Tendon Transfers Flashcards
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
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
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
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
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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
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
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
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
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
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)
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
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
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
-
FDS transfer
High Ulnar nerve palsy
- avoid any trasnfer using FDS (will weaken grip further)
-
DIP FLEXION D4/5
- side to side trasnfer to FDP 3
What pre-operative splint is beneficial for radial nerve palsy
- Wrist cock-up splint
- consdier early PT to ECRB trasnfer
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
