Tendon Transfers

TENDON TRANSFERS

PREFACE

Tendon transfers have long been a valuable treatment modality for the im-paired upper extremity. Many of the principles of tendon transfers were developedduring the treatment of poliomyelitis, leprosy, and residual war injuries. Theseguidelines have been expanded to treat deficits after peripheral nerve trauma, bra-chial plexopathy, spinal cord injury, brain injury, and congenital anomaly.

This edition of the Atlas of the Hand Clinics is dedicated to tendon transfers formany of these difficult problems. The content is organized according to the underly-ing diagnoses to allow easy reference. A highly regarded ensemble of authors hasbeen assembled with particular expertise in tendon transfers. Their contribution oftime and effort has provided the substance to this monograph.

The goal of this text is to present a variety of tendon transfer techniquesspecific to a particular problem. Each article focuses on the author’s preferredmethod and provides specific technical details to perform the intended tendontransfer. This manner of organization facilitates the performance of the tendontransfer and improves the overall outcome. The ultimate goal, however, is to en-hance function to the impaired limb and to improve the quality of life of thepatient.

I would like to thank A. Lee Osterman, MD, for the opportunity to serve as aneditor for the Atlas of the Hand Clinics and all the contributors for their timelycomposition of superb manuscripts. In addition, this edition of Atlas of the HandClinics would not have been possible without the support of Deb Dellapena and thestaff at W.B. Saunders who were instrumental to the completion of this text.

Scott H. Kozin, MDGuest Editor

Shriners Hospitals for Children3551 North Broad StreetPhiladelphia, PA 19140

ix

Tendon Transfers for ThumbOppositionAlexander Y. Shin, MD, and Khiem D. Dao, MD

On the length, strength, free lateral motion, and perfect mobility of thethumb, depends the power of the human hand.

SIR CHARLES BELL

The loss of thumb opposition, especially when associated with median nervepalsy or traumatic loss of the thenar musculature, results in a severe impairment ofthe function of the hand. The numerous publications and types of proceduresdescribing the restoration of thumb opposition attest to the importance of the op-posable thumb.* The earliest surgeries to restore thumb opposition focused onrestoration of the short flexors to the completely intrinsic-minus thumb.11,25,31,34 In1924 Bunnell9 described an opponensplasty in which he passed a tendon through aconstructed pulley at the level of the pisiform, subcutaneously tunneled it across thepalm, and attached it to the dorsal ulnar aspect of the thumb metacarpal, allowingfor mechanically superior opposition. Fourteen years later, Bunnell reported theresults of this technique in 46 cases.8 That report underscored some of the basicprinciples of tendon transfers, including the appropriate direction of action, singularfunction, and sufficient muscle strength of the donor tendon-muscle unit. Usingthese precepts, Bunnell was able to achieve true opposition (thumb brought awayfrom the fingers and pronated to oppose the fingers pulp to pulp) rather than shortflexor action.

Since Bunnell’s report, a variety of tendon and muscles have been used toreconstruct opposition of the thumb. These tendon-muscle units include the flexordigitorum superficialis of the long or ring finger,30,31 the extensor indicis proprius(EIP),10 the extensor pollicis longus,29 the extensor carpi ulnaris,21 the extensor carpibrevis longus,19 the extensor digitorum quinti,32 the palmaris longus,11 and the

TENDON TRANSFERS 1082–3131/02 $15.00 + .00

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002 1

The views expressed in this article are those of the authors and do not reflect the official policy ofposition of the Department of the Navy, Department of Defense, or the United States Government.

*References 1–3, 5, 6, 9, 10, 13–15, 17–19, 21, 22, 24–29, 31, 32, 34, and 35.

From the Division of Hand and Microvascular Surgery, Department of Orthopaedic Surgery, NavalMedical Center San Diego, San Diego, California (AYS, KDD); Division of Hand Surgery, Depart-ment of Orthopaedics, Mayo Clinic, Rochester, Minnesota

abductor digiti quinti.24 A description of each of these tendon transfers is beyondthe scope of this article. Herein, the technique of two tendon transfers that arecommonly performed for the restoration of thumb opposition, that is, the (EIP), andthe flexor digitorum superficialis (FDS) of the ring finger, are described.

PRINCIPLES OF TENDON TRANSFER

Prerequisites

Before any tendon transfer, the surgeon and the patient must understand thefunctional and aesthetic goals along with the limitations and expectations of sur-gery. Once this understanding is established, several fundamental prerequisites arerequired when undertaking a tendon transfer.33 First and foremost, tissue equilib-rium must be established. Inflammation and edema must be subsided, joint contrac-tures must be resolved, and a stable osseous framework must be present. Oncethese prerequisites are established, selection of a donor tendon and muscle is madebased on a donor that is functional and expendable. These requirements provideadequate strength and amplitude without loss of function. The optimal donor ten-don travels a straight route and performs a single function.

INDICATIONS FOR OPPONENSPLASTY

The most common indication for opponensplasty is an isolated median nervepalsy. Median nerve paralysis is most frequently caused by penetrating or perforat-ing injuries to the forearm or wrist, and typically involves damage to the flexortendon.10 Other indications include traumatic or developmental loss of the thenarmusculature or ruptured or avulsed tendons or muscles.

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METHODS OF DISTAL TENDON INSERTION

Several options exist for attachment of the tendon transfer, all of which can beclassified as single or dual insertions (Fig. 1).

TENDON TRANSFERS FOR THUMB OPPOSITION 3

Figure 1. Four common techniques for distal tendon attachment for opponens-plasty. From Curtis RM: Opposition of the thumb. Orthop Clin North Am 5:314,1974.

Dual insertion techniques are designed to rotate (pronate) the thumb and eitherpassively stabilize the metacarpophalangeal joint (MPJ) or minimize interphalangealjoint (IPJ) flexion. This movement is theoretically beneficial in patients with com-bined median and ulnar nerve deficits who lack all thumb intrinsic function16;however, some surgeons question the utility of dual insertion techniques becausethe transfer will function predominantly on the tighter of the two insertions.16

Brand’s technique of distal tendon insertion involves splitting the tendon endinto two slips. One slip is woven through the abductor pollicis brevis tendon andthen passed distal to the MPJ and attached to the extensor pollicis longus tendon.7The second slip is passed subcutaneously across the extensor mechanism dorsallyand attached to the adductor pollicis on the ulnar side of the MPJ.15 This maneuverprovides rotation of the thumb and stabilizes the MPJ, which is recommended inpatients with complete loss of thenar musculature function and an unstable MPJ.15

Other options for distal attachment include the Royle-Thompson method, whichalso involves splitting the tendon into two slips.37 One slip is passed through a drillhole made in the metacarpal neck from radial to ulnar, with the metacarpal pulledinto as much opposition as possible. This slip is tied to the other half that is initiallypassed dorsally over the extensor hood at the MPJ and through a small tunnel inthe fascia and periosteum at the base of the proximal phalanx. The proximal inser-tion onto the metacarpal head assists in rotation of the thumb, and the distalinsertion achieves slight rotation of the MPJ without causing its flexion, anundesired effect.37

Riordan’s technique of attachment involves interweaving the transferred tendoninto the abductor pollicis brevis tendon, with continuation onto the extensor pollicislongus tendon distal to the MPJ.30 This maneuver aids in extension of the terminalphalanx of the thumb in patients with flexed posturing of the IPJ, as seen incombined median and ulnar nerve deficits.15

In Littler’s technique, the transferred tendon is attached into the abductor polli-cis brevis tendon radially because Littler believes that the abductor pollicis brevis isthe most important thenar musculature in normal opposition.23 Bunnell’s methodinvolves passing the tendon through a small drill hole made at the proximal pha-lanx base from the dorsoulnar to palmar-radial direction to provide pronation of thethumb.8 The tendon may be secured by anchoring it to the periosteum on the radialside of the phalanx, sutured onto itself or secured with a pull-out suture.

TRANSFER TENSIONING

Regardless of the attachment method selected, correct tensioning is imperativeto achieve optimal results. Tensioning is achieved when the thumb is in maximalopposition with passive wrist extension and in maximal extension with passivewrist flexion. The corollary dictates that the tension requires tightening if full thumbopposition is not obtained with maximal wrist extension, and loosening if fullthumb extension is not obtained with maximal wrist flexion. Provisional sutures areplaced at the selected attachment sites, and the wrist is placed through a range ofmotion. Final sutures are placed to secure the transfer after the desired tension isachieved.

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PULLEY PLACEMENT

To determine the optimal direction of action or pulley location, Cooney andassociates14 performed a cadaveric study that simulated tendon transfer to restorethumb opposition. The results indicated that any tendon transfer for thumb opposi-tion required an adequate moment arm for the thumb trapeziometacarpal joint andthe thumb MPJ. Furthermore, a pulley in the area of the pisiform restored thenecessary direction of action of the thenar muscles and provided motion in theplanes of abduction, flexion, or combined abduction-flexion (Fig. 2).


Figure 2. Pulley placement for thumb op-position tendon transfers includes pulleysproximal to the pisiform (extensor carpiulnaris, extensor carpi radialis longus),rotated on the pisiform (abductor digitiquinti [muscle]), distal to the pisiform ex-tensor indicis proprius (EIP), tendonloops of the flexor carpi ulnaris (FCU)and the carpal tunnel (Camittransfer).(From Cooney WP, Linscheid RL, An KN:Opposition of the thumb: An anatomicand biomechanical study of tendon trans-fers. J Hand Surg 9A:3, 1984.)

EXTENSOR INDICIS PROPRIUS TENDON TRANSFER

The EIP opponensplasty was described in 1956 by Chouhy-Aguirre of BuenosAires12 and was subsequently popularized by Burkhalter,10 who reported on a largeseries in 1973. This transfer is easy to perform, and the results of treatment havebeen uniformly good. The EIP opponensplasty has little, if any, donor-site morbidityand adequate strength to position the thumb.

With the patient under regional or general anesthesia, the operative extremity isexsanguinated and an arm pneumatic tourniquet used. The incisions are outlined(Fig. 3A and B), and a longitudinal incision is made over the index MPJ.

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Figure 3. An 18–year–old mechanic whose hand was caught in the intake of a jet,with resultant traumatic loss of the thenar muscles and the motor recurrent branchof the median nerve. The patient underwent several debridements and woundcoverage procedures, that left him with a sensate hand without thumb opposition.The preoperative incisions are drawn on the dorsal (A) and volar (B) aspects of thehand in preparation for an EIP opponensplasty. The dotted line represents the pathof the tendon transfer.

The EIP tendon is identified ulnar to the extensor communis tendon (Fig. 4A, B,and C).


Figure 4. The EIP tendon at the metacarpophalangeal joint is the ulnarmost struc-ture prior to the sagittal band (A). The EIP is isolated by dividing the sagittal bandattachment and its attachment to the extensor digitorum communis (EDC) of theindex finger (B). The harvested tendon is then tapered distally (C), and the sagittalband is reconstructed to the EDC tendon, closing the gap of the harvested tendon.

An incision is made on the ulnar side of the EIP through the sagittal band, andextended distally. Similarly, an incision is made on the radial side of the EIP,separating it from the extensor digitorum communis and tapering to the distalincision on the ulnar side. The sagittal band is then reconstructed using nonabsorb-able 4-0 sutures. Once the distal attachment of the EIP is released, a linear incisionis made over the dorsal ulnar aspect of the distal forearm. The deep fascia isdivided longitudinally, and the EIP tendon and muscle belly are identified anddelivered into the proximal wound (Fig. 5).

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Figure 5. A longitudinal incision is made along the dorso-ulnar aspect of the forearm, andthe deep fascia divided longitudinally. The EIP muscle belly and tendon are identified anddelivered from the wound.

Frequently, it is necessary to make a small transverse incision over the EIP tendonin the dorsum of the hand to free it from the extensor digitorum communis of theindex finger (Fig. 6A and B).


Figure 6. A and B, Often, the EIP muscle belly and tendon cannot be deliveredsecondary to adhesions or connection of the EIP tendon in the dorsum of the hand.As such, an incision in the dorsum of the hand is often required to free the EIPtendon.

A small longitudinal incision is made just distal to the pisiform, and a subcutaneoustunnel is created across the ulnar border of the forearm from the dorso-ulnar distalforearm incision to the incision distal to the pisiform (Fig. 7A, B, and C).

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Figure 7. A small longitudinal incision is made just distal to the pisiform, and a subcuta-neous tunnel across the ulnar border of the forearm is created from the dorso-ulnar distalforearm incision to the incision distal to the pisiform (A). The subcutaneous tunnel needsto be large enough to accept the muscle belly of the EIP, otherwise it may prevent fullexcursion of the donor tendon. The tendon is passed using a tendon passer or a hemo-stat (B and C).

A large enough subcutaneous tunnel must be created to allow the entire EIP musclebelly to lie against the subcutaneous border of the ulna. The EIP tendon is passedthrough the tunnel and out the pisiform incision. A second subcutaneous tunnel ismade across the palm to the thumb MPJ (Fig. 8A and B).


Figure 8. The line of pull of the donor tendon is estimated by placing the donortendon to the proposed insertion site on the distal portion of the thumb metacarpal(A). A subcutaneous tunnel is then fashioned between the incision at the pisiformand the thumb MPJ (B), and the EIP tendon is passed through the tunnel.

The method of attachment of the distal tendon transfer is controversial and hasbeen discussed previously. Regardless of the method of distal attachment, the trans-ferred EIP needs to be securely fixed, either through bone tunnels or by weavingthrough the abductor pollicis brevis, EIP, or flexor pollicis brevis (Fig. 9A and B).The thumb is placed into full opposition with the small finger, and the EIP transferis tensioned and secured.

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Figure 9. A and B, The EIP tendon is then weaved into the abductor pollicis brevistendon and secured with nonabsorbable 3-0 suture with the thumb in maximalopposition to the small finger. Once this is completed, a bulky hand dressingmaintains the position of maximal thumb opposition for 2 weeks, at which time thesutures are removed and a custom orthoplast splint is fabricated to hold theposition of maximal opposition until 4 weeks after surgery.

The tourniquet is released, hemostasis is obtained, and the wounds are meticu-lously closed. A bulky hand dressing with plaster splints is placed with the wrist inflexion and the thumb in full opposition for 10 to 14 days, at which time the skinsutures are removed. Hand therapy is initiated to maintain motion in the fingers,and an orthoplast splint is fabricated to maintain wrist flexion and full thumbopposition for a total of 4 weeks. At this time, range of motion exercises, tendongliding exercises, and retraining of the transferred tendon and muscle begin (Fig.10A, B, and C).


Figure 10. A–C, At approximately 3 months after surgery, the patient demon-strated well healed wounds and excellent thumb opposition and strength.

FLEXOR DIGITORUM SUPERFICIALIS TENDON TRANSFER

Another common tendon transfer to restore thumb opposition is the flexordigitorum superficialis tendon from the ring finger (FDS IV). This technique beginswith a palmar transverse skin incision made over the MPJ of the ring finger (Fig.11).

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Figure 11. Skin incision markingsfor ring finger FDS tendon transfer.A � The incision to harvest the FDS.B � The incision to create the FCU pul-ley. C � The incision to expose the newinsertion of the transfered FDS. (FromJablon M: Oppensplasty with ring fingerflexor digitorum superficialis tendon. InBlair WF, Steyers CM (eds): Techniquesin Hand Surgery. Baltimore, Williamsand Wilkins, 1996, pp 675–681.)

The A1 pulley is identified and incised longitudinally, and the FDS tendon isidentified. Passive pull on the tendon will ascertain whether the FDS IV tendon hasbeen isolated. With the finger passively flexed, the FDS tendon is divided trans-versely just proximal to its bifurcation.

At this point, a pulley for the FDS IV tendon is constructed. A second curvilin-ear or zig-zag incision is made at the volar ulnar distal forearm in the region of theFCU tendon insertion (see Figure 11). The FCU and the FDS IV tendons are exposedwhile the ulnar nerve and artery are protected. The radial half of the FCU tendon isdivided transversely approximately 4 cm proximal to its insertion onto the pisiform.The radial half of the tendon is separated longitudinally from the ulnar half, creat-ing a distally based strip of tendon graft. The tendon graft is looped distally andpassed through the distal portion of the FCU near the pisiform insertion andsecured with nonabsorbable sutures (Fig. 12).


Figure 12. Pulley con-struction using the dis-tally based radial half ofthe distal FCU tendon,with attachment onto thepisiform. Arrow indicatespath of tendon throughthe FCU pulley. (FromJablon M: Oppensplastywith ring finger flexor dig-itorum superficialis ten-don. In Blair WF, SteyersCM (eds): Techniques inHand Surgery. Baltimore,Williams and Wilkins,1996, pp 675–681.)

The FDS IV tendon is isolated from the surrounding tendons at the wrist anddelivered through the volar ulnar forearm incision. The FDS IV tendon is passedthrough the constructed pulley and wrapped in saline-soaked gauze to preventdesiccation.

A third incision is made on the dorsum of the thumb MPJ, with care to prevent

injury to branches of the superficial radial nerve (see Fig. 11). A subcutaneoustunnel is created between this incision and the wrist incision that is wide enough toaccept the FDS IV tendon. The FDS IV tendon is passed through this tunnel to exitat the thumb incision. The thumb is placed into full opposition with the smallfinger, and the FDS IV tendon is secured with the surgeon’s preference for distalattachment of the tendon to the thumb.

The postoperative course is similar to that described for the EIP opponens-plasty.

RESULTS OF TREATMENT

Burkhalter and associates10 reported excellent results in 57 of 65 patients under-going EIP opponensplasty, defined as 75% function compared with the opposite/normal thumb or less than 20 degrees difference between the plane of the oppositethumbnail and the plane of the palm with good power. Fair results were seen infour patients, and four others had complete failure (i.e., no rotation or opposition ofthe thumb). Extensor lag of the index finger was seen in one patient in this series.

