ANATOMY AND PHYSIOLOGY OF REPRODUCTIVE SYSTEM.pptx
radial nerve palsy
1. Radial Nerve Injury
Early and Late Management
Dr Sumer Yadav
Mch- Plastic and Reconstructive Surgery
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2. Introduction
Loss of radial nerve function in the hand
creates a significant disability
Patient can not extend the fingers and thumb
and therefore has great difficulty in grasping
objects.
Loss of active wrist extension robs grasp and
power grip
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4. Anatomy
The radial nerve is
the largest branch
of the brachial
plexus
Continuation of the
posterior cord, with
nerve fibers from
C6, C7, C8, and,
occasionally, T1.
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5. The radial nerve innervates
the extensor and supinator
musculature located in the
arm and forearm and
provides distal sensation.
Lies first in the posterior
compartment of the arm,
Anterior compartment of the
arm,
Continues in the posterior
compartment of the forearm.
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6. Course
Passes across the LD
deep to the axillary
artery.
Winds around the
medial side of the
humerus,
And enters the triceps
muscle between the
long and medial heads.
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7. Course
It follows the spiral groove of
the humerus, piercing the
lateral intermuscular septum
(10 cm proximal to the
lateral epicondyle) from
posterior to anterior,
Runs between the brachialis
and brachioradialis to lie
anterior to the lateral
condyle of the humerus.
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8. The nerve then divides into a
superficial branch and a deep branch.
The superficial branch, purely sensory,
Runs under cover of the brachioradialis
in the forearm.
Innervates the radial wrist, dorsal radial
hand, and dorsum of the radial 3.5
digits
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9. The deep branch of the radial nerve, the
posterior interosseous nerve,
winds to the dorsum of the forearm,
around the lateral side of the radius,
and through the muscle fibers of the
supinator.
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13. Cutaneous innervation
Posterior cutaneous nerve of arm (originates
in axilla)
Inferior lateral cutaneous nerve of arm
(originates in arm)
Posterior cutaneous nerve of forearm
(originates in arm)
The superficial branch of the radial nerve
provides sensory innervation to much of the
back of the hand, including the web of skin
between the thumb and index finger.
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14. Topography
In the proximal part of the nerve
monofascicular pattern is seen. Each fasicle
cointains a mixture of motor and sensory
fibres.
In the distal forearm, the fascicles contain
nearly pure motor or pure sensory axons.
Generally, the sensory fascicles are
considered to sit more superficially and the
motor fibers more dorsal.
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15. Topography –
Radial Nerve
Divides into the superficial
radial nerve and the
posterior interosseous nerve
at the level of the supinator
But they can be neurolysed
proximally for 7 to 9 cm
without any
interconnections,
Remaining fairly separate to
the level of the spiral groove
The distal sensory fibres are
identified and excluded from
the repair or harvested and
used as a graft.
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16. Etiology
Penetrating injury
Compression injury
Saturday night palsy
Crush injury
Avulsion or traction injuries,
Ischemia and other non-mechanical factors
thermal injury, electric shock, radiation, percussion.
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17. Etiology
Holstein-Lewis fracture
Most commonly caused by fracture of the
humerus,
at the junction of the middle and distal thirds.
(Holstein-Lewis fracture)
Radial nerve in particular jeopardy
The proximal spike of this radial # breaks
through the lateral cortex at a point where the
nerve is most closely apposed to the bone
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18. High Radial–
Proximal to
Spiral Groove
High Radial– AT,
or Distal to,
Spiral Groove
Posterior
Interosseous
Neuropathy
Superficial
Radial
Neuropathy
Fracture
Callus
formation
Crutches
“Saturday night
palsy”
Fracture
Callus
formation
Lipoma
Radial artery
aneurysm
Radial tunnel
syndrome
Supinator
syndrome
Monteggia
fracture
Ganglia
Fibroma
Postsurgical
Cheiralgia
paresthetica
Fracture
Postsurgical
Venous
canulation
Laceration
Blunt trauma
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19. EXAMINATION OF THE RADIAL
NERVE
Physical Examination
Sensory
pinprick
light touch testing,
Sites
posterior arm
posterior forearm
posterior lateral hand and thumb.
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20. Improper technique may incorrectly suggest median
or ulnar weakness.
Inability to stabilize the wrist results in decreased
strength in grip (median nerve),
key pinch (ulnar nerve),
and thumb palmar adduction (median nerve).
