Introduction Principles of tendon transfersmatch 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 appropriate tensioning 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 surgical priorities elbow flexion (musculocutaneous n.) shoulder stabilization (suprascapular n.) brachiothoracic pinch (pectoral n.) sensation C6-7 (lateral cord) wrist extension and finger flexion (lateral and posterior cords) selection determine what function is missing determine what muscle-tendon units are available evaluate the options for transfer 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 age leading prognostic factor worse after age 30 location distal is better than proximal Presentation Physical exam 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 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) 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 (APB function) high median nerve palsy loss of thumb opposition loss of thumb, index finger, and middle finger flexion 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 Studies Sensory and motor evoked potentials better than standard EMG/NCS Treatment Nonoperative physical therapy, splinting, and antispasticity medications indications decreased passive range of motion spasticity Operative early surgical intervention (3 weeks to 3 months) indications total or near-total brachial plexus injury high energy injury 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 regain FROM: Donor tendon (working) TO: Recipient Tendon (deficient) Axillary nerve palsy Shoulder stability (flail shoulder) glenohumeral arthrodesis glenohumeral arthrodesis Musculocutaneous nerve palsy Elbow flexion pectoralis major, latissimus dorsi to biceps Elbow flexion common flexor mass point more proximal on humerus (Steindler flexorplasty) Radial nerve & PIN palsy Elbow extension deltoid, latissimus dorsi, or biceps to triceps Wrist extension PT ECRB Finger extension FDS, FCR, or FCU EDC Thumb extension PL or FDS EPL Low median nerve palsy Thumb opposition and abduction FDS (ring) base proximal phalanx or APB tendon (use FCU as pulley - classic Bunnell opponensplasty) EIP APB (pulley around ulnar side of wrist) High median nerve palsy Thumb IP flexion BR FPL Index and long finger flexion FDP of ring and small finger (ulnar nerve) FDP of index and middle (side-to-side transfer) Ulnar nerve palsy Thumb adduction FDS or ECRB adductor pollicis Finger abduction (index most important) APL, ECRL, or EIP 1st dorsal interosseous Reverse clawing effect FDS, ECRL (must pass volar to transverse metacarpal ligament to flex proximal phalanx) lateral bands of ulnar digits Complications Adhesions necessitate aggressive therapy and possible secondary tenolysis
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ13.103) A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures A through C. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition? Review Topic | Tested Concept QID: 4738 FIGURES: A B C Type & Select Correct Answer 1 Ring flexor digitorum superficialis transfer to the abductor pollicis brevis 22% (857/3924) 2 Extensor indicis proprius transfer to the abductor pollicis brevis 54% (2101/3924) 3 Neurotization of thenar muscles 5% (192/3924) 4 Camitz palmaris longus transfer to the abductor pollicis brevis 16% (614/3924) 5 Thumb carpometacarpal joint arthrodesis 2% (98/3924) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ10.14) A 50-year-old woman sustains an open both bone forearm fracture seen in Figure A and undergoes the treatment seen in Figure B. During surgery the posterior interosseous nerve was transected and primary repair was attempted. One year following surgery the patient continues to have no posterior interosseous nerve function. Which of the following treatments will best restore function? Review Topic | Tested Concept QID: 3102 FIGURES: A B Type & Select Correct Answer 1 Sural nerve grafting to the posterior interosseus nerve 5% (127/2465) 2 Wrist fusion with transfer of the flexor carpi ulnaris to the finger extensors 2% (39/2465) 3 Transfer of the flexor carpi radialis to extensor digitorum and the palmaris longus to the extensor pollicis longus 65% (1601/2465) 4 Transfer of the pronator teres to the wrist extensors and the palmaris longus to the finger extensors 9% (210/2465) 5 Transfer of the flexor carpi ulnaris to the wrist extensors and the palmaris longus to the extensor pollicis longus 19% (469/2465) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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