The preliminary results of FDS opponensplasty using the Royle-Thompson tech-nique in nine patients (10 hands) were reported by Thompson.37 There were fiveexcellent, three good, one fair, and one poor result. Although an objective gradingscheme was not provided, the good and excellent results “exceeded expectations.”

Jacobs and Thompson20 reported their results for 96 patients (103 transfers)based on a grading scheme.36 A good or excellent result had at least 75% of thefunction of the opposite thumb or less than 20 degrees difference between the planeof the opposed thumbnail and the palm, with good power. A fair result had goodrotation of thumb and poor power or less rotation and good power. Patients with apoor result had no thumb rotation or slight thumb rotation and poor power fromthe opponensplasty. All but three of the patients had opposition transfers for polio-myelitis. Using a variety of donor tendons (mainly, FDS IV and FDS III tendons),pulley designs, and insertion techniques (mainly, the Royle-Thompson attachment),77 good/excellent, 9 fair, and 17 poor results were reported. Similar results wereobtained with the FDS IV and FDS III tendons.

Sundararaj and Mani36 reported their results in 20 patients using FDS IV (17)and FDS II (3) transfers for triple nerve palsies (radial, ulnar, and median) second-ary to Hansen’s disease. Unfortunately, they did not elaborate on the methods ofdistal tendon insertion. Their results were classified as excellent if the pulp of thethumb could oppose to the pulp of the small or ring finger with the thumb IPJextended, good if the pulp of the thumb could only touch the middle or indexfinger, fair if opposition was possible only with the thumb IPJ flexed, and poor if noopposition was possible. Excellent or good results were obtained in 85% of cases.

Anderson and associates2 compared 50 extensor indicis proprius with 116 FDSring finger opponensplasties. Their analysis demonstrated that the EIP opponens-plasty was best in supple hands, whereas the FDS opponensplasty was more suit-able in less pliable hands. Complications were more frequent in the FDS group andincluded limitation of extension of the donor ring finger, flexion contractures of theproximal interphalangeal joint, and radial migration of the transferred tendon in thewrist.

SUMMARY

The choice of opponensplasty of the thumb should be based on the availabledonor muscle-tendon units, the overall condition of the hand, and a thoroughdiscussion with the patient. Regardless of the muscle-tendon unit chosen, the princi-ples of tendon transfer must be strictly adhered to to obtain optimal results.

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References

1. Anderson GA, Lee V, Sundararaj GD: Extensorindicis proprius opponensplasty. J Hand Surg16B:334–338, 1991

2. Anderson GA, Lee V, Sundararaj GD: Oppo-nensplasty by extensor indicis and flexor digi-torum superficialis tendon transfer. J HandSurg 17B:611–614, 1992

3. Baek GH, Jung JM, Yoo WJ, et al: Transferof extensor carpi radialis longus or brevisfor opponensplasty. J Hand Surg 24B:50–53,1999

4. Bell C: The Hand—Its Mechanism and VitalEndowments as Evincing Design. The Bridge-water Treatises, vol. 4. London, William Pick-ering, 1833

5. Bindra RR, Bhandarkar DS, Taraporvala JC:Opponensplasty—an experience of twenty-three cases using three techniques. J PostgradMed 36:9–12, 1990

6. Bourrel P, Courbil JL, Giraudeau P: Transplan-tation of the extensor indicis proprius for res-toration of opposition of the thumb: Aproposof 15 cases. Ann Chir 32:597–600, 1978

7. Brand PW: Tendon transfers for median andulnar nerve paralysis. Orthop Clin North Am1:447–454, 1970

8. Bunnell S: Opposition of the thumb. J BoneJoint Surg 20A:269–284, 1938

9. Bunnell S: Reconstructive surgery of the hand.Surg Gynecol Obstet 39:259–279, 1924

10. Burkhalter W, Christensen RC, Brown P: Ex-tensor indicis proprius opponensplasty. J BoneJoint Surg 55A:725–732, 1973

11. Camitz H: Uber die behandlung der opposi-tionslahmung. Acta Chir Scand 65:77–81, 1929

12. Chouhy-Aguirre S, Caplan S: Sobre secuelas delesion alta e irreparable de nervios mediano ycubital, y su tratamiento. Prensa Med Argen-tina 43(31):2341–2346, 1956

13. Cooney WP: Tendon transfer for median nervepalsy. Hand Clin 4:155–165, 1988

14. Cooney WP, Linscheid RL, An KN: Oppositionof the thumb: An anatomic and biomechanicalstudy of tendon transfers. J Hand Surg 9A:777–786, 1984

15. Curtis RM: Opposition of the thumb. OrthopClin North Am 5:305–321, 1974

16. Davis TRC, Barton NJ: Median nerve palsy. InGreen DP, Hotchkiss RN, Pederson WC (eds):Operative Hand Surgery, vol. 2, ed 4. NewYork, ChurchillLivingstone, 1999, pp 1497–1525

17. Foucher G, Malizos C, Sammut D, et al: Pri-mary palmaris longus transfer as an opponens-plasty in carpal tunnel release: A series of 73cases. J Hand Surg 16B:56–60, 1991

18. Goldner JL, Irwin CE: An analysis of paralyticthumb deformities. J Bone Joint Surg 32A:627–639, 1950

19. Henderson ED: Transfer of wrist extensors and

brachoradialis to restore opposition of thethumb. J Bone Joint Surg 44A:513–522, 1962

20. Jacobs B, Thompson TC: Opposition of thethumb and its restoration. J Bone Joint Surg42A:1015–1026, 1960

21. Kessler I: Transfer of extensor carpi ulnaris totendon of extensor pollicis brevis for oppo-nensplasty. J Bone Joint Surg 51A:1303–1308,1969

22. Lin CH, Wei FC: Immediate Camitz opponens-plasty in acute thenar muscle injury. Ann PlastSurg 44:270–276, 2000

23. Littler JW: Tendon transfers and arthrodesis incombined median and ulnar nerve paralysis. JBone Joint Surg 31A:225–234, 1949

24. Littler JW, Cooley SGE: Opposition of thethumb and restoration by abductor digitiquinti transfer. J Bone Joint Surg 45A:1389–1396, 1963

25. Makin M: Translocation of the flexor pollicislongus tendon to restore opposition. J BoneJoint Surg 49B:458–461, 1967

26. Mehta R, Malaviya GN: Evaluation of the re-sults of opponensplasty. J Hand Surg 21B:622–623, 1996

27. Oberlin C, Alnot JY: Opponensplasty throughtranslocation of the flexor pollicis longus: Tech-nique and indications. Ann Chir Main MembSuper 7:25–31, 1988

28. Ogino T, Minami A, Fukuda K: Abductor dig-iti minimi opponensplasty in hypoplasticthumb. J Hand Surg 11B:372–377, 1986

29. Riley WB, Mann RJ, Burkhalter WE: Extensorpollicis longus opponensplasty. J Hand Surg5A:217–220, 1980

30. Riordan DC: Surgery of the Paralytic Hand.Instructional Course Lectures, The AmericanAcademy of Orthopaedic Surgeons, vol. 16. St.Louis, CV Mosby, 1959, pp 79–90

31. Royle ND: An operation for paralysis of theintrinsic muscles of the thumb. JAMA 612–613,1938

32. Schneider LH: Opponensplasty using the ex-tensor digiti minimi. J Bone Joint Surg 51A:1297–1302, 1969

33. Smith RJ, Hasting H: Principles of TendonTransfers to the Hand. Instructional CourseLectures, American Academy of OrthopaedicSurgeons, vol. 21. St. Louis, CV Mosby, 1980,pp 129–149

34. Steindler A: Flexor plasty of the thumb in the-nar palsy. Surg Gynecol Obstet 50, 1930

35. Steindler A: Orthopedic operations for thehand. JAMA 71:1288–1291, 1918

36. Sundararaj GD, Mani K: Surgical reconstruc-tion of the hand with triple nerve palsy. J BoneJoint Surg 66B:260–264, 1984

37. Thompson TC: A modified operation for oppo-nens paralysis. J Bone Joint Surg 26A:632–640,1942

Address reprint requests to

Alexander Y. Shin, MDDepartment of Orthopaedic Surgery

Division of Hand SurgeryMayo Clinic E14A

200 First Street SWRochester, MN55905

[email protected]


Tendon Transfers for IntrinsicFunction in Ulnar Nerve PalsyDavid M. Kalainov, MD, and Mark S. Cohen, MD

The ulnar nerve innervates approximately 80% of the intrinsic muscles in thehand. Consequently, loss of ulnar nerve function can be disabling. The lumbricaland interosseous intrinsic muscles are responsible for coordinated flexion of themetacarpophalangeal (MCP) joints and extension of the interphalangeal (IP) joints.Although full finger flexion and extension are still possible with intrinsic paralysis,the fingers tend to roll up during flexion owing to asynchronous motion of theMCP and IP joints. The ability to position the hand effectively around objects suchas a glass or door knob is impaired. In addition, grip and pinch strength aremarkedly diminished.

Clinical features of ulnar nerve palsy include muscle wasting with atrophy ofthe hypothenar eminence and dorsal first web space (Fig. 1A). The Froment sign ispositive and involves hyperflexion of the thumb IP joint during attempted keypinch (Fig. 1B). Concomitant hyperextension of the thumb MCP joint may developowing to volar plate laxity and paralysis of the adductor pollicis muscle (Jeanne’ssign). Loss of the third volar interosseous muscle leads to an abduction deformity ofthe small finger from unopposed eccentric pull of the extensor digiti minimi (War-tenberg’s sign) (Fig. 1C). Interosseous loss also impairs lateral finger movements,demonstrated by the cross-finger test (Fig. 1D). Clawing of the ring and smallfingers typically ensues from unopposed actions of the extrinsic flexor and extensortendons (Fig. 1E). The small finger always exhibits a greater degree of clawing thanthe ring finger.



From the Department of Orthopaedic Surgery, Northwestern University Medical School (DMK), andRush-Presbyterian St. Luke’s Medical Center (MSC), Chicago, Illinois

Figure 1. Ulnar paralysis leads to several deformities of the hand. A, Intrinsicmuscle wasting is often best visualized in the first web space. B, Froment signinvolves thumb interphalangeal joint hyperflexion during pinch.

Illustration continued on opposite page

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Figure 1 (Continued). C, Wartenburg’s sign is an abducted posture to the small finger due to loss ofthe third volar interosseous muscle and eccentric pull of the extensor digiti minimi. D, Loss ofinterosseous function also leads to an inability to cross the fingers. E, Clawing is most pronounced inthe small finger and to a lesser degree in the ring finger.

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY 21

The index and long fingers may appear uninvolved if the median nerve re-mains functional owing to the intact first and second lumbrical muscles. Althoughrelatively weak, the lumbrical muscles often balance the radial digits and maintainsynchronized joint motion. In 50% of individuals, the third lumbrical muscle isdually innervated (median and ulnar nerves), and the ring finger may be protectedfrom clawing. When both the ulnar nerve and the distal median nerve are affectedby disease or injury, claw deformities will develop in all fingers, with concomitantatrophy of the thenar and hypothenar muscles. The appearance is that of a simianhand.

Variations in intrinsic muscle deficiency are encountered occassionally withulnar nerve palsy and often can be attributed to normal interconnections betweenthe median and ulnar nerves. Crossover can occur between the anterior interosseousbranch of the median nerve and the ulnar nerve in the forearm (Martin-Grubercommunication) or between the motor branch of the median nerve and the ulnarnerve in the palm (Riche-Cannieu communication). Partial nerve injuries and highpalsies of the median or ulnar nerves may also lead to different patterns of handdysfunction. Effective management in each case requires an understanding of theanatomic lesions and the resultant motor and sensory deficits. Numerous combina-tions of nerve palsies are possible. This article focuses on the management ofintrinsic muscle paralysis from isolated ulnar nerve lesions.

ETIOLOGY

Ulnar nerve motor deficits most often result from direct trauma to the nerve orfrom long-standing nerve compression (e.g., cubital tunnel syndrome). The differen-tial diagnosis in atraumatic cases includes cervical spine disease with impingementof the lower cervical nerve roots (C8-T1) and lesions of the brachial plexus. Cervicalnerve root compression typically manifests as neck pain with radicular symptomsdown the arm. Weakness and atrophy are expected in the thenar and hypothenarmusculature, both of which are innervated by the lower cervical and first thoracicnerve roots. Injury or compression of the lower elements of the brachial plexus (e.g.,by a Pancoast tumor) may result in similar findings.

Other causes of peripheral nerve dysfunction can lead to a confusing clinicalpresentation, including leprosy (Hansen’s disease) and hereditary motor-sensoryneuropathy (Charcot-Marie-Tooth disease). Intrinsic atrophy with or without sen-sory loss may be seen in syringomyelia or amyotrophic lateral sclerosis. Theseconditions often result in diffuse and symmetrical involvement of the upper extrem-ities. In all cases, nerve conduction velocity and electromyogram studies may behelpful in localizing a suspected lesion and in excluding a more generalized nervedisorder.

22 KALAINOV & COHEN

CONSERVATIVE TREATMENT

Optimal treatment of the patient with ulnar nerve dysfunction requires theexpertise and assistance of a hand therapist. Exercises are directed at maintaining orimproving mobility of the finger joints. Fabrication of a hand-based orthosis isparticularly useful to address the initial claw deformity and to prevent the develop-ment of fixed joint contractures.

A lumbrical bar splint fits over the dorsum of the metacarpal heads and proxi-mal phalanges of the ring and small fingers (Figs. 2A and B).


Figure 2. A, Lumbrical bar splint frontal view. B, Lateral view. This splint blocks theclaw deformity of the ring and small fingers, allowing the extrinsic extensor tendonsto extend the interphalangeal joints. It will improve function and diminish the likeli-hood of fixed contractures and attenuation of the central extensor tendons.

The design protects the MCP joints from hyperextension without impending fingerflexion. The splint will not improve grip strength or correct asynchronous motion ofthe digits; however, by blocking the MCP joints, it enables the extrinsic extensortendons to extend the IP joints more effectively. The patient will be able to manipu-late the fingers around large objects and place the hand into tight spaces. Addition-ally, attenuation of the extensor tendons may be prevented.

SURGICAL TREATMENT

Many surgical procedures have been described to treat functional deficits result-ing from intrinsic muscle paralysis in ulnar nerve palsy. Tendon transfers are avail-able to correct the claw deformity, to improve integrated joint motion, and toincrease grip and pinch strength. These transfers require a motivated patient andfull passive mobility of the digits. The choice of transfer depends largely on the ageand expectations of the patient, the availability of donor tendons, and the level ofthe ulnar nerve deficit (high or low). Lack of protective sensation may adverselyaffect outcome.

The differences between high and low ulnar nerve palsy are relatively few. In aproximal lesion, there is additional loss of the flexor carpi ulnaris and the ring andsmall finger flexor digitorum profundus muscles. Although the same tendon trans-fer techniques can be applied to both categories of ulnar nerve deficit, considerationshould be given to forearm level transfers of the ring and small finger flexordigitorum profundus tendons to the adjacent profundus or superficialis tendons inhigh ulnar nerve palsy. This technique will balance finger flexion and improvefunctional grasp. In addition, one should try to avoid using the flexor carpi radialistendon as a donor in a high ulnar nerve lesion given the absence of a functionalflexor carpi ulnaris muscle.

Integrated Finger Motion, Clawing, and Grasp

Several techniques to correct these specific deficiencies have been described,employing extrinsic muscles of the wrist and fingers as donor tendons. Two of themore commonly performed operations include transfer of a wrist motor with ten-don graft extensions (four-tail graft) and transfer of one flexor digitorum superfici-alis (FDS) from either the index or long finger (Stiles-Bunnell). Although bothprocedures rebalance the hand and improve asynchronous finger motion and claw-ing, only the addition of a wrist motor will increase grip strength. This use of awrist motor usually is indicated for younger individuals and for persons withhigher functional demands.

Four-Tail Graft

The extensor carpi radialis brevis (ECRB) is an ideal motor unit for tendontransfer in intrinsic paralysis. The flexor carpi radialis can be substituted if theECRB is absent or required for another procedure (e.g., thumb adductorplasty).Although clawing of the index and long fingers is typically absent in low ulnarnerve lesions, inclusion of all four fingers in the transfer is recommended forimproved hand strength and dexterity. Four slips of tendon graft are required toprolong the ECRB for insertion into the proximal phalanges. The plantaris tendonsfrom both lower extremities are readily accessible, and each will typically supplytwo tendon graft lengths. These slips are harvested through limited incisions usinga tendon-stripping instrument. The long toe extensors may be used if the plantaristendons are absent or of insufficient size.

24 KALAINOV & COHEN

Preoperatively, the function of the ring and small finger extrinsic extensortendons is assessed with the Bouvier test (Fig. 3)


Figure 3. The Bouvier test consists of blocking metacarpophalangeal jointhyperextension while the patient attempts digital extension. With suppleinterphalangeal joints, near complete active finger extension should bepresent if the central extensor tendons are competent.

If it is difficult to achieve active extension of supple proximal interphalangeal (PIP)joints with MCP hyperextension blocked, the central tendons have attenuated. Inthis setting, an improvement in active extension may be achieved by insertion of thetransfers into the dorsal apparatuses rather than into the proximal phalanges; how-ever, caution is advised with this variation in technique because PIP hyperextensionand swan neck deformities may develop.

For bony insertion, angled skin incisions approximately in length are2 cmmade at the radial bases of the middle, ring, and small fingers. A fourth angledincision is made at the ulnar base of the index finger (Fig. 4).

26 KALAINOV & COHEN

Figure 4. Proposed incisions for the extensor carpi radialis brevis four-tail tendongraft procedure.

