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Radial Nerve Injury
Early and Late Management
Dr Sumer Yadav
Mch- Plastic and Reconstructive Surgery
sumeryadav2004@gmail....
Introduction
 Loss of radial nerve function in the hand
creates a significant disability
 Patient can not extend the fin...
sumeryadav2004@gmail.com
Anatomy
 The radial nerve is
the largest branch
of the brachial
plexus
 Continuation of the
posterior cord, with
nerve f...
 The radial nerve innervates
the extensor and supinator
musculature located in the
arm and forearm and
provides distal se...
Course
 Passes across the LD
deep to the axillary
artery.
 Winds around the
medial side of the
humerus,
 And enters the...
Course
 It follows the spiral groove of
the humerus, piercing the
lateral intermuscular septum
(10 cm proximal to the
lat...
The nerve then divides into a
superficial branch and a deep branch.
The superficial branch, purely sensory,
 Runs under...
 The deep branch of the radial nerve, the
posterior interosseous nerve,
 winds to the dorsum of the forearm,
 around th...
sumeryadav2004@gmail.com
Motor supply
All extensor muscles:
1. Abductor pollicis longus
1. Extensor pollicis brevis
2. Extensor carpi radialis
long...
Motor supply
Triceps (long, medial, lateral)
Anconeus
Brachioradialis
Supinator
sumeryadav2004@gmail.com
Cutaneous innervation
 Posterior cutaneous nerve of arm (originates
in axilla)
 Inferior lateral cutaneous nerve of arm
...
Topography
 In the proximal part of the nerve
monofascicular pattern is seen. Each fasicle
cointains a mixture of motor a...
Topography –
Radial Nerve
 Divides into the superficial
radial nerve and the
posterior interosseous nerve
at the level of...
Etiology
 Penetrating injury
 Compression injury
Saturday night palsy
 Crush injury
 Avulsion or traction injuries,
 ...
Etiology
Holstein-Lewis fracture
 Most commonly caused by fracture of the
humerus,
 at the junction of the middle and di...
High Radial–
Proximal to
Spiral Groove
High Radial– AT,
or Distal to,
Spiral Groove
Posterior
Interosseous
Neuropathy
Supe...
EXAMINATION OF THE RADIAL
NERVE
Physical Examination
 Sensory
pinprick
light touch testing,
 Sites
posterior arm
po...
 Improper technique may incorrectly suggest median
or ulnar weakness.
 Inability to stabilize the wrist results in decre...
Location Motor Sensory
High Radial–
Proximal to Spiral
Groove
Weak elbow, loss
of wrist, and finger
and thumb
extension
(W...
Location Motor Sensory
Posterior
Interosseous
Neuropathy
Normal elbow
and wrist
extensors.
Weak finger and
thumb extensors...
sumeryadav2004@gmail.com
Work up
 Radiographs
– Radial nerve injury in the arm, X ray of arm to
detect or rule out a fracture
– In Posterior inter...
Electro-myographic (EMG) and nerve
conduction velocity (NCV)
 Help to locate the site of injury
 Help to monitor the ner...
Acute injury and its management
sumeryadav2004@gmail.com
Timing of nerve repairs
Open injuries
 Require early exploration.
 Sharp lacerations can be repaired immediately and
dir...
 At 3 weeks (or when the wound permits), the
nerve is re-explored, and definitive repair or
graft can be performed.
 At ...
Gunshot wound
 Exception to the general rule of early
exploration of open injuries.
 Mechanisms of nerve damage are
pred...
Closed injuries
 In closed or blunt trauma, initial
management is expectant with close
observation.
 If complete recover...
 Monthly clinical and EMG evaluation

 If motor unit potentials are seen with EMG,
► spontaneous reinnervation is antic...
Intra operative nerve conduction
study.
 Electric activity is
present

 Grade 2 or 3 injury

 Neurolysis is done
No ...
RNP with Fracture Humerus
 Incidence 1.8% to 18%
 Managed in three ways
 Early exploration of the nerve
 Exploration a...
Early exploration of the nerve
Advantages
 Can know the status of the nerve.
 Stabilization of the fracture protects the...
