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Pre and post operative management in tendon transfer
1. Pre and Post Operative
Physiotherapy Management In
Tendon Transfer of Hand
By Dr. Rajal Sukhiyaji
(M.PT. in Sports Science)
2. Contents
⢠Definition
⢠Principles of tendon transfer
⢠Prerequisites for tendon transfer
⢠Treatment goals
⢠Indications, Contraindications, Precautions
⢠Radial nerve palsy ( Purpose, Preoperative requirements,
Tendon transfer, Post operative Management, Different
splint)
⢠Ulnar nerve palsy
⢠Median nerve palsy
⢠Post operative complication
⢠Evaluation time
⢠Recent advances
⢠References
3. Definition :-
⢠Tendon transfer is a surgical procedure that
involves moving the insertion of a tendon muscle
unit from one location to another location.
⢠A tendon transfer can be used to restore grasp,
improve the position of the hand in space, and to
prevent deformity, dislocations and contractures.
4. General Principles Of Tendon Transfer
Three important principles should be emphasized
1) The transfer should not significantly decrease
the remaining function of the hand.
2) The transfer should not create a deformity if
significant return of function occurs following
a nerve repair.
3) The transfer should be phasic or capable of
phase conservation.
5. Fundamental principles of muscle-
tendon units include the following:
1) Correction of contracture
2) Adequate strength
3) Amplitude of motion
4) Straight line of pull
5) One tendon, one function
6) Synergism
7) Expendable donor
8) Timing of tendon transfer
6. Prerequisites for tendon transfer
⢠The patient must be a suitable candidate.
⢠All joints must be fully passively mobile.
⢠All skin and soft tissue in the vicinity of the
transfer must be pliable and mobile.
⢠The muscle-tendon unit to be transferred must
be sufficiently strong to perform its new function
in its altered position.
7. Treatment Goals
ď Preoperative goals
A) Achieving and maintaining full PROM and AROM if
possible.
B) Achieving maximum strength of the donor muscle and
antagonist muscles
C) Maintaining supple, soft tissue by minimizing scar,
edema, and adhesions and resolving intrinsic/extrinsic
muscle tightness. Use gel, elastomer molds, kinesiotape,
and so on.
8. D. Complete comprehensive evaluation, including sensory
testing, functional assessments, ROM measurements,
strength testing, and photographs for postoperative
comparison.
E. Educate the patient about the therapy process, splinting
demands, and realistic postoperative expectations.
F. Establish good communication with the surgeon,
schedule postoperative therapy. Review operative report
when available.
9. ďPostoperative goals
A.Protect transferred tendon.
B. Maintain ROM of uninvolved joints and involved joints.
C. Control postoperative edema and pain.
D. Control scar tissue (skin and subcutaneous) and prevent
adhesions to decrease drag on transfer.
E. Progress patient to functional use of hand.
10. Indications
⢠Poliomyelitis
⢠Paralysis of muscle
⢠Nerve injury (peripheral or brachial plexus)
⢠Injured (ruptured or avulsed) tendon or muscle
⢠Balancing deformed hand e.g. cerebral palsy or
rheumatoid arthritis
⢠Some congenital abnormalities
11. ⢠Prompt consideration of tendon transfers is indicated if,
(a) The prognosis for neurologic recovery is poor even with
nerve repair,
(b) Muscles have been destroyed, or
(c) Nerve grafts have been required to restore nerve continuity.
12. Contraindications
1. Contracture of joints or skin that would limit movement.
2. Lack of a suitable muscle or muscles for transfer.
3. A progressive neuropathy, e.g. nerve damage following
radiation therapy.
4. Complicating medical conditions, e.g. muscle spasm or
circulatory inadequacy.
13. Precaution
A. Acceptance of less than full PROM before transfer.
B. Overestimation of donor muscle strength
C. âDragâ along transfer route secondary to scar
D. Technical failures (e.g., rupture of juncture, too loose or
too tight)
E. Be mindful of stretching out transfer. Wait until 6 weeks
after surgery before addressing tightness of transfer.
14. Radial Nerve Palsy
⢠The classic âwrist dropâ result.
⢠When the wrist cannot be stabilized in extension, the power
of the long flexors is minimized, thereby seriously
impairing grip function.
⢠Where the radial nerve is irreparable, the following
functions will need to be restored:
1. Wrist extension.
2. Finger extension (at the MCP joints).
3. Thumb extension and abduction.
15. ďPurpose
⢠It is impossible for the patient with this condition to
open the hand to grasp objects; therefore, the transfer of
normally functioning muscleâtendon units is frequently
used to overcome the deficit.