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21. Location Motor Sensory
High Radial–
Proximal to Spiral
Groove
Weak elbow, loss
of wrist, and finger
and thumb
extension
(WRIST DROP)
Sensory loss over
posterior arm,
forearm, and
posterolateral
hand
High Radial– At,
or Distal to, Spiral
Groove
Elbow normal
Loss of Wrist,
finger, and thumb
extensors
Normal
sensation over
posterior arm
and forearm.
Sensory loss over
posterolateral
hand
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22. Location Motor Sensory
Posterior
Interosseous
Neuropathy
Normal elbow
and wrist
extensors.
Weak finger and
thumb extensors
Normal
sensation over
posterior arm,
forearm, and
posterolateral
hand
Superficial Radial
Neuropathy
Normal extensors Sensory loss
over
posterolateral
hand.
Normal sensation
over posterior arm
and forearm
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24. Work up
Radiographs
– Radial nerve injury in the arm, X ray of arm to
detect or rule out a fracture
– In Posterior interosseous nerve injury, X ray
radius and ulna
– rule out elbow or forearm fractures, dislocations
or instabilities, and arthrosis.
MRI is useful in detecting tumors such as lipomas
and ganglions
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25. Electro-myographic (EMG) and nerve
conduction velocity (NCV)
Help to locate the site of injury
Help to monitor the nerve recovery over time.
EMGs may not be positive for 3-6 weeks following
injury.
EMG may be performed initially to provide a
baseline, but unless the nerve is severed, no
changes will be observed for 3-6 weeks.
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27. Timing of nerve repairs
Open injuries
Require early exploration.
Sharp lacerations can be repaired immediately and
directly.
Wound must be relatively clean and free of gross
contamination.
A primary repair is not recommended with injuries
secondary to a crush injury
significant soft tissue damage.
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28. At 3 weeks (or when the wound permits), the
nerve is re-explored, and definitive repair or
graft can be performed.
At the time, the zone of injury is apparent
based on the extent of scar formation.
Open injuries
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29. Gunshot wound
Exception to the general rule of early
exploration of open injuries.
Mechanisms of nerve damage are
predominantly heat and shock effects.
They are treated as closed trauma.
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30. Closed injuries
In closed or blunt trauma, initial
management is expectant with close
observation.
If complete recovery is not observed within 6
weeks,
Electrodiagnostic studies should be obtained
for baseline evaluation.
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31. Monthly clinical and EMG evaluation
If motor unit potentials are seen with EMG,
► spontaneous reinnervation is anticipated,
Lack of clinical or electrical evidence of
reinnervation at 3 months requires
operative exploration.
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32. Intra operative nerve conduction
study.
Electric activity is
present
Grade 2 or 3 injury
Neurolysis is done
No electrical activity
Grade 4 or 5 injury
Injured nerve is
excised and nerve is
grafted
`
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33. RNP with Fracture Humerus
Incidence 1.8% to 18%
Managed in three ways
Early exploration of the nerve
Exploration at 6 to 8 weeks
Exploration after longer waiting
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34. Early exploration of the nerve
Advantages
Can know the status of the nerve.
Stabilization of the fracture protects the nerve
Technically easy
Disadvantages
No lesions in more than 95% patients explored
Accurate assessment cannot be made
Nonoperative management is the treatment of
choice in the initial period.
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35. Exploration at 6 to 8 weeks
An unnecessary operation is avoided
No interference with fracture healing
Absence of advancing Tinels sign is an
added indication for exploration at 6 to 8
weeks
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36. Exploration after
longer waiting
Initial signs of recovery
may take 4 or 5 months
Time for recovery can
be calculated.
Distance from the
fracture site to the point
of innervation of
Brachioradialis ( 2 cm
above the lateral
epicondyle)
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37. Sufficient time
Regeneration start in about 21 to 30 days
after the repair.
Proceeds at the rate of 1mm/ day
About 21 to 30 days to establish neuro-
muscular continuity.
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38. Choice of management
Patients are treated non operatively initially
Exploration only after a realistic waiting
period
Indications for early exploration
Open fractures
Operative intervention for # reduction
Associated with vascular injuries
Patients with multiple trauma.
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42. Epineurial versus group fascicular repair
In a prospective clinical study, no
significant differences were observed
between fascicular repairs and epineurial
repairs.
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43. Tension on the repair
Gapping at the repair, ischemia, and scar
formation.
Postural maneuvers to decrease tension
should be avoided.
Extensive mobilization should be avoided.
Mobilization of the nerve for 1 to 2 cm can
provide some relief of tension.
