surgical technique used in Tendon transfer for radial nerve palsy

1. Tendon transfer for Radial Nerve
Palsy
By:
Dr.mohammed Abd-Alhussein Laftah
Plastic surgery resident
Baghdad university –Alkindy college of medicine

2. • Radial nerve losses are divided into high and low
nerve disruptions.
• Low lesions: are essentially posterior
interosseous palsies, without loss of wrist
extension. They demonstrate:
1. loss of thumb extension–abduction and
2. loss finger extension at their
metacarpophalangeal (MCP) joints, the intrinsic
muscles providing interphalangeal extension.

3. • High lesions:
demonstrate the losses of low nerve lesions
with the addition of total loss of active wrist
extension as a result of paralysis of the
extensor carpi radialis longus (ECRL) and
brevis (ECRB).

4. Anatomy
- Innervation Order of Muscles: Radial Nerve
• BR
• ECRL
• Supinator*
• ECRB
• EDC
• ECU
• EDM
• APL
• EPL
• EPB
• EIP
Main radial
nerve
posterior interosseous nerve

6. Requirements in a Patient with Radial
Nerve Palsy
• A patient with irreparable radial nerve palsy
needs to be provided with
(1) wrist extension.
(2) finger (metacarpophalangeal [MP] joint)
extension.
(3) a combination of thumb extension and
abduction.

7. Amplitude of Motion
The surgeon must also have some appreciation of the amplitude of tendon
excursion for each Muscle:
• Wrist flexors and extensors: 33 mm
• Finger extensors and EPL: 50 mm
• Finger flexors: 70 mm
These above-listed values have practical significance because it is impossible
for a wrist flexor with an excursion of 33 mm to substitute fully for a finger
extensor that requires an amplitude of 50 mm. Although the true
amplitude of tendon excursion cannot be increased, two things can be
done to augment its effective amplitude.
First:the natural tenodesis : the effective amplitude of the tendon is increased
significantly by active volar flexion of the wrist, allowing the transferred
wrist flexor to extend the fingers fully
second factor: that can increase amplitude is extensive dissection of the
• muscle from its surrounding fascial attachments. This is particularly true of
the BR.

8. Historical Review
• Jones is credited with being the major
innovator of radial nerve transfers, and all the
article in the post–World War I era
acknowledged his fundamental contributions.

9. Jones Transfers
--
• PT to ECRL and ECRB
• FCU to EDC III-V
• FCR to EIP, EDC II,
• PT to ECRL and ECRB
• FCU to EDC III-V
• FCR to EIP, EDC II, EPL, EPB, and APL

10. Best Combinations of Tendon
Transfers for Radial Nerve Palsy
FCR transfer
• PT to ECRB
• FCR to EDC
• PL to rerouted EPL
Superficialis Transfer :
• PT to ECRL and ECRB
• FDS III to EDC
• FDS IV to EIP and EPL
• FCR to APL and EPB
FCU Transfer
• PT to ECRB
• FCU to EDC
• PL to reroute EPL

11. Operative technique
Incisions
used in the
FCU
combination
of transfers

12. PT to ECRB transfer. It is
important to take a strip of
periosteum in continuity
with PT insertion
to ensure adequate length
for transfer

13. FCU to EDC transfer. FCU must be
freed up extensively to create a
direct line of pull from its
origin to the new insertion into EDC
tendons just proximal to dorsal
retinaculum. End-to-side juncture is
shown here. Moberg and
Nachemson suggested that 4 to 5
cm of paralyzed EDC tendons be
resected proximal to the juncture,
allowing an end-to-end suture and a
more direct line of pull

14. Draw back of FCU transfer
(1) The FCU is too strong and its excursion is too
short for transfer to the finger extensors.
(2) its function as the prime ulnar stabilizer of
the wrist is too important to sacrifice.

15. PL to rerouted EPL transfer. By
rerouting EPL out of dorsal
retinaculum, the transfer creates a
combination of abduction and
extension force on thumb.

