Tendon transfers in hand
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Revision for FRCS / Hand diploma - tendon transfers in hand
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Tendon transfers in hand
- 1. 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 Surgeon Fellowship Director, Upper Limb Fellowship Wrightington Hospital
- 2. ISCP – Tendon Transfer Hand ST3-8 (T&O) ST3-6 (Plastic) Specialty interest ST7/8 TIG Applied clinical knowledge 3 Basic – Intermediate – Advanced 4 Applied clinical skills 2 Basic – Intermediate – Advanced 4 Applied Clinical Knowledge 1. knows of 2. knows basic concepts 3. knows generally 4. knows specifically and broadly Applied Clinical Skills 0 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
- 4. Indications Restore function Muscle paralysis/nerve injuries Irreparable injuries to the musculotendinous units Restore balance Stroke, cerebral palsy, tetraplegia Why?
- 5. It is not the actual strength that matters but balance. Paul Brand
- 6. Decision making What is missing What needs reconstructing (think of FUNCTION) What is available What is appropriate What? HOT
- 7. Principles Tissue equilibrium is achieved Bony stability Good soft tissue envelope/gliding plane Full passive range of motion Expendable donor Minimum 1 wrist extensor, 1 wrist flexor 1 extrinsic flexor & extensor to each digit When?
- 8. 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: 33mm Finger extensors, FPL, EPL: 50mm Finger flexors: 70mm Tenodesis effect +20mm Expect decrease of one MRC grade after transfer PrinciplesHow?
- 9. Single line Single joint Single function Synergy Sensibility PrinciplesHow? Ideal principles but not obeyed all the times
- 10. Median Nerve Palsy Low Donor Tendon Camitz Palmaris longus Burkhalter Extensor indicis proprius Bunnell FDS IV Huber Abductor digiti minimi High Lost Function Donor Tendon Opposition EIP APB Thumb IPJ flexion Brachioradialis FPL Index finger flexion FDP I Sutured to neighbour FDPs
- 11. Radial Nerve Palsy PIN High Lost 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
- 13. Ulnar Nerve Palsy Low Lost Function Donor Tendon Clawing (Grasp) FDS III slips lateral bands Thumb adduction ECRB + PL graft Adductor pollicis Index finger abduction Accessory APL 1st dorsal interosseous Little finger adduction (Wartenberg sign) EDM radial lateral band High Lost Function Donor Tendon In addition to low FDP IV/V DIPJ flexion Side-to-side tenorrhaphy FDP III
- 14. Anti-clawing Procedures Static Zancolli capsulodesis Fasciodermadesis Tenodeses Dynamic MCPJ flexion MCPJ flexion + IPJ extension Bouvier manoeuvre?
- 15. Donor options to correct clawing
- 16. Surgery Radial nerve set Opponensplasty Anti-claw procedure Adductorplasty EI-EPL How?
- 17. Summary What is missing What needs reconstructing (think of FUNCTION) What is available What is appropriate HOT
- 18. Recommended reading Jones 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.
- 19. Thank you and good luck!