⢠The radial nerve supplies all of the wrist extensors and
finger extensors, including the thumb.
16. Preoperative requirements
1. The wrist must be passively mobile in extension.
2. The MCP joints must be passively mobile in extension.
3. The thumb web space must be normal.
4. There must be a full range of forearm supination/pronation
and also elbow flexion/extension.
5. Minimize edema if present.
17. Tendon transfer for radial nerve palsy
1)Flexor carpi radialis transfer
⢠PT to ECRB for wrist extension
⢠Flexor carpi radialis (FCR) to EDC for finger MP
extension
⢠Palmaris longus (PL) rerouted to EPL for thumb
extension
18. 2)Flexor carpi ulnaris transfer
⢠PT to ECRB for wrist extension
⢠FCU to EDC for finger MP extension
⢠PL to rerouted EPL for thumb extension
3)Boyes transfer (Superficialis transfer)
⢠PT to ECRL and ECRB
⢠Flexor Digitorum Superficialis (FDS) III to EDC
⢠FDS IV to Extensor Indicis and EPL
⢠FCR to APL and EPB
19. Flexor carpi ulnaris (FCU) transfer for radial nerve
palsy using pronator teres (PT), FCU and palmaris
longus (PL) as motors.
20. Post operative Management
ďSplint position
1. Elbow in 90 degrees of flexion.
2. Forearm in about 30 to 90 degrees of
pronation.
3. Wrist in 30 to 45 degrees of extension.
4. MCP joints in 10 to 15 degrees of
flexion; PIP joints free or at 20 to 45
degrees flexion. The splint extends just
proximal to the PIP joints which are
left free to move.
5. Thumb in maximum extension and
abduction.
21. ⢠Week 0 to week 3 or 4: Splint/cast.
A. Maintain ROM of uninvolved joints
B. Protective ROM of individual joints
C. Avoid composite wrist and digit flexion.
D. Edema management
E. Scar management
F.Desensitization techniques
⢠Week 3 or 4: Splint. Fabricate splint, according to
surgeonâs guidance, which may or may not include the
elbow. Position the hand and wrist in same positions as in
the original cast.
A. ROM: as above.
B. Scar management
22. ⢠Weeks 5 to 6: Muscle reeducation.
⢠Week 7: Begin dynamic flexion splinting if extrinsic
extensor tendon tightness is present.
⢠Week 8: Discontinue protective daytime splinting;
introduce resistive exercises. Begin passive wrist flexion
to gain maximum pronator teres length.
⢠Week 12: Resume unrestricted activities.
24. Ulnar Nerve Palsy
⢠Affect pinch and grip strength and manipulation and
cause difficulty with the approach of objects due to a
claw-hand deformity.
⢠Denervation of the flexor digitorum profundus (FDP) to
the ring finger (RF) and small finger (SF) complicates
the deficits of intrinsic weakness by further weakening
grasp.
25. ⢠The signs indicative of ulnar nerve palsy are as
follows:
⢠Fromentâs sign:
⢠Jeanneâs sign:
27. ⢠Purpose
⍠Restore balance and function of a hand
⍠This may occur as a result of prolonged compression
as in cubital tunnel syndrome, trauma, disease,
infectious processes, congenital anomalies, or spastic
paralysis.
⢠Where the Ulnar nerve is irreparable, the following
functions will need to be restored:
1) MCP joints Flexion
2) Thumb adduction.
28. ⢠Preoperative requirements for ulnar
nerve lesion
1. The PIP joints must be fully mobile in passive extension
and the MCP joints fully mobile in passive flexion.
2. Soft tissues should be free of contracting scar and have
adequate circulation.
29. ďśTendon Transfer for Ulnar nerve palsy
o Suitable muscle-tendon units include:
⢠Flexor digitorum superficialis, extensor carpi radialis
longus, extensor carpi radialis brevis, flexor carpi radialis,
brachioradialis and palmaris longus.
⢠The smaller extensors, i.e. extensor indicis proprius and
extensor digiti minimi (quinti) can provide intrinsic
function with the transfer of a muscle to two fingers each
(original Fowler technique)
30. ⢠Superficialis transfers are designed to integrate MCP
joint and IP joint motion. They do not, result in
increased grip strength . The use of a wrist extensor to
flex the MCP joints will improve gross power grip.