Figure 5. Intraoperative view depicting drill hole in the proximal phalanx positioned near themidline (or slightly palmar) and approximately at the distal half of the second annular pulley.

The lateral bands are identified and retracted dorsally, exposing the proximal pha-langes. A 2.0-mm transverse drill hole is made through each proximal phalanx at apoint in the mid–axiscorresponding to the second annular pulley. The near corticesare enlarged with a 2.7-mm drill bit or curette to accommodate insertion of thetendon grafts (Fig. 5).

Two transverse skin incisions are made over the dorsal hand, one between thesecond and third metacarpals and one over the fourth metacarpal. The interosseousfascia is incised longitudinally between each metacarpal. Sutures are placed in thedistal ends of all four tendon slips using a pull-through technique (Bunnell orKessler). A Chevron incision approximately 8 cm in length is designed over thedorsoradial border of the extensor retinaculum. The insertion of the ECRB is re-leased sharply from the base of the middle metacarpal, taking care to protectbranches of the dorsal sensory radial nerve. The tendon is withdrawn proximallyfrom beneath the extensor retinaculum.

Two tendon grafts are passed through the interspace between the second andthird metacarpals for the index and middle fingers. One graft is passed through theinterspace between the third and fourth metacarpals and the other slip through theinterspace between the fourth and fifth metacarpals. Each graft must follow anunimpeded course through the interosseous muscles, under the transverse metacar-pal ligament (through the lumbrical canal), and toward the prepared insertion sitein the proximal phalanx. A curved tendon passer is helpful in this regard, andpassage is aided by flexion of the MCP joints.

The tendons are seated securely by passing the attached sutures through thebone tunnels with Bunnell or Keith needles (Fig. 6).


Figure 6. Routing of the tendon graft extensions.

The suture ends are tied snuggly over padded buttons on the opposite side of eachdigit. All four tendon grafts are tunneled through subcutaneous tissues proximallyin a direct line toward the ECRB tendon (Fig. 7). Once this maneuver is accom-plished, all distal wounds are closed.

28 KALAINOV & COHEN

Figure 7. Tendon grafts have been secured distally and are drawn in a straight-line pathinto the proximal wound. Note the closure of all distal wounds.

The grafts are first sutured to one another under appropriate balance. It ishelpful to combine the ring and small and the index and middle grafts separatelybefore joining all four grafts together. Care should be taken not to overtighten theindex finger graft relative to the others, which can lead to an adduction contractureof the index finger and scissoring. Once balanced, the tendon mass is woven in aPulvertaft fashion into the ECRB and secured (Fig. 8).


Figure 8. Tendon grafts have been sutured to the extensor carpi radialis brevis with a Pulvertaft weave.

Correct tensioning is achieved with the wrist held in full dorsiflexion and the fingerMCP joints in maximum flexion, taking up approximately 50% of the excursion ofthe donor tendon. Following repair, the wrist is brought through a range of motion,demonstrating tenodesis of all finger MCP joints into flexion with the wrist flexed.Full passive MCP joint extension should be possible with the wrist extended. Thewrist is immobilized postoperatively in approximately 45 degrees of extension, withthe MCP joints flexed 60 degrees and the IP joints extended.

Flexor Digitorum Superficialis Transfer (Stiles-Bunnell)

This procedure uses one flexor digitorum superficialis (FDS) tendon as thedonor transfer. The FDS tendon from either the index or middle finger is releasedand split. The two tendon slips are transferred through the lumbrical canals of thering and small fingers and inserted most commonly into the lateral bands of thefinger extensor mechanisms. Usually, the tendon slips are of adequate length and donot require tendon graft extensions. The goal is to rebalance the hand, correcting theclaw deformities and improving a synchronous finger motion (Figs. 9A and B).

30 KALAINOV & COHEN

Figure 9. A, Follow-up revealing intrinsic plus posture with meta-carpophalangeal flexion and interphalangeal joint extension. B,Restoration of synchronous finger flexion.

No increase in strength is anticipated. Several variations of this technique have beendescribed, including subdividing the long finger FDS into four slips for transfer toall four fingers, attachment of the tendon slips to the flexor tendon sheaths, andattachment of the tendon slips to the proximal phalanges through bone tunnels aspreviously described.

The middle finger FDS is harvested over the PIP joint palmarly, and both slipsare released sharply, dividing Camper’s chiasm. A transverse incision is made inline with the distal palmar crease across the fourth metacarpal. The FDS tendon iswithdrawn into the proximal wound, and the longitudinal split in the tendon isextended proximally to create two slips of equal caliber (Fig. 10).


Figure 10. Stiles-Bunnell transfer. Two slips of the middlefinger flexor digitorum superficialis are created and passeddorsal to neurovascular structures in preparation for transfer.

Sutures are placed into both distal tendon ends to assist in the transfer.

Curvilinear or angled skin incisions approximately 2 cm in length are made atthe dorsoradial bases of the ring and small fingers. The lateral band projecting toeach extensor mechanism is identified. Both tendon slips must follow an unimpededcourse through the hand, dorsal to common digital arteries and nerves and palmarto the transverse metacarpal ligaments. A tendon passer is used to create this pathand to draw each tendon slip separately to the target finger (Fig. 11). The palmarwounds are closed.

32 KALAINOV & COHEN

Figure 11. The flexor digitorum superficialis tendon slipsare rerouted distally through the lumbrical canals andpassed into the dorsal wounds.

With the wrist positioned in neutral and the ring and small fingers in theintrinsic plus position, the tendon slips are sutured to the lateral bands, taking up50% to 80% of allowable FDS excursion. Proper tensioning is tested with passivewrist motion. Flexion of the wrist should allow near full extension of the ring andsmall finger MCP joints, whereas extension of the wrist should lead to a normalcascade of MCP joint flexion (Figs. 12A and B).


Figure 12. A, Following suture to the lateral bands, extension of the ring andsmall fingers is present with passive wrist flexion that deactivates the transfer.B, Normal intrinsic plus cascade of metacarpophalangeal joint flexion is seenwith passive wrist extension.

The tendon junctions are loosened or tightened as deemed necessary. Postopera-tively, the wrist is positioned in neutral to slight flexion, with the MCP joints flexedto approximately 60 degrees and the IP joints extended.

Thumb Pinch

Many procedures have been developed to restore thumb adduction in patientswith ulnar nerve palsy. Most of these operations address balance and cosmeticissues rather than improved pinch and adduction strength. Similar to techniquesaddressing claw deformities in the fingers, a strong motor is necessary if enhancedpower is to be expected. Adductorplasty with transfer of the ECRB has been shownto almost double thumb pinch strength. The operation entails lengthening the ECRBtendon with a graft to insert into the adductor pollicis tendon. A concomitant fusionof the thumb MCP joint is considered to augment pinch strength and improvelongitudinal stability of the thumb. Not all patients with ulnar nerve palsy areappropriate candidates for adductor plasty and MCP joint fusion. Even with aweakened pinch, a patient may report minimal thumb deficits.

Extensor Carpi Radialis Brevis Thumb Adductorplasty

A Chevron incision approximately 8 cm in length is made over the dorsoradialborder of the extensor retinaculum. The insertion of the ECRB is released sharplyfrom the base of the third metacarpal, and the tendon is withdrawn proximallyfrom beneath the extensor retinaculum. A 2- to 3-cm transverse incision is madeover the proximal aspect of the second intermetacarpal space, and the fascia overly-ing the second dorsal interosseous muscle is incised longitudinally. A subcutaneoustunnel is created with a curved clamp, connecting the dorsal wrist and handwounds. A 2- to 3-cm curvilinear incision is then made along the dorsoulnar borderof the thumb MCP joint, and the insertion of the adductor pollicis tendon is ex-posed. If fusion of the MCP joint is planned, then it is completed at this time.

A curved clamp is passed through the second intermetacarpal space beneaththe metacarpal and directed toward the thumb MCP joint in the interval betweenthe adductor pollicis and first dorsal interosseous muscles (Fig. 13).

34 KALAINOV & COHEN

Figure 13. Incisions and donor extensor carpi radialis brevis tendon for adductorplasty. A curvedclamp is positioned in the interval between the adductor pollicis and first dorsal interosseousmuscles. Note plantaris tendon graft in the foreground.


The ipsilateral palmaris longus tendon is harvested through two or three smalltransverse incisions or with the aid of a tendon stripper. A graft approximately 16cm in length usually can be obtained. If the palmaris longus is absent or of insuffi-cient size, other sources of autogenous tendon graft may be used (e.g., plantaris,long toe extensor).

One end of the tendon graft is sutured to the adductor pollicis tendon at itsbony insertion into the phalanx (Fig. 14).

Figure 14. The graft is first secured to the adductor pollicis tendon at its bonyinsertion.

The free end of the graft is then withdrawn through the second intermetacarpalspace with a curved clamp. The graft is then passed through the subcutaneoustunnel proximally, lying dorsal to the extensor retinaculum. The distal incisions areclosed.

36 KALAINOV & COHEN

With the wrist in neutral alignment and the thumb held tightly against thevolar radial border of the index finger, the graft is woven into the ECRB, taking up50% to 80% of the donor tendon’s excursion (Fig. 15).

Figure 15. The distal wounds are closed and the tendon graft is woven into the extensor carpiradialis brevis donor under the appropriate tension.


When the wrist is placed in flexion, the thumb should adduct firmly against theindex metacarpal. With the wrist extended, the thumb should easily be abductedaway from the palm (Figs. 16A and B).

Figure 16. A, Following transfer, passive flexion of the wrist results in strong thumbadduction. B, Full palmar abduction is possible with wrist extension, which deactivatesthe transfer.

Postoperatively, the wrist is splinted in 45 degrees of extension with the thumbin palmar abduction. The thumb IP joint may be left free. Modifications in the splintmay be required to accommodate concomitant tendon transfers to the fingers.

38 KALAINOV & COHEN

REHABILITATION

In patients treated with an ECRB four-tail graft procedure, a short-arm dorsalsplint is fabricated, which maintains the wrist in 45 degrees of extension and theMCP joints in 60 degrees of flexion. Early active IP joint flexion and extension areencouraged. Composite motion exercises of the wrist and digits are initiated out ofthe splint after 3 weeks, and the pull-out sutures are removed between 4 and 6weeks postoperatively. The forearm splint may be converted to a smaller hand-based lumbrical bar splint during that time period. Protective splinting is discontin-ued 6 to 8 weeks following surgery, and grip-strengthening exercises are added tothe rehabilitation program. Unrestricted activities are permitted after 3 months.

The forearm splint is modified for the Stiles-Bunnell procedure to position thewrist in neutral-to-slight flexion. The MCP joints are maintained in 60 degrees offlexion, and early IP finger motion exercises are encouraged. Composite motion ofthe wrist and fingers out of the splint is permitted 3 weeks postoperatively, andgrip strengthening is initiated at 8 weeks. A hand-based lumbrical splint may besubstituted for the forearm splint 3 weeks postoperatively and slowly weaned fromuse over a 2- to 4-week period. Unrestricted activities are allowed after 3 months.

Following an ECRB adductorplasty, extension of the thermoplast splint to in-clude the proximal phalanx of the thumb is indicated, and IP joint motion of thethumb is not restricted. The wrist should be positioned in neutral to 45 degrees ofextension. A supervised range of motion program is initiated after 3 weeks andincludes active thumb abduction with the wrist flexed and extended and passivethumb adduction. Active thumb adduction exercises and strengthening are includedin the rehabilitation program 6 weeks postoperatively. Protective splinting is discon-tinued at that time, with unrestricted activities permitted 4 to 6 weeks later.

SUMMARY

Ulnar nerve dysfunction leads to sensory loss, a claw deformity with asynchro-nous finger motion, diminished digital abduction and adduction, and weakenedgrip and pinch strength. Often, the index and long fingers appear uninvolved.Various tendon transfers can effectively treat clawing and improve finger balance.Transfer of a wrist flexor or extensor muscle-tendon unit will enhance grip strengthand maximize hand coordination. Use of a finger flexor for transfer simply redistrib-utes balance within the hand and may diminish grip strength.

Transfer selection is based on patient age, expectations, joint mobility, andtendon availability. Patient compliance with a postoperative rehabilitation programis important for an optimal outcome.

Thumb adductorplasty is reserved for patients who are functionally impairedby weak thumb pinch. A concomitant MCP joint arthrodesis can be considered forimproved longitudinal stability to the thumb.

References

1. Brand PW: Tendon transfers for correction ofparalysis of intrinsic muscles of the hand. InHunter JW, Schneider LH, Mackin EJ (eds):Tendon Surgery of the Hand. St. Louis, Mosby,1987, pp 439–499

2. Brand PW: Ulnar nerve paralysis. In ChapmanMW (ed): Operative Orthopaedics, ed 2. Phila-delphia, JB Lippincott, 1993, pp 1477–1485

3. Burkhalter WE, Strait JL: Metacarpophalangealflexor replacement for intrinsic muscle paraly-sis. J Bone Joint Surg 55A:1667–1676, 1973

4. Hastings H II: Ulnar nerve paralysis. In Strick-land JW (ed): The Hand. Philadelphia, Lippin-cott-Raven, 1998, pp 335–350

5. Hastings H II, Davidson S: Tendon transfersfor ulnar nerve palsy: Evaluation of results andpractical treatment considerations. Hand Clin4:167–178, 1988

6. Hentz VR: Stiles-Bunnell tendon transfer forulnar nerve palsy. Atlas of the Hand Clinics 5:31–45, 2000

7. Jebson PJL, Steyers CM: Adductorplasty with


the extensor carpi radialis brevis. In Blair WF(ed): Techniques in Hand Surgery. Baltimore,Williams and Wilkins, 1996, pp 682–687

8. Omer GE Jr: Ulnar nerve palsy. In Green DP,Hotchkiss RN, Pederson WC (eds): Green’sOperative Hand Surgery, ed 4. Philadelphia,Churchill Livingstone, 1999, pp 1526–1541

9. Smith RJ: ECRB tendon transfer for thumb ad-duction: A study of power pinch. J Hand Surg8:4–15, 1983

10. Smith RJ: Tendon transfers to restore intrinsicmuscle function to the fingers. In TendonTransfers of the Hand and Forearm. Boston,Little, Brown, 1987, pp 103–133


David M. Kalainov, MDNorthwestern Center for Orthopaedics

676 North St. Clair, Suite 450Chicago, IL 60611

e-mail: [email protected]

Tendon Transfer for RadialNerve PalsyMichael E. Rettig, MD, and Keith B. Raskin, MD

Complete injury to the radial nerve results in the inability to extend the wristand fingers actively, resulting in a considerable impairment of hand function. Lossof active wrist extension impairs the ability to pick up objects and inhibits wriststabilization for power grip. When an attempt is made to extend the digits, thewrist is simultaneously flexed to use the tenodesis effect of wrist flexion. Tendontransfers for radial nerve palsy must restore active wrist, finger, and thumb exten-sion without sacrificing key median nerve– and ulnar nerve– innervated motorunits.

ANATOMY

The radial nerve is the continuation of the posterior cord of the brachial plexus.It passes through the triangular space beneath the teres major muscle in the poste-rior aspect of the shoulder. In the arm, the nerve lies on the posterior humeralspiral groove, between the lateral and medial heads of the triceps muscle. Aftergiving off branches to the lateral head of the triceps, the radial nerve penetrates thelateral intermuscular septum and enters the anterior compartment. After the nerveenters the anterior compartment, motor branches exit to the brachioradialis and theextensor carpi radialis longus (ECRL).

The radial nerve traverses down the arm anterior to the elbow in the intervalbetween the brachialis and the brachioradialis. It then divides into the posteriorinterosseous nerve (PIN), which enters the arcade of Froshe at the proximal edge ofthe supinator muscle and the superficial radial nerve. The PIN then innervates, inorder, the supinator, extensor digitorum communis (EDC), extensor carpi ulnaris(ECU), extensor digiti quinti (EDQ), abductor pollicis longus (APL), extensor pollicislongus (EPL), extensor pollicis brevis (EPB), and extensor indicis proprius (EIP). Theextensor carpi radialis brevis (ECRB) can receive its innervation from the radialnerve proper, superficial radial nerve, or PIN.1



From the Department of Orthopaedic Surgery, New York University Medical Center, New York, NewYork (MER, KBR)

Most injuries to the radial nerve occur distal to its innervation of the triceps.The nerve is vulnerable to injury from an adjacent fracture of the humerus typicallyat the junction of the middle and distal thirds of the humerus where the radialnerve can be tethered as it enters the lateral intermuscular septum. Many of theseinjuries are neurapraxias and spontaneously recover. The radial nerve also can bedamaged by traumatic lacerations in this area, or during surgical procedures aroundthe lateral aspect of the elbow and the posterior aspect of the proximal forearm.

GENERAL PRINCIPLES

Tendon transfers to restore wrist and digit extension are performed when radialnerve recovery can no longer be expected or for wrist stabilization alone as aninternal splint after radial nerve repair. Depending on the mechanism of injury andthe time elapsed from injury, this damage can be determined by repeat physicalexamination in conjunction with electromyography of the radial nerve– innervatedmuscles.

General principles of tendon transfer must be followed to ensure a satisfactoryfunctional outcome when performing tendon transfer for radial nerve palsy. Athorough examination of the upper extremity should be completed preoperatively toidentify any previous lacerations that could adversely affect the tendon transferprocedure. Alternatively, previous surgical incisions can be used for tendon trans-fers as long as the basic principles of transfer are followed. Tendon transfer surgeryshould be performed only after tissue equilibrium has been reached. The skin andsubcutaneous tissues must be pliable and soft, and all of the joints that will bemotored by the tendon transfer need to be supple without contractures. The activerange of motion achieved by the transfer will not exceed the preoperative passiverange of motion.

