Describe the indications, benefits, and drawbacks for various tendon transfer procedures used to treat median and ulnar nerve palsy. This issue of hand clinics will include articles on tendon transfers in the upper limb such as. Group v patients have all muscles functioning but with varying degrees of intrinsic weakness. In june 2016, cpt assistant said that it is acceptable to use code 28285 when the tendon transfer is performed for hammertoe, claw toe, or crossover deformity correction. Tendon transfer surgery massachusetts general hospital. Tendon transfers in the upper limb, an issue of hand clinics. Claw hand caused by paralysis of the intrinsic muscles. If finger grasp was good and thumb function ineffective only opponents transfers were done in order to achieve key pinch. Surgeons perform some tendon transfers in the lower extremity legs, ankles, and feet, but these are less common. Depending on the extent of the spinal cord injury, tendon transfers can enable a patient to grasp objects, open the hand, pinch the thumb and straighten the elbow. The basic techniques date back to the 19th century. Most tendon transfers are performed in the forearm and hand. The patient underwent static and dynamic splinting and a modified tendon transfer protocol starting at 3 weeks and ending at 16 weeks postsurgery.
Tendon transfers used for treatment of rheumatoid disorders raymond j. If a wrist extensor having less amplitude of excursion than the flexor digitorum profundus fdp is used for finger flexion, full finger extension is achieved by simulta. Despite having all patients referred to tendon transfer clinic by a supportive physiatrist, only 7. The patient attended therapy 1 to 3 times a week, depending on protocol stage and need for skilled therapy intervention. Phase 1 protect transfer, motor retraining 06 weeks 1160 kepler drive 1 p a g e green bay, wi 54311 9202885555. Flexor tendon repair therapy protocol sideline orthopedics. The purpose of these procedures can vary in function in order to strengthen a weakened tendon, reduce an overpowered tendon andor keep the foot in a biomechanically stable alignment. The most important aspect of assessment of an ulnar nerve palsy is determining whether the patient can extend the pip joint with the examiner correcting the mcp joint hyperextension bouvier maneuver fig. Tendon transfers tendon or muscle transfers restore balance to a hand crippled by loss of muscle function. Principles of tendon transfers for persons with tetraplegia. The muscles that are no longer functioning have left their antagonist muscles unchecked. Tendon transfers used for treatment of rheumatoid disorders.
Describe the anatomy and function of the radial nerve in the forearm and hand. Describe the clinical deficits associated with injury to each nerve. Tendon transfer surgery may also be needed if a muscle function has been lost due to a disorder of the nervous system. The primary goals of tendon transfer procedures for ulnar nerve palsy are restoration of small and ring finger dipj flexion in cases of high ulnar nerve palsy, restoration of key pinch, correction of clawing, integration of mcpj and ipj flexion, and improvement in grip strength.
The mtpj, pipj, and dipj are stabilized by collateral ligaments 16 tendon transfers for digital deformities and hammertoes. Jack choueka performs transfer of flexor digitorum superficialis to extensor digitorum communis. Tendon transfers for radial, median, and ulnar nerve palsy. All three transfers use the pt to ecrb transfer to restore wrist extension, but vary in the transfers used to restore finger and thumb extension. Injuries that result in fractures broken bones, ruptured ligaments and dislocations. The main advantage of these tendon transfer procedures over the superficialis transfers is. Patients with cervical spinal cord injury can gain useful hand function from a good rehabilitation programme and nonoperative hand care. Adults referred to the rics tendon transfer clinic between 19982007. After reading this article part i of ii, the participant should be able to. Instead of moving the nerve supply from one muscle to another muscle as is done with a nerve transfer the surgeon takes the end of a tendon, cuts it and moves it to perform a different function. Shoulder and elbow function was reconstructed using the neurotization technique, while the lost c 7 function of the hand was reconstructed by the tendon transfer method. In groups iii and iv tendon transfers were done only when automatic grasp was poor or absent.
It is often necessary to use alternatives such as splinting, tenodesis, arthrodesis, nerve transfer, or free functional muscle transfer in combination with tendon transfer procedures to improve the function of the extremity. Live surgery tendon transfer for radial nerve palsy. List and understand the principles and biomechanics of tendon transfers. Flexor carpi ulnaris to extensor carpi radialis brevis and extensor pollicis longus reroutement. They involve the same basic concept as all reconstructive surgery. When you contract tighten a group of muscles, the attached tendons will pull on certain bones, allowing you to make a wide range of. Tendon transfers in hand surgery journal of hand surgery. Hand clinics tendon transfers in the upper limb sciencedirect. Most patients have successful tendon transfer surgeries. Tendon should insert around joint at 90 degrees to maximize power and excursion 4. The process of tendon transfers offers a rebalancing of the hand. Extensor tendon repair and rehabilitation surgical indications and considerations anatomical considerations. During the operation the extensor indicis tendon is cut through a small skin cut near the knuckle joint and pulled out at the wrist, next to where the extensor pollicis. A tendon transfer procedure takes an extra tendon from the upper limb and transfers it to the other muscle or other limb and restores movement in that function, says michael d.