16. CRITICAL POINTS: TENDON TRANSFERS
FCU to EDC
▪ Do not use for tendon transfer in posterior interosseous nerve palsy.
▪ The FCU must be freed up extensively, requiring a long incision.
▪ Generously excise muscle from the distal half of the tendon to reduce bulk.
▪ Free up the muscle sufficiently to allow it to be redirected obliquely across the
forearm.
▪ Protect the muscle's innervation in the proximal muscle belly.
▪ Create a line of pull from the medial epicondyle to the EDC as straight as possible.
▪ Tendon juncture: weave the FCU through the EDC tendons at a 45-degree angle
just proximal to the dorsal retinaculum.
▪ Include the EDM only if there is a lag in extension of the small finger.
▪ Tension:
▪ Wrist in neutral (0 degrees)
▪ MP joints in neutral (0 degrees)
▪ FCU under maximum tension

17. CRITICAL POINTS: TENDON TRANSFERS
PL to Rerouted EPL
▪ Transect the EPL at its musculotendinous junction.
▪ The EPL tendon is rerouted to pass along the radial
border of the thumb metacarpal.
▪ The tendon juncture of PL to EPL is in the snuffbox
superficial to the dorsal retinaculum in line with the
thumb metacarpal.
▪ Tension:
▪ Wrist in neutral (0 degrees)
▪ Maximum tension on distal stump of EPL
▪ PL under maximum tension

18. CRITICAL POINTS: TENDON TRANSFERS
PT to ECRB
▪ Take a strip of periosteum from the radius in continuity with
the PT insertion.
▪ Free up the muscle proximally to gain maximum excursion.
▪ Pass the tendon around the radial border of the forearm
superficial to the BR and ECRL.
▪ Suture only into the ECRB—do not include the ECRL—just
distal to the musculotendinous junction.
▪ Tension:
▪ Wrist in 45 degrees of extension
▪ PT under maximum tension
▪ Reinforce juncture with a strip of free tendon graft.

19. Flexor Carpi Radialis Transfer
FCR to EDC transfer. Brand suggested that EDC
tendons be transected and transposed
superficial to dorsal retinaculum to create a
straight-line, end-to-end juncture with FCR

20. Flexor Carpi Radialis Transfer
• A straight longitudinal incision is made in the distal half of the volar radial aspect of
the forearm between the FCR and PL. Both tendons are identified, transected near their
insertions, and freed up to the middle of the forearm to allow redirection of the tendons to
their new insertions.
• A second longitudinal incision is made on the dorsum, extending from just distal to the
dorsal retinaculum to the mid-forearm.
• The FCR is passed around the radial border of the forearm through a subcutaneous tunnel.
• The juncture between the FCR and EDC can be made by:
1. Leaving the EDC in continuity (similar to the FCU transfer depicted in Figure).
2. the EDC tendons be divided so that a formal end-to-end suture can be done between the
FCR and EDC, as shown in Figure. To avoid the problem of multiple exposed raw tendon
ends, burying each cut tendon end.
• The finger extensor tendons all are tested for extension of the MP joint, and “four good
tendons are chosen.” These are divided at their musculotendinous junctions; withdrawn
distally, superficial to the intact dorsal retinaculum; and redirected to a point over the distal
radius, where they can meet the FCR tendon in a straight line.

21. CRITICAL POINTS: FCR TO EDC
▪ Divide the FCR near its insertion and pass it
subcutaneously around the radial border of
forearm.
▪ Divide the EDC tendons just proximal to the
retinaculum, and reposition the stumps
superficial to the retinaculum.
▪ Tension:
▪ Wrist in neutral (0 degrees)
▪ MP joints in neutral (0 degrees)
▪ FCR under maximum tension

22. Superficialis Transfer
• two finger superficial flexor muscles, not their
tendons, can be brought through the
interosseous membrane, using one for the
thumb and the other for the combined
fingers.

23. Postoperative Management
a long arm splint is applied that
• immobilizes the forearm in 15 to 30degrees of pronation.
• the wrist in approximately 45 degrees of extension.
• the MP joints in slight (10 to 15 degrees) flexion.
• the thumb in maximum extension and abduction.
• The proximal interphalangeal joints of the fingers are left
free.
The cast is removed 4 weeks postoperatively; removable
short arm splints to hold the wrist, fingers, and thumb in
extension are made, which the patient wears for an
additional 2 weeks, removing them only for exercise.