The strength and excursion of the potential donor tendons are tested. If thepotential donor tendon has been injured, or if the nerve supplying innervation tothe donor tendon has been traumatized, an alternative donor tendon should beconsidered. The donor tendon must be expendable without residual functional im-pairment. Planning of radial nerve tendon transfers can be facilitated by evaluatingwhat deficits need to be replaced and what donor tendons are available to transfer.In an upper extremity with an isolated injury to the radial nerve, all muscle-tendonunits innervated by the median and ulnar nerve are potentially available to transferfor wrist and finger extension.

One of the earliest descriptions of tendon transfer for radial nerve palsy was byFranke in 1899, who transferred the flexor carpi ulnaris (FCU) to the EDC throughthe interosseous membrane. During the same year, Capellen reported transfer of theflexor carpi radialis (FCR) to the EPL. Sir Robert Jones, regarded as one of the majorcontributors describing radial nerve tendon transfers, added the pronator teres (PT),ECRL and ECRB to these transfers. Jones made further modifications in 1916 andagain in 1921. In 1946 Zachary reported that the FCR should be preserved for wristflexion.3–8

Over 50 modifications of tendon transfers have been described for radial nervepalsy. Three major groups of transfers have gained popularity. The FCU and theFCR transfer use the pronator teres to the ECRB and the palmaris longus to thererouted EPL. These two transfers differ in the motor to the EDC, using either theFCU or the FCR. The major criticism of the FCU transfer is the detrimental loss ofthe major wrist flexor and ulnar deviator of the wrist, the FCU being too short andtoo strong to be effective for finger extension, and the potential disabling radialdeviation with wrist extension that can occur with loss of stabilization on the ulnaraspect of the wrist.5–8

42 RETTIG & RASKIN

Boyes developed the superficialis transfer for digital extension.2 The superfici-alis tendons have a greater excursion than the FCU or FCR and are ideal motors forfinger extension. The superficialis transfer uses the pronator teres to ECRL or ECRB,FDS III to EDC, FDS IV to EIP and EPL, and FCR to APL and EPB.

The most common tendon transfer used for radial nerve palsy remains thepronator teres to ECRB, FCU to EDC, and a rerouted palmaris longus to EPL,despite the potential problems with the FCU transfer. Raskin and Wilgis demon-strated the long-term maintenance of wrist range of motion and power to performdaily activities and an overall excellent functional recovery with the FCU transfer.Furthermore, cadaver studies showed the ability to deviate the wrist despite loss ofthe FCU.4

The final decision as to which transfer to perform ultimately depends on therequirements of the patient, the experience of the surgeon, and the available donortendons. All of these tendon transfers adhere to the principles of one tendon–onefunction, synergism, adequate excursion and strength of the donor tendon, andestablishing a straight line of pull to the tendon insertion. Only when these conceptscan be adhered to should surgery proceed to restore wrist and digit extension.

SURGICAL TECHNIQUE

Tendon transfer for radial nerve palsy is performed as an outpatient procedureunder either regional or general anesthesia. The arm is prepared and draped in theusual sterile fashion, and hemostasis is obtained through exsanguination and upperarm tourniquet elevation.

Preoperative planning includes skin markings in the appropriate locationsbased on an accurate assessment of surface anatomy. Two incisions are used. Forharvesting of the FCU and palmaris longus tendon, an inverted L-shaped incision isdrawn out on the volar ulnar aspect of the distal forearm and wrist, extending fromthe transverse wrist crease along the ulnar border of the forearm. The insertion ofthe palmaris longus can be accessed through the most radial aspect of the transversecomponent of the incision. For exposure of the pronator teres and the insertion sitesof the transfer, a Chevron incision with the apex ulnarly is drawn over the middleto distal forearm level, allowing the skin flap to be elevated to harvest the pronatorteres with an extended strip of periosteum, as well as the performance of transfersinto the EPL, EDC, and ECRB. Any previously healed surgical incisions should beevaluated and incorporated into these incisions.

TENDON TRANSFER FOR RADIAL NERVE PALSY 43

44 RETTIG & RASKIN

The incision over the volar ulnar aspect of the wrist is followed by elevation ofthe skin flap while cutaneous nerves are identified and protected. The FCU tendonis isolated and dissected in a distal-to-proximal direction. Protecting the ulnar nerveand artery, the surgeon transects the FCU at its insertion into the pisiform. The FCUtendon and its proximal muscle belly are dissected from surrounding fascial attach-ments in a distal-to-proximal direction while protecting the ulnar nerve and artery.This mobilization increases the FCU excursion and allows for adequate redirectionof the tendon for transfer. The most distal muscle belly of the FCU can be trimmedto decrease the muscle bulk around tendon to improve coaptation to the EDCtendon. The FCU proximal muscle belly must be mobilized adequately. The fasciallayer along the ulnar border of the forearm, between the FCU and the ECU, isexcised to facilitate this mobilization and to ensure a straight line of pull to theEDC. Care is taken to avoid the motor branches of the ulnar nerve that enter theFCU distal to the medial epicondyle. The palmaris longus is located after identifica-tion and protection of the palmar cutaneous branch of the median nerve, transectedat its distal insertion into the palmar fascia, and mobilized in a distal-to-proximaldirection (Fig. 1A–C).


FCU

FCU

PL

PT

Ulnar n.

Ulnar a.

FCU

A

B

Palmar incision

Figure 1. A, Volar ulnar incision for exposure of flexor carpi ulnaris (FCU) and palmaris longus(PL) tendon insertion. PT � pronator teres. B, Transection of FCU at its insertion into thepisiform and proximal mobilization.

Illustration continued on following page

Once both of these tendons have been prepared for transfer, the dorsal incisionis made. The soft-tissue flaps are carefully elevated. The wrist and finger extensortendons are identified proximal to the extensor retinaculum. The tendon of thepronator teres is identified on the volar radial aspect of the forearm at its attach-ment to the radial shaft. The tendon insertion of the pronator teres is sharplyelevated off of the radial shaft with a several-centimeter, broad-based strip of peri-osteum to ensure satisfactory length to complete the transfer to the ECRB. Thetendon is then dissected in a distal-to-proximal direction to free the fascial attach-ments of the muscle to allow for a straight line for tendon transfer insertion. Theperiosteal strip is imbricated before completing the transfer to increase the strengthof the distal aspect of the pronator teres (Fig. 2A–C).

46 RETTIG & RASKIN

FCU

C

PL

Cutaneous branchof median n.

Figure 1 (Continued). C, Palmaris longus transected at its insertion intothe palmar fascia.

HA0203.12.02abc.lay

Insertion ofPT

Branches of radialsensory n.

Periostealstrip

Radial view

Dorsal view

Brachioradialis

SupinatorInsertion ofPT

Dorsal incision

A

C

Extensorretinaculum

TransectEPL

B

Figure 2. A, Dorsal Chevron incision for exposure of the extensor tendons and pronator teres (PT). B,Elevation of the PT tendon from the radial shaft with a periosteal strip. C, Rerouting of the extensor pollicislongus (EPL) from the extensor retinaculum after proximal transection.


At the extensor retinaculum, the EPL is identified and rerouted out of the thirdcompartment to the radial aspect of the thumb after transection of the most proxi-mal end of the tendon at the musculotendinous junction. The distal stump of theEPL is now dorsal to the first dorsal compartment. The terminal branches of theradial sensory nerve remain superficial to the EPL so they are not compressed bythe tendon transfer.

Subcutaneous tunnels are made in preparation for transfer. All of the donortendons must be freed sufficiently from the surrounding fascial and muscle attach-ments to allow a straight line of pull to their recipient tendon. The FCU is broughtaround the subcutaneous ulnar aspect of the forearm to the EDC with a tendonpasser (Fig. 3).

48 RETTIG & RASKIN

Dorsal view

Branches of radialsensory n.

Transected EPLabove extensorretinaculum

Extensorretinaculum

PT with imbricatedperiosteal strip

FCU

Figure 3. Flexor carpi ulnaris is brought around ulnar forearm to the extensor digitorumcomminus (EDC) tendons. Pronator teres periosteal sleeve imbricated in preparation for trans-fer.

The EDC tendons are identified proximal to the extensor retinaculum. The EIPand EDQ, lying ulnar to the EDC to the index and little fingers, are not included inthe transfer. The skin is elevated in the volar radial distal forearm for the palmarislongus tendon stump to be delivered to the EPL, and the pronator teres is tunneledto the ECRB, superficial to the brachioradialis and ECRL.

Once the donor tendons are tunneled to their insertion sites and the threemotor muscles are ready for transfer, the tourniquet can be deflated. Hemostasis canbe obtained before competing the transfers. The incision over the volar ulnar distalforearm can be repaired.

Setting the proper tension for the transfer is one of the critical steps in theprocedure. The tension must be enough to provide for sufficient extension of thewrist, fingers, and thumb, but not too tight to restrict wrist or digit flexion. Thetendon transfer tends to lose slight tension than that obtained intraoperatively;therefore the transfer is performed with a slightly increased tension. The tendontransfer for the thumb and fingers should be completed before the wrist transferbecause the tenodesis effect through passive wrist flexion and extension is used togauge the tension of the thumb and finger extensor transfer. Once the wrist extensortension is completed intraoperatively, wrist flexion should be avoided.

Transfer to the EDC is completed by using a No. 11 scalpel blade or tendonbraider to fenestrate each of the EDC tendons, proximal to the extensor retinaculum.The FCU is then passed through each of the recipient EDC tendons in a slightoblique fashion from proximal ulnar to distal radial (Fig. 4A and B).


EDC tendons EDC tendons

Fenestration ofEDC tendons

Fenestration ofEDC tendons

FCU

FCU

AB

Figure 4. A and B, Flexor carpi ulnaris tendon transferred to fenestrated EDC recipient tendons in anoblique fashion proximal to extensor retinaculum.

The transfer is set by placing the FCU under maximum tension and securing it toeach of the EDC tendons individually with 4-0 nonabsorbable suture. The wrist isplaced in slight extension and the metacarpophalangeal joints in full extension. Thetension is then evaluated by passively flexing and extending the wrist. With thewrist in 30 degrees of flexion, the fingers should be in full extension; with the wristfully extended, the fingers should be able to be flexed passively into the palm. Thefingers should all extend while maintaining a normal cascade. Once the appropriatetension is set, additional sutures between the FCU and each individual digitalextensor tendon secure the repair.

Intraoperative assessment of the completed transfer with wrist flexion and ex-tension must also include evaluating the line of pull and the excursion. The EDCtendons proximal to the transfer can be transected if their intact musculotendinousjunction seems to be interfering with a direct line of pull to digit extension. If theexcursion of the transfer is impeded by the proximal aspect of the extensor retinacu-lum, the leading edge of the retinaculum should be opened.

The next transfer is the palmaris longus to the EPL. The transfer is dorsal to theextensor retinaculum overlying the first dorsal compartment tendons. A Pulvertaftweave of three passes of the palmaris longus through the EPL is accomplished andsecured with 4-0 nonabsorbable sutures (Fig. 5A and B).

50 RETTIG & RASKIN

EPL

FCUPL

EPL

PL

EDC

A B

Figure 5. A and B, PL woven into rerouted extensor pollicis longus (EPL) superficial to theextensor retinaculum.

The palmaris longus is transferred under maximum tension, with the EPL alsounder maximum tension, with the wrist in neutral and the thumb extended andabducted in a radial direction. The tension is again evaluated by passively flexingand extending the wrist. With the wrist in flexion, the thumb extends and abducts.With the wrist in full extension, the thumb should be able to contact the radialborder of the index finger at the interphalangeal joint.

The pronator teres and periosteal extension are then woven into the ECRB, justdistal to its musculotendinous junction with a Pulvertaft weave. If the periostealstrip is not substantial, part of the ECRB proximal to the weave can be divided andfolded back on itself to improve the strength of the transfer. The transfer is suturedinto position with the wrist in 60 degrees of extension and with maximum tensionon the pronator teres. The ECRB tendon proximal to the transfer can be transected ifits intact musculotendinous junction seems to be interfering with a direct line ofpull to wrist extension (Fig. 6A and B).


ECRB

ECRL

PT

A B

ECRB

PT

Figure 6. A and B, Transfer completed with the PT woven into the extensor carpi radialis brevis (ECRB)with the wrist in 60� of extension. ECRL � extensor carpi radialis longus.

After completion of the tendon transfers, the wrist and digits are supported andthe dorsal wound approximated. The upper extremity is placed into a volar plastersplint maintaining the elbow flexed at 90 degrees, the wrist in extension, andsupporting the metacarpophalangeal joints in flexion of approximately 30 to 45degrees. The plaster splint maintains the thumb in an extended and abductedposition.

After suture removal, a fiberglass cast is applied and maintained for 4 to 6weeks. The wrist and fingers are then placed into a volar orthoplast splint provid-ing resting extension support. The splint is worn between occupational therapysessions for an additional 4 weeks. A formal occupational therapy program isinstituted for transfer training.

References

1. Adams RA, Ziets RJ, Lieber RL, et al: Anatomyof the radial nerve motor branches in the fore-arm. J Hand Surg 22A:232–237, 1997

2. Chiunard RG, Boyes JH, Stark HH, et al: Ten-don transfers for radial nerve palsy: Use of su-perficialis tendons for digital extension. J HandSurg 3:560–570, 1978

3. Jones R: Tendon transplantation in cases ofmusculospiral injuries not amenable to suture.Am J Surg 35:333–335, 1921

4. Raskin KB, Wilgis EFS: Flexor carpi ulnaristransfer for radial nerve palsy: Functional test-ing of long-term results. J Hand Surg 20A:737–742, 1995

5. Riordan DC: Tendon transfers in hand surgery.J Hand Surg 8:748–753, 1983

6. Riordan DC: Radial nerve paralysis. OrthopClin North Am 5:283–287, 1974

7. Smith RJ: Tendon transfers to restore wrist anddigit extension. In Tendon Transfers of theHand and Forearm. Boston, Little, Brown, 1987,pp 35–56

8. Strickland JW, Kleinman WB: Tendon transfersfor radial nerve paralysis. In Strickland JW: TheHand. Philadelphia, Lippincott-Raven, 1998, pp303–318


Michael E. Rettig, MDDepartment of Orthopedic Surgery

New York University Medical Center317 East 34th Street, 3rd Floor

New York, NY 10016

52 RETTIG & RASKIN

Tendon Transfers for ElbowFlexionScott H. Kozin, MD

A brachial plexus injury, central nervous system lesion (e.g., spinal cord injury),or birth anomaly (e.g., arthrogryposis) can result in impaired function of the limb.Restoration of elbow flexion is a main priority to increase the available workspaceand allow hand-to-mouth function.5,10 The goal of tendon transfer for elbow flexionis to regain a functional elbow range of motion, which is from 30 to 130 degrees.5,9

The conditions of the adjacent shoulder, forearm, wrist, and hand are importantconsiderations during formulation of a comprehensive surgical plan. In general,tendon transfers proceed from proximal to distal to restore a stable foundation andfulcrum for hand use. Additional transfers about the forearm and hand may benecessary to optimize use of the limb fully after restoration of elbow flexion. Thepreoperative evaluation is critical and should include subjective and objective mea-sures. This process ensures realistic goals and expectations before surgical interven-tion.

PATIENT SELECTION

Appropriate patient selection is critical to any tendon transfer. The patientshould be stable from an emotional and physical standpoint. The patient must beable to undergo a prolonged operative procedure and to comply with a rigorouspostoperative regimen.5 Realistic goals and expectations are prerequisites to tendontransfer because no operation will restore the limb to normalcy.

The examination begins with an assessment of the overall limb posture andstatus of the surrounding soft tissues. A poor soft-tissue envelope and cicatrix mustbe corrected before transfer. Supple soft-tissue coverage along the arm and acrossthe antecubital fossa is a requirement before tendon transfer. Preliminary soft-tissuereconstruction may be required using flaps (local, regional, or distant) or tissueexpanders for coverage.



From the Department of Orthopaedic Surgery, Temple University and Shriners Hospitals for Children,Philadelphia, Pennsylvania

The active and passive motion of the joints within the limb is assessed, begin-ning at the shoulder and progressing in a distal direction. Passive motion of theelbow is carefully recorded because the transfer can only restore the amount ofavailable motion. A flexion contracture greater than 30 degrees warrants preliminarytreatment to regain elbow extension before tendon transfer. Similarly, an extensioncontracture with inadequate passive flexion must be corrected before tendon trans-fer. Manual muscle testing of all the prime movers about the shoulder, elbow,forearm, wrist, and hand is performed. Each muscle is graded from 0 to 5 accordingto the Medical Research Council Scale.5 This information provides a baseline assess-ment of motion (active and passive) and strength of the muscles throughout thelimb. A comprehensive plan for reconstruction of the impaired limb can be formu-lated, including secondary tendon transfers to improve wrist and hand functionfollowing restoration of elbow flexion.

The degree of stability about the shoulder girdle requires careful considerationbecause scapulothoracic or glenohumeral instability or both negatively affect limbpositioning and control. Scapulothoracic instability secondary to dysfunction of thelong thoracic nerve causes medial winging and can create a treatment dilemma. Atendon transfer to the scapula or a scapulothoracic fusion may be required beforemanagement of the elbow deficiency. Glenohumeral instability can be mild ormarked depending on the status of the rotator cuff and deltoid muscle. Mild insta-bility can be improved during tendon transfer for elbow flexion by attaching theproximal aspect of the transfer to the clavicle or acromion. This procedure providesan anterior support to the anterior glenohumeral joint and can improve shoulderstability. Frank shoulder instability may require formal arthrodesis as part of theupper extremity reconstruction as long as adequate scapular muscles are present.7Insufficient scapular motors are a contraindication to shoulder fusion because scapu-lar winging will increase, which worsens scapulothoracic dysfunction.

