tendon transfers and upper limb disorders aws khanfar, mbbs, mrcsi, mfsem, chsorth, febot
TRANSCRIPT
TENDON TRANSFERS AND UPPER LIMB DISORDERS
Aws Khanfar, MBBS, MRCSI, MFSEM, CHSOrth, FEBOT
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.
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
Indications• Paralysed muscle• Injured (ruptured or avulsed) tendon or muscle• Balancing deformed hand e.g. cerebral palsy or
rheumatoid arthritis• Some congenital abnormalities
General principles- Only justified in restoring functional motion of the
hand,
-. 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
General principles-. Recipient site
• 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
General principles-. Donor muscle factors
Amplitude of the donor muscle ( TENDON EXCURSION)
General principlesPower of the donor muscle– Any transferred muscle loses at least one grade of
strength, so only Grade 5 muscles are satisfactory
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
General principlesLine of transfer– Should approximate pull of original tendon if
possible– Acute angles should be avoided
Expendability– Transfer must not cause loss of an essential
function
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
Basic Principles of Post Operative Rehabilitation
1. Pro tective phase• Begins at surgery and lasts 3 – 5 weeks• Objectives:-– Protective splinting– Oedema control– Mobilise uninvolved joints
2. Mobilisation phase• Begins when tendon healing is adequate for
activation (usually 3 – 5 weeks post op)• Objectives– Mobilise tendon transfer– Continue mobilisation of uninvolved joints to
prevent joint stiffness from disuse– Reinforce preoperative teaching and patient
education– Continue oedema control and protective splinting
Basic Principles of Post Operative Rehabilitation
3. 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
Radial Nerve Palsy• Wrist extension is critical for stability, which is
essential for grip and assisting the function of many tendons crossing the wrist
Tendon Transfers
• Well defined and highly effective, aiming to replace– Wrist extension– Finger extension– Thumb extension and abduction
• Standard
Radial Nerve Palsy
• Non-Operative Treatment– Splintage
– Maintenance of full passive ROM in all joints of the wrist/hands and prevent contractures
Radial Nerve Palsy
• Early transfers (“Internal Splintage”)– greatest functional loss is grip strength
PT to ECRB
FCU to EDC
PL to EPL
Common Upper limb disorders
• Symptoms:• Muscle/tendon problems : • Pain , Swelling ,Weakness• Nerve related :• Tingling/altered sensation , Weakness•
• Tendon problems: Dequervain’s • History: New, repetitive activity Pain over thumb side of the wrist Pain on making a fist, grasping or holding objects
• Examination Swelling Thickening Tenderness Freinklestein test
• Treatment Activity modificationNSAIDSplintage – thumb widely abductedSteroid Injection
• . Surgical Release
• Tennis/Golfers elbow• Incidence General population: 0.6% Tennis players: 9%Age: 35 and 50 years, with an equal distribution
between males and females Associated Rotator cuff problems: 20-40%
• EtiologyMultiple microtraumatic events Disruption of the internal structure of the
tendon and degeneration of the cells and matrix
• Presentation• Pain : outer aspect (Tennis elbow )of elbow/
inner aspect (Golfers) • Increases with activity and Lifting objects
Sometimes pain at rest• Palapation : Tenderness• Special test Resisted wrist extension , Elbow
flexion , Elbow Extension
• Non- Operative Treatment options• Topical NSAIDs• Oral NSAIDs• Orthotic devices• Physiotherapy
• Operative treatmentSurgery to repair the tendon
CTS
Incidence: 1-3 cases per 1000 persons per year Prevalence: 50 cases per 1000 persons aged in
their 30s and 50sWomen are affected 2-3 times more often
• Association of CTS in computer workers
• SymptomsPins and needlesPain The pain may travel up the forearm. Numbness of fingerDryness of the skin Weakness of muscles
• AnatomyContents:Nine flexor tendonsTendons Median Nerve
• Examination• Dry pulps• Wasting of Thenar muscles• Tinels
• Investigations• Nerve conduction test
• Treatment • Night splints• Surgical release
Shoulder Impingement syndrome
• Pain in shoulderIncreases with activityClicking sensation in shoulderPain with overhead activities/ reaching for seat
belt, wearing cloths
•Treatment
Pain medication Activity modificationPhysio ,To improve scapular position ,
Strengthen a specific group of musclesInjection into shoulderSurgery