Exploration at 6 to 8 weeks
 An unnecessary operation is avoided
 No interference with fracture healing
 Absence of adv...
Exploration after
longer waiting
 Initial signs of recovery
may take 4 or 5 months
 Time for recovery can
be calculated....
Sufficient time
 Regeneration start in about 21 to 30 days
after the repair.

 Proceeds at the rate of 1mm/ day

 Abo...
Choice of management
 Patients are treated non operatively initially
 Exploration only after a realistic waiting
period
...
Nerve Repair
sumeryadav2004@gmail.com
Types of repair- epineural
sumeryadav2004@gmail.com
Group fascicular Fascicular
sumeryadav2004@gmail.com
Epineurial versus group fascicular repair
 In a prospective clinical study, no
significant differences were observed
betw...
Tension on the repair
 Gapping at the repair, ischemia, and scar
formation.
 Postural maneuvers to decrease tension
shou...
Management of a nerve gap
 Methods of reconstruction significant nerve
gap
 Grafting with non-vascularized, autogenous
n...
Nerve transfers to reconstruct the radial
nerve
 Redundant portion of the median nerve
supplying the FDS.
 The triceps b...
Postoperative management
Early range of motion is critical.
On Day 3, Dressings are removed,
wounds are examined.
The r...
Postoperative management
 After the short period of protection, restricted
movements are started.
 Goals are to
 regain...
Tendon transfer
sumeryadav2004@gmail.com
REQUIREMENTS IN RNP
 Irreparable RNP needs to be provided with
1. Wrist extension
2. Finger ( MCP) extension
3. Combinati...
Nerve repair verses tendon transfers
 Time since injury is critical factor
 If prognosis of nerve repair is poor it woul...
PRINCIPALS OF TENDON
TRANSFERS
sumeryadav2004@gmail.com
Correction of contractures
 All joints must be kept supple
 Easier to prevent than to correct
 Maximum motion must be p...
Adequate strength
 Avoid a muscle that was previously
denervated and now has returned to
function
 A muscle will usually...
Amplitude of motion
 Wrist flexors and extensors : 33 mm
 Finger extensors and EPL : 50 mm
 Finger flexors : 70 mm
 Im...
Tenodesis effect
 Convert from monoarticular to biarticular
 FCU transferred to EDC is converted to
multiarticular
 Eff...
Straight line of pull
One tendon - one function
If inserted into two tendons, the force and
amplitude of the donor tendo...
Expendable donor
 Removal of tendon must not result in
unacceptable loss of function
sumeryadav2004@gmail.com
Tissue equilibrium
 It implies that
 No soft tissue induration
 Wounds are mature
 Joints are supple
 The scars are s...
Tissue equilibrium
 Tendon transfer works best when passed
between subcutaneous fat and deep fascial
layer
 Least likely...
Timing of tendon transfers
 Early - when there is questionable or poor
prognosis of nerve repair.
 Nerve gap is more tha...
Timing of tendon transfers
 In other cases consider doing nerve repair.
 If good nerve repair has been accomplished
wait...
Timing of tendon transfers
 Little support for Bevins concept
 Proceed directly to tendon transfer and never
repairing t...
History
 Evolved during the two
world wars
 Sir Robert Jones major
inventor of radial nerve
transfers.
 Classic Jones t...
History
 Jones used both strong wrist flexors.
 Zachary showed that it is desirable to leave
to leave atleast one wrist ...
History
 Evolved into standard set of transfers for
radial nerve palsy:
 PT to ECRB
 FCU to EDC 2-5
 PL to rerouted EP...
Tendon transfer
 INFINITE NUMBER OF POSSIBLE COMBINATIONS
AVAILABLE
 THREE SETS OF TRANSFERS ARE WIDELY USED
 USING FCU...
FCU Transfer
 The first incision
 The FCU tendon is
transected from the
pisiform
 Detached as far
proximally as the
inc...
 SEPARATED FROM
DENSE FASCIAL
ATTACHMENTS►
CARROLL TENDON
STRIPPER
 WHEN STRIPPER IS NOT
AVAILABLE ► EXTEND
FIRST INCISI...