The selection of an appropriate muscle to transfer for elbow flexion requires anunderstanding of potential donors.9,10 Potential candidates include the pectoralismajor muscle, the latissimus dorsi muscle, the triceps muscle, and the flexor-prona-tor group (Steindler transfer).1–9,11 Many factors must be considered when choosingthe donor muscle, including the strength of the proposed muscle, the line of pull forelbow flexion, available excursion, and donor morbidity.5,9 In addition, the overallplan for limb reconstruction must be reviewed to ensure that secondary transfers donot intend to use similar muscles. A proposed donor muscle must have normal ornear-normal strength (grade 4 to 5) to achieve a grade 3 or better elbow flexionstrength. A weaker muscle should not be used because functional range of motionagainst gravity will not be attained.

The advantages and disadvantages of the potential donor muscles must beconsidered during the decision-making process. The triceps muscle should not betransferred in individuals who rely on elbow extension for propulsion (e.g., wheel-chair users or crutch ambulators).3 The Steindler transfer often results in weakelbow flexion and a limited arc of active motion, which makes this transfer lesspreferable.8 The pectoralis major muscle can be transferred using a unipolar orbipolar method.1,2,4 The unipolar technique detaches the origin or insertion andtransfers this portion to the biceps tendon.2 This procedure also results in weakelbow flexion through an incomplete range. The bipolar technique transfers theorigin and insertion of the pectoralis major muscle.4 The insertion is attached to theacromion, clavicle, or both while the origin is secured to the biceps tendon. Thebipolar pectoralis major muscle transfer provides adequate range and strength forelbow flexion. The disadvantage of this transfer is the extensive incision across thechest that is required for muscle harvest.

54 KOZIN

The latissimus dorsi is the author’s preferred donor muscle for tendon transferto restore elbow flexion.5,11 The latissimus dorsi has unique attributes that make thistransfer preferable, including a minimal functional loss and an exceptional excursionto generate a functional arc of elbow flexion. This muscle can be transferred using aunipolar or bipolar technique. The unipolar method transfers the origin of thelatissimus dorsi muscle along with a strip of attached thoracolumbar fascia to thebiceps tendon. The insertion site into the humerus is not disturbed. The bipolarmethod detaches the origin and insertion of the latissimus dorsi muscle and trans-fers the entire muscle within the arm.11 The tendon of insertion is secured to theclavicle, acromion, or both while the facial origin is woven into the biceps tendon.The underlying neurovascular pedicle (i.e., thoracodorsal nerve, artery, and veins)must be carefully preserved during bipolar transfer. The bipolar technique is pre-ferred over the unipolar method for restoration of elbow flexion. The bipolar trans-fer repositions the latissimus dorsi muscle in line with the innate elbow flexormuscles, provides a superior line of pull, and takes advantage of the substantialexcursion of the latissimus dorsi muscle.

TENDON TRANSFERS FOR ELBOW FLEXION 55

TREATMENT

Restoration of Passive Elbow Motion

Adequate passive range of motion must be present before muscle transfer(Fig. 1).

56 KOZIN

Figure 1. A 10-year-old patient with residual left obstetric brachialplexus palsy. Full passive range of motion is present before muscletransfer.

Because functional elbow motion ranges from 30 to 130 degrees, this amount ofpassive movement is the goal. A joint flexion contracture greater than 30 degrees istreated before tendon transfer. The management depends on the cause of contrac-ture, with consideration of soft-tissue or bony abnormalities. A soft-tissue contrac-ture is initially treated by stretching, heat, and serial casting. Failure to achieve anadequate correction or the presence of an underlying bony problem requires initialsurgical release before tendon transfer.

Latissimus Dorsi Transfer

The patient is placed in the lateral decubitus position, and all bony promi-nences are padded. A beanbag facilitates positioning of the patient. The entireextremity, hemithorax, and ipsilateral thigh are prepared and draped for the proce-dure (Fig. 2).


Figure 2. The patient is placed in the lateral decubitus position and theentire extremity, hemithorax, and ipsilateral thigh are prepared anddraped for the procedure.

Contrary to described techniques, the author prepares the shoulder, elbow, andthigh before dissection of the latissimus dorsi muscle. This sequence allows prepara-tion of the origin and insertion sites without the fear of jeopardizing the latissimusdorsi muscle or pedicle.

A deltopectoral approach is performed across the anterior shoulder with mobili-zation of the cephalic vein in a medial direction. The incision is extended in aproximal direction to expose the distal clavicle by reflection of the deltoid origin.Deep to the deltopectoral interval, the underlying conjoined tendon is traced to thecoracoid process. The proximal third of the pectoralis muscle insertion into thehumerus is released to facilitate passage of the latissimus dorsi muscle from theback of the thorax to the front of the arm. The latissimus dorsi transfer can beattached to either the distal clavicle or the coracoid. The specific site varies accord-ing to the resting length of the muscle and the stability of the shoulder. Coracoidfixation is easier to accomplish and avoids additional stretch to the neurovascularpedicle; however, the muscle may not expand to its optimal resting length whenattached to the coracoid. In contrast, linkage to the clavicle enhances tension acrossthe muscle fibers and augments anterior shoulder stability; therefore, clavicle attach-ment is more commonly performed and fixation accomplished by sutures placedthrough the clavicle (Fig. 3).

58 KOZIN

Figure 3. Proximal fixation accomplished by nonabsorb-able sutures placed through the clavicle.

Drill holes are made through the clavicle with a malleable retractor placed beneaththe clavicle for protection. Three drill holes are made and nonabsorbable suturespassed using a suture passer.

The biceps tendon is exposed via a transverse incision across the antecubitalfossa. Occasionally, a longitudinal extension along the medial aspect of the arm isperformed when a concomitant humeral osteotomy is required (Fig. 4).


Figure 4. Isolation of the biceps tendon is exposed by way of an incision across theantecubital fossa.

The biceps tendon is isolated with careful protection of the lateral antebrachialcutaneous nerve and the medial neurovascular bundle (median nerve and brachialartery). The neurovascular bundle resides directly beneath the lacertus fibrosus(bicipital aponeurosis). A subcutaneous tunnel is made between the antecubitalincision and the deltopectoral interval. This tunnel must be large enough to accom-modate the latissimus dorsi muscle.

A 10-cm lateral incision from the greater trochanter toward the knee providesample exposure for fascia lata harvest (Fig. 5).

60 KOZIN

Figure 5. Lateral incision along the thigh for fascia lata harvest.

Sharp dissection is performed directly to the fascia lata, which is isolated along thelength of the incision. A 10-cm by 3-cm strip of fascia is removed and rolled into along tube to create a tissue of considerable caliber. This wound is closed over asuction drain after the fascia has been removed.

The operating table is rotated away from the surgeon to ease harvest of thelatissimus dorsi muscle. A long posterior incision is made from the posterior axil-lary fold to the thoracolumbar area. The skin and subcutaneous tissue are elevatedover the latissimus dorsi muscle to the midline. A Teflon-coated electrocauteryfacilitates dissection. The lateral border of the latissimus dorsi muscle is identifiedand elevated from the underlying serratus anterior muscle (Fig. 6).


Figure 6. The lateral border of the latissimus dorsi muscle is identified and elevatedfrom the underlying serratus anterior muscle.

Figure 7. The neurovascular bundle (i.e., thoracodorsal artery, veins, and nerve)is isolated carefully.

The neurovascular bundle (thoracodorsal artery, veins, and nerve) is carefully iso-lated at the junction of the proximal one third and distal two thirds of the muscle(Fig. 7).

This pedicle is mobilized into the axilla to increase its length and to prevent a kinkduring transfer. The vascular pedicle is traced back to the subscapular artery withligation of the branch to the serratus anterior muscle (Fig. 8).

62 KOZIN

Figure 8. The vascular pedicle is traced back to the subscapular artery with ligation ofthe branch to the serratus anterior muscle.

The entire latissimus dorsi muscle is harvested on the thoracodorsal pedicle withdivision of the origin and insertion (Fig. 9).

Figure 9. The entire latissimus dorsi muscle is harvested on the thoracodorsal pediclewith division of the origin and insertion.

The humeral insertion release must include the latissimus dorsi tendon for proximalfixation within the arm. The thoracodorsal origin release attempts to include aportion of the fascia for attachment into the biceps tendon (Fig. 10).


Figure 10. The thoracodorsal origin is released including a portion of the thoracolumbarfascia.

The latissimus dorsi muscle is then transferred from the back of the thorax tothe front of the arm through the deltopectoral interval (Fig. 11).

Figure 11. The latissimus dorsi muscle is transferred from the back of the thorax to thefront of the arm.

The thoracodorsal origin is passed first and the neurovascular bundle monitoredduring passage. Subsequently, the humeral insertion is passed through the intervaland the neurovascular bundle reassessed. Any undue tension across the neurovascu-lar bundle must be resolved, usually by additional dissection within the axilla.

The operating table is rotated toward the surgeon to facilitate attachment of thelatissimus dorsi muscle along the anterior arm. The fascia lata is woven through thethoracodorsal origin using a tendon braider and leaving the ends of the fascia lataprotruding from the muscle for attachment into the biceps tendon (Figs. 12 and 13).

64 KOZIN

Figure 12. The fascia lata is rolled to form a long strip of tissue with considerable caliber.

Figure 13. The fascia lata is woven through the thoracodorsal origin, and the ends ofthe fascia lata are left protruding from the muscle for attachment into the biceps tendon.

The muscle and fascia are then passed through the subcutaneous tunnel and intothe antecubital incision. The muscle must pass easily to allow gliding within thearm. The fascia is woven through the biceps tendon using a tendon braider andsecured with nonabsorbable sutures. The antecubital incision is then closed beforeproximal fixation. This maneuver allows the incision to be sutured and dressed withthe elbow extended.

The elbow is placed in full flexion and the latissimus dorsi tendon of insertionattached to the clavicle using the previously placed transosseous sutures. The shoul-der and back incision are closed in layers, and two suction drains are placed withinthe thoracic wound. The arm is positioned in full flexion, and a posterior plastersplint is applied. The arm is also immobilized to the chest and trunk using a cottonand Ace wrap.

POSTOPERATIVE CARE

Immediate

Intravenous antibiotics are continued for 24 hours, and the patient is placed onadequate pain medications, usually patient-controlled analgesia (i.e., pain pump).The position of immobilization is maintained for 6 weeks from the time of surgery.The suction drain from the leg is removed 1 to 2 days after surgery. The drainsalong the back are left in place for up to 1 week because of the large dead spacecreated by latissimus dorsi harvest, which is prone to seroma formation. Thesedrains should not be removed until the patient is ambulatory to ensure a firm sealbetween the chest wall and overlying tissues.

Therapy

After 6 weeks of strict immobilization, the patient is initiated on a therapyprogram. A static splint is fabricated to maintain the arm in 90 to 100 degrees ofelbow flexion. Modalities to reduce scar formation along the incisions are instituted,and tendon transfer retraining is initiated. The patient is educated on maneuvers toactivate the latissimus dorsi muscle to produce elbow flexion. This transfer is usu-ally not difficult for the patient to activate and retrain. The splint is remoldedweekly over the subsequent 6 weeks to allow progressive extension while protectingthe transfer.

Some patients have difficulty with activation of the transfer or co-contraction ofthe surrounding muscles. This problem can be treated with biofeedback, whichenhances stimulus to the patient and increases selective muscle activation.

OUTCOME

The Steindler and unipolar transfers often result in a limited arc of activemotion and weak elbow flexion.5,9 The results after bipolar tendon transfer to restoreelbow flexion are favorable.1–4,6,8,9,11 Most patients regain the ability to flex the armagainst gravity, which results in an improvement in function; however, these trans-fers are weak and provide limited lifting strength, which must be discussed withthe patient before surgery.

COMPLICATIONS

A tendon transfer to restore elbow flexion is a demanding procedure. Compli-cations can occur despite careful surgical technique. During bipolar transfer, the


neurovascular pedicle must be carefully isolated and protected to prevent injury,which could cause ischemia or denervation of the muscle. Any injury to the neuro-vascular pedicle during surgery must be recognized and repaired immediately.

Specific complications are related to the donor site of the fascia lata and muscle.Harvest of the fascia creates a hernia along the lateral thigh and allows the musclesto bulge through this rent. Usually, this creates some mild temporary discomfortoccurs along the lateral thigh that resolves over time. This discomfort is best treatedby symptomatic measures, such as compression wraps or neoprene supports. Thelateral thigh and muscle donor site are prone to seroma and hematoma formation.This donor-site morbidity is especially true after bipolar transfer of the latissimusdorsi or pectoralis major. Drainage of these sites will decrease the incidence of fluidcollection. Drains are placed deep within the dead space and not removed until thepatient is ambulatory. This step promotes drainage of any fluid and prevents un-wanted accumulation.

One of the most prevalent and disappointing complications is deficient motionagainst gravity or weakness. This problem is multifactorial and can be related toattenuation of the origin or insertion site, scarring about the transfer, and transfer ofa muscle with unrecognized denervation. Attenuation about the transfer can belessened by the use of fascia lata augmentation and meticulous preparation of theorigin and insertion sites. Inadvertent transfer of a weak muscle is less likely aftercareful preoperative manual muscle testing supplemented by electrophysiologic test-ing. Unfortunately, scar formation is unavoidable after tendon transfer. Healing ofthe coaptation sites is required for function; excessive scar proliferation will impedetendon transfer gliding and limit motion. The early detection of motion-limiting scarcan be helped by therapeutic modalities, including formal therapy, ultrasound, andbiofeedback. Established dense scar is difficult to manage with therapy or surgery.Tenomyolysis of the transfer is indicated for scar recalcitrant to therapy, althoughthis technique is not uniformly successful in restoration of motion.

References

1. Beaton DE, Dumont A, Mackay MB, et al:Steindler and pectoralis major flexorplasty: Acomparative analysis. J Hand Surg 20A:747–756, 1995

2. Brooks DM, Seddon HJ: Pectoral transplanta-tion for paralysis of the flexors of the elbow. JBone Joint Surg 41B:36–50, 1959

3. Carroll RE, Hill NA: Triceps transfer to restoreelbow flexion: A study of fifteen patients withparalytic lesions and arthrogryposis. J BoneJoint Surg 52A:239–244, 1970

4. Carroll RE, Kleinman WB: Pectoralis majortransplantation to restore elbow flexion to theparalytic limb. J Hand Surg 4:501–507, 1979

5. Kozin SH: Injuries of the brachial plexus. InIannotti JP, Williams GR (eds): Disorders of theShoulder: Diagnosis and Management. Phila-delphia, Lippincott Williams & Wilkins, 1999,pp 847–880

6. Marshall RW, Williams DH, Birch R, et al: Op-erations to restore elbow flexion after brachialplexus injuries. J Bone Joint Surg 70B:577–582,1988

7. Richards RR, Waddell JP, Hudson AR: Shoul-der arthrodesis for the treatment of brachialplexus palsy. Clin Orthop 198:250–258, 1985

8. Steindler A: Tendon transplantation of the up-per extremity. Am J Surg 44:534, 1939

9. Stern PJ, Caudle RJ: Tendon transfers for el-bow flexion. Hand Clin 4:297–307, 1988

10. Van Heest A, Waters PM, Simmons BP: Surgi-cal treatment of arthrogryposis of the elbow. JHand Surg 23A:1063–1070, 1998

11. Zancolli E, Mitre H: Latissimus dorsi transferto restore elbow flexion: An appraisal of eightcases. J Bone Joint Surg 55A:1265–1275, 1973


Scott H. Kozin, MDShriners Hospitals for Children

3551 North Broad StreetPhiladelphia, PA 19140

e-mail:[email protected]

66 KOZIN

Tendon Transfers for LateralPinchAlbert A. Weiss, MD, and Scott H. Kozin, MD

The paralyzed hand that could benefit from transfers to restore lateral pinch isseen in an impaired individual who is nearly always tetraplegic, although suchparalysis can conceivably be caused by a combination of peripheral nerve lesions orincomplete brachial plexus palsy. The additional independence gained from thistransfer affords a monumental leap in functional capabilities, often providing theability to self-feed, independently catheterize, and seek employment.1,4 The restora-tion of lateral pinch also allows activities of daily living without brace encumbrance,which blocks sensory feedback.

HISTORY

Early writings on the restoration of prehensile function in the paralyzed handfocused on peripheral nerve injuries or brachial plexus palsies. Survival rates forcervical spinal cord injury were low, owing largely to the challenges in nursingcare, dysautonomia, and genitourinary system complications. The Symposium onReconstructive Surgery of the Paralyzed Upper Limb of the Royal Society of Medi-cine in 1949 made no mention of the treatment of paralysis secondary to spinal cordinjury.3 A flexor hinge splint to restore grasp in patients with intact wrist extensorswas introduced, although this device found little acceptance until the general care ofquadriplegics improved in the early 1960s.10 Bunnell2 described a flexor tenodesis in1948, and Lipscomb and coworkers6 published a series in 1958 in which transferswere used for what was termed “thumb opposition,” which was actually lateralpinch. In many early reports, the terms “thumb opposition” or “adduction opposi-tion” were used to refer to what is currently defined as “lateral pinch,” “key pinch,”or “lateral grasp.”



From the Department of Orthopaedic Surgery, MCP Hahnemann University (AAW); Temple University;and Shriners Hospital for Children (SHK), Philadelphia, Pennsylvania

PATIENT SELECTION

Tetraplegia secondary to spinal cord injury is defined according to the Ameri-can Spinal Injury Association or the International Classification of Surgery of theHand in Tetraplegia (ICSHT).7 The ICSHT is designed to guide surgical reconstruc-tion of the upper limb in tetraplegia (Table 1).

