discontinue protective daytime splinting;
introduce resistive exercises. Begin passive wrist flexion
to gain maximum pronator teres length.
• Week 12: Resume unrestricted activities.

23. Different splints

24. Ulnar Nerve Palsy
• Affect pinch and grip strength and manipulation and
cause difficulty with the approach of objects due to a
claw-hand deformity.
• Denervation of the flexor digitorum profundus (FDP) to
the ring finger (RF) and small finger (SF) complicates
the deficits of intrinsic weakness by further weakening
grasp.

25. • The signs indicative of ulnar nerve palsy are as
follows:
• Froment’s sign:
• Jeanne’s sign:

26. • Duchenne’s sign:
• Wartenburg’s sign:

27. • Purpose
▫ Restore balance and function of a hand
▫ This may occur as a result of prolonged compression
as in cubital tunnel syndrome, trauma, disease,
infectious processes, congenital anomalies, or spastic
paralysis.
• Where the Ulnar nerve is irreparable, the following
functions will need to be restored:
1) MCP joints Flexion
2) Thumb adduction.

28. • Preoperative requirements for ulnar
nerve lesion
1. The PIP joints must be fully mobile in passive extension
and the MCP joints fully mobile in passive flexion.
2. Soft tissues should be free of contracting scar and have
adequate circulation.

29. Tendon Transfer for Ulnar nerve palsy
o Suitable muscle-tendon units include:
• Flexor digitorum superficialis, extensor carpi radialis
longus, extensor carpi radialis brevis, flexor carpi radialis,
brachioradialis and palmaris longus.
• The smaller extensors, i.e. extensor indicis proprius and
extensor digiti minimi (quinti) can provide intrinsic
function with the transfer of a muscle to two fingers each
(original Fowler technique)

30. • Superficialis transfers are designed to integrate MCP
joint and IP joint motion. They do not, result in
increased grip strength . The use of a wrist extensor to
flex the MCP joints will improve gross power grip.

31. • Low Ulnar Nerve Injury
A) Intrinsic Rebalancing
1) FDS of middle finger (MF)

32. 2) Zancolli lasso procedure
3) Brand transfer of ECRL/ECRB to intrinsics with
tendon graft
B) Restoration of power pinch
1) Smith-Hastings procedure
ECRB  ADP with graft
2) FDS of RF  ADP
• High Ulnar Nerve Injury
1) ECRL  FDP

33. Post operative management
• Splint position
1. Wrist in 45 degrees of extension.
2. MCP joints in 70 degrees of flexion.
3. IP joints in full extension.
4. The thumb remains free

34. Postoperative day 10 to 14:
• Remove postoperative cast, have tension checked by
surgeon, and immobilize patient in splint or recast.
▫ A. Fit the patient with a splint
▫ B. Gentle AROM and PROM within the restraints of the
splint.
Week 4:
• The hand and forearm are maintained in the described
position for the first postoperative month.
• Begin AROM out of splint, avoiding composite extension.

35. Week 6:
• When the hand is removed from the splint and placed on
the table, there will be a slight relaxation of the positions of
wrist extension and MCP joint flexion.
• The patient is then asked to actively extend the wrist which
should result in some MCP joint flexion. Extension of the IP
joints should be maintained during this manoeuvre.
• The hand is returned to the splint after each exercise
session until the end of the 6th week.

36. • The patient should perform this exercise on a 1 to 2
hourly basis with 5 to 10 repetitions during the 1st week
of active exercise.
• By the 2nd week, the patient learns to localize the action
of MCP joint flexion without having to extend the wrist
and practises the movement with the hand in all
positions, i.e. palm up and with the hand on the side.
• By the 5th week, emphasis is placed on active flexion and
extension of the fingers while maintaining MCP joint
flexion. Gentle active wrist flexion is also begun. May
introduce light resistance.

37. Week 6 to 12:
• Progressive resistive exercises. It is important not to fatigue
the transfer.
• Light gripping activities are commenced.
• Graded resistance is applied to MCP joint flexion with the
IP joints extended, i.e. intrinsic flexion.
• The activity programme is upgraded to restore maximum
power grip.

38. Different splints

39. Median nerve Palsy
• Functional impairment from a median nerve lesion is
primarily the result of lost skin sensibility on the working
surfaces of the thumb, index and middle finger, those used
for precision manipulation, rather than the loss of muscle
function.
• The main function that needs to be replaced is opposition of
the thumb.
• Three muscles are used for this function
▫ Abductor pollicis brevis,
▫ Opponens pollicis and
▫ Flexor pollicis brevis.

40. Purpose
• Restore balance and function of a hand.
• This may occur through prolonged compression as in
carpal tunnel syndrome, trauma, disease, infectious
process, congenital anomalies, or spastic paralysis.