 The second incision
 Begins 2 inches below the
medial epicondyle and
angles across the dorsum of
the proximal forearm,
...
 The third incision
 begins on the volar-radial
aspect of the mid forearm,
passes dorsally around the
radial border of t...
TENDON OF PT IS IDENTIFIED
ITS INSERTION IS FREED UP WITH
AN INTACT LONG STRIP OF
PERIOSTEUM TO ENSURE
SUFFICIENT LENGTH...
 The PT tendon is passed
subcutaneously around the
radial border of the forearm,
 Superficial to the BR and
ECRL
 Inser...
 The FCU muscle is
pulled subcutaneously
over the ulnar border.
 THE FCU TENDON is
weaved through the
EDC tendons at 45
...
 Suture FCU tendon into
each EDC slip separately
with 4-0 non absorbable
suture
 Adjust the tension in each
EDC tendon i...
 The EPL is divided and
rerouted toward the volar
aspect.
 The PL tendon is transected at
the wrist and detached
proxima...
Summary of repair
PT to ECRB
FCU to EDC
PL to the EPL
sumeryadav2004@gmail.com
 SETTING THE PROPER TENSION IN THE
SUTURES IS ESSENTIAL
 SUTURES SHOULD BE TIGHT ENOUGH ---
 CONSIDERING THE FACT THAT
...
POST OPERATIVE MANAGEMENT
 LONG ARM SPLINT –
 FOREARM IN 15-30 DEGREES
PRONATION,
 WRIST IN 45 DEG EXTENSION,
 MP JOIN...
POST OPERATIVE MANAGEMENT
 Planned Exercise Program –To begin at 4
weeks.
 Instruct to work in synergistic movements
 M...
POTENTIAL PROBLEMS
 Excessive radial Deviation
-Due to removal of FCU
-Aggravated if PT is inserted in ECRL
 In patients...
Absence of Palmaris Longus
Compromises FCU set of transfers.
 Include the EPL into the FCU to EDC
transfer, limits the ab...
SUPERFICIALIS TRANSFER
(Boyes transfer)
 In 1960 Boyes offered a reasonable alternative to the
standard set of transfer.
...
SUPERFICIALIS TRANSFER
(Boyes transfer)
 Despite the clinical concerns, studies
have shown no functional loss of power
gr...
SUPERFICIALIS TRANSFER
(Boyes transfer)
 Full active extension of fingers with an FCU
or FCR transfer can be achieved onl...
SUPERFICIALIS TRANSFER
(Boyes transfer)
The combination of transfer are
 PT to ECRL and ECRB
 FCR to ECB and APL
 FDS r...
SUPERFICIALIS TRANSFER
(Boyes transfer)
 The PT to ECRB transfer is done.
 Expose superficialis of long & ring finger
th...
SUPERFICIALIS TRANSFER
 FDS 2 routed to radial side of profundus mass through
the interossous membrane
 FDS 3 routed to ...
SUPERFICIALIS TRANSFER
FCR tendon at the base of the thumb is
divided and detached.
And sutured to APL and EPB tendons.
...
Summary of Boyes transfer
PT to ECRB
FDS long to EPI and EPL
FDS ring to EDC
FCR to APL and EPB
sumeryadav2004@gmail.c...
FCR transfer
 PT to the ECRB transfer is performed.
 The FCR tendon is exposed through a longitudinal incision on
the vo...
 The finger extensor
tendons are withdrawn
distally and sutured to
the flexor carpi radialis.
 After that, reroute the
P...
CHOICE OF SURGERY
 RADIAL OR INTEROSSEOUS N PALSY—
FCR SET OF TRANSFERS
 LEAVES THE FCU INTACT WHICH IS A
PRIME ULNAR ST...
NONOPERATIVE TRETMENT
 Maintenance of full passive range of
movement in all joints of wrist and hand
 Prevention of cont...
 Splints
 Dynamic and static
 Stabilizing the wrist in extension imparts
good temporary function.
sumeryadav2004@gmail....
sumeryadav2004@gmail.com
INTERNAL SPLINT (Early
transfers)
 Early PT to ECRB transfer to eliminate the
need for an external splint and to restore
...
