Tendon Transfers Flashcards Preview

Upper Extremity > Tendon Transfers > Flashcards

Flashcards in Tendon Transfers Deck (23):
1

List principles of tendon tranfer

  • Donor expandable
  • Donor has synergistic activity to recipient
  • Single function of one donor per recipient (Muscle tendon unit MTU)
  • Straight line of pull
  • Adequate excursion 
  • Adequate strength
  • No more than 1 pulley for tendon excursion
  • Supple full PROM for joints
  • Stable Soft tissues

2

What are key biomechanical principles of tendon trasnfer

  • Excursion of MTU
    • must be adequate for needed ROM
  • Force generation of MTU
    • force directly proporitonal to CSA of muscle belly. 
  • Moment arm
    • line of tendon to koint axis is moment arm
    • greater the distance = greater moment arm = greater ROM at expense of stregnth
  • Tension
    • miust be set to muscle resting tension to maximize excursion with contraction of muscle

3

What are preop prequisites for potential tendon trasnfer candidate

  • Sensate hand
  • Supple joints w full PROM
  • Sot ST coverage
  • Pt investment
  • control of donor tendon is voluntary

4

what is the appropriate timing for TT

early

  • nerve irreparable
  • internal splint

late (9-12mth)

  • expected recovery from nerve regen (spontaneous or surgical) has not occured
  •  

5

What are deficits with low and high median nerve palsy

Low median nerve palsy

  • loss of thumb opposition 
  • loss of sensation

High median nerve palsy

  • loss of finger flexion DIP/PIP 2,3
  • loss of finger flexion DIP 4,5
  • and above

6

What are reconstructive options for low median nerve palsy, adv/disadv of each

OPPONENSPLASTY

  • Camitz - PL
    • PL 2cm proximal wrist to proximal palm creasein line with D4.
    • Pulley via sub cut tunnel 
    • Insertion on AbdPB
    • Adv: quick if done at time of CTS
    • Disadv: no sig. opposition - mainly abduction
  • EIP
    • EIP tunnels around ulna 
    • Incision at MCP jt, distal forearm, at pisiform, radial IPjt
    • Adv: good opposition, good for median/ulnar deficit, no donot morbidity to flexors
    • Disadv; retraining
  • Huber - AbDM 
    • AdBDM harvested w NV pedicle
    • tunnel sc to radial PP of thumb
    • ADv: great for peds, muscle bulk
    • Disadv: my have tension at tendon insertion, poor abduction
  • Royles-Thompson - FDS D4
    • FDS to thumb AdbPB throuhg pulley creasted in FCU
    • Adv: great excursion, restting excursion not as critical

7

What are reconstructive options for High median nerve palsy 

Finger flexion

  • Flexor tenodesis (side-to-side transfer) - secure D2,3 FDP to D4,5
  • ECRL to FDP D2,3
  • BR ot FPL
  • ECRL to FPL

8

What are the rehab protocols for opponensplasties and flexor reconstruction

Median nerve palsy => Pre-op 1st web space splint

Opponensplasty

  • 4wks immobilize in thumb spica
  • 4-8wks - long opponens splint
  • 8wks - stregthening

Finger flexion protocol

  • 4wks sugar tong splint w elbow 90, wrist flex 20, DB fingers, Duran protocol
  • 4wks-6wks place and hold for digits
  • 6wks- active WE with tenodesis effect then strengthening

9

What are the ulnar nerve low and high palsy deficits?

Low Ulnar Nerve deficits

  • loss of D4,D5 MCP flexion (clawing)
  • loss of coordinated MCP and IP flexion
  • loss of finger coordination
  • loss of key pinch, tip pinch
  • Loss of grip strength
  • loss of protectiv eulnar hand sensation

High Ulnar Nerve deficits

  • loss of D4 D5 DIP flexion
  • Loss of wrist flexion and ulnar deviation
  • further loss of grip strength
  • as above

10

What is an important PE manuever for assessment of clawing?

