Transcript
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 SurgeonFellowship Director, Upper Limb Fellowship
Wrightington Hospital
ISCP – Tendon Transfer Hand
ST3-8 (T&O) ST3-6 (Plastic) Specialty interest ST7/8TIG
Applied clinical knowledge
3 Basic – Intermediate – Advanced
4
Applied clinical skills
2 Basic – Intermediate – Advanced
4
Applied Clinical Knowledge1. knows of 2. knows basic concepts 3. knows generally 4. knows specifically and broadly
Applied Clinical Skills0 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
FRCS RevisionWhy?
What?
When?
How?
HOTHigher Order
Thinking
IndicationsRestore function
Muscle paralysis/nerve injuriesIrreparable injuries to the musculotendinous units
Restore balanceStroke, cerebral palsy, tetraplegia
Why?
It is not the actual strength that matters but balance.
Paul Brand
Decision makingWhat is missing
What needs reconstructing (think of FUNCTION)
What is available
What is appropriate
What?
HOT
PrinciplesTissue equilibrium is achieved
Bony stability
Good soft tissue envelope/gliding plane
Full passive range of motion
Expendable donorMinimum 1 wrist extensor, 1 wrist flexor1 extrinsic flexor & extensor to each digit
When?
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: 33mmFinger extensors, FPL, EPL: 50mmFinger flexors: 70mmTenodesis effect +20mm
Expect decrease of one MRC grade after transfer
PrinciplesHow?
Single line
Single joint
Single function
Synergy
Sensibility
PrinciplesHow?
Ideal principles but not obeyed all the times
Median Nerve Palsy
LowDonor Tendon
Camitz Palmaris longus
Burkhalter Extensor indicis proprius
Bunnell FDS IV
Huber Abductor digiti minimi
HighLost Function Donor Tendon
Opposition EIP APB
Thumb IPJ flexion
Brachioradialis FPL
Index finger flexion
FDP I Sutured to neighbour FDPs
Radial Nerve Palsy
PIN HighLost 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
Ulnar Nerve Palsy
LowLost Function Donor TendonClawing (Grasp) FDS III slips
lateral bandsThumb adduction
ECRB + PL graft Adductor pollicis
Index finger abduction
Accessory APL 1st dorsal interosseous
Little finger adduction(Wartenberg sign)
EDM radial lateral band
HighLost Function Donor TendonIn addition to lowFDP IV/V DIPJ flexion
Side-to-side tenorrhaphy FDP III
Anti-clawing ProceduresStatic
Zancolli capsulodesisFasciodermadesisTenodeses
DynamicMCPJ flexionMCPJ flexion + IPJ extension
Bouvier manoeuvre?
Donor options to correct clawing
SurgeryRadial nerve setOpponensplastyAnti-claw procedureAdductorplastyEI-EPL
How?
SummaryWhat is missing
What needs reconstructing (think of FUNCTION)
What is available
What is appropriateHOT
Recommended readingJones 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.
Thank you and good luck!
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