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44. Management of a nerve gap
Methods of reconstruction significant nerve
gap
Grafting with non-vascularized, autogenous
nerve- Gold standard
Vascularized nerve grafting
Conduit interposition
Nerve allograft
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45. Nerve transfers to reconstruct the radial
nerve
Redundant portion of the median nerve
supplying the FDS.
The triceps branch of the radial nerve.
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46. Postoperative management
Early range of motion is critical.
On Day 3, Dressings are removed,
wounds are examined.
The repair sites are protected
using splints for 2 weeks.
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47. Postoperative management
After the short period of protection, restricted
movements are started.
Goals are to
regain full passive range of motion
prevent joint stiffness and contractures.
Later-stage rehabilitation is focused on motor
or sensory re-education.
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49. REQUIREMENTS IN RNP
Irreparable RNP needs to be provided with
1. Wrist extension
2. Finger ( MCP) extension
3. Combination of thumb extension and
abduction
Motors available includes
extrinsic muscles innervated by the median
and ulnar nerves
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50. Nerve repair verses tendon transfers
Time since injury is critical factor
If prognosis of nerve repair is poor it would
be prudent to proceed directly to tendon
transfers
Nerve grafts can be used if the gap is too
great
Results are better if grafts are less than 5 cm
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52. Correction of contractures
All joints must be kept supple
Easier to prevent than to correct
Maximum motion must be present before a
tendon transfer
No tendon transfer can move a stiff joint,
Impossible for a joint to have more active
motion post-op than passive motion pre-op
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53. Adequate strength
Avoid a muscle that was previously
denervated and now has returned to
function
A muscle will usually loose one grade of
strength after transfer
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54. Amplitude of motion
Wrist flexors and extensors : 33 mm
Finger extensors and EPL : 50 mm
Finger flexors : 70 mm
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
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55. Tenodesis effect
Convert from monoarticular to biarticular
FCU transferred to EDC is converted to
multiarticular
Effective amplitude of tendon is increased by
active volar flexion of wrist.
Thereby allowing the transferred wrist flexors
to extend the fingers fully
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56. Straight line of pull
One tendon - one function
If inserted into two tendons, the force and
amplitude of the donor tendon will be dissipated
and will be less effective.
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57. Expendable donor
Removal of tendon must not result in
unacceptable loss of function
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58. Tissue equilibrium
It implies that
No soft tissue induration
Wounds are mature
Joints are supple
The scars are soft
Consider providing new tissue cover with
flaps.
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59. Tissue equilibrium
Tendon transfer works best when passed
between subcutaneous fat and deep fascial
layer
Least likely to work in the pathway of scar
Skin incisions should be planned so as to
place tendon junctures beneath flaps rather
than directly beneath incisions
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60. Timing of tendon transfers
Early - when there is questionable or poor
prognosis of nerve repair.
Nerve gap is more than 5 cm
Large wound
Extensive scaring
Skin loss over the nerve
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61. Timing of tendon transfers
In other cases consider doing nerve repair.
If good nerve repair has been accomplished
wait a sufficient time before transfers.
Which is determined by Seddon’s figures for
nerve regeneration about 1 mm per day.
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62. Timing of tendon transfers
Little support for Bevins concept
Proceed directly to tendon transfer and never
repairing the nerve
Results of radial nerve repair are good to
warrant routine repair in all cases.
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63. History
Evolved during the two
world wars
Sir Robert Jones major
inventor of radial nerve
transfers.
Classic Jones transfer
1916
PT – ECRL and ECRB
FCU – EDC 3-5
FCR – EIP, EDC 2 and
EPL
1921
PT – ECRL and ECRB
FCU – EDC 3-5
FCR – EIP, EDC 2, EPL,
EPB and APL
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64. History
Jones used both strong wrist flexors.
Zachary showed that it is desirable to leave
to leave atleast one wrist flexor intact.
PL alone is not adequate to provide for wrist
flexion.
Scuderi rerouted the PL to EPL.
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65. History
Evolved into standard set of transfers for
radial nerve palsy:
PT to ECRB
FCU to EDC 2-5
PL to rerouted EPL
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66. Tendon transfer
INFINITE NUMBER OF POSSIBLE COMBINATIONS
AVAILABLE
THREE SETS OF TRANSFERS ARE WIDELY USED
USING FCU
BOYES’ PROCEDURE—UTILISES SUPERFICIALIS TENDON
FOR FINGER EXTENSION
STARR’S METHOD –UTILISES FCR INSTEAD OF FCR
IN POSTERIOR INTEROSSEOUS NERVE PALSY,
PT TRANSFER IS NOT NECESSARY
THE INDICATION FOR FCR TRANSFER
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67. FCU Transfer
The first incision
The FCU tendon is
transected from the
pisiform
Detached as far
proximally as the
incision allows.