Bouvier test - to determine if clawing is complex or simple

 

Correct MCP hyperextension by flexing MCP & check IP extension

  • if IP extension improved, simple claw and extensor mchanism is intact (positive bouvier)
  • if IP remains flexed, complex claw (negative bouvier)

 

11

What are the goals of reconstruction for ulnar nerve palsy

  • Restore DIP flexion D4D5
  • Restore coordination flexion MCP and IP
  • Correct claw deformity
  • Restore key pinch
  • Restore grip strength

12

What pre-operative splint is beneficial for ulnar nerve palsy

  • MCP blocking splint - prevent clawing and allow EDC to extend IPs
  • thumb figure of 8 wrap for support

13

List and describe the reconstructive procedures for ulnar nerve palsy (low and high)

Low Ulnar Nerve palsy

  • KEY PINCH (ADDUCTION + 1ST DO)
    • FDS 3 to AdP (not if high ulnar n palsy)
    • ECRB to AdP with graft 
      • pass b/w D2 D3 MCs and deep to flexors
  • CLAW (SIMPLE + BOUVIER), STATIC
    • Zancolli MCP  VP capsulodesis (distal based)
    • Bunnell partial A1+A2 release (allow bowstring
    • Dynamic tenodesis  (Fowler Tsuge)
      • Graft looped through extensor retinaculum and insert to lumbrical
  • CLAW (COMPLEX, - BOUVIER), DYNAMIC
    • FDS transfer
      • FDS3 split into 4 and inserte into PP or lateral band or looped through A1 and sutured to itself (Zancolli lasso)
    • ECRB
      • with 4 grafts, through lumbrical canal, insert to lat band/PP/A1

High Ulnar nerve palsy

  • avoid any trasnfer using FDS (will weaken grip further)
  • DIP FLEXION D4/5
    • ​side to side trasnfer to FDP 3

14

What pre-operative splint is beneficial for radial nerve palsy

 

  • Wrist cock-up splint
  • consdier early PT to ECRB trasnfer

15

List the deificits for a low and high radial nerve palsy

LOW RADIAL NERVE PALSY

  • proximal PIN: loss of ECU, finger extension, thumb extension+abduction = radial wrist deviation
  • distal PIN: no loss of wrist extension and balanced

HIGH RADIAL NERVE PALSY

  • loss of wrist, finger, thumb extension and abduction
  • decreased grip b/c loss of balance in wrist

16

List the reconstrucive goals for radial nerve palsy

  • restore thumb extension and abduction
  • restore finger extension
  • restore wrist extension

17

What are radial nerve palsy reconstructive options

  • THUMB ABDUCTION AND EXTENSION
    • PL to EPL
      • EPL routed radial to Listers
    • FDS D4 to EPL
      • can be splint to trasnfer to EPL and EIP
      • FDS is cut b/w A1/2, passed via IOM
  • FINGER EXTENSION
    • FCR to EDC (Brand)
    • FCU to EDC (Jones)
    • Superficialis trasnfer (Boyes)
  • Wrist extension
    • Pt to ECRB
      • end to end if no nerve recovery expected
      • end to side if acting as an internal splint 

18

What is post op care/rehab followign radial nerve palsy recon

  • above elbow cast at 90, pronated, wrist extended, thumb spika
  • PROM at 6wks
  • strengthing 8wks

19

What are recosntructive options for combined ulnar/median palsy (eg volar wrist lac)

  • Key pinch (thumb adduction)
  • Claw correction
  • thumb opposition
  • integrate MCP PIP flexion
  • protective sensation

PLAN

  • ECRB for Key pinch (graft and pass b/w D2/3MC)
  • EIP opponensplasty
  • ECRL or BR for clawing

 

Combined median-ulnar HIGH

  • Key pinch: ECRB, EIP,  BR
  • flexion fingers ECRL to FDP
  • MCP VP capsulodesis for clawing
  • EIP/ECU for opponensplasty

20

What are reconstructive options for high ulnar radial palsy

  • Wrist extension - PT to ECRB
  • finger/thumb extension - FDS 3
  • DIP flexion D4,5 trasnfer to FDP 3
  • Coordination - FDS for trasnfer to lateral bands
  • Key pinch - FDS

21

What are options for combined high median radial palsy

DIFFICULT

  • Wrist arthrodesis
  • FDP sutured side to side
  • FCU fo rfinger/thumb extension
  • HUber for thumb opposition
  • FPL tenodesis for IP flexion

22

What are options for secondary recon procedures for OBPP

  • Shoulder stability
    • ​ABDUCTION: Trapezius transfer to deltoid tuberosity
    • EXTERNAL ROTATION: Episcopo: Latdorsi + T major to posterolat humerus
    • Arthrodesis if above fails
  • Elbow flexion
    • Steindeler flexorplasty
    • Pectoralis major trasnfer bipolar
    • Lat dorsi trasnfer
    • Triceps trasnfer
  • Elbow Extension - key for assist walking dvice
    • lat dorsi to triceps

23