Tendon Transfers in the Hand

Chye Yew Ng MBChB(Hons) FRCS(Tr&Orth) British Diploma in Hand Surgery

European Board of Hand Surgery Diploma

Consultant Hand & Peripheral Nerve SurgeonFellowship Director, Upper Limb Fellowship

Wrightington Hospital

ISCP – Tendon Transfer Hand

ST3-8 (T&O) ST3-6 (Plastic) Specialty interest ST7/8TIG

Applied clinical knowledge

3 Basic – Intermediate – Advanced

4

Applied clinical skills

2 Basic – Intermediate – Advanced

4

Applied Clinical Knowledge1. knows of 2. knows basic concepts 3. knows generally 4. knows specifically and broadly

Applied Clinical Skills0  No experience expected 1  Has observed or knows of 2  Can manage with assistance 3  Can manage whole but may need assistance 4  Able to manage without assistance including potential common complications

radial nerve set opponensplasty for opposition intrinsic replacement for claw hand adductorplasty for key pinch

FRCS RevisionWhy?

What?

When?

How?

HOTHigher Order

Thinking

IndicationsRestore function

Muscle paralysis/nerve injuriesIrreparable injuries to the musculotendinous units

Restore balanceStroke, cerebral palsy, tetraplegia

Why?

It is not the actual strength that matters but balance.

Paul Brand

Decision makingWhat is missing

What needs reconstructing (think of FUNCTION)

What is available

What is appropriate

What?

HOT

PrinciplesTissue equilibrium is achieved

Bony stability

Good soft tissue envelope/gliding plane

Full passive range of motion

Expendable donorMinimum 1 wrist extensor, 1 wrist flexor1 extrinsic flexor & extensor to each digit

When?

Force proportional to cross-sectional area of muscle

Average fibre length proportional to potential excursion

Amplitude/Excursion (The 3-5-7 rule)Wrist flexors/extensors: 33mmFinger extensors, FPL, EPL: 50mmFinger flexors: 70mmTenodesis effect +20mm

Expect decrease of one MRC grade after transfer

PrinciplesHow?

Single line

Single joint

Single function

Synergy

Sensibility

PrinciplesHow?

Ideal principles but not obeyed all the times

Median Nerve Palsy

LowDonor Tendon

Camitz Palmaris longus

Burkhalter Extensor indicis proprius

Bunnell FDS IV

Huber Abductor digiti minimi

HighLost Function Donor Tendon

Opposition EIP APB

Thumb IPJ flexion

Brachioradialis FPL

Index finger flexion

FDP I Sutured to neighbour FDPs

Radial Nerve Palsy

PIN HighLost Function Donor Tendon

Wrist extension PT ECRB

Fingers extension

FCR EDC

Thumb extension

PL EPL

Lost Function Donor Tendon

Fingers extension

FCR EDC

Thumb extension

PL EPL

Ulnar Nerve Palsy

LowLost Function Donor TendonClawing (Grasp) FDS III slips

lateral bandsThumb adduction

ECRB + PL graft Adductor pollicis

Index finger abduction

Accessory APL 1st dorsal interosseous

Little finger adduction(Wartenberg sign)

EDM radial lateral band

HighLost Function Donor TendonIn addition to lowFDP IV/V DIPJ flexion

Side-to-side tenorrhaphy FDP III

Anti-clawing ProceduresStatic

Zancolli capsulodesisFasciodermadesisTenodeses

DynamicMCPJ flexionMCPJ flexion + IPJ extension

Bouvier manoeuvre?

Donor options to correct clawing

SurgeryRadial nerve setOpponensplastyAnti-claw procedureAdductorplastyEI-EPL

How?

SummaryWhat is missing

What needs reconstructing (think of FUNCTION)

What is available

What is appropriateHOT

Recommended readingJones NF, Machado GR. Tendon transfers for radial, ulnar and median nerve injuries: current surgical techniques. Clin Plastic Surg 2011;38:621-42.

Green’s operative hand surgery

Brand PW, Beach RB, Thompson DE. Relative tension and potential excursion of muscles in the forearm and hand. JHSAm 1981;6:209-19.

Thank you and good luck!