31. ⢠Low Ulnar Nerve Injury
A) Intrinsic Rebalancing
1) FDS of middle finger (MF)
32. 2) Zancolli lasso procedure
3) Brand transfer of ECRL/ECRB to intrinsics with
tendon graft
B) Restoration of power pinch
1) Smith-Hastings procedure
ECRB ď ADP with graft
2) FDS of RF ď ADP
⢠High Ulnar Nerve Injury
1) ECRL ď FDP
33. Post operative management
⢠Splint position
1. Wrist in 45 degrees of extension.
2. MCP joints in 70 degrees of flexion.
3. IP joints in full extension.
4. The thumb remains free
34. ďPostoperative day 10 to 14:
⢠Remove postoperative cast, have tension checked by
surgeon, and immobilize patient in splint or recast.
⍠A. Fit the patient with a splint
⍠B. Gentle AROM and PROM within the restraints of the
splint.
ďWeek 4:
⢠The hand and forearm are maintained in the described
position for the first postoperative month.
⢠Begin AROM out of splint, avoiding composite extension.
35. ďWeek 6:
⢠When the hand is removed from the splint and placed on
the table, there will be a slight relaxation of the positions of
wrist extension and MCP joint flexion.
⢠The patient is then asked to actively extend the wrist which
should result in some MCP joint flexion. Extension of the IP
joints should be maintained during this manoeuvre.
⢠The hand is returned to the splint after each exercise
session until the end of the 6th week.
36. ⢠The patient should perform this exercise on a 1 to 2
hourly basis with 5 to 10 repetitions during the 1st week
of active exercise.
⢠By the 2nd week, the patient learns to localize the action
of MCP joint flexion without having to extend the wrist
and practises the movement with the hand in all
positions, i.e. palm up and with the hand on the side.
⢠By the 5th week, emphasis is placed on active flexion and
extension of the fingers while maintaining MCP joint
flexion. Gentle active wrist flexion is also begun. May
introduce light resistance.
37. ďWeek 6 to 12:
⢠Progressive resistive exercises. It is important not to fatigue
the transfer.
⢠Light gripping activities are commenced.
⢠Graded resistance is applied to MCP joint flexion with the
IP joints extended, i.e. intrinsic flexion.
⢠The activity programme is upgraded to restore maximum
power grip.
39. Median nerve Palsy
⢠Functional impairment from a median nerve lesion is
primarily the result of lost skin sensibility on the working
surfaces of the thumb, index and middle finger, those used
for precision manipulation, rather than the loss of muscle
function.
⢠The main function that needs to be replaced is opposition of
the thumb.
⢠Three muscles are used for this function
⍠Abductor pollicis brevis,
⍠Opponens pollicis and
⍠Flexor pollicis brevis.
40. ďPurpose
⢠Restore balance and function of a hand.
⢠This may occur through prolonged compression as in
carpal tunnel syndrome, trauma, disease, infectious
process, congenital anomalies, or spastic paralysis.
41. ⢠Preoperative Requirements prior to
opponensplasty for low level lesion (wrist)
1. Normal or maximal thumb web span.
2. Mobile thumb joints.
3. Full mobility of the unaffected digits.
4. Soft tissues should be free of contracting scar and have
adequate circulation.
42. Tendon transfer for Median nerve
Low Median nerve palsy
⢠Opponensplasty :-
A. FDS of ring finger (RF) or
PL to APB : long opponens
splint
46. Post operative Management
⢠Splint position
⢠The wrist is immobilized in neutral
extension with the thumb held in full
opposition and the IP joint of the
thumb held in extension
⢠The fingers are left free to move.
⢠If the PIP joint has been tenodesed to
prevent hyperextension deformity, it
should be splinted in about 45 degrees
of flexion during the immobilization
period.
47. ďPostoperative day 10 to 14:
Remove postoperative cast, have tension checked by
surgeon, and immobilize patient in splint. Address wound
care, edema reduction, and scar management if indicated.
ďWeek 3: Begin AROM of thumb in splint to activate
transfer, six to eight times per day
ďWeek 4: Begin AROM of thumb and other joints out of
splint. Focus on activation of transfer. May use light grasp
and prehension tasks.
48. ďWeek 6: Discharge splint for protection and begin
unrestricted AROM/PROM. May introduce light resistance.
ďWeek 8: Progressive resistive exercises. Preferably the
patient should complete frequent low-resistance exercise
sessions rather than occasional higher-resistive exercises. It
is important not to fatigue the transfer.
ďWeek 12: Resume unrestricted activities.