A 38yearold woman with a medical diagnosis of multifocal motor neuropathy, which caused muscle imbalance and weakness in the right hand, underwent a multiple tendon transfer to correct the loss of digit and wrist extension. How to recover from tendon surgery on the hand healthfully. Radial nerve median nerve ulnar nerve not included combined injuries. Tendon transfer is a surgical procedure that involves moving the insertion of a tendon muscle unit from one location to another location. Flexor tendon repair therapy protocol 5 of 5 education for light activityuse of newly splintfree hand criteria for advancement absent flexor lag. A tendon transfer is a surgery that moves a working muscle and tendon to replace a nonworking muscle and tendon. Postoperative physical therapy management of tendon transfer. Tendon transfers of the hand and forearm monographs in hand surgery. Principles of tendon transfers linkedin slideshare.
The tendons on the top of the hand straighten the fingers. Jul 12, 2018 tendon transfers in reconstructive hand surgery pdf under the auspices of the federation of european societies for surgery of the hand, dr friden has here assembled a collection of international experts to detail the practical and surgical implications of tendon transfers in a number of different clinical scenarios. Evaluation of results and practical treatment considerations. In general, tendon transfer is indicated for restoration of muscle function after peripheral nerve injury, injury to the brachial plexus or spinal cord, or irreparable injury to tendon or muscle. Tendon transfer definition of tendon transfer by medical. In a tendon transfer, muscles that still work are redirected to do the jobs of muscles that are paralyzed. Describe the anatomy and function of the median and ulnar nerves in the forearm and hand. Tendon transfer surgery is a type of hand surgery that is performed in order to improve lost hand function. The most prominent tendons in the hands join muscles extending from the arms to the fingers and thumb, or pollux. Disruption of terminal extensor tendon distal to or at the dip joint of the fingers and ip joint of the thumb epl mallet finger. Prolong phase iii until 1012 weeks postoperatively responsive flexor lag. Progress to phase iv by week 8 unresponsive flexor lag. Postoperative physical therapy management of tendon. Chapter 16 tendon transfers for digital deformities and.
Dorsal outrigger with dynamic suspension slings holding the mp joints in 0 degrees. The full text of this article is available in pdf format. Registrar presentation by dr scott tulloch on upper limb tendon transfers at the western hospital footscray, melbourne. Create strong insertion tendon tendon or tendon bone to maximize mobilization 6. Describe the history of tendon transfer procedures. Tendon transfers help hands and arms work normally again after an injury by improving how muscles move. Principles of tendon transfers for persons with tetraplegia michael s. Because of their superficial location, the extensor tendons are often involved with inuries to the dorsum of the hand and are very likely to form adhesions with injuries to the bone.
He proposed a surgery that would help her to regain use of her right arm. Early on, the technique was used for reconstruction following obstetric brachial plexus palsy or paralysis secondary to polio. Carpal tunnel syndrome compression of a nerve as it goes through the wrist, often making your fingers feel numb. Pdf tendon transfers for the upper extremity in cerebral palsy. Insert distance away from joint to improve power at expense of decreased excursion 5. Tendon transfers in bpbp bmc proceedings full text.
For example, after a broken wrist, the tendon to the thumb epl tendon that allows you to make a thumbsup can break. In 2016, 19yearold hamda was evaluated by apurva shah, md, a hand and upper limb surgeon with expertise in pediatric conditions. Genesis birth palsy cerebral palsy polio world war goal principles of tendon transfer focus on radial nerve transfers specific transfers for. The triceps tendon is wider than most of the other tendons in the upper extremity. Fundamental principles of muscle tendon units include the following. Standard tendon transfer motors are often not available for a given functional deficit in the hand. One tendons inserts onto the forearm bone, the radius, and the second spreads out to join the fascia along the upper part of the forearm. Flexor carpi ulnaris to extensor carpi radialis brevis and extensor pollicis longus reroutement anchal bansal, lindley b. Tendon repair of the hand is surgery to repair damaged or divided tendons. If both wrist and nger extension transfers were done, fashion a longarm splint holding the elbow in 90 degrees and wrist in 45 degrees of pronation. Aug 18, 2012 this is a video in which tendons are transferred from the functioning volar side of the forearm to the dorsal forearm to assist with hand functioning called prehension. Principles of tendon transfers request pdf researchgate.
Tendon transfers are carried out to restore functional deficits by rerouting the remaining intact muscles. Tendon transfer surgery is necessary when a certain muscle function is lost. When you bend or straighten your finger, the flexor tendons slide through snug tunnels, called tendon sheaths, that keep the tendons in place next to the bones. Pre and post operative management in tendon transfer. Tendons are tough cords of tissue that connect muscles to bones. And this can lead to additional problems of contractures and deformity.
