Tendon transfers for radial nerve palsy

Radial nerve Tendon transfers and basics of anatomy and principles

1. TENDON TRANSFERS IN
RADIAL NERVE PALSY
DR G AVINASH RAO
FELLOW HAND AND
MICROSURGERY
SKIMS
MODERATOR -DR MIR YASIR

2. ANATOMY -Largest branch of the brachialplexus
Arises from the posterior cord of the brachial plexus(C5–T1)
Mixed nerve

3. Course of Radial Nerve (RN) in thearm
In the axilla, RN lies
anterior to
subscapularis, teres
major and LD
•Sensory supply:
Posterior cutaneous
nerve of arm
RN leaves the axilla
via the triangular
space
:
•Motorsupply
longheadof
Triceps
It then comes to lie
along spiral groove
on posterior aspect of
humeral shaft along
with arteria profunda
brachii
•Motor: medial and lateral
heads of triceps,
Anconeus
•Sensory: posterior
cutaneous nerve of
forearm, lower lateral
cutaneous nerve of arm

5. RN then leaves the
spiral groove by
piercing the lateral
intermuscular septum
to enter the anterior
compartment of the
arm, 10-12 cm above
the lateral epicondyle
•Motor supply: Brachialis
(lateral part), BR, ECRL
Anterior to lateral
epicondyle, RN divides
into its terminal branches
•Terminal branches:
Posterior Interosseous Nerve
(PIN) and Dorsal or
Superficial radial sensory
nerve
Here it lies b/w brachialis andBR

6. Dorsal digital nerves ECRL
Dorsal Radial Sensory BR
Nerve
8 cm
Radial styloid
Dorsal radial nerve
courses through the
forearm immediately
deep to the BR
It emerges b/w
tendons of BR and
ECRL ≈ 8 cm
proximal to radial
styloid, to become
subcutaneous
It crosses the
anatomical snuffbox
b/w EPB and EPL,
dividing into multiple
branches to supply
sensation to hand
Course of Radial Nerve (RN) in the
forearm

7. Lower lateral cutaneous
nerve of arm
Posterior cutaneous
nerve of arm
Posterior cutaneous
nerve of forearm
Dorsal radial sensory
nerve
Gives sensibility to the
dorsum of the hand over the
radial two-thirds, the dorsum
of the thumb, and the index,
middle finger proximal to the
distal interphalangeal joint.
Cutaneous innervation from radial nerve

8. Deepterminalbranch→
Posteriorinterosseous
nerve(PIN)
Supinator
EIP
EDC and EDM
ECU
ECRB
Radial NerveProper
Superficialterminal
EPL
EPB
APL
PIN reaches the back of
forearm by passing
around the lateral aspect
of the radius b/w the
superficial and deep
heads of the Supinator
to supply all extensor
compartment muscles
Finally, PIN ends by
supplying carpal joint
sensation

9. Abraham & associates

10. Very high RN Palsy
High RN Palsy
Low RN Palsy

11. What is a tendon transfer?
Atendontransferprocedurerelocatestheinsertionofa
functioningmuscle-tendonunit(MTU)inordertorestorelost
movementandfunctionatanothersite.
Internalsplinting-Recipientinsertionispresevedin
anticipationofnerverecovery(endtoside).

12. How tendon transfer works ?
Tendontransfersworktocorrect:
–instability
–imbalance
–lackofco-ordination
–restorefunctionbyredistributingremainingmuscular
forces

14. FUNCTIONAL LOSS WITH RN -
PALSY
Power Grip -loss of active wrist extension -awkward
flexed position of the wrist.
Grasp -loss of finger and thumb extension -restricts
interosseousmuscle function -Loss of active finger
abduction.
The loss of cutaneoussensibility in the radial nerve
distribution is well tolerated.

15. Absolute Indications
1.Irrepairable radial nerve injury with no likely
chance of recovery.
2.No clinical electrophysiological recovery after 6
months of nerve injury / repair / nerve grafting.
3.Untidy injuries at pes anserinus –difficult to
repair / not suitble for DNT.
4.Late presentation of >6-9 months
5.Severe PIN syndrome >9 months –Nerve
release + TT.

16. TENDON TRANSFER –Goals in RN Palsy
There are three main goals when treating radial nerve
palsy.
Restoration of finger (MCPJ)extension,
Restoration of thumbextension,
Incases of high radial nerve palsy, restoration of wrist
extension.
(Accredited to Riordan1964)

17. Selecting donor tendons
•Based on Smith & Hastings (Principles of tendon transfers to the hand. Instr
Course Lect 29:129, 1980)
1.List functioning muscles
2.List which of those muscles are expendable
3.List hand functions requiring restoration.
4.Match #2 and #3
5.Staging
Available donors –Extrinsics innervated by median and ulnar nerve.

