Principles Principles of tendon transfers match muscle strength force proportional to cross-sectional area login to view 1 more bullet amplitude proportional to length of muscle work capacity = (force) x (amplitude) motor strength will decrease one grade after transfer login to view 2 more bullets appropriate tensioning appropriate excursion can adjust with pulley or tenodesis effect Smith 3-5-7 rule login to view 3 more bullets 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 Presentation Physical exam brachial plexus injury Horner's sign login to view 2 more bullets severe pain in anesthetic limb login to view 1 more bullet loss of rhomboid function login to view 1 more bullet radial nerve palsy classified according to location of lesion proximal or distal to the origin of PIN login to view 4 more bullets median nerve palsy classified according to location of lesion proximal or distal to the origin of AIN login to view 5 more bullets ulnar nerve palsy low ulnar nerve palsy login to view 4 more bullets high ulnar nerve palsy login to view 3 more bullets Studies Sensory and motor evoked potentials better than standard EMG/NCS Treatment Nonoperative physical therapy, splinting, and antispasticity medications indications login to view 2 more bullets Operative early surgical intervention (3 weeks to 3 months) indications login to view 2 more bullets late surgical intervention (3 to 6 months) indications login to view 2 more bullets postoperative care login to view 3 more bullets Specific Transfers & Indications Goal to regain FROM: Donor tendon (working) TO: Recipient Tendon (deficient) Musculocutaneous nerve palsy Elbow flexion Pectoralis major, latissimus dorsi Biceps Elbow flexion Common flexor mass Point more proximal on humerus (Steindler flexorplasty) Radial nerve & PIN palsy Elbow extension Deltoid, latissimus dorsi, or biceps Triceps Wrist extension Pronator teres ECRB Finger extension FDS, FCR, or FCU EDC Thumb extension Palmaris longus 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 Prognosis Age leading prognostic factor worse after age 30 Anatomic location distal is better than proximal