INTERNAL SPLINT
 PRICIPLES OF TRANSFERS
 Do not decrease remaining function in hand
 Do not create deformity
 Be a pha...
THANK YOU
sumeryadav2004@gmail.com
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radial nerve palsy

  1. 1. Radial Nerve Injury Early and Late Management Dr Sumer Yadav Mch- Plastic and Reconstructive Surgery sumeryadav2004@gmail.com
  2. 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 sumeryadav2004@gmail.com
  3. 3. sumeryadav2004@gmail.com
  4. 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. sumeryadav2004@gmail.com
  5. 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. sumeryadav2004@gmail.com
  6. 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. sumeryadav2004@gmail.com
  7. 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. sumeryadav2004@gmail.com
  8. 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 sumeryadav2004@gmail.com
  9. 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. sumeryadav2004@gmail.com
  10. 10. sumeryadav2004@gmail.com
  11. 11. Motor supply All extensor muscles: 1. Abductor pollicis longus 1. Extensor pollicis brevis 2. Extensor carpi radialis longus 2. Extensor carpi radialis brevis 3. Extensor pollicis longus 4. Extensor digitorum communis 4. Extensor indicis proprius 5. Extensor digiti minimi quinti 6. Extensor carpi ulnaris sumeryadav2004@gmail.com
  12. 12. Motor supply Triceps (long, medial, lateral) Anconeus Brachioradialis Supinator sumeryadav2004@gmail.com
  13. 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. sumeryadav2004@gmail.com
  14. 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. sumeryadav2004@gmail.com
  15. 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. sumeryadav2004@gmail.com
  16. 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. sumeryadav2004@gmail.com
  17. 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 sumeryadav2004@gmail.com
  18. 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 sumeryadav2004@gmail.com
  19. 19. EXAMINATION OF THE RADIAL NERVE Physical Examination  Sensory pinprick light touch testing,  Sites posterior arm posterior forearm posterior lateral hand and thumb. sumeryadav2004@gmail.com
  20. 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). sumeryadav2004@gmail.com
  21. 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 sumeryadav2004@gmail.com
  22. 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 sumeryadav2004@gmail.com
  23. 23. sumeryadav2004@gmail.com
  24. 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 sumeryadav2004@gmail.com
  25. 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. sumeryadav2004@gmail.com
  26. 26. Acute injury and its management sumeryadav2004@gmail.com
  27. 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. sumeryadav2004@gmail.com
  28. 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 sumeryadav2004@gmail.com
  29. 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. sumeryadav2004@gmail.com
  30. 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. sumeryadav2004@gmail.com
  31. 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. sumeryadav2004@gmail.com
  32. 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 ` sumeryadav2004@gmail.com
  33. 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 sumeryadav2004@gmail.com
  34. 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. sumeryadav2004@gmail.com
  35. 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 sumeryadav2004@gmail.com
  36. 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) sumeryadav2004@gmail.com
  37. 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. sumeryadav2004@gmail.com
  38. 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. sumeryadav2004@gmail.com
  39. 39. Nerve Repair sumeryadav2004@gmail.com
  40. 40. Types of repair- epineural sumeryadav2004@gmail.com
  41. 41. Group fascicular Fascicular sumeryadav2004@gmail.com
  42. 42. Epineurial versus group fascicular repair  In a prospective clinical study, no significant differences were observed between fascicular repairs and epineurial repairs. sumeryadav2004@gmail.com
  43. 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. sumeryadav2004@gmail.com
  44. 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 sumeryadav2004@gmail.com
  45. 45. Nerve transfers to reconstruct the radial nerve  Redundant portion of the median nerve supplying the FDS.  The triceps branch of the radial nerve. sumeryadav2004@gmail.com
  46. 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. sumeryadav2004@gmail.com
  47. 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. sumeryadav2004@gmail.com
  48. 48. Tendon transfer sumeryadav2004@gmail.com
  49. 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 sumeryadav2004@gmail.com
  50. 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 sumeryadav2004@gmail.com
  51. 51. PRINCIPALS OF TENDON TRANSFERS sumeryadav2004@gmail.com
  52. 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 sumeryadav2004@gmail.com
  53. 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 sumeryadav2004@gmail.com
  54. 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 sumeryadav2004@gmail.com
  55. 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 sumeryadav2004@gmail.com
  56. 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. sumeryadav2004@gmail.com
  57. 57. Expendable donor  Removal of tendon must not result in unacceptable loss of function sumeryadav2004@gmail.com
  58. 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. sumeryadav2004@gmail.com
  59. 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 sumeryadav2004@gmail.com
  60. 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 sumeryadav2004@gmail.com
  61. 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. sumeryadav2004@gmail.com
  62. 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. sumeryadav2004@gmail.com
  63. 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 sumeryadav2004@gmail.com
  64. 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. sumeryadav2004@gmail.com
  65. 65. History  Evolved into standard set of transfers for radial nerve palsy:  PT to ECRB  FCU to EDC 2-5  PL to rerouted EPL sumeryadav2004@gmail.com
  66. 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 sumeryadav2004@gmail.com
  67. 67. FCU Transfer  The first incision  The FCU tendon is transected from the pisiform  Detached as far proximally as the incision allows. sumeryadav2004@gmail.com
  68. 68.  SEPARATED FROM DENSE FASCIAL ATTACHMENTS► CARROLL TENDON STRIPPER  WHEN STRIPPER IS NOT AVAILABLE ► EXTEND FIRST INCISION PROXIMALLY sumeryadav2004@gmail.com
  69. 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. sumeryadav2004@gmail.com
  70. 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. sumeryadav2004@gmail.com
  71. 71. TENDON OF PT IS IDENTIFIED ITS INSERTION IS FREED UP WITH AN INTACT LONG STRIP OF PERIOSTEUM TO ENSURE SUFFICIENT LENGTH sumeryadav2004@gmail.com
  72. 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 sumeryadav2004@gmail.com
  73. 73.  The FCU muscle is pulled subcutaneously over the ulnar border.  THE FCU TENDON is weaved through the EDC tendons at 45 degree angles. sumeryadav2004@gmail.com
  74. 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. sumeryadav2004@gmail.com
  75. 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. sumeryadav2004@gmail.com
  76. 76. Summary of repair PT to ECRB FCU to EDC PL to the EPL sumeryadav2004@gmail.com
  77. 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 sumeryadav2004@gmail.com
  78. 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. sumeryadav2004@gmail.com
  79. 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 sumeryadav2004@gmail.com
  80. 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. sumeryadav2004@gmail.com
  81. 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 sumeryadav2004@gmail.com
  82. 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. sumeryadav2004@gmail.com
  83. 83. SUPERFICIALIS TRANSFER (Boyes transfer)  Despite the clinical concerns, studies have shown no functional loss of power grip with FCU transfer. sumeryadav2004@gmail.com
  84. 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 sumeryadav2004@gmail.com
  85. 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) sumeryadav2004@gmail.com
  86. 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 sumeryadav2004@gmail.com
  87. 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 sumeryadav2004@gmail.com
  88. 88. SUPERFICIALIS TRANSFER FCR tendon at the base of the thumb is divided and detached. And sutured to APL and EPB tendons. sumeryadav2004@gmail.com
  89. 89. Summary of Boyes transfer PT to ECRB FDS long to EPI and EPL FDS ring to EDC FCR to APL and EPB sumeryadav2004@gmail.com
  90. 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. sumeryadav2004@gmail.com
  91. 91.  The finger extensor tendons are withdrawn distally and sutured to the flexor carpi radialis.  After that, reroute the PL to the EPL. sumeryadav2004@gmail.com
  92. 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 sumeryadav2004@gmail.com
  93. 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 sumeryadav2004@gmail.com
  94. 94.  Splints  Dynamic and static  Stabilizing the wrist in extension imparts good temporary function. sumeryadav2004@gmail.com
  95. 95. sumeryadav2004@gmail.com
  96. 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 results are poor sumeryadav2004@gmail.com
  97. 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
  98. 98. THANK YOU sumeryadav2004@gmail.com
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radial nerve palsy

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