Radial nerve median nerve ulnar nerve not included. The flexor carpi radialis fcr, wrist extensors, finger flexors, and pronator teres pt all have a relative strength of 1. If only nger extension transfers were done, fashion a shortarm splint. Three main patterns of tendon transfer procedures for radial nerve palsy have emerged over the last century. Tendon transfers are commonly done to improve shoulder abduction and external rotation. Read the latest articles of hand clinics at, elseviers leading. Tendon transfers are undertaken to restore muscle function and can be used for any kind of nerve injury. It is acceptable to report a tendon transfer in conjunction with a shortening metatarsal osteotomy, but there are no codes for reporting tendon transfers in the toes.
To achieve a good result from the tendon transfer, patients must have good passive range of motion at the ip and the mcp joints. Often, the two ends of the tendon are very damaged and cannot be sewn back together. Tendon transfers for ulnar nerve palsy request pdf. Request pdf tendon transfers for ulnar nerve palsy ulnar nerve injury impairs extrinsic and intrinsic hand movements along with sensory loss in the ulnar 1 and. A functioning tendon is shifted from its original attachment to a new one to restore the action that has been lost. The therapist promotes motor retraining of the transferred tendon and treatment to control scarring and edema to regain normal function of the thumb. Purchase tendon transfers in the upper limb, an issue of hand clinics, volume 323 1st edition. Tendon transfers in reconstructive hand surgery pdf libribook. The insertion can be into the lateral band, the proximal phalanx, or the a1 or a2 pulley.
In order to understand the disease process, one must have a sound understanding of the anatomy. A tendon transfer can be performed when a muscle ruptures, is lacerated and cannot be repaired or a nervous disorder destroys muscle function. Lubahn definition rheumatoid arthritis is a progressive disease that, if uncontrolled, leads to joint destruction, secondary to progressive synovitis, ligament instability, joint dislocation or subluxation, and attrition of adjacent tendons either by bony erosion or direct. Tendon or muscle transfers restore balance to a hand crippled by loss of muscle function. There are many tendon transfers described but this sheet will describe the commonest transfer. Transfers are highly attractive in the context of hand. Most children with bbpp do have good spontaneous recovery of the shoulder abductors but they are not able to act to their full potential because of the tight and abnormally cocontracting adductors. Tendon transfers tendon transfers surgically reroute arm muscles to restore hand function in people with paralysis. In this situation, the nervous system disease or injury prevents normal nerve signals from being sent to a muscle, and imbalance in hand function occurs. Principles of tendon transfers, biomechanics of tendon transfers, restoration of shoulder function, restoration of elbow flexion, radial nerve tendon transfers. Pdf tendon transfers for the upper extremity in cerebral. According to the american academy of orthopaedic surgeons aaos, when tendons in the hand are accidentally cut or tear, it may make bending or straightening the fingers challenging, and surgery is usually required 1. Tendon transfers for ulnar nerve palsy clinical gate.
Apr 20, 2018 for more information on tendon transfer in the hand, see hand, tendon transfers. These tendon transfers are useful tools in the correction of a deforming force of the. Tendon transfers are used to restore balance and function to a paralyzed, injured, or absent neuromuscularmotor unit. Tendon transfers have been used in upper extremity reconstruction for well over a century. Tendon transfers were performed for a patient with left upperarmtype c 57 rupture brachial plexus injury.
Most tendon damage is caused by cuts to the hands from glass or knives. Progress to phase iv by week 6 postoperative phase iv 816 weeks. Mar 31, 2016 these mtus require a free tendon graft which is split into two or four slips to pass through the intermetacarpal spaces into the corresponding lumbrical canals. Restoration of function and balance of the wrist and hand by tendon transfers.
Once this outpatient surgery is performed, recovery involves. Obviously, the choice between one protocol and another is a matter. When hand surgery evolved as a subspecialty, transfer techniques expanded. Many different conditions can be treated by tendon transfer surgery. Tendon transfer surgery what is tendon transfer surgery. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Tendon transfer is the transfer of the power of an innervated muscle to a denervated or weaker muscle or muscles by way of transfer of its tendinous insertion. Upper limb tendon transfers by dr scott tulloch youtube. Bednar, md loyola university medical center hines va hospital shriners hospital for children chicago tetraplegia and hand function physical limitations decreased control of arm in space limited to no grippinch strength functional limitations decreased mobility. Describe the indications, benefits, and drawbacks for various tendon transfer procedures performed for radial nerve palsy. A flexor carpi radialis and palmaris longus were harvested from.
A tendon transfer can be used to restore grasp, improve the position of the hand in space, and to prevent deformity, dislocations and contractures. Fashion a daytime extension splint with the following characteristics. Since the pl muscle tendon is used frequently in tendon transfer surgery and the radial half of the rce muscle tendons presents morphological and morphometric characteristics similar to it, we believe based on our results that the radial half of the rce muscle tendons is a good candidate for tendon transfer surgery when the pl muscle is absent. Osteoarthritis wearandtear arthritis, which can also cause deformity. Effective prehension can usually be achieved by proper.
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