18. Radial nerve –predominantly motor & targetted re-innervation is close
to injury site –results are good.

19. Timing of tendontransfer–Debatable ?
The timing of a tendon transfer -depends on the likelihood of spontaneous
reinnervation and nerve recovery.
If nerve repairs or nerve transfers were performed initially -sufficient time
should be allowed to determine the outcome of the initial treatment before
considering tendon transfers. (axons regenerate at a rate of approximately
1 mm/d.)
But, some hand surgeons advocate early tendon transfers, particularly
inpatients with radial nerve palsies, even if recovery is still possible.

20. Brownadvisedignoringthenerveandproceedingdirectly
tothetendontransfersiftherewasanervedefectofmore
than4cm,alargewoundorextensivescarring,orskinloss
overthenerve.
Otherssay,ifagoodrepairofthenerveisachieved-wait
5-6monthstoallownerveregenerationtooccur.They
wouldonlyproceedtotendontransfers,ifitwasclearthat
inadequatemusclereinnervationhadoccurredbyboth
clinicalandelectrodiagnosticcriteria.

21. Bevinsuggestedapolicyofneverrepairingtheradialnerveand
proceedingdirectlytotendontransfers.Thisreducedtheperiodof
disabilityafterinjuryto8weeks.
Theredoesnotseemtobeanytimelimitastohowlongadelaycanbe
toleratedbeforetransfersaredoneafternerveinjury.
Brodmanreportedsuccessfultransfers24yearsafterradialnerveinjury,
despitewhathedescribedas“gelatinousdegeneration”(i.e.,translucent
appearance)oftheparalyzedtendonsatthetimeofoperation.

22. In 1974, Burkhalterreported -Early transfers .
Burkhalterbelieves greatest functional loss is grip strength therefore
advocated early Tendon transfer
Therefore eliminate need for external splint plus also restore grip strength
3 Advantages:
1.Works as substitute during early regeneration.
2.Works as helper by adding power to reinnervatedmuscle
3.Acts as substitute in cases which results of nerve repair are poor (eg
chronic/crush injuries or elderly).

23. CONTRAINDICATIONS:
•Absolutecontraindication-lackofappropriatedonors.
•Relativecontraindication–
•Theavailabilityofmuscle-tendonunitswithlessthangrade5strength.
•Musclesthathavebeendenervatedandthenreinnervatedareavailable.
•Transfersplannedinindividualswithprogressiveneuromuscular
diseases.
•Transfersperformedtoproducemotioninless-than-supplejoints.

24. History
World War I and World War II -major advancements.
Jones is credited with being the major innovator of radial nerve transfers
-“classic” Jones transfer.

25. JonesusedPT–ECRBisuniversallyaccepted–wristEXT.anfCUand
FCRfor–finger,thumbEXT.
1922StarrwasthefirsttotransferthePLandtheFCR,leavingtheFCU
intact.
BoyesadvocatedusingtheStarrFCRtransfer.
Zachary-illustratedthebenefitofleavingonewristflexorintact.
ScuderirefinedthePLtoreroutedEPLtransfer-functionisbetterwhen
thetransferisdoneintoonlyonetendon.
In France, a slightly modified version (i.e., PT to ECRB, FCU to EDC and
EPL; PL to EPB and APL)is known as the Merle d’Aubignéprocedure.

26. Brand’s biomechanical and clinical studies -FCU should not be used
as a tendon transfer for two reasons:
(1)the FCU is too strong and its excursion is too short for transfer to the
finger extensors, and
(2)Its function as the prime ulnarstabilizer of the wrist is too important to
sacrifice.
(3)It cannot provide simultaneous wrist and finger extension.
Despite these concerns, studies have shown no functional loss of
power grip with the FCU set.

27. Donor Insertion Function Reference
PT
FDS MF
FCU
ECRB
EPL (re routed)
EDC
Wrist extension
Thumb extension & abduction
Finger extension
Goldner1974
PT
PL FCR
ECRB
EPL EDC
Wrist extension
Thumb extension Finger extension
Brand 1975
PT ECRL & ECRB Wrist extension Boyes 1970
FCR APL & EPB Thumb abduction
FDS RF EPL & EIP Thumb & index extension
FDS MF EDC via interosseous m Finger extension
PT ECRB Wrist extension Beasley 1970
PL APL Thumb abduction
FDS LF EPL Thumb extension
FDS RF EDC Finger extension
PT ECRB Wrist extension Smith &
FCU EDC & EPL Digit extension Hastings
PT
FCU
PL
ECRB
EDC (IF/LF)
EPL(rerouted)
Wrist extension
Finger extension
Thumb extension
Riordan

28. Three sets of transfers are currently favored for
radial nerve palsy

29. FCR Transfer –Brand & Tsuge

32. MobergandNachemsonsuggestedthatbetterresultscanbeachieved
if4to5cmofinactivatedEDCmuscletendonisresectedjustproximal
totheintendedsiteofsuture,allowinganend–endjunctureandamore
directlineofpull.
IncludingEDMornot–Dependsonintra-opassessment.
Weshoulderronthesideofsuturingextensortendontransferstootight
ratherthantooloosebecausetheextensorstendtostretchovertime.
If PL is absent –
1.Suture FCR /FCU to EPL, or use BR to EPL in PIN palsy.
2.TsugeandAdachisubstitutedtheFDSIIIorIVforanabsentPL.
3.Boyes–superficialistransferisprefferedincaseofabsentPL.

33. FirstsuturedthePTtoECRB-justdistaltothemusculotendinous
junction-asaPulvertaftweave.
ThetransferissuturedwiththePTinmaximumtensionandthewristinat
least45degreesofextension.
ThentheFCUtransferisthensutured.
OmerweavedtheFCRor(FCU)tendonend-to-sidethroughtheEDC
tendonsata45-degreeanglejustproximaltothedorsalretinaculum.
Finallyusingretractingthethirdincision–torerouteEPLandtransferred
toPL.
BotharesuturedinNeutralwristandMCP.

34. Critical points

35. Critical points

36. Critical points

37. Tension assessment –intra op
Thetensionmustbetestedbypassivelymovingthewristtoshowthe
synergisticactionofthenewtransfer.Withthewristinextension,it
shouldbepossibletoeasilyflexthefingerscompletelyintothepalm,and
withthewristinflexion,theMPjointsshouldpullintofullextensionbut
nothyperextend.

38. Post-op protocol
Long arm splint is applied that immobilizes the forearm in 15 to 30 degrees
of pronation,the wrist in 45 degrees of extension, the MP joints in 10–15
degrees of flexion, and the thumb in maximum extension and abduction.The
PIP joints of the fingers are left free.
The splint and sutures are removed at 10 to 14 days, and a further long arm
cast is applied in the same position as noted previously.
The cast is removed 4 weeks postoperatively and a short arm splint is
applied to hold the wrist, fingers, and thumb in extension. This should be
worn for 2 weeks, though is removed intermittently for exercise.
A planned exercise program, begun at week 4.
Well-motivated patient should have good control of function by 3 months,
although many patients need 6 months to reach maximum recovery.

39. FCU TRANSFER

40. Critical points

41. Problems with FCU transfer
ContraindicationforFCUtransferisPINpalsy.
Excessiveradialdeviationofwrist–especiallywithPINpalsy/Transferto
ECRL.
FCUtransfershouldnotincludeECRL.OrAlterinsertionofwristextensors.
The“simplest”waytothisistoresectthedistal2to3cmofthefunctioning
ECRLtendonandsuturethetendonmoreproximallyintotheadjacent
nonfunctionalECRB.
Brand-attachedthePTtotheECRLandECRBtogetherproximallyand
thendetachtheinsertionofECRLandreinsertitintothebaseofthefourth
metacarpal.

42. Tubianaandcolleaguesalsopreferredtocentralizetheinsertionofthe
ECRL.InadditiontothedifferentmomentarmsofECRLandECRBfor
wristextensionandradialdeviation,theywerealsoconcernedabout
adhesionsbetweenthetwotendons.
TheysuturedthePTtotheECRBonly,butalsoreroutedtheinsertionof
theECRL.TheECRLtendonisdividedatitsinsertionintothebaseofthe
secondmetacarpal,freedupproximallytoitsmusculotendinousjunction,
reroutedbeneaththedorsalretinaculuminthefourth(EDC)
compartment,andfixedtothebaseofthethirdandfourthmetacarpals
withsuturesandstaples.

43. Superficialis / Boyes Transfer
Boyes suggested that the superficialis (sublimis) tendons, with their
greater excursion (70 mm), would be better motors for finger extensors.
It also provided more independent control of the thumb and index finger.
PT to ECRL and ECRB
FCR to APL and EPB
FDS long finger (III) to EDC (via interosseous membrane)
FDS ring finger (IV) to EPL and EIP (via interosseous membrane)

44. 2
1
2
3
1

46. Tension adjustment
The tension is set with an assistant clenching the patient’s fingers and
thumb into a fist and bringing the wrist into 20 degrees of extension. This
position is maintained until all the transferred tendons are attached to
their new insertions under “considerable tension.”

47. Damage to the interosseous vessels and potential
serious bleeding

48. Post-op protocol
Postoperativesplintsareappliedandwornfor4weeks,atwhichtimethe
suturesareremovedandasplintisworndayandnight,exceptduring
exerciseperiods,forafurther2weeks.
Allexternalsupportisdiscontinuedat6weekspostoperatively.The
exerciseprogramshouldemphasizespecificcontrolofthesuperficialis
musclestotrytotakeadvantageofthegreaterexcursionofthese
tendons.
Avoidusingthetenodesistechniquesthatareusefulaftersynergistic
(i.e.,FCUandFCR)transfers.

49. Single-Tendon Transfer. Gousheh and Aratesh
IsolatedtransferoftheFCUforradialnervepalsytotheEDC,EIP,and
EPL,withoutanadditionalPTto-ECRBtransferasasimplealternativeto
multipletendontransfersin108patientswithradialnervepalsy
Simplicity of the procedure, reduced operating time, and quite adequate
hand function despite incomplete restoration of wrist extension.
Gousheh J, Arasteh E: Transfer of a single flexor carpi ulnaris tendon for treatment of
radial nerve palsy. J Hand Surg [Br] 31:542–546, 2006.

50. Outcome and Results
Altintasetalassessed77patients60monthsaftertransfersusingthe
FCRmuscletorestorefingerextensionin19casesandtheFCUmuscle
in56cases;73%ofcontralateralsidewristextensionand32%of
contralateraldigitalextensionwereregained.Powergripwasreducedto
49%andpinchgripwasreducedto28%.ThemeanDASHscorewas15
±9,indicatinggoodfunction,and89%ofpatientsremainedemployed.

51. MoussavietalcomparedtheuseofFCR,FCU,orFDSIII+IVfor
restorationoffingerextensionin41Iranianpatientswithisolatedradial
nervepalsies.122Theyfoundnodifferenceintheoutcomesofthese
threeprocedures,exceptthatallthreeofpatientswhowereableto
extendtheirfingersandwristatthesametimehadundergoneFDS
transfers.TheyreportedmeanDASHscoresof30to38forthethree
treatmentgroupsandthat30oftheir41patientswereabletoreturnto
workwithoutdifficulty.

52. Dabasetalassessedtheobjectiveoutcomesof10patientswho
underwentanearlytransferofpronatorterestoECRBastreatmentofa
highradialnervepalsy.
At6-monthfollow-upthereweremedianincreasesof48%inpowergrip,
162%intippinch,90%inkeypinch,and98%inpalmarpinchfromthe
preoperativevalues;however,decreasedpalmarflexionwasseeninfour
patients.Therewasoneunsatisfactoryresult.Theauthorsadvisedearly
tendontransfertoquicklyimprovehandfunctionandavoidtheneedfor
splintagewhileawaitingreinnervationofwristextensors.

55. Very High RN Palsy
Crutchpalsy/Saturdaynightpalsy/TorniquetPlasy/HoneymoonPalsy.
Elbowextensionloss+featuresofLowRNpalsy.
Forpatientslackingactiveelbowextension.Optionsforreconstruction:
1.DeltoidtoTricepstransfer.
2.BicepstoTricepstransfer.
OtherOptions-FunctionalmuscleTransfer–UsingLat.Dorsi,Sartoriusetc.

59. Tips to maximise success during surgical
procedure
1.Incisionsshouldnotcrossthepathofthetransferredtendon
2.Avoidinterferencewithnormalstructures
3.Tendonshouldinsertintothejointofmotionat90
0
tomaximisepowerand
excursion.Insertioncanbemovedawayfromthejointtoimprovepower,
butthisisattheexpenseofdecreasedexcursion.
4.Thetransferredtendonshouldinsertintoanothertendonorbone.Strong
insertionsallowearliermobilisation.

60. 5.Asingleinsertionisbest.Dualinsertionstendtoprovidemotiontothe
tighterinsertion.Canbeanadvantageincomplexmovements,where
oneinsertionistighterduringonephaseofmotion,andtheothertakes
overduringanotherphase
6.Tensionshouldbesettoproducethenecessaryjointmovementwith
maximalmusclecontraction.Someinitialovercorrectionshouldbe
planned,assometendonstretchisusual.
7.Jointshouldbeinitiallyimmobilisedinapositionthatrelievestensionat
theinsertionofthetransfer

61. Take Home Message
Tendontransferstorestorefunctioninradialnervepalsyarethebestand
themostpredictableintheupperextremity;however,aspointedoutby
Riordan-
“Thereisverylittlehopethaterrorsintechniquecanbeovercomebylocal
adaptation.Thesuccessorfailureofanoperationdependsonthe
technicalcompetenceoftheoperatorandhispainstakingafter-care.”
Riordanalsonotedthat“thereisusuallyonlyonechancetoobtaingood
restorationoffunctioninsuchaparalyzedhand.”