49. High Median Nerve Injury
⢠Flexor Pollicis Longus
⢠Brachioradialis/FDS to FPL: dorsal blocking splint (possibly
long arm splint with elbow in 90 degrees flexion for
brachioradialis)
50. ďPostoperative day 10 to 14:
ďWeek 3: AROM of MCP/IP within splint to activate
transfer, six to eight times per day9
ďWeek 4: AROM out of splint for transfer activation and
light prehension
ďWeek 6: Discharge splint; PROM and splinting to
decrease tightness if present
ďWeeks 7 to 8: Progressive resistive exercises
52. Post operative Complication
⢠Scarring of tendon to surrounding structures
⢠Difficulty activating transfer.
⢠Transfer too loose or too tight. Wait 6 weeks before
doing any PROM or splinting against transfer.
⢠Rupture of transfer repairs
⢠Overstretching of transferred tendon
53. Evaluation Timeline
ďPostoperative day 10 to 14 (after tension has been
checked by surgeon)
A. Control of edema and pain, wound care
B. ROM of uninvolved joints and protected ROM of
involved joints as allowed
C. Splint for protection and immobilization
ďWeek 3: AROM of joints and activation of tendon
transfer in splint
54. ď Week 4: AROM of all joints with splint removed;
nonresistive activities in therapy, NMES for transfer
activation
ďWeeks 6 to 8: Discharge protective splint. AROM/PROM
and functional activities, splinting for tightness.
Progressive resistive exercises at week 8.
ďWeek 10: Manual muscle testing and functional outcomes
55. Recent advances
⢠Flexor digitorum superficialis opposition tendon transfer
improves hand function in children with Charcot-Marie-
Tooth disease: Case series, December,2013
⢠Transfer of the flexor digitorum superficialis tendons of
the middle and ring fingers to restore extension of fingers
and thumb (Boyes' transfer), August,2013
56. References
⢠Burke, Higgins, McClinton, Saunders, Valdata. Hand
and Upper Extremity Rehabilitation, A Practical Guide,
3rd Edition.
⢠Judith Boscheinen-Morrin. The hand: fundamentals of
therapy â 3rd Edition
⢠Robert w. Beasley, Tendon Transfers, Ch.-88
57. ⢠Cynthia Cooper, Fundamentals of hand therapy, Clinical
Reasoning and Treatment Guidelines for common
diagnosis of Upper Extremity
⢠Dr Jason Crane, Tendon transfers for nerve injuries of
the Upper Limb
⢠GS Kulkarni, Textbook of Orthopedics and Truma,
Volume One.
58. ⢠Flexor digitorum superficialis opposition tendon transfer
improves hand function in children with Charcot-Marie-
Tooth disease: Case series. T. Estilow; S.H. Kozin; A.M.
Glanzman; J. Burns; R.S. Finkel, January, 2014.
⢠Transfer of the flexor digitorum superficialis tendons of
the middle and ring fingers to restore extension of
fingers and thumb (Boyes' transfer). Pillukat T;
Blanarsch B; Schädel-HÜpfner M; Windolf J; van
Schoonhoven J; August, 2013.
The tendon of the functioning muscle is detached from its insertion and reattached to the another tendon and bone to replace the function of the paralysed muscle or injured tendon. The transferred tendon remains attached to its parent muscle with an intact neurovascular pedicle.
1) All joints that will be affected either directly or indirectly by the transfer must be fully passively mobile as transferred tendons cannot move or correct stiffened or contracted joints. 2) All skin and soft tissue in the vicinity of the transfer must be pliable and mobile. Any preexisting soft tissue adherence will prevent effective tendon glide of the transferred tendon. Also, any soft tissue tightness, e.g. a contracted thumb web, will require correction prior to surgery.
a) It is not appropriate to address joint stiffness or contracture after the transfer procedure. C) . Any scar tissue will increase drag on the transfer.
, and arrange to observe the surgery, if possible.
Tendon transfers do not prevent recovered function of a paralyzed muscle if an unanticipated degree of neurologic recovery occurs.
The classic âwrist dropâ resulting from a radial nerve palsy has significant consequences for hand function.
1. Pronator teres is stripped with its periosteal insertion from the radius, rerouted superficial to the brachioradialis and extensor carpi radialis longus, and then sutured as distally as possible to the extensor carpi radialis brevis.
2. Flexor carpi ulnaris is freed extensively to create a direct line of pull from its origin to its new insertion into the tendons of extensor digitorum communis (using an end-to-side junction) just proximal to the extensor retinaculum.
3. Extensor pollicis longus is rerouted out of the extensor retinaculum. The palmaris longus is divided at the flexor retinaculum and sutured to
the rerouted EPL, creating a combined abduction- extension force to the thumb.