68 WEISS & KOZIN

Table 1. INTERNATIONAL CLASSIFICATION OF SURGERY OF THE HANDIN TETRAPLEGIA

SensibilityO on Cu* Group Motor Characteristics Description of Function

0 No muscle below elbow suitable for transfer1 Brachioradialis Flexion of elbow2 Extensor carpi radialis longus Extension of the wrist (weak or strong)3 Extensor carpi radialis brevis Extension of the wrist4 Pronator teres Pronation of the wrist5 Flexor carpi radialis Flexion of the wrist6 Finger extensors Extrinsic extension of the fingers7 Thumb extensor Extrinsic extension of the thumb8 Partial digital flexors Extrinsic flexion of the fingers (weak)9 Lacks only intrinsics Extrinsic flexion of the fingersX Exceptions

*O � occular (visual) sensibility only; Cu � cutaneous sensibility �-visual.

Persons with high-level tetraplegia (ICSHT groups 0) have insufficient availableinnervated motors for restoration of lateral pinch using tendon transfer withoutsupplemental electrical stimulation. Persons with lower-level tetraplegia (ICSHT 2and greater) have enough available motors to reconstruct lateral pinch and othergrasp patterns (e.g., palmar grasp). In activities of daily living, more tasks areperformed with lateral pinch compared with palmar grasp, which underscores theimportance of pinch reconstruction. Utensils such as a toothbrush, pen, fork, floppydisk, and compact disc are acquired and manipulated with lateral pinch, unless amore sophisticated precision pinch (opposition or pulp-to-pulp) is available. Opposi-tion pinch requires an opposable thumb with good control and sensibility, which isoften beyond the scope of conventional transfer restorability.

Candidates for a tendon transfer to restore lateral pinch must have an absenceof contracture, control of spasticity, and the capability of undergoing postoperativerehabilitation (i.e., without chronic pain or psychiatric disorders).

CATEGORIES OF PINCH RECONSTRUCTION

Passive

Effective lateral pinch can be restored by tenodesis of the flexor pollicis longus,as long as a grade 3 or better volitional wrist extension is present. Active wristextension produces tension in the flexor pollicis longus tendon and positions thethumb against the index finger. The preferred point of contact is the index proximalinterphalangeal joint. The magnitude of wrist extension and the tautness of theflexor pollicis longus directly affect pinch strength. In patients in ICSHT group 1,active wrist extension can be achieved by transfer of the brachioradialis to theextensor carpi radialis brevis (Fig. 1A). The brachioradialis must be freed from its

insertion into the radial styloid and forearm fascia to maximize available excursion.Because the need to mobilize proximally is critical, the passive amplitude of excur-sion should be measured repeatedly until 2.0 to 2.5 cm of excursion is evident (Fig.1B).

TENDON TRANSFERS FOR LATERAL PINCH 69

Figure 1. A, Brachioradialis tendon harvested and transferred to extensor carpi radialis brevis. B,Brachioradialis excursion can be increased by proximal dissection of muscle belly.

Mobilization proximal to the musculotendinous junction is required, which ensuresadequate excursion to provide sufficient amplitude for wrist extension and concomi-tant tension within the tenodesis.

Technique

Preoperatively, the overall thumb posture must be evaluated when planninglateral pinch reconstruction. The first ray must be positioned sufficiently to allowthe thumb to contact the index proximal interphalangeal joint. This requires somethumb carpometacarpal joint stability and mild pronation. An unstable thumb car-pometacarpal joint or supinated posture will result in malpositioning during at-tempted lateral pinch. A thumb carpometacarpal joint capsulodesis or arthrodesismay be required to rectify this problem.

Through a longitudinal volar incision just radial to the flexor carpi radialistendon, the flexor pollicis longus tendon is exposed and divided from its muscle asfar proximally in the forearm as possible (Fig. 2A). Two holes are drilled in themetaphysis of the palmar radius, separated by a bony bridge (Fig. 2B).

70 WEISS & KOZIN

Figure 2. A, Longitudinal incision and exposure of flexor pollicis longus tendon. B, Drill holes in distalradius for passage of flexor pollicis longus tendon.


The holes are enlarged to accept the flexor pollicis longus tendon. The tendon ispassed into a hole, under the bony bridge, out the other hole, and then securedback to itself around the bony bridge. This maneuver provides a stable anchor offixation for the tenodesis that is secure enough to permit rapid postoperative use.

Tension is set such that lateral pinch is achieved with the wrist positioned inextension, and thumb extension is attained with the wrist placed in flexion. Tenode-sis of the extensor pollicis longus may be necessary to enhance thumb extension andfacilitate release; however, the extensor pollicis longus has an unwanted adductionvector and must be rerouted into the vicinity of the first dorsal compartment beforetenodesis. Interphalangeal joint stabilization is routinely performed to maximizeeffective contact between the thumb and index finger and is performed beforetensioning.

Criticisms of the flexor pollicis longus tenodesis are related to stretching of thetenodesis over time and ineffective pinch strength. Currently, passive pinch is re-served for ICSHT group 1, when functional electrical stimulation is not a viablealternative.

Active

Patients with strong active wrist extension but absent thumb flexion can regainactive lateral pinch using a tendon transfer. Depending on the patient’s motorinventory, options for powering the flexor pollicis longus include the brachioradialisor the pronator teres (elongated with radial periosteum).

Technique

The skin incision varies slightly according to the chosen motor and concomitanttendon transfers. A longitudinal radial incision allows access to the flexor pollicislongus tendon and the brachioradialis and pronator teres (Fig. 3A). The harvestedtendon is woven into the flexor pollicis longus using a three-pass Pulvertaft weavetechnique. This method provides enough integral strength to allow early active useof the transfer without fear of transfer dehiscence. Similar to passive pinch, propertension of the transfer is determined by placing the wrist in flexion and extensionand gauging tenodesis lateral pinch position and thumb release, respectively.

As is true in passive tenodesis, the interphalangeal joint of the thumb is stabi-lized before tensioning the transfer. A split flexor pollicis longus transfer is per-formed, which preserves some interphalangeal joint mobility. This joint stabilizationmaximizes the lever arm for pinch strength and avoids unwanted interphalangealflexion, which would compromise the lateral pinch pattern (Fig. 3B).

72 WEISS & KOZIN

Figure 3. A, Longitudinal radial incision to expose brachioradialis, extensor carpi radialis brevis,flexor pollicis longus, and pronator teres tendons. B, Inefficient pinch pattern following tendon transferto restore lateral pinch without concomitant interphalangeal joint stabilization.

Functional Electrical Stimulation

Specific selection criteria for functional electrical stimulation are beyond thescope of this article. The general selection criterion for functional electrical stimula-tion (FES) is high-level tetraplegia (ICSHT groups 0 and 1) without considerabledenervation (i.e., lower motor neuron injury).5 Functional electrical stimulation–controlled lateral pinch can be superb, with better strength than many active trans-fers; however, FES often limits applicability and requires caregiver support.

Ideal conditions for functional electrical stimulation–restored lateral pinch al-low implantation of electrodes into the flexor pollicis longus and the adductorpollicis muscles. Interphalangeal joint stabilization with or without carpometacarpaljoint capsulodesis or arthrodesis is also required. Denervation of the flexor pollicislongus or the adductor pollicis muscles precludes a usable response to stimulationand requires transfer of other paralyzed but not denervated muscles to provide anelectrically controllable lateral pinch. Determination of a viable motor for transferrequires an inventory of all paralyzed muscles that can be stimulated. The ability tostimulate indicates an intact reflex arc (upper motor neuron injury) without injuryto the anterior horn cells (lower motor neuron injury). General principles of tendontransfer surgery apply, except that synergy of action (desirable in volitional trans-fers) is irrelevant with computer-controlled transfers. The flexor carpi radialis nor-mally would not be an ideal substitute motor for the flexor pollicis longus becausewrist flexion and thumb flexion are not synergistic acts. Nevertheless, the paralyzedbut not denervated flexor carpi radialis would work well by transfer to the flexorpollicis longus with electrical control.

Surgical approaches for these procedures are dependent on the total numberand location of motor points to be supplied with electrodes, along with considera-tion for any necessary tendon transfers. Typically, a longitudinal incision is neededon the volar and dorsal forearm, as well as incisions for hand electrodes (thumbabductor and adductor muscles).

Interphalangeal Joint Stabilization

Moberg3 recognized the need to block interphalangeal joint flexion duringflexor pollicis longus tenodesis to achieve an effective pinch against the index finger(Fig. 3B). He further recognized the potential dissatisfaction with stiff joints inpersons with tetraplegia. Provisional Kirschner wire fixation across the interphalan-geal joint provided immediate stability for lateral pinch and offered reversibility. Ifthe patient sensed that the loss of flexibility outweighed the gain in pinch strength,simple wire removal could be performed; however, these pins often migrated,broke, or caused pain, which necessitated a second procedure for their removal andoverall dissatisfaction with an unstable interphalangeal joint.


The split flexor pollicis longus transfer described by Mohammed and colleagues9

offered a solution to retain a supple joint and still provide an improved lateralpinch pattern (Fig. 4).

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Figure 4. Split flexor pollicis longus tendon transfer to providestability to lateral pinch.

Technique

A radial midaxial incision is developed on the thumb. The neurovascular bun-dle is retracted in a palmar direction and the flexor sheath incised to expose theflexor pollicis longus tendon (Fig. 5A). The tendon is divided in its midline and in alongitudinal direction. The radial half of the tendon is incised at its insertion pointon the distal phalanx and pulled into the midaxial region of the thumb (Fig. 5B). Adorsal flap is elevated to expose the extensor hood and terminal tendon. The cuthalf of the flexor pollicis longus tendon is passed through a slit in the midportion ofthe extensor hood and sutured back to itself (Fig. 5C). The proximal end of the slitin the extensor hood is reinforced with a suture to prevent proximal propagation ofthe slit and the transfer further secured to the extensor tendon directly. A longitudi-nal Kirschner wire is passed retrograde across the interphalangeal joint to providetemporary stabilization and protection of the transfer and to allow early motion(Fig. 5D). This pin is removed 4 to 5 weeks after surgery.

Figure 5. A, Radial mid-axial incision to expose flexor pollicis longus tendon. B, Radial half of flexorpollicis longus incised at distal phalanx insertion.



Figure 5 (Continued). C, Radial half of flexor pollicis longus routed in a dorsal direction and passedthrough extensor hood. D, Longitudinal Kirschner wire passed across interphalangeal joint to protectsplit flexor pollicis longus transfer.

76 WEISS & KOZIN

Carpometacarpal Joint Stabilization

The thumb position can adversely affect transfers for lateral pinch. In theabsence of an opponens muscle, supination of the thumb ray often develops, whichplaces the thumb pulp poorly on the index finger. This malrotation is furthercompromised when combined with a thumb adduction contracture. The thumb raycan be repositioned by osteotomy, capsulodesis, or arthrodesis. A soft-tissue proce-dure (i.e., capsulorrhaphy) tends to stretch over time, and an osteotomy does notprevent continued supination; therefore, arthrodesis of the first carpometacarpaljoint is preferred to provide a stable platform for the first ray and simultaneouscorrection of any first web space malposition. A dorsal approach between the firstand third compartments is used to expose the carpometacarpal joint. The articularsurface is removed with a saw and rigid fixation accomplished with plate andscrews (e.g., minicondylar plate). Interphalangeal joint stabilization is still necessaryto prevent unwanted interphalangeal joint flexion, which leaves only the metacarpo-phalangeal joint for motion.

References

1. Allieu Y, Coulet B, Chammas M: Functionalsurgery of the upper limb in high-level tetra-plegia. Techniques in Hand and Upper Ex-tremity Surgery 4:50–68, 2000

2. Bunnell S: Bunnell’s Surgery of the Hand. Phil-adelphia, JB Lippincott, 1948

3. D’Aubigne RM: Treatment of residual paralysisafter injuries of the main nerves (superior ex-tremity). (Symposium on Reconstructive Sur-gery of the Paralyzed Upper Limb): Proceed-ings of the Royal Society of Medicine XLII:831–844, 1949

4. House J, Gwathmey FW, Lundsgaard DK: Res-toration of strong grasp and lateral pinch intetraplegia due to cervical spinal cord injury. JHand Surg 1:152–159, 1976

5. Kilgore KL, Peckman PH, Keith MW, et al: Animplanted upper-extremity neuroprosthesis:Follow-up of five patients. J Bone Joint Surg79A:533–541, 1997

6. Lipscomb PP, Elkins EC, Henderson ED: Ten-don transfers to restore function of hands intetraplegia, especially after fracture-dislocationof the sixth cervical vertebra on the seventh. JBone Joint Surg 40A:10–58, 1958

7. McDowell CL, Moberg EA, House JH: The sec-ond international conference on surgical reha-bilitation of the upper limb in tetraplegia(quadriplegia). J Hand Surg 11A:604–608, 1986

8. Moberg E: The Upper Limb in Tetraplegia.Stuttgart, Georg Thieme Publishers, 1978

9. Mohammed KD, Rothwell AG, Sinclair SW, etal: Upper limb surgery for tetraplegia. J BoneJoint Surg 74B:873–882, 1992

10. Nickel VL, Perry J, Garrett AL: Developmentof useful function in the severely paralyzedhand. J Bone Joint Surg 45A:933, 1963


Albert A. Weiss, MDMCP Hahnemann University

230 N. Broad StreetPhiladelphia, PA 19102



Tendon Transfers forRestoration of Active GraspAllan E. Peljovich, MD, MPH

Traumatic tetraplegia represents about one-half of all spinal cord injuries, andthe C5 and C6 levels are the most commonly injured. As such, the common cervicallevel spinal injury leaves patients with some shoulder and elbow function andperhaps minimal wrist function. This pattern translates into a weak tenodesis graspand release in C6 level patients but no effective grasp ability in C5 patients. Lowercervical injury in which patients retain some hand function is uncommon, as ishigh-level injury that leaves patients ventilator dependent. Among the most dis-abling aspects of traumatic tetraplegia is the loss of hand and upper extremityfunction. Previous study has demonstrated that restoration of hand and upperextremity function is rated above bowel/bladder control, sexual function, and am-bulation among patients and caregivers alike. Surgery to restore hand function canthus have a significant impact on the quality of life of tetraplegic patients.

Most activities of daily living are performed through two fundamental grasppatterns: (1) lateral thumb pinch and release (key pinch) and (2) palmar grasp andrelease. The author typically prioritizes key pinch and restores palmar grasp andrelease when sufficient donor muscles exist. Enhancing the natural wrist tenodesiseffect through orthotics or passive tenodesis procedures or through voluntary ten-don transfers is the means by which function is restored. A novel method to restorepalmar grasp and release not discussed herein is through neuroprosthetic implanta-tion (NeuroControl Freehand; NeuroControl Corp., Valley View, OH), typically re-served for American Spinal Injury Association (ASIA) C5 and C6 patients, or Inter-national Classification of Surgery of the Hand in Tetraplegia (ICSHT) groups 0 to 2.

Grasp and release restoration must be viewed from the larger perspective ofupper extremity restoration. Not all tetraplegic patients are good candidates forsurgical intervention. Among the criteria listed below perhaps the most important isthat the patient’s desires and goals from surgery are realistic.



From the Shepherd Center; The Hand Treatment Center, PC; the Department of Orthopaedic Surgery,Atlanta Medical Center; and Emory University, Atlanta, Georgia

Patient Criteria for Surgical Consideration in Tetraplegic Hand Restoration

IndicationsNeurologic stability (at least 10–12 months from injury)Motivation and desireRealistic goalsGood cognitionGood general healthWheelchair/trunk stabilitySupple/pain-free upper extremity (consider other injuries sustainedduring trauma)Minimal to no problem with recurrent pressure soresGood support systems (family, friends, attendants)Suitable physical examination for tendon transfer or neuroprostheticMinimal to no problems with upper extremity spasticity

ContraindicationsUnrealistic expectationsUncontrollable upper extremity spasticityUpper extremity painSignificant upper extremity or hand contractures or both

In addition, the ability to grab and manipulate an object is enhanced by the abilityto be able to reach out with one’s arm; therefore, restoration of palmar grasp andrelease is most efficacious when other functions are present or provided, namely,key pinch, supple pronosupination, and elbow extension. Often, multiple proceduresare combined in a single or a staged series of operations to minimize the disabling“downtime” tetraplegic patients face after surgery.

INTERNATIONAL CLASSIFICATION

In 1984 at the First International Conference on Surgical Rehabilitation of theUpper Limb in Tetraplegia held in Edinburgh, a classification system was devisedby a group of experienced surgeons, which has since been modified for the tetra-plegic hand. The system categorizes patients by the most distally innervated volun-tary muscle with grade 4 British Medical Research Council (BMRC) strength orgreater (Table 1).

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Table 1. THE INTERNATIONAL CLASSIFICATION FOR SURGERY OF THE HAND IN TETRAPLEGIA

Group Motor Function

0 None Elbow flexion and supination1 Brachioradialis Elbow flexion and supination, pronation with neutral forearm position2 Extensor carpi radialis longus Wrist extension3 Extensor carpi radialis brevis Strong wrist extension4 Pronator teres Active forearm pronation5 Flexor carpi radialis Wrist flexion6 Extrinsic finger extensors Partial or complete digital extension7 Extrinsic thumb extensors Thumb extension8 Radial extrinsic digital flexors Partial digital flexion9 Complete digital flexion (thumb included) Intrinsic minus handX Incomplete/exceptions Unpredictable

Medical Research Council; carpi radialis brevis.BMRC � British ECRB � extensorNote: System only applies to muscles of the forearm and hand. Upper extremity function is not included but becomes increasingly functional as the

group level increases. Sensibility is based on the presence of thumb/index two-point discrimination of 10 mm. If present, the classification has the prefixCu (cutaneous), such as Cu 4. If two-point discrimination is greater than 10 mm, the classification has the prefix O (ocular), such as O 1. Motor is basedon the presence of at least grade 4 BMRC strength. Weaker voluntary function may be present, such as a weak ECRB in a group 2 patient.