41. • Preoperative Requirements prior to
opponensplasty for low level lesion (wrist)
1. Normal or maximal thumb web span.
2. Mobile thumb joints.
3. Full mobility of the unaffected digits.
4. Soft tissues should be free of contracting scar and have
adequate circulation.

42. Tendon transfer for Median nerve
Low Median nerve palsy
• Opponensplasty :-
A. FDS of ring finger (RF) or
PL to APB : long opponens
splint

44. B. Extensor indicis proprius (EIP) to APB: long opponens
splint

45. C. Abductor digiti minimi (ADM) to APB : hand-based or
long opponens

46. Post operative Management
• Splint position
• The wrist is immobilized in neutral
extension with the thumb held in full
opposition and the IP joint of the
thumb held in extension
• The fingers are left free to move.
• If the PIP joint has been tenodesed to
prevent hyperextension deformity, it
should be splinted in about 45 degrees
of flexion during the immobilization
period.

47. Postoperative day 10 to 14:
Remove postoperative cast, have tension checked by
surgeon, and immobilize patient in splint. Address wound
care, edema reduction, and scar management if indicated.
Week 3: Begin AROM of thumb in splint to activate
transfer, six to eight times per day
Week 4: Begin AROM of thumb and other joints out of
splint. Focus on activation of transfer. May use light grasp
and prehension tasks.

48. Week 6: Discharge splint for protection and begin
unrestricted AROM/PROM. May introduce light resistance.
Week 8: Progressive resistive exercises. Preferably the
patient should complete frequent low-resistance exercise
sessions rather than occasional higher-resistive exercises. It
is important not to fatigue the transfer.
Week 12: Resume unrestricted activities.

49. High Median Nerve Injury
• Flexor Pollicis Longus
• Brachioradialis/FDS to FPL: dorsal blocking splint (possibly
long arm splint with elbow in 90 degrees flexion for
brachioradialis)

50. Postoperative day 10 to 14:
Week 3: AROM of MCP/IP within splint to activate
transfer, six to eight times per day9
Week 4: AROM out of splint for transfer activation and
light prehension
Week 6: Discharge splint; PROM and splinting to
decrease tightness if present
Weeks 7 to 8: Progressive resistive exercises

51. Different splint

52. Post operative Complication
• Scarring of tendon to surrounding structures
• Difficulty activating transfer.
• Transfer too loose or too tight. Wait 6 weeks before
doing any PROM or splinting against transfer.
• Rupture of transfer repairs
• Overstretching of transferred tendon

53. Evaluation Timeline
Postoperative day 10 to 14 (after tension has been
checked by surgeon)
A. Control of edema and pain, wound care
B. ROM of uninvolved joints and protected ROM of
involved joints as allowed
C. Splint for protection and immobilization
Week 3: AROM of joints and activation of tendon
transfer in splint

54.  Week 4: AROM of all joints with splint removed;
nonresistive activities in therapy, NMES for transfer
activation
Weeks 6 to 8: Discharge protective splint. AROM/PROM
and functional activities, splinting for tightness.
Progressive resistive exercises at week 8.
Week 10: Manual muscle testing and functional outcomes

55. Recent advances
• Flexor digitorum superficialis opposition tendon transfer
improves hand function in children with Charcot-Marie-
Tooth disease: Case series, December,2013
• Transfer of the flexor digitorum superficialis tendons of
the middle and ring fingers to restore extension of fingers
and thumb (Boyes' transfer), August,2013

56. References
• Burke, Higgins, McClinton, Saunders, Valdata. Hand
and Upper Extremity Rehabilitation, A Practical Guide,
3rd Edition.
• Judith Boscheinen-Morrin. The hand: fundamentals of
therapy – 3rd Edition
• Robert w. Beasley, Tendon Transfers, Ch.-88

57. • Cynthia Cooper, Fundamentals of hand therapy, Clinical
Reasoning and Treatment Guidelines for common
diagnosis of Upper Extremity
• Dr Jason Crane, Tendon transfers for nerve injuries of
the Upper Limb
• GS Kulkarni, Textbook of Orthopedics and Truma,
Volume One.

58. • Flexor digitorum superficialis opposition tendon transfer
improves hand function in children with Charcot-Marie-
Tooth disease: Case series. T. Estilow; S.H. Kozin; A.M.
Glanzman; J. Burns; R.S. Finkel, January, 2014.
• Transfer of the flexor digitorum superficialis tendons of
the middle and ring fingers to restore extension of
fingers and thumb (Boyes' transfer). Pillukat T;
Blanarsch B; Schädel-Höpfner M; Windolf J; van
Schoonhoven J; August, 2013.

59. THANK YOU