Edema management: While observing sterile technique, apply electrical stimulation, elevation, fluid flushing massage, and Coban and Ace wrapping.
Scar management: Use techniques to minimize edema,which will in turn minimize fibroblast infiltration and scar formation.
Desensitization techniques: gentle stroking, touching and tapping to tolerance and application of transcutaneous electrical nerve stimulation (TENS).
Begin brief sessions of muscle contractions and education of transferred muscle. Progress to full ROM during light pick upârelease activities for digits and twisting activities for thumb (e.g., nut and bolt assembly). The physician should be contacted for approval to use functional electrical stimulation (FES) before using it to acquire gentle muscle stimulation. Timing of FES varies from surgeon to surgeon
Extensor tendon splint
Rehabilitation after extensor tendon repair
Bunnel Thomas suspension splint
Radial nerve plalsy splint
Motor deficits are are as a result of the loss of intrinsic function,
Fromentâs sign: hyperflexion of the thumb interphalangeal (IP) joint when loading the thumb for pinch due to loss of thenar
musculature and first dorsal interossei (Fig. 13-1) â Jeanneâs sign: hyperextension of the thumb metacarpophalangeal (MCP) joint when attempting pinch. Due to intrinsic weakness.
Duchenneâs sign: With the claw deformity of the hand, there is hyperextension of the metacarpophalangeal (MCP) joints and increased flexion of the distal
interphalangeal (DIP) and proximal (PIP) joints to create a roll-up deformity due to the lack of flexion of the MCP joints that is provided by the lumbrical muscles.
Wartenburgâs sign: abduction of the SF due to the unopposed power of the extensor digiti quinti (EDQ)
The goal of tendon transfer procedures is to restore balance and function to a hand that has been compromised through the loss of a muscle or group of muscles, or through irreplaceable loss of nerve innervation. This may occur as a result of prolonged compression as in cubital tunnel syndrome, trauma, disease, infectious processes, congenital anomalies, or spastic paralysis.
Zancolli lasso procedure: The flexor digitorum superficialis (FDS) tendon is split and passed between the A1 and A2 pulleys of the ring and small fingers. It is
then sewn back over on itself, creating a âlasso.â
ADP â Adductor Pollicis
Immobilization in the cast for 3 to 4 weeks is common. Apply wound care, edema reduction, and scar management measures if indicated.
If postoperative swelling has been significant, it may be necessary to change the cast after several days so that the position of immobilization is not lost.
6:When the hand is removed from the splint and placed on the table, there will be a slight relaxation of the positions of wrist extension and MCP joint flexion. To prevent further extension of the MCP joints, the therapist places light pressure over the PIP joints. . The hand is returned to the splint after each exercise session until the end of the 6th week.
Preferably frequent low resistance exercise sessions rather than occasional high-resistive exercises.
If active finger flexion is incomplete, the handles of everyday utensils can be temporarily enlarged to encourage function.
Workers involved in manual work can return to employment after the 14th week.
Ulnar nerve splint-Indicated to correct intrinsic minus position of the ring and little fingers
Volar wrist splint
With low lesions, the major motor deficit is a loss of functional opposition, resulting in a loss of dexterity and difficulty with palmar grasp. With high median
nerve injury, the most significant functional deficits are a result of denervation of the flexor pollicis longus (FPL) and of the flexor digitorum profundus
(FDP) of the index finger (IF), and possibly of the middle finger. Patients also will have denervation of the radial two lumbricals and possibly of the
flexor carpi radialis (FCR) and palmaris longus (PL); however, clinically and functionally these losses are not as significant.
The wrist is immobilized in neutral extension with the thumb held in full opposition and the IP joint of the thumb held in extension to protect the attachment to the extensor mechanism. The fingers are left free to move. If the PIP joint has been tenodesed to prevent hyperextension deformity, it should be splinted in about 45 degrees of flexion during the immobilization period.
Remove postoperative cast, have tension checked by surgeon, and immobilize patient in splint. Address wound care, edema reduction, and scar management if indicated.
May need to use neuromuscular electrical stimulation (NMES) or biofeedback to assist patient in activation of transfer.
Charcot-Marie-Tooth disease (CMT) is a genetically based progressive peripheral neuropathy often beginning in childhood. The main features are length-dependent impairment of motor (weakness, muscle atrophy) and sensory (reduced sensation) function resulting from either a primary axonal or demyelinating neuropathy [1]. These impairments result in functional limitations in self-care, work, and leisure tasks requiring hand strength, stability, and coordination.