Unlike in the ASIA system, its utility is that the groupings provide informationconcerning which specific muscles are voluntary and sufficiently strong, therebygiving the treating physician concise information regarding surgical options for thepatient. For example, a group 3 patient has a voluntary strong brachioradialis (BR),extensor carpi radialis longus (ECRL), and extensor carpi radialis brevis (ECRB).This observation suggests that group 3 patients have three potential donor musclesfor transfer. On the other hand, an ASIA C6 patient who also has voluntary wristextension may or may not have a strong and voluntary ECRB. The InternationalClassification is more useful when describing hand function and is used throughoutthis article.

SURGICAL PRINCIPLES

Successful restoration of palmar grasp and release involves addressing fourphases: (1) object acquisition, (2) grasp, (3) hold/manipulation, and (4) object re-lease. Each phase must be attended to for the best results as follows:

1. Object acquisition: The patient must be able to acquire the object he or shedesires to manipulate. This ability involves coordinated upper extremity mo-tion, such as elbow extension and forearm rotation, for wrist positioning inspace in addition to digital extension to reach around an object.

2. Grasp: In the second phase, the hand must grasp the object through digitalflexion. The mass of the object the patient can grasp is proportionate to thestrength of digital flexion and wrist stability, whereas the size of the object isproportionate to digital extension. Another factor in the size of the object isthe type of flexion that a patient achieves. A curl or hook grasp, in whichthere is hyperflexion of the interphalangeal joints with relative extension ofthe metacarpophalangeal (MCP) joint, would be effective for small objectsand power.

On the other hand, a balanced grasp with flexion of all of the phalan-geal joints allows grasp of a larger object, such as a book or cup. The lattergrasp pattern is more versatile for activities of daily living, whereas theformer is fairly inefficient.

3. Hold and manipulate: The patient must then be able to hold and manipulatethe object. This ability is correlated with endurance of digital flexion strengthand upper extremity coordination.

4. Object release: The patient must be able to release the object to its desiredlocation effectively. The fingers and thumb must extend in a coordinatedfashion.

The muscle functions addressed in reconstruction of palmar grasp and release in-clude the flexor digitorum profundus (FDP), extensor digitorum communis (EDC),extensor pollicis longus (EPL), abductor pollicis longus (APL), flexor pollicis longus(FPL), and, occasionally, the flexor digitorum superficialis (FDS) and intrinsic handmuscles. For the sake of economy in these patients, the FDP is prioritized for digitalflexion because its action results in flexion of all of the interphalangeal joints asopposed to the FDS. When muscles are available as donors to be transferred topower grasp, the author usually prioritizes FDP activation as opposed to EDCactivation to provide strength for grasp and hold/manipulation phases, expectingtenodesis finger extension that is passively associated with gravity-produced wristflexion to provide sufficient acquisition and release phases. If the FPL is activated aswell, which is often true if a motor is available to power the FDP because key pinchrestoration is prioritized, grasp is even stronger. Tendon transfers to activate digitalextension are performed when there are sufficient donor muscles available, that is,the patient is in group 4 or higher, and EDC, EPL, and APL activation can beachieved with a single donor motor.

TENDON TRANSFERS FOR RESTORATION OF ACTIVE GRASP 81

General principles of tendon transfer are often “extended” in this population ofpatients. Regardless of the technique or procedure, ideal patients have supple joints,are motivated, are healthy, and have sufficient cognition to understand, and cooper-ate in their postoperative therapy. Transferring strong muscles that are under volun-tary control is the norm; however, occasionally, muscles with grade 3 strength areused, that is, transfer of the ECRB to FDP through interosseous membrane in group2 patients. Donor muscles must have sufficient amplitude of motion, especiallyconsidering that the excursion for the FDP is approximately 7 cm. Of course, thefunction of the donor muscle must be expendable; and the BR, one of the two radialwrist extensors (ECRL preferred over the ECRB) and pronator teres (PT) meet thiscriterion best. The author preserves the flexor carpi radialis when present (group 5)because, usually, sufficient donor muscles are available to restore meaningful func-tion, and voluntary wrist flexion generally produces better tenodesis digital exten-sion than gravity alone. Use of the ECRB is limited to the previous example;otherwise, the ECRL is the prime wrist extensor used for transfer if the ECRB isunder voluntary control and is of sufficient strength. Sensation is not critical be-cause the goal is restoration of fundamental grasp patterns that can be controlledvisually. If touch, stereognosis, and proprioception were criteria for surgery, almostno tetraplegic patients would qualify for surgery, and this requirement belies expe-rience with the success of surgery. Synergism as achieved with an ECRL to FDPtransfer is ideal but not required.

RESTORATIVE LADDER

The foundation for palmar grasp and release restoration lies in the presence orprovision of wrist extension, which powers the passive tenodesis coupling of wristextension/digital flexion and gravity-produced wrist flexion/digital extension. Onceadequate and voluntary wrist extension is present, a tenodesis grasp and release canbe enhanced as necessary through therapy, orthotics, or surgery. Some patients aresatisfied with tenodesis grasp alone. Most patients desire to become brace free andto have a stronger grasp and key pinch. Restorative or reconstructive surgery isthen based on transferring and tightening tendons along with judicious use of jointstabilization, whether through capsulodesis or arthrodesis.

Patients with group 0 function do not have wrist motion or a suitable donormuscle for transfer into the hand and wrist. As such, restoration of hand function isachievable only through neuroprosthetic implantation, which is primarily used forpatients in groups 0 to 3. In group 1 patients, the BR is available for transfer intothe ECRB, thereby providing wrist extension. Palmar grasp and release is thenenhanced as necessary with orthotics or tendon tenodesis, if necessary. Key pinchrestoration alone is more commonly performed in this group. In group 2 patients,the ECRL is sufficiently strong. Key pinch is still prioritized and powered withtransfer of the BR to FPL, in addition to other thumb-stabilizing procedures. Palmargrasp and release is enhanced as necessary with tenodesis procedures, or can beprioritized over key pinch and restored with a BR to FDP transfer. Some group 2patients retain a present but weak ECRB (BMRC 3 strength). This weak ECRB canbe passed through the interosseous membrane to act as a strong tenodesis transferwithout sacrificing critical wrist extension. In group 3 patients, palmar grasp andrelease can be restored without sacrificing key pinch and is activated by transferringthe ECRL into the FDP; EDC tenodesis is used to “balance” the finger. Two-stageflexor/extensor reconstructions are often performed in patients who function at agroup 3 level or higher but are more commonly used in patients who are at leastgroup 4. In group 4 and 5 patients, options depend on the choice of thumb recon-struction, and available donor motors to power the FDP include the PT and ECRL.At this level, the BR is potentially available to power finger/thumb extension, againdepending on the choice of thumb/key pinch reconstruction. In group 6 patients,

82 PELJOVICH

some digital extension is present, and the EPL alone is activated in addition tofinger flexion. In group 7 patients, only flexion activation is required. In group 8patients, there may be good flexion of the radial digits. In this circumstance, theECRL can be used to power some or all of the FDS. In patients at group 4 level orhigher, and in some patients of higher-level cervical tetraplegia, consideration ofintrinsic balance is included in the surgical plan.

Two-Stage Flexion and Extension Reconstruction

Patients who can undergo restoration of active flexion as well as lateral pinchshould be considered for two-stage reconstructions (group 3 or greater) (Table 2)because joint balancing enhances digital restoration. Unopposed or unbalanced func-tion can result in inefficient function, long-term contractures, and failure of trans-fers, such as finger flexion contractures following isolated activation of the FDP.Either active transfer or, more commonly, tenodesis of the antagonist achieves bal-ance. In this fashion, EDC/EIP tenodesis or activation balances function gainedthrough FDP activation. At the same time, intrinsic reconstruction also achievesdigital balance. The problem is that the rehabilitation for flexion restoration iscontradictory and endangers the rehabilitation for extension restoration; therefore,restoration is performed in two stages, one for flexion and a second for extension.The higher the group level, the more functional the hand. The details of suchprocedural algorithms are found in texts written by House and Zancolli and areoutlined in Table 2.3,7


Table 2. EXAMPLES OF TWO-STAGE FLEXION AND EXTENSION RECONSTRUCTIONS

Zancolli Method (2–6 months between stages) House Method (2–6 months between stages)

1. Extensor reconstructiona. EDC/EPL/APL tenodesis versus BR to EDC/EPL transferb. Thumb CMC arthrodesisc. Zancolli lasso

2. Flexor reconstructiona. BR to FDP transfer versus ECRL to FDP and ECRB/

FPL synchronizationb. BR to FPL versus FPL tenodesisc. PT to FCR for group 4

For groups 4–51. Flexor reconstruction

a. ECRL to FDP transferb. PT to FPL transferc. BR to adductor pollicis/opponens transfer (via FDS graft)

2. Extensor reconstructiona. EDC synchronization and tenodesisb. EPL/APL tenodesisc. Free graft intrinsic index/long tenodesis

For group 61. Flexor reconstruction

a. ECRL to FDP transferb. BR or PT to FPL transferc. Zancolli lasso

2. Extensor reconstructiona. Thumb CMC arthrodesisb. EDC and EPL tenodeses versus BR to EDC/EPL

carpi radialis longus; digitorum communis; carpi radialis brevis;BR � brachioradialis; ECRL � extensor EDC � extensor ECRB � extensor EPL �pollicis longus; pollicis longus; metacarpal; digitorum profundus; pollicis longus;extensor APL � abductor CMC � carpo FDP � flexor FPL � flexor

teres; carpi radialis; digitorum superficialis.PT � pronator FCR � flexor FDS � flexor

TENDON SYNCHRONIZATION

Tendon synchronization is a useful technique whereby all of the FDP or EDC/EIPtendons, respectively, are sutured to each other to create efficiency and economy. It isimpossible to activate flexor or extensor function individually for each digit indepen-dently in the setting of traumatic tetraplegia. In this technique, either the FDP or EDCis transformed into a single tendon unit. In both procedures, the natural cascade of thefingers is ignored, and the synchronization is set such that all the fingers flex andextend level to each other (Fig. 1).

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Figure 1. Synchronization of the flexor digitorum profundus (FDP) and the extensor digitorum commu-nis converts four independent tendons into one “mass” that allows for efficient control of finger motion.Synchronization is performed by tying the tendons in a side to side fashion using at least threehorizontal mattress sutures. At least three sutures are required to control relative translation betweenthe tendons themselves. Note that the fingers are synchronized in a straight, equal fashion, rather thanin the natural cascade. This reverse cascade improves grasp and release ability. The proximal musclewould be transected if a tenodesis procedure were being performed as well.

At least three interrupted nonabsorbable sutures are used to tie the tendons to eachother to create translational control of the mass. This suturing is carried out proxi-mal to the retinaculum on the extensor surface, such that the sutures do not enterthe extensor compartments. With this “reverse cascade,” force is applied through allof the fingers equally and with equal motion, thereby maximizing the size of anobject that can be grasped or manipulated. Synchronization is routinely performedwhen individual finger motion is not already present, that is, at less than group 6function. A minimum of 3 weeks of immobilization is required before sufficienthealing occurs to allow therapy.

TENODESIS TECHNIQUE

Tenodesis refers to tightening tendons to phases of motion, in this case, tighten-ing the extrinsic finger muscles in sync with wrist motion to strengthen or enhancea function that occurs naturally. Finger flexion can be enhanced with wrist extensionby tightening the FDP. Finger extension can be enhanced with gravity-induced wristflexion by tightening the EDC/EIP. Tenodesis procedures are used when donormuscles are absent, and the natural tenodesis effect achieved through the wrist isinadequate. Another circumstance in which tenodesis commonly is applied is whenjoint balancing is necessary. For example, it is desirous to perform tenodesis of theEDC when activating the FDP to prevent late flexion deformities. The problem withtenodesis is that it is generally weak and can stretch with time.

For flexor tenodesis, exposure of the FDP is achieved depending on othersimultaneously performed procedures. This maneuver can be performed through aradial approach (approach of Henry), or a more radial, near-midaxial approach(Fig. 2).


Figure 2. The surgical approaches for most reconstructiveprocedures for palmar grasp and release vary from volarand dorsal combinations to single utilitarian approaches.This view demonstrates two alternative utilitarian exposures.One single straight incision can be created just volar to themidaxial line of the forearm (near-midaxial). Alternatively, asingle “lazy-S” incision can be created in a similar location.Mobilization of full-thickness soft tissue flaps and rotation ofthe forearm provide excellent access to the three forearmcompartments during tetraplegia reconstruction.

Any of these latter approaches are fairly utilitarian because they provide exposurefor other simultaneous procedures, such as key pinch restoration. If EDC/EIP teno-desis or any other extensor-sided procedure is desired, whether at the same settingor in a staged fashion, a lazy-S–shaped or straight radial, near-midaxial incision isideal because access to extensors and flexors is provided through a single approach;otherwise, a separate dorsal approach may be required. Ulnar-sided forearm expo-sures are not useful because the access to muscles and tendons that will be manipu-lated is more limited. FDP synchronization in a reverse cascade is performed, andthe tendons are transected at the musculotendinous junction. The length of tendonrequired for proper tension is estimated because the tendon unit will be anchored tobone via a corticotomy. Wrist extension will pull on the FDP, tensioning the fingersinto flexion. The surgeon must choose the appropriate tension based on factors suchas the patient’s wrist extension strength and motion and passive digital motion. Asimple guideline is to adjust tension such that the fingers are maximally flexed atabout 30 to 45 degrees of extension. In this manner, further wrist extension pro-duces more tension than excursion, adding strength of grasp. Because the corticot-omy is a fixed distance from the radiocarpal joint, shortening the tendon mass bytrimming the proximal edge sharply sets tension. This tension is estimated andcompleted before securing the tenodesis. The corticotomy performed about the dia-physeal/metaphyseal junction must be large enough to accommodate the synchroni-zation mass (1–2 cm diameter). The corticotomy can be created with drill holes andosteotomies or a high-speed burr. Once created, the corticotomy is deepened withcurettes or a burr to create a sizeable cavity large enough to accommodate theproximal FDP tendon unit. Three drill holes are then made proximal to the corticot-omy, leaving a sufficient bone bridge in between and connected to the cavity justcreated. Mimicking the created tenodesis effect using hemostats and temporarysutures allows for final adjustments. Once the tendon mass is appropriately short-ened for proper tension, a locking whipstitch is secured to the outer margins of theproximal synchronization mass using large-caliber nonabsorbable suture (no. 3 or 5).A more centrally placed locking suture is applied as well, leaving four free strandsof suture through which the tendon mass will be anchored. The tendon unit isattached to the volar aspect of the distal radius similar to reattachment of a distalbiceps tendon rupture (Fig. 3A).

86 PELJOVICH

Figure 3. Passive tenodesis procedures. A, For the flexor side, the flexor digitorumprofundus (FDP) is first synchronized, then secured to the volar distal radial surfacethrough a bone tunnel or defect. B, For the extensor side, a similar procedure isperformed using the extensor digitorum communis (EDC �/� the EIP), but proximalto the extensor retinaculum. If necessary, the proximal 1/3 to 1/2 of the retinaculumcan be excised to create room for the synchronized EDC mass in order to avoidadhesions under the fourth dorsal extensor compartment that could reduce the effec-tive excursion achieved during surgery.


The sutures are passed through the cavity and out the proximal drill holes, and thetendon mass is snugged down into the cavity and secured by tying the suturestogether.

Gravity-induced wrist flexion extends the digits, which can be equally affectedvia tenodesis of the EDC. This form of tenodesis is more commonly performedwhen restoring palmar grasp and release when wrist flexion fails to result inadequate finger extension, or when a tendon transfer powers the FDP to achievebetter digital balance. As in the FDP tenodesis, the EDC is synchronized and se-cured proximal to the wrist joint through a corticotomy (Fig. 3B). The corticotomyshould be performed proximal to the extensor retinaculum to prevent postoperativescarring within the dorsal extensor compartments. If significant adhesions alreadyexist with the extensor tendons within the retinaculum, the tendons can be removedfrom the retinaculum and tenodesis performed superficially. The proximal portionof the retinaculum can be removed to avoid adhesions between the tendons nowsynchronized and the fourth dorsal extensor compartment. Tension is set such thatfinger extension is full by about 30 to 45 degrees of flexion and should be individu-alized to the patient. Consideration should be given to EPL/APL tenodesis. Thumbextension is part of palmar grasp release. The wrist and fingers are immobilized ina relaxed neutral position for a minimum of 3 weeks. Afterward, rehabilitation isstarted, consisting of tendon-gliding exercises. Passive motion is not generally usedto avoid stretching the tenodesis.

TENDON TRANSFERS FOR FINGER FLEXION

When activating finger flexion, the typical donor muscle is the ECRL. TheECRL has sufficient excursion and power and is a synergistic transfer. Despite itsavailability, the BR usually used to restore key pinch through transfer into the FPL.In patients having group 4 or greater function, in whom two-stage flexor andextensor reconstruction is often performed, the PT is an available donor muscle andcan be used to power the FDP or, more commonly, thumb motion. For the ECRL,exposure must be extensive enough to allow mobilization of the muscle to reroute itvolarly and to provide sufficient passive excursion to be an effective transfer for theFDP. One can use separate incisions to release, mobilize, and transfer the tendonvolarly, or a longer utilitarian single radial incision, which is especially useful ifother simultaneous procedures are performed.

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The donor muscle is released from its insertion and freed from any fascial orintermuscular connections to maximize excursion. The FDP is identified, and areverse cascade tenodesis is performed. The donor tendon is then routed volarlyaround the radial aspect of the forearm suprafascially and subcutaneously, whenusing the ECRL, and attached to the FDP in the tenodesis zone using a standardPulvertaft weave (the author generally passes the tendon a minimum of three timesthrough the recipient tendon) (Fig. 4).


