Transcript Radial Nerve Palsy Tendon Transfers

TENDON TRANSFERS AND UPPER
LIMB DISORDERS
Aws Khanfar,
MBBS, MRCSI, MFSEM, CHSOrth, FEBOT
What is a tendon transfer?
• The tendon of a functioning muscle is detached from
its insertion and reattached to another tendon or
bone to replace the function of a paralysed muscle or
injured tendon. The transferred tendon remains
attached to its parent muscle with an intact
neurovascular pedicle.
What is a tendon transfer?
• “Using the power of a functioning muscle unit to
activate a non functioning nerve/muscle/tendon
unit”.
• Tendon transfers work to correct:
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instability
imbalance
lack of co-ordination
restore function by redistributing remaining muscular
forces
Indications
• Paralysed muscle
• Injured (ruptured or avulsed) tendon or muscle
• Balancing deformed hand e.g. cerebral palsy or
rheumatoid arthritis
• Some congenital abnormalities
General principles
- Only justified in restoring functional motion of the
hand,
-. Patient factors
• Age
• Functional disabilities with poor non operative
prognosis
• Ability to understand nature and limitations of
surgery, including aesthetic goals
• Motivated to co-operate with post operative
physiotherapy
General principles
-. Recipient site
• Tissue bed into which transfer is placed should be
soft and supple
• Good soft tissue coverage
• Stable underlying skeleton
• Full passive range of motion of joints to be powered
• Area to be powered must be sensate
General principles
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Donor muscle factors
Amplitude of the donor muscle ( TENDON
EXCURSION)
General principles
Power of the donor muscle
– Any transferred muscle loses at least one grade of
strength, so only Grade 5 muscles are satisfactory
General principles
One tendon, One function
– Effectiveness reduced in transfer designed to
produce multiple functions
Synergistic muscle groups are generally easier to
retrain
– Fist group – wrist extensors, finger flexors, digital
adductors, thumb flexors, forearm pronators,
intrinsics
– Open hand group – wrist flexors, finger extensors,
digital abductors, forearm supinators
– Use of synergistic muscles tends to help retain
joint balance
General principles
Line of transfer
– Should approximate pull of original tendon if
possible
– Acute angles should be avoided
Expendability
– Transfer must not cause loss of an essential
function
General Post Operative Management
• Rehabilitation is equally important in tendon transfer success
as surgical execution
• Rehabilitation / physiotherapy is essential in
– Regaining joint mobility lost during splinting
– Training tendon to glide in new course
– Teaching patients to activate a new muscle to achieve a certain
function, which requires development of new neural pathways
• The more that a patient notices a disability, the greater the
motivation, so the easier the retraining
• Children are usually managed with static protocols or longer
protective phase
Basic Principles of Post Operative Rehabilitation
. Pro tective phase
• Begins at surgery and lasts 3 – 5 weeks
• Objectives:– Protective splinting
– Oedema control
– Mobilise uninvolved joints
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. Mobilisation phase
• Begins when tendon healing is adequate for
activation (usually 3 – 5 weeks post op)
• Objectives
– Mobilise tendon transfer
– Continue mobilisation of uninvolved joints to
prevent joint stiffness from disuse
– Reinforce preoperative teaching and patient
education
– Continue oedema control and protective splinting
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Basic Principles of Post Operative Rehabilitation
Intermediate phase
• Begins 5 – 8 weeks post operatively
• Gradually increases hand activity and passive range
of motion exercises
• Limited functional movements permitted
4. Resistive phase
• Beginning at 8 – 12 weeks
• Tendon junctions are strong enough to withstand
increasing resistance
• Therapeutic objective is to increase endurance and
strength of transferred muscles
• Work related simulated tasks are begun to patient
tolerance
3.
Radial Nerve Palsy
• Wrist extension is critical for stability, which is
essential for grip and assisting the function of many
tendons crossing the wrist
Tendon Transfers
• Well defined and highly effective, aiming to
replace
– Wrist extension
– Finger extension
– Thumb extension and abduction
• Standard
Radial Nerve Palsy
• Non-Operative Treatment
– Splintage
– Maintenance of full passive ROM in all joints of the
wrist/hands and prevent contractures
Radial Nerve Palsy
• Early transfers (“Internal Splintage”)
– greatest functional loss is grip strength
PT to ECRB
FCU to EDC
PL to EPL
Common Upper limb disorders
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Symptoms:
Muscle/tendon problems :
Pain , Swelling ,Weakness
Nerve related :
Tingling/altered sensation , Weakness
• Tendon problems: Dequervain’s
• History:
New, repetitive activity
Pain over thumb side of the wrist
Pain on making a fist,
grasping or holding objects
• Examination
Swelling
Thickening
Tenderness
Freinklestein test
• Treatment
Activity modification
NSAID
Splintage – thumb widely abducted
Steroid Injection
• . Surgical Release
• Tennis/Golfers elbow
• Incidence
General population: 0.6%
Tennis players: 9%
Age: 35 and 50 years, with an equal distribution
between males and females
Associated Rotator cuff problems: 20-40%
• Etiology
Multiple microtraumatic events
Disruption of the internal structure of the
tendon and degeneration of the cells and
matrix
• Presentation
• Pain : outer aspect (Tennis elbow )of elbow/
inner aspect (Golfers)
• Increases with activity and Lifting objects
Sometimes pain at rest
• Palapation : Tenderness
• Special test Resisted wrist extension , Elbow
flexion , Elbow Extension
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Non- Operative Treatment options
Topical NSAIDs
Oral NSAIDs
Orthotic devices
Physiotherapy
• Operative treatment
Surgery to repair the tendon
CTS
Incidence: 1-3 cases per 1000 persons per year
Prevalence: 50 cases per 1000 persons aged in
their 30s and 50s
Women are affected 2-3 times more often
• Association of CTS in computer workers
• Symptoms
Pins and needles
Pain
The pain may travel up the forearm.
Numbness of finger
Dryness of the skin
Weakness of muscles
• AnatomyContents:
Nine flexor tendons
Tendons
Median Nerve
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Examination
Dry pulps
Wasting of Thenar muscles
Tinels
• Investigations
• Nerve conduction test
• Treatment
• Night splints
• Surgical release
Shoulder Impingement syndrome
• Pain in shoulder
Increases with activity
Clicking sensation in shoulder
Pain with overhead activities/ reaching for seat
belt, wearing cloths
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Treatment
Pain medication
Activity modification
Physio ,To improve scapular position ,
Strengthen a specific group of muscles
Injection into shoulder
Surgery