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68. SEPARATED FROM
DENSE FASCIAL
ATTACHMENTS►
CARROLL TENDON
STRIPPER
WHEN STRIPPER IS NOT
AVAILABLE ► EXTEND
FIRST INCISION
PROXIMALLY
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69. The second incision
Begins 2 inches below the
medial epicondyle and
angles across the dorsum of
the proximal forearm,
moving directly toward the
Lister tubercle.
The rest of the fascial
attachments to FCU muscle
is incised.
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70. The third incision
begins on the volar-radial
aspect of the mid forearm,
passes dorsally around the
radial border of the forearm
in the region of insertion of
the pronator teres (PT)
muscle, and angles back on
the dorsum of the distal
forearm towards the Lister
tubercle.
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71. TENDON OF PT IS IDENTIFIED
ITS INSERTION IS FREED UP WITH
AN INTACT LONG STRIP OF
PERIOSTEUM TO ENSURE
SUFFICIENT LENGTH
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72. The PT tendon is passed
subcutaneously around the
radial border of the forearm,
Superficial to the BR and
ECRL
Inserted into the ECRB
muscle just distal to its
musculotendinous junction.
ECRL NOT INCLUDED
WRIST IN 45 DEGREE
EXTENSION
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73. The FCU muscle is
pulled subcutaneously
over the ulnar border.
THE FCU TENDON is
weaved through the
EDC tendons at 45
degree angles.
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74. Suture FCU tendon into
each EDC slip separately
with 4-0 non absorbable
suture
Adjust the tension in each
EDC tendon individually so
that all 4 MP joints can
extend synchronouly &
evenly
Wrist & MP joints in neutral
(0 degrees) & FCU under
maximum tension.
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75. The EPL is divided and
rerouted toward the volar
aspect.
The PL tendon is transected at
the wrist and detached
proximally to allow a straight
line of pull between the PL and
EPL tendons.
Keep wrist in neutral & with
maximum tension on both EPL
& PL.
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77. SETTING THE PROPER TENSION IN THE
SUTURES IS ESSENTIAL
SUTURES SHOULD BE TIGHT ENOUGH ---
CONSIDERING THE FACT THAT
EXTENSORS GET STRETCHED WITH
TIME
TO PROVIDE FULL EXTENSION, YET NOT
SO TIGHT AS TO RESTRICT FULL
FLEXION
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78. POST OPERATIVE MANAGEMENT
LONG ARM SPLINT –
FOREARM IN 15-30 DEGREES
PRONATION,
WRIST IN 45 DEG EXTENSION,
MP JOINTS IN 10-15 DEG FLEXION
THUMB IN MAXIMUM ABDUCTION.
PIP JOINTS ARE LEFT FREE.
Remove SPLINT after 4 weeks.
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79. POST OPERATIVE MANAGEMENT
Planned Exercise Program –To begin at 4
weeks.
Instruct to work in synergistic movements
Maximum recovery occurs in 3-6 months
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80. POTENTIAL PROBLEMS
Excessive radial Deviation
-Due to removal of FCU
-Aggravated if PT is inserted in ECRL
In patients with PIN palsy FCU transfer is
contraindicated
Do Boyes’ superficialis transfers or FCR
transfer.
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81. Absence of Palmaris Longus
Compromises FCU set of transfers.
Include the EPL into the FCU to EDC
transfer, limits the abduction component of
the transfer.
BR( brachioradialis )can be used only in Post
interosseous nerve palsy
FDS 3 or 4 can be substituted for absent PL
(Tsug& Goldner)
Boyes superficialis transfer is the preferred
method in absent PL
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82. SUPERFICIALIS TRANSFER
(Boyes transfer)
In 1960 Boyes offered a reasonable alternative to the
standard set of transfer.
FCU is a more important wrist flexor to preserve
Normal axis of wrist motion is from dorsiradial to
volar-ulnar
FCU is too strong and its excursion too short for
transfer to the finger extensors
Prime ulnar stabilizer of wrist is too important to
sacrifice.
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83. SUPERFICIALIS TRANSFER
(Boyes transfer)
Despite the clinical concerns, studies
have shown no functional loss of power
grip with FCU transfer.
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84. SUPERFICIALIS TRANSFER
(Boyes transfer)
Full active extension of fingers with an FCU
or FCR transfer can be achieved only by
simultaneous volar flexion of the wrist, relying
on the tenodesis effect of the transfer.