Figure 4. The extensor carpi radialis longus (ECRL) to flexordigitorum profundus (FDP) transfer. The ECRL is mobilizedand transferred radially to the flexor side of the forearm andtransferred into the FDP. The FDP is initially synchronized,and the ECRL is weaved into the synchronized mass, or justproximal to it. A standard Pulvertaft weave is used to attachthe ECRL into the FDP.

If the PT is chosen, it is released from its long insertion on the radius along with acontinuous strip of periosteum to maximize length for tendon weaving (Fig. 4). Thetendon is then weaved into the FDP tendon unit after it is released and sufficientlyfreed. Regardless of the donor motor chosen, tension is set in a similar fashion. Theresting tension of the transfer is set such that the fingers are flexed with the wrist inabout 30 to 45 degrees of extension. Finger extension with the wrist flexed must bepresent or provided by tenodesis to optimize digital balance and prevent late fingerflexion contractures. The wrist and fingers are immobilized in a relaxed neutralposition for a minimum of 3 weeks. Training exercises are then begun, along withthe use of a removable splint.

TENDON TRANSFERS FOR FINGER EXTENSION

Finger extension is not powered unless there are sufficient donor muscles avail-able. The ideal patient for consideration is in group 5 or higher; group 4 patientscan be considered. In this circumstance, the BR is chosen as the donor muscle; thePT and ECRL are used to power thumb pinch and finger flexion using a two-stagereconstruction. Given the presence of three potentially good donor muscles, one canrely on tenodesis procedures to power finger and thumb extension, use the ECRL topower finger flexion, and use the BR and PT to restore thumb mobility elegantly.Selection of the specific method must be individualized to the patient’s goals anddesires and based on the hand function before surgery. This decision is also basedon the surgeon’s experience. Appropriate descriptions by House and Zancollishould be reviewed, and there is no gold standard.3,7

The BR can be mobilized from the same radial, near-midaxial incision describedearlier. To increase the passive excursion of the BR sufficiently, which is typicallyabout 4 cm, its long expansive tendon must be freed of its more proximal fascialand intermuscular attachments to increase its passive excursion to up to 8 cm(Fig. 5).

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Figure 5. The brachioradialis must be both released and freed from its intramuscular and intrafascialattachments to create sufficient excursion to be a suitable donor motor. A, The brachioradialis is identifiedby the top forceps. The proximity of the median nerve is shown through the bottom forceps. B, Extensivemobilization of the brachioradialis is required to create the sufficient amount of excursion to make it a moresuitable donor motor. The forceps at the top right points to the superficial sensory branch of the radialnerve that should be protected during the dissection.

The incision should reach proximally enough to allow the surgeon to mobilize thismuscle fully. Once freed, it is transferred suprafascially to a synchronized EDC/EIPproximal to the extensor retinaculum (Fig. 6).


Figure 6. Brachioradialis (BR) to extensor digitorum communis (EDC)transfer. The BR is extensively mobilized and routed subcutaneouslyand dorsally into the synchronized EDC. A Pulvertaft weave is used.

The EPL and APL can also be incorporated into this transfer to provide activethumb extension as opposed to a tenodesis. Tension is set such that the fingers areextended with the wrist in about 30 degrees of flexion. The elbow should be flexedabout 70 to 90 degrees as well because the BR crosses two joints. In fact, transfer ofthe BR in general is more effective when the elbow is also stabilized, that is, adeltoid or biceps to triceps transfer. Immobilization is for 3 to 4 weeks. Training isthen begun and is aided by stabilizing the elbow with a brace, especially if asimultaneous elbow extension transfer has been performed, and the patient is notyet able to flex the elbow for fear of overstretching the triceps transfer.

INTRINSICS

Intrinsic reconstruction should be considered in patients undergoing two-stagereconstructions because the restoration of finger flexion and extension could behampered by the lack of intrinsic balance (group 4 patients or higher). Strongcandidates are patients who will have both the finger flexors and extensors acti-vated by tendon transfer. The intrinsic minus hand that can result produces aninefficient and progressively weakening curl grasp. Other situations in which intrin-sic reconstruction should be considered include patients with hyperextensible MCPjoints, which will weaken grasp, and proximal interphalangeal (PIP) joint extensorlags. Patients who exhibit index hyperflexion with the wrist extended may have animpaired key pinch, and this effect could be reversed by intrinsic reconstruction. Afinal patient in whom intrinsic reconstruction should be considered as part of grasprestoration is the rare group 8 patient who is hampered by intrinsic minus handfunction. Two passive tenodesis techniques have been developed to balance theintrinsics, one proposed by Zancolli and one by House. Both techniques are effec-tive, and the relative merits are discussed in the literature.3,7 The author favors theZancolli method but recognizes that postoperative finger stiffness may result; there-fore, in a two-stage reconstruction, the technique should be performed during theflexor phase to minimize scarring.

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Figure 7. Examples of intrinsic reconstruction. A, The Zancolli method. The flexor digitorum sublimus(FDS) is transected between the A1 and A2 pulley, routed over the A1 pulley, and sutured to itself. B, TheHouse method. A graft of palmaris longus is woven into each of the radial lateral bands and central slipsof the index and long finger, and under the extensor communis of the index finger.


The “lasso” method described by Zancolli involves a tenodesis of the FDS tothe A1 pulley, thereby mimicking intrinsic function with wrist extension. Inducingslight MCP joint flexion and preventing interphalangeal hyperflexion with the wristextended improve grasp posturing. Significant PIP lag should be treated simulta-neously by a tenodesis of the central slip and by temporarily pinning the PIP jointin near extension for 2 to 3 weeks. The FDS to each finger is approached by anoblique incision extending from the distal palmar crease to the radial border of theMCP flexion crease. If necessary, the incision for each digit can be extended distallyin a zigzag fashion. The A1 pulley is identified but not transected, but the proximalportion of the A2 pulley can be incised for exposure. The FDS is transected proxi-mal to the chiasm or distal to it if length is required. It is then routed out of theA1/A2 pulley interval. The transected FDS tail is then sewn to itself proximal to theA1 pulley (Fig. 7A).

The alternative method described by House involves tenodesis of the index andlong finger alone. A palmaris longus tendon graft is woven into the radial lateralband/central slip of the index finger and then passed deep through the lumbricalcanal of the index finger, under the index extensor mechanism ulnarly, and deepthrough the lumbrical canal of the long finger, and woven into the radial lateralband/central slip of the long finger (Fig. 7B). This weave now links MCP motion toPIP motion. MCP joint hyperextension is prevented because, when the finger flexeswith the wrist extended, PIP flexion results in MCP flexion. Finger extension is alsoenhanced as both joints extend with EDC tenodesis or activation. Balanced fingerflexion occurs as PIP flexion initiated through an active FDP transfer results in MCPflexion, thereby preventing excessive curling. House recommends that this transferbe performed during the extensor phase of a two-stage reconstruction.3

SURGICAL ALTERNATIVES

Almost no standards exist in approaching restoration in patients with traumatictetraplegia. Although several studies demonstrate the improvements in function andstrength following surgery, few compare one method with another. Most recom-mendations are based on sound knowledge of pathophysiology, anatomy, bio-mechanics, and accrued experience. With regard to tenodesis, any one of a numberof techniques for anchoring the tendon to bone is likely to be effective. Manysurgeons advocate that the tendons be anchored using a “horseshoe” corticotomy.In addition, and depending on the patient’s hand, one can choose to perform flexortenodesis using the FDS. The author prefers a fairly standard, albeit technicallyinvolved method. Another important alternative to strengthen flexor tenodesis canbe performed in group 2 patients with a voluntary but weak ECRB. Because theECRB is not a useful wrist extender in this particular circumstance but retains somefunction and strength, it can be transferred through the interosseous membrane tothe FDP to create a strong FDP tenodesis. This is useful in a patient who mightotherwise be limited to a thumb key pinch restoration, and the presence of a weakbut voluntary ECRB should be determined.

Options exist with regard to the choice of donor muscle for transfer and,perhaps, the priorities for which functions are restored first. The author gives prior-ity to lateral pinch and release and prioritizes activating finger flexion when restor-ing palmar grasp and release. Depending on the patient, these priorities may bechanged, and individualizing treatment to the patient’s goals and needs is one ofthe important concepts in treating tetraplegic patients. For group 4 or higher pa-tients undergoing two-stage reconstruction, various alternative schemes have beenpresented based on the choice of thumb (lateral pinch) restoration.

When activating finger flexion, the ECRL can be transferred into the FDP of theindex and long fingers and the FDS of the little and ring fingers because, occasion-ally, there is excess curling of the ulnar fingers. In such a circumstance, tendonsynchronization would match the FDP of the index and long fingers with the FDSof the ring and little fingers. The FDS can be chosen as the flexor activated inrestoring finger flexion, but one loses the hooking effect on an object achieved bydistal interphalangeal flexion.

With intrinsic reconstruction, especially in the presence of a concurrent PIP lag,the Stiles-Bunnell technique is a useful alternative. In this procedure, the FDS distalto the chiasm is transected, and the slips are woven into the radial lateral band toaddress intrinsic dysfunction by creating simultaneous MCP flexion and PIP exten-sion moments.

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SUMMARY

Restoration of hand function in the setting of traumatic tetraplegia is challeng-ing but extremely rewarding for the patient. Previous outcomes research has dem-onstrated significant gains in function, use, and subjective improvement followingsuch surgery. The key lies in proper patient selection, understanding what goals arereasonable and achievable, and individualizing the surgical plan to fit the patient.

References

1. Gonzalez E, Keith MW: Surgical management ofthe upper limb in tetraplegia. In Lee, Ostrander(eds): The Spinal Cord Injured Patient. DemosMedical Publishing, New York

2. Haque MA, Keith MW, Bednar M, et al: Clinicalresults of ECRB to FDP transfer through theinterosseous membrane to restore finger flexion,in Press

3. House JH, Shannon MA: Restoration of stronggrasp and lateral pinch in tetraplegia: A com-parison of two methods of thumb control ineach patient. J Hand Surg 10A:21–29, 1985

4. Keith MW, Lacey SH: Surgical rehabilitation ofthe tetraplegic upper extremity. Journal of Neu-rology and Rehabilitation 5:75–87, 1991

5. McCarthy CK, House JH, Van Heest A, et al:Intrinsic balancing in reconstruction of the tetra-plegic hand. J Hand Surg 22A:596–604, 1997

6. Peljovich AE, Kucera K, Gonzalez E, et al: Reha-bilitation of the hand and upper extremity intetraplegia. In Mackin EJ, Callahan AD, SkirvenT, et al (eds): Hunter, Mackin, Callaghan Reha-bilitation of the Hand and Upper Extremity, ed5. St. Louis, Mosby, 2002

7. Zancolli EA: Functional restoration of the upperlimb in traumatic quadriplex. In Structural andDynamic Basis of Hand Surgery, ed 2. Philadel-phia, JB Lippincott, 1979, pp 229–262


Allan Peljovich, MD, MPHThe Hand Treatment Center, PC

Suite 1020980 Johnson Ferry Road

Atlanta, GA 30342



Tendon Transfers forRestoration of Active GraspAllan E. Peljovich, MD, MPH

Traumatic tetraplegia represents about one-half of all spinal cord injuries, andthe C5 and C6 levels are the most commonly injured. As such, the common cervicallevel spinal injury leaves patients with some shoulder and elbow function andperhaps minimal wrist function. This pattern translates into a weak tenodesis graspand release in C6 level patients but no effective grasp ability in C5 patients. Lowercervical injury in which patients retain some hand function is uncommon, as ishigh-level injury that leaves patients ventilator dependent. Among the most dis-abling aspects of traumatic tetraplegia is the loss of hand and upper extremityfunction. Previous study has demonstrated that restoration of hand and upperextremity function is rated above bowel/bladder control, sexual function, and am-bulation among patients and caregivers alike. Surgery to restore hand function canthus have a significant impact on the quality of life of tetraplegic patients.

Most activities of daily living are performed through two fundamental grasppatterns: (1) lateral thumb pinch and release (key pinch) and (2) palmar grasp andrelease. The author typically prioritizes key pinch and restores palmar grasp andrelease when sufficient donor muscles exist. Enhancing the natural wrist tenodesiseffect through orthotics or passive tenodesis procedures or through voluntary ten-don transfers is the means by which function is restored. A novel method to restorepalmar grasp and release not discussed herein is through neuroprosthetic implanta-tion (NeuroControl Freehand; NeuroControl Corp., Valley View, OH), typically re-served for American Spinal Injury Association (ASIA) C5 and C6 patients, or Inter-national Classification of Surgery of the Hand in Tetraplegia (ICSHT) groups 0 to 2.

Grasp and release restoration must be viewed from the larger perspective ofupper extremity restoration. Not all tetraplegic patients are good candidates forsurgical intervention. Among the criteria listed below perhaps the most important isthat the patient’s desires and goals from surgery are realistic.



From the Shepherd Center; The Hand Treatment Center, PC; the Department of Orthopaedic Surgery,Atlanta Medical Center; and Emory University, Atlanta, Georgia

Patient Criteria for Surgical Consideration in Tetraplegic Hand Restoration

IndicationsNeurologic stability (at least 10–12 months from injury)Motivation and desireRealistic goalsGood cognitionGood general healthWheelchair/trunk stabilitySupple/pain-free upper extremity (consider other injuries sustainedduring trauma)Minimal to no problem with recurrent pressure soresGood support systems (family, friends, attendants)Suitable physical examination for tendon transfer or neuroprostheticMinimal to no problems with upper extremity spasticity

ContraindicationsUnrealistic expectationsUncontrollable upper extremity spasticityUpper extremity painSignificant upper extremity or hand contractures or both

In addition, the ability to grab and manipulate an object is enhanced by the abilityto be able to reach out with one’s arm; therefore, restoration of palmar grasp andrelease is most efficacious when other functions are present or provided, namely,key pinch, supple pronosupination, and elbow extension. Often, multiple proceduresare combined in a single or a staged series of operations to minimize the disabling“downtime” tetraplegic patients face after surgery.

INTERNATIONAL CLASSIFICATION

In 1984 at the First International Conference on Surgical Rehabilitation of theUpper Limb in Tetraplegia held in Edinburgh, a classification system was devisedby a group of experienced surgeons, which has since been modified for the tetra-plegic hand. The system categorizes patients by the most distally innervated volun-tary muscle with grade 4 British Medical Research Council (BMRC) strength orgreater (Table 1).

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Table 1. THE INTERNATIONAL CLASSIFICATION FOR SURGERY OF THE HAND IN TETRAPLEGIA

Group Motor Function

0 None Elbow flexion and supination1 Brachioradialis Elbow flexion and supination, pronation with neutral forearm position2 Extensor carpi radialis longus Wrist extension3 Extensor carpi radialis brevis Strong wrist extension4 Pronator teres Active forearm pronation5 Flexor carpi radialis Wrist flexion6 Extrinsic finger extensors Partial or complete digital extension7 Extrinsic thumb extensors Thumb extension8 Radial extrinsic digital flexors Partial digital flexion9 Complete digital flexion (thumb included) Intrinsic minus handX Incomplete/exceptions Unpredictable

Medical Research Council; carpi radialis brevis.BMRC � British ECRB � extensorNote: System only applies to muscles of the forearm and hand. Upper extremity function is not included but becomes increasingly functional as the

group level increases. Sensibility is based on the presence of thumb/index two-point discrimination of 10 mm. If present, the classification has the prefixCu (cutaneous), such as Cu 4. If two-point discrimination is greater than 10 mm, the classification has the prefix O (ocular), such as O 1. Motor is basedon the presence of at least grade 4 BMRC strength. Weaker voluntary function may be present, such as a weak ECRB in a group 2 patient.

Unlike in the ASIA system, its utility is that the groupings provide informationconcerning which specific muscles are voluntary and sufficiently strong, therebygiving the treating physician concise information regarding surgical options for thepatient. For example, a group 3 patient has a voluntary strong brachioradialis (BR),extensor carpi radialis longus (ECRL), and extensor carpi radialis brevis (ECRB).This observation suggests that group 3 patients have three potential donor musclesfor transfer. On the other hand, an ASIA C6 patient who also has voluntary wristextension may or may not have a strong and voluntary ECRB. The InternationalClassification is more useful when describing hand function and is used throughoutthis article.

SURGICAL PRINCIPLES

Successful restoration of palmar grasp and release involves addressing fourphases: (1) object acquisition, (2) grasp, (3) hold/manipulation, and (4) object re-lease. Each phase must be attended to for the best results as follows:

1. Object acquisition: The patient must be able to acquire the object he or shedesires to manipulate. This ability involves coordinated upper extremity mo-tion, such as elbow extension and forearm rotation, for wrist positioning inspace in addition to digital extension to reach around an object.

2. Grasp: In the second phase, the hand must grasp the object through digitalflexion. The mass of the object the patient can grasp is proportionate to thestrength of digital flexion and wrist stability, whereas the size of the object isproportionate to digital extension. Another factor in the size of the object isthe type of flexion that a patient achieves. A curl or hook grasp, in whichthere is hyperflexion of the interphalangeal joints with relative extension ofthe metacarpophalangeal (MCP) joint, would be effective for small objectsand power.

On the other hand, a balanced grasp with flexion of all of the phalan-geal joints allows grasp of a larger object, such as a book or cup. The lattergrasp pattern is more versatile for activities of daily living, whereas theformer is fairly inefficient.

3. Hold and manipulate: The patient must then be able to hold and manipulatethe object. This ability is correlated with endurance of digital flexion strengthand upper extremity coordination.

4. Object release: The patient must be able to release the object to its desiredlocation effectively. The fingers and thumb must extend in a coordinatedfashion.

The muscle functions addressed in reconstruction of palmar grasp and release in-clude the flexor digitorum profundus (FDP), extensor digitorum communis (EDC),extensor pollicis longus (EPL), abductor pollicis longus (APL), flexