Tendon Transfers

General Principles for Tendon Tranfers

• Prognosis decline > age 30

• Prioritize distal and similar muscles to be more effective

  • Ex: using a radial nerve ext based muscle for EIP to EPL - similar synergistic movements

  • the more distal the muscles, the more effective the transfer

• Clarity on locations donor muscle motor point; ask dr “where is that motor point location for that muscle?”

• MMT >4 (4+ or 5) to be useful as donor tendon; donor tendons lose 1 MMT following transfer

• Expendable donor (i.e EIP, palmarus longus)

Treatment Principles

• Tx as a laceration repair - splint as if laceration

• Immobilize 0- 3 weeks

• Early short arc 3+ weeks

  • 3-6 weeks work on light mobility, AROM, soft tissue work to affected area

  • 4 weeks avoid composite movements

• 6+ weeks: neuromotor retraining and reeducation

  • NMES, biofeedback, mirror therapy

  • “training old muscle to do new muscle job”

• 8+ weeks: strengthening and weaning out of orthosis

• 12+ weeks: return to work

General Principles for Tendon Tranfers

• Prognosis decline > age 30

• Prioritize distal and similar muscles to be more effective

  • Ex: using a radial nerve ext based muscle for EIP to EPL - similar synergistic movements

  • the more distal the muscles, the more effective the transfer

• Clarity on locations donor muscle motor point; ask dr “where is that motor point location for that muscle?”

• MMT >4 (4+ or 5) to be useful as donor tendon; donor tendons lose 1 MMT following transfer

• Expendable donor (i.e EIP, palmarus longus)

Treatment Principles

• Tx as a laceration repair - splint as if laceration

• Immobilize 0- 3 weeks

• Early short arc 3+ weeks

  • 3-6 weeks work on light mobility, AROM, soft tissue work to affected area

  • 4 weeks avoid composite movements

• 6+ weeks: neuromotor retraining and reeducation

  • NMES, biofeedback, mirror therapy

  • “training old muscle to do new muscle job”

• 8+ weeks: strengthening and weaning out of orthosis

• 12+ weeks: return to work

High Median Nerve Presentation

• Everything distal to this area involved

• Hand of Benediction:

1. FCR

2. FPB/FPL

3. Th intrinsics: APB, FPB, OP

4. Lumbricals of IF/LF

FA DBS Splint indicated

Low Median Nerve Presentation

Muscles affected, resulting in loss of opposition and pinch:

1. Thenar intrinsics

2. IF, LF lumbricals (1st and 2ns lumbricals)

Hand based DBS splint

APB is primary muscle of thumb opposition

Median Nerve Transfers

• Bunnel Transfer: FDS of RF to APB for TH retropusion for low injury

• EIP to ABP for TH retropulsion for high injury

• Camitz Transfer: PL to APB for Th opposition for low injury - augments palmer abd, but flex and pronation of Th are lost - indicated for severe CTS

• Huber Transfer: ADM to APB for Th opposition - indicated for congenital conditions such as TH hypoplasia

• ECRL or Brachioradialis to FPL - TH IP flex - can also be transferred to FDP for IP flex

• FDP side-to-side: For DIP flexion to IF, LF and full flexion of digits for high nerve injuries

Bunnel Transfer

• Median Nerve Tendon transfer for low median nerve palsy

• FDS of RF to APB

  • for Th opposition

FDS of RF is taken and split - then re-routed via carpal tunnel and then redirected distally via tendon sheath and inserted into TH

EIP to APB Transfer

• high median nerve injury transfer; where FDS is not available

• non synergistic and harder to train, but easy to transfer

• restores TH opposition

  • tunneled under ulnar aspect of wrist and routed across palm to level of pisiform and inserted to abductor pollicis brevis

Camitz Transfer

• Median Nerve Tendon transfer

• PL to APB

  • for Th opposition

Pronation and flexion component of TH lost with this transfer; purpose to augment palmar abduction in patients who have severe motor loss from severe CTS; only an option for low median nerve injuries

Huber Transfer

• Median Nerve Tendon transfer for high median nerve injury

• ADM to APB

  • for Th opposition OR EIP, EPL, EDM, ECU

ADM is released from its insertion point and then turned 180 degrees and inserted into APB

Used in congenital cases or with absence of thenar muscles

• thumb hypoplasia or aplasia

ECRL or Brachialradialis to FPL

• Median nerve transfer for high injury

• ECRL and ECU can also be used to IF FDP

• For TH IP flexion

FDP Side-to-Side

• Median Nerve transfer for high nerve injuries

• For DIP flexion to IF, LF and full flexion of digits

Radial Nerve

1. Innervates 3 heads of the triceps first

2. Brachioradialis

3. ECRL - high injury above here (above elbow)

4. ECRB - PIN starts here - low injury here, below elbow

5. Supinator

6. EDC

7. ECU

8. APL

9. EDM

10. EPB

11. EPL

12. Extensor indicis

MMT for these to determine tendon worth transferring

-wrist drop

-finger drop

-poor grip strength

-Min sensory issues

Goals:

• restore MCP ext

• restore TH ext

• restore wrist ext

Orthotic position: Elbow flexion to 90 degrees and FA in pronation with slight wrist extension; TH abd and extended at MCPs and IPs free

4-6 weeks post: isolated movement; avoid composite

8+ weeks: strengthen

12 weeks: return to full activity

Radial Nerve Transfers

• Boyes Transfer: FDS of RF to EDC for MCP ext

• Paul Brand Transfer: FCR to EDC to MCP ext

• PL to EPL: for TH ext and retropulsion

• FDS of RF to EPL: for TH ext and retropulsion

• PT to ECRB: for wrist ext

• Bicep to Tricep: for elbow ext

all high injuries

Boyes Transfer

• Radial nerve transfer

• FDS of RF to EDC

• for MCP extension

Paul Brand Transfer

• Radial nerve transfer

• FCR to EDC

• for MCP extension

PL to EPL or FDS of RF to EPL

• radial nerve transfer

• for Th ext and retropulsion (abd)

PT to ECRB

• radial nerve transfer for high radial nerve injuries

• for wrist extension

• most common to restore wrist extension; done while waiting on nerve to return

Bicep to Tricep

stores elbow extension in high radial nerve injuries

Ulnar Nerve Injuries

Presentation:

• loss of key pinch, loss of power grasp, excessive IP flex

High injury: above elbow level (FCU and FDP RF/SF) - loss of grip strength

• restore SF & RF DIP flex

• improve functional grip strength

Low injury: below elbow level (deep branch intrinsics)

• correct the clawing position

• regain key pinch

• restore balance to IP/MCP

TX:

Orthotic: DBS with wrist in flexion for claw; DBS on TH if included

no full ext of hand to avoid stretching transfer

mobilize 3-4 weeks

6+ weeks neuro reeducation

8+ weeks strenthen

12+ weeks return to work

Brand Transfer

• Ulnar nerve transfer for low ulnar nerve injuries

• ECRB to lumbricals

• restores tenodesis

ECRB free graft through extensor retinaculum

• ulnar nerve transfer for high ulnar nerve injury

• muscle connected to EDC to restore tenodesis

• decrease claw deformity

Stiles Bunnel Transfer

• ulnar nerve transfer for low ulnar nerve injury

• Each FDS split, Run along lumbricals or P2 of RF or SF

• restores digit tenodesis

Zancolli Lasso Transfer

• ulnar nerve transfer for low ulnar nerve injury

• FDS loops around A1 pulley of RF/SF

• Blocks MCP hyperextension and Claw deformity

Smith Transfer

• Ulnar nerve transfer for low ulnar nerve injury

• ECRB to AP; not synergistic

  • ECRB rerouted around 2nd MCP and attached to AP

• restores key pinch

Brachioradialis to AP

• Ulnar nerve transfer for low ulnar nerve injury

• restores key pinch

• BR rerouted around 2nd MCP and attached to AP

Littler Transfer

• Ulnar nerve transfer for low ulnar nerve injury

• LF FDS to AP

• restores key pinch

FDP Side-to-Side

• ulnar nerve transfer for high ulnar nerve injury

• FDP side to side

  • all 4 FDP tendons are lassoed together

• for DIP flexion to RF, SF

Brachial Plexus Injury Transfers

• loss of suprascapular nerves: loss of supraspinatus and infraspinatus

  • Signs:

