Updated: 10/4/2016

Opposition Transfer FDS

Preoperative Patient Care

A

Intermediate Evaluation and Paitient Management

1

Obtain focused history and performs focused exam

  • night pain, paresthesias
  • Median nerve motor/ sensory evaluation
  • MN numbness
  • thumb abduction
  • provocative maneuvers:
  • Tinel
  • tap the median nerve over the volar carpal tunnel
  • Phalen
  • wrist flexed with elbow extended for ~60 sec produces symptoms
  • Durkins compression test
  • is the most sensitive test to diagnose carpal tunnels syndrome
  • press thumbs over the carpal tunnel and hold pressure for 30 seconds.
  • onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result.

2

Orders and interprets required diagnostic studies

  • EMG and NCV studies
  • often the only objective evidence of a compressive neuropathy (valuable in work comp patients with secondary gain issues)
  • not needed to establish diagnosis (diagnosis is clinical)
  • NCV
  • increase latencies (slowing) of NCV
  • distal sensory latency of > 3.2 ms
  • motor latencies > 4.3 ms
  • decreased conduction velocities less specific than latencies
  • velocity of < 52 m/sec is abnormal
  • EMG
  • test the electrical activity of individual muscle fibers and motor units
  • detail insertional and spontaneous activity
  • potential pathologic findings
  • increased insertional activity
  • sharp waves
  • fibrillations
  • fasciculations
  • complex repetitive discharges

3

Prescribes and manages nonoperative treatment

  • night splints
  • steroid injections
  • attempts trial of physical therapy

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides simple post operative management and rehabilitation

  • postop: 2-3 Week postoperative visit
  • wound check
  • remove sutures
  • remove plaster splint
  • diagnose and management of early complications
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
B

Advanced Evaluation and Patient Management

1

Complex postop management

  • worsening numbness
  • worsening pain
  • additional radiating symptoms
C

Preoperative H & P

1

Obtain basic preoperative history and physical exam

  • identify medical co-morbidities that might impact surgical treatment
  • screen medical studies to identify and contraindications for surgery

2

Perform operative consent

  • describe complications of surgery including
  • suboptimal tendon transfer due to stiff joints
  • selection of suboptimal or weak muscle-tendon unit for transfer
  • incorrect vector of pull
  • rupture of transferred tendon
  • tendon adhesions
  • loss of grip strength after FDS ring transfer
  • difficulty with muscle-tendon reeducation

Operative Techniques

E

Preoperative Plan

1

Execute surgical walkthrough

  • resident to repeat steps to the attending verbally prior to the beginning of the case
  • describe the potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • Loupes recommended

2

Room setup and equipment

  • standard OR table with a hand table

3

Patient positioning

  • place in supine position with shoulder abducted and hand on hand table
G

Superficial Dissection

1

Identify landmarks and draw incision.

  • make a palmar skin incision over the first annular pulley of the ring finger

2

Identify the A1 pulley

3

Incise A1 pulley longitudinally

  • this isolates the FDS tendons
H

Isolate the FDS

1

Divide the FDS tendon

  • apply traction to the FDS to flex the PIP joint
  • divide the FDS transversely
  • do this 4 cm proximal to its bifurcation while protecting the FDP tendon
I

Isolate the FCU

1

Expose the FCU tendon

  • make a zigzag incision over the volar ulnar distal forearm in the region of the FCU tendon insertion

2

Isolate the FCU and the ring finger FDS tendons

  • protect the ulnar neurovascular bundle

3

Divide the FCU tendon

  • transversely cut the radial half of the FCU tendon about 4 cm proximal to its insertion on the pisiform
  • separate the radial half of the tendon longitudinally from the other half
  • this creates a distally-based strip of tendon graft
J

Create Pulley

1

Loop the tendon graft distally

  • pass it through the distal portion of the FCU near the pisiform insertion

2

Pass the FDS tendon

  • pull the cut ring finger FDS tendons into the volar ulnar forearm incision
  • pass it through the constructed pulley
K

Create Tunnel

1

Expose thumb MCP joint

  • make an incision on the radial aspect of the thumb MCP joint

2

Create a subcutaneous tunnel between this incision and the wrist incision

3

Pass the ring FDS tendons through this tunnel to the thumb incision

L

Suture Tendon

1

Align digits

  • place the thumb into opposition with the small finger

2

Suture tendon

  • suture the FDS tendons to the thumb with a 3-0 or 4-0 braided polyester suture
  • The attachment site usually include the abductor tendon plus or minus the dorsal capsule and extensor pollicis brevis tendon
N

Wound Closure

1

Irrigation, hemostasis, and drain

  • copiously irrigate both incisions

2

Superficial closure

  • use 3-0 nylon for closure

3

Dressing and immediate immobilization

  • place a bulky dressing and short arm plaster cast with the wrist in flexion and the thumb in full opposition

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Discharges patient appropriately

  • prescribe outpatient physical therapy
  • immediate hand therapy
  • pain meds
  • wound care
  • schedule follow up in 2 weeks
 

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