Boyes concluded that because of the greater
excursion (70mm) FDS was a ideal motor for
finger extensors
New transfer provided for independent
control of thumb and index finger
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85. SUPERFICIALIS TRANSFER
(Boyes transfer)
The combination of transfer are
PT to ECRL and ECRB
FCR to ECB and APL
FDS ring to EDC (via interosseous
membrane)
FDS long to EPL and EIP (via interosseous
membrane)
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86. SUPERFICIALIS TRANSFER
(Boyes transfer)
The PT to ECRB transfer is done.
Expose superficialis of long & ring finger
through distal palm transverse incision .
Make opening in interosseous membrane.
Protect both anterior & posterior
interosseous vessels
Divide tendons & deliver them through
forearm wound
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87. SUPERFICIALIS TRANSFER
FDS 2 routed to radial side of profundus mass through
the interossous membrane
FDS 3 routed to ulnar side of profundus mass
Avoid injury to median nerve
FDS 2 is intervowen into tendons of EIP,EPL
FDS 3 into EDC
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88. SUPERFICIALIS TRANSFER
FCR tendon at the base of the thumb is
divided and detached.
And sutured to APL and EPB tendons.
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89. Summary of Boyes transfer
PT to ECRB
FDS long to EPI and EPL
FDS ring to EDC
FCR to APL and EPB
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90. FCR transfer
PT to the ECRB transfer is performed.
The FCR tendon is exposed through a longitudinal incision on
the volar-radial aspect of the forearm.
The tendon is divided at the wrist and redirected around the
radial border of the forearm to the wrist dorsally via a
subcutaneous tunnel.
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91. The finger extensor
tendons are withdrawn
distally and sutured to
the flexor carpi radialis.
After that, reroute the
PL to the EPL.
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92. CHOICE OF SURGERY
RADIAL OR INTEROSSEOUS N PALSY—
FCR SET OF TRANSFERS
LEAVES THE FCU INTACT WHICH IS A
PRIME ULNAR STABILIZER OF THE
WRIST
BOYE’S SET BEST FOR PTS WITH NO PL
FCU SET OF TRANSFERS
CONTRAINDICATED IN PTS WITH
POSTERIOR INTEROSSEOUS N PALSY
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93. NONOPERATIVE TRETMENT
Maintenance of full passive range of
movement in all joints of wrist and hand
Prevention of contractures mainly thumb and
index web
Physiotherapy has to be thought and closely
monitored
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94. Splints
Dynamic and static
Stabilizing the wrist in extension imparts
good temporary function.
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96. INTERNAL SPLINT (Early
transfers)
Early PT to ECRB transfer to eliminate the
need for an external splint and to restore
some amount of power grip
Indications
1. Substitute during regeneration of the nerve
to eliminate the need for splintage
2. Act as helper by adding power of normal
muscle to the reinnervated muscles
3. Substitute in cases in which nerve repair
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97. INTERNAL SPLINT
PRICIPLES OF TRANSFERS
Do not decrease remaining function in hand
Do not create deformity
Be a phasic transfer or capable of phase
conversion
Early PT to ECRB transfer fulfills all these
indications and principals so can be done at
the time of radial nerve repair or soon
thereafter sumeryadav2004@gmail.com
These causes may be grouped into the following general categories including
1. falls, collisions, motor vehicle accidents, high-velocity missiles, fractures, dislocations, lacerations.
Specific important etiology for radial nerve
Sensory examination of the radial nerve should include
3. Optimal conditions must be present before undertaking primary repair…………
4………. In these instances, the zone of injury is not apparent initially, and a delayed repair allows the zone of injury to declare itself.
If it is determined that primary………
During operation intra operative…………….
1. Assessed intra-operatively to determine the need for grafting.
2 .Adversely affects nerve repairs by causing gapping………..
Application of certain fundamental principles is needed for successful transfer of tendons.
4 he upheld that the transfer to one tendon improves function. Jones used to transfer FCR to four tendons with different functions
Although an infinite number of possible combinations for transfer of the radial nerve are available,
directed longitudinally over the FCU in the distal half of the forearm. Its distal end is J-shaped with a transverse extension long enough to reach the palmaris longus (PL) tendon.
Ecrl IS MORE OF A RADIAL DEVIATOR THAN A WRIST EXTENSOR. ECRB IS MORE CENTRALLY LOCATED THAN ECRL
through a long incision on volar side of radial aspect of mid forearm
INTERNAL SPLINT is not a definitive operation
Greatest functional loss in RNP is weakness of power grip