    • loss of strength in ER and first 30 deg abd, coordination and stability

    • + sulcus sign

    • Increased joint mobility

• Musculocutaneous nerve: loss of brachialis, coracobrachialis, and biceps brachii resulting in loss of elbow flexion

  • MMT of each of these; all must present with limitations to indicate nerve injury

L’Episcopo Transfer

• Lattissimus Dorsi & Teres Major to Rotator Cuff

• restores external rotation and GH stability, due to suprascapular loss

• Orthotic: shoulder sling for 6 weeks, 30-40 deg abduction and in ER - wedge needed for this position

• 6 weeks p/o: light short arc ; grade I joint mobs; avoid fatigue during exercise

• no weight bearing or resistance until 12 weeks post

Lats, Pec Major, or Triceps to Biceps

• restores bicep flexion, due to musculocutaneous loss

• these muscles are re-routed to bicep

• proximal muscle group transfers less successful that distal: lats and pec major

• triceps more successful but still tricky as its not a synergistic muscle

• Orthotic: Immobilize at 110-120 degrees of elbow flexion

  • hinged elbow ideal to begin slow progression of ext block weekly at 6 weeks

  • Proximal muscle group: extend 15 degrees weekly for pec or lat transfer

Week 6: AROM to block of hinge or splint; no PROM

Week 8: PROM appropriate; let gravity help at this point

D/C orthotic when able to demo 90 degrees of flexion against gravity

Steindler Transfer

• Common flexor tendon transferred more proximally to distal humerus

• restores elbow flexion after musculocutaneous loss

• “when you close, now you’re elbow flexes” - synergistic

• Orthotic: Immobilize at 110-120 degrees of elbow flexion

  • hinged elbow ideal to begin slow progression of ext block weekly at 6 weeks

  • Steindler: progress 30 degrees per week

Week 6: AROM to block of hinge or splint; no PROM

Week 8: PROM appropriate; let gravity help at this point

D/C orthotic when able to demo 90 degrees of flexion against gravity

5lb max lifting restriction for life

Lats, Bicep, or Deltoid to Triceps

• restores elbow extension after loss of radial nerve

Mannerfelt Syndrome Transfer

• RA rupture transfer

  • loss of FPL of TH or IF FDP - frays and ruptures over osteophytes over scaphoid

  • Assess FDP of LF to rule out AIN paralysis

• FDS RF or LF to FPL or IF FDP

• restores TH or IF IP flex

• Orthotic: FA based dorsal blocking TH spica in wrist flex for FPL

  • If FDP, DBS for digits

• 4 weeks p/o: early mobilization

• 6 weeks p/o neuromuscular reeducation

• 8 weeks p/o strengthening

• 12 weeks p/o return to activity

Vaughn Jackson Transfer

• RA rupture transfer

  • EDC ruptures over styloid resulting in loss of ext in RF, SF

• EIP to EDC of SF, RF

  • they may also use FDS if more than SF, RF EDC lost

• restores RF and SF extension

• Orthotic: Volar resting orthotic with MCPs in ext and IPs free

• 4 weeks p/o: early mobilization

• 6 weeks p/o neuromuscular reeducation

• 8 weeks p/o strengthening

• 12 weeks p/o return to activity

EIP to EPL Transfer

• RA rupture transfer

  • EPL rupture over lister’s tubercle

    • APB can extend IP slightly in some cases but retropulsion fully lost

    • synergistic movement

• restores TH extension

Orthotic: full ext of TH, volar FA based TH spica orthotic

delay mobility to 4 weeks p/o

• 4 weeks p/o: early mobilization

• 6 weeks p/o neuromuscular reeducation

• 8 weeks p/o strengthening

• 12 weeks p/o return to activity

Nerve regeneration timeline

and sequence of return

• Apparent 6-8 weeks after nerve repair

• Sequence of return

  1. deep pressure and pin prick

  2. moving touch

  3. static touch

  4. discriminative touch

Successful Tx for Intrinsic Minus Hand

• Dorsal MCP jt. blocking orthosis

• FDS to A1 pulley

• FDS to lateral bands