Ulnar nerve injury

1. TENDON TRANSFER FOR
ULNAR NERVE PALSY
MYO KO KO
YEAR 3

2. 2
INTRODUCTION
Paralysis of the extremity produces major functional impairment.
The ability to perform activities of daily life can be severely
compromised, especially in bilateral paralysis.
When muscle-tendon units remain functional in an extremity, consider
sacrificing one function to restore another by transferring the working unit to a
new location.
Restoring something as simple as a pinch grip can
create major improvement in the function of the
extremity.

3. HISTORY
• Tendon transfers have been used in upper extremity
• reconstruction for well over a century.
• Early on, the technique was used for reconstruction following
• obstetric brachial plexus palsy or paralysis secondary to polio.
• The middle part of the 20th century the development of
• transfers for multiple peripheral nerve paralyses, including
• median, ulnar, and radial nerve palsies

4. HISTORY
In the latter part of the century, microvascular techniques were
developed that added free muscle transfers as a possible tool for
paralysis reconstruction.
tendon transfer remains a primary tool in upper extremity paralysis
management.

5. DEFINITION
Tendon transfer surgery is a type of surgery that is
performed in order to improve lost extremities function.
A functioning tendon is shifted from its original
attachment to a new one to restore the action that has
been lost.

6. Fundamental Principles of Tendon Transfers
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. Tissue Equilibrium

7. ANATOMY

12. 12
ulnar nerve palsy

13. Motor
High
Low
hypothenar
Intrinsic
Thenar and 1st web
(Abd digiti minimi)

14. • Ulna nerve palsy is a more devastating injury than radial nerve palsy
• Key pinch is lost because of absent adductor pollics and first dorsal
interosseous muscle function
• Clawing as a result of paralysis of the interosseous muscles in the
presence of functioning extrinsic finger flexors . Claw hand prevents
the patient from cupping the hand around objects.
• Difficult to grasp objects.
• Unlike radial nerve palsy, the sensory deficit in ulnar nerve palsy is
clinically disabling.

15. Clinical examination
• Clawing, with hyperextension at MP joint and flexion at IP joints, is
the characteristic resting posture of the ring and little finger
(Duchenne sign)

16. • Bouvier maneuver is used to test the integrity of the central slip and
the lateral bands of the extensor expansion

17. • abduct the middle finger from side to side (Pitres-Testut sign)
• Another sign of loss of ulnar nerve function is the inability to cross
the middle finger dorsally over the index finger, or the index over the
middle finger (a test of the first palmar interosseous and second
dorsal interosseous muscles).
•

18. • Froment sign, marked thumb IP joint flexion when pinching
sheets of paper between the thumb and index finger, indicates
paralysis of the AD and first dorsal interosseous muscles with
replacement of their pinch function by FPL.
• The Wartenberg sign is the inability
to adduct the extended little finger to
touch the extended ring finger.

19. Restoration of Function in Ulnar Nerve Palsy
• Low” ulnar nerve palsy are to improve thumb pinch, correct finger
clawing, and restore the normal pattern of finger flexion.
• “High” ulnar nerve surgery also can be performed to restore ring and
little finger distal IP joint flexion
• Attempts to restore sensibility to the ring and little fingers are
possible, but not normally performed and the loss of sensation in
ulnar nerve palsy is not as devastating as in median nerve palsy.

20. Restoration of Function in Ulnar Nerve Palsy
• Correction of the claw deformity
• Restoration of Thumb-Index Key Pinch
1. Restoration of the transverse metacarpal arch

21. The Ulnar Claw Hand and Its Management
Aim
• Flexion of MCB joint
• Extension of IPJs

22. The Ulnar Claw Hand and Its Management
Surgical Techniques for Correction of the Ulnar Claw Hand
• static and dynamic procedures
• Static Techniques. These prevent hyperextension of the finger MP
joints by either shortening their palmar capsules or creating
“checkrein” ligaments/tenodeses
• static procedure is contraindicated if Bouvier maneuver (+)

23. The Ulnar Claw Hand and Its Management
Surgical Techniques for Correction of the Ulnar Claw Hand

24. 1. Palmar Capsulodesis of the MP Joint (Zancolli)
2. Omer modified Zancolli's technique
3. Palmar Capsulodesis of the MP Joint (Zancolli)
4. Omer modified Zancolli's technique
5. Riordan Static Tenodesis.
6. Parkes Static Tenodesis.
7. Fowler's Wrist Tenodesis Technique

27. Dynamic Tendon Transfers
1. Superficialis Tendon Transfer Techniques and Modifica-tions.
2. Modified Stiles-Bunnell procedure.
3. Modifications of the superficialis transfer.
4. Dynamic Tendon Transfers
5. Superficialis Tendon Transfer Techniques and Modifica-tions.
6. Modified Stiles-Bunnell procedure
7. Modifications of the superficialis transfer
8. Extensor Indicis Proprius and Extensor Digiti Minimi Transfers
9. Transfers Using Wrist Flexor and Extensor Muscles
10. Dorsal route transfer of ECRB/ECRL
11. Flexor route transfer of ECRL

30. Restoration of Thumb–Index Key Pinch and Tip Pinch

31. Restoration of Thumb–Index Key Pinch and Tip Pinch
1. Dynamic Procedures to Restore Thumb Adduction ECRB as Motor
(Smith)
2. Dynamic Procedures to Restore Thumb Adduction ECRB as Motor
(Smith)
3. Extensor Indicis as a Motor (Brown)
4. Combination of EIP and EDC (Little) Tendon Transfers for Pinch
5. Index Abduction Techniques Accessory Slip of APL Transfer
6. EIP Transfer to First Dorsal Interosseous. Th
7. Palmaris Longus to the First Dorsal Interosseous.

35. Other Techniques for Restoring Index Finger Abduction

36. Restoration of the Transverse Metacarpal Arch
1. Bunnell's “Tendon T” Operation.
2. EDM Transfer (Ranney).
3. Palande's Modification of Brand's Flexor Route Transfer of ECRL.

38. Correction of Little Finger Abduction Deformity
• Split EDM Transfer

39. High Ulnar Nerve Palsy
Restoration of Ring and Little Finger Flexion and Strength
• Little and Ring Finger FDP Suture to the Middle Finger FDP

40. Restoration of Sensibility
• Digital Nerve Transfer.
• Transfer of two or three tendons cannot be expected to restore the
fine function of the many intrinsic muscles whose function is lost with
a complete ulnar nerve lesion
• aim of surgery for ulnar nerve palsy is to improve rather than restore
normal function

41. THANK YOU