Tendon transfer

Definition:
Tendon transfer involve detachment of the tendon of functioning
muscle from its insertion, mobilization without damage to the
neurovascular pedicle and rerouting it to a new distal attachment to
tendon or bone.

Muscle selection
Availability
Control
Amplitude of Excurtion
Anatomic location
Synergism
Only muscles 4/5 power are suitable for TT

Radial nerve
Tendon transfers:
1. pronator teres to the short radial extensor of the wrist,
2. flexor carpi radialis to the long finger extensors and
3. palmaris longus to the long thumb abductor.

 Principles of tendon transfers

o match muscle strength
  force proportional to cross-sectional area
 greatest force of contraction exerted when
muscle is at resting length
 amplitude proportional to length of muscle
 work capacity = (force) x (amplitude)
 motor strength will decrease one grade after transfer
 should transfer motor grade 5
o appropriate tensioning
o appropriate excursion
 can adjust with pulley or tenodesis effect
 Smith 3-5-7 rule
 3 cm excursion - wrist flexors, wrist extensors
 5 cm excursion - EDC, FPL, EPL
 7 cm excursion - FDS, FDP
o surgical priorities

1. elbow flexion (musculocutaneous n.)

2. shoulder stabilization (suprascapular n.)
3. brachiothoracic pinch (pectoral n.)
4. sensation C6-7 (lateral cord)
5. wrist extension and finger flexion (lateral and
posterior cords)
o selection

 determine what function is missing

 determine what muscle-tendon units are available
 evaluate the options for transfer
o basic principles

 donor must be expendable and of similar excursion

and power
 one tendon transfer performs one function
 synergistic transfers rehabilitate more easily
 it is optimal to have a straight line of pull
 one grade of motor strength is lost following transfer
 Prognosis
o age
 leading prognostic factor
 worse after age 30
o location
 distal is better than proximal

Presentation

 Physical exam
o brachial plexus injury
  Horner's sign
 correlates with C8-T1 avulsion
 often appears 2-3 days following injury
 severe pain in anesthetic limb
 indication of root avulsion
 loss of rhomboid function
 indication of root avulsion
o radial nerve palsy
 classified according to location of lesion proximal or
distal to the origin of PIN
 low radial nerve palsy
 PIN syndrome
 high radial nerve palsy
 loss of radial nerve proper function
(triceps, brachioradialis, ECRL plus
muscles innervated by PIN)
o median nerve palsy
 classified according to location of lesion proximal or
distal to the origin of AIN
 low median nerve palsy
 loss of thumb opposition (ABP function)
 high median nerve palsy
 loss of thumb opposition
 loss of thumb, index finger, and middle
finger flexion
o ulnar nerve palsy
 low ulnar nerve palsy
 loss of power pinch
 abduction of the small finger (Wartenberg
sign)
 clawing
 results from imbalance between intrinsic
and extrinsic muscles
 high ulnar nerve palsy
 loss of ring and small finger FDP function
 primary distinguishing deficit
 clawing less pronounced because extrinsic
flexors are not functioning

Treatment
 Nonoperative
o physical therapy, splinting, and antispasticity
medications
 indications
 decreased passive range of motion
 spasticity
 Operative
o early surgical intervention (3 weeks to 3 months)
 indications
 total or near-total brachial plexus injury
 high energy injury
o late surgical intervention (3 to 6 months)
 indications
 partial upper-level brachial plexus palsy
 low energy injury
 postoperative care
 protect for 3-4 weeks then begin ROM
 continue with protective splint for 3-6 weeks
 synergistic transfers are easier to rehabilitate
(synergistic actions occur together in normal
function, e.g., finger flexion and wrist
extension)

Specific Transfers & Indications

Goal to FROM: Donor tendon TO: Recipient Tendon
regain (working) (deficient)
Axillary nerve palsy
Shoulder glenohumeral arthrodesis glenohumeral arthrodesis
stability (flail
shoulder)
Musculocutaneous nerve palsy
Elbow flexion pectoralis to biceps
major, latissimus dorsi
Elbow flexion common flexor mass point more proximal on
humerus (Steindler
flexorplasty)
Radial nerve & PIN palsy
Elbow deltoid, latissimus dorsi, to triceps
extension or biceps
Wrist
PT ECRB
extension
Finger
FDS, FCR, or FCU EDC
extension
Thumb
PL or FDS EPL
extension
Low median nerve palsy
Thumb FDS (ring) base proximal phalanx or
opposition and APB tendon (use FCU as
abduction pulley - classic Bunnell
opponensplasty)
EIP APB (pulley around ulnar
side of wrist)
High median nerve palsy
Thumb IP BR FPL
flexion
Index and long FDP of ring and small FDP of index and middle
finger flexion finger (ulnar nerve) (side-to-side transfer)
Ulnar nerve palsy
Thumb FDS or ECRB adductor pollicis
adduction
Finger APL, ECRL, or EIP 1st dorsal interosseous
abduction
(index most
important)
Reverse FDS, ECRL (must pass lateral bands of ulnar digits
clawing effect volar to transverse
metacarpal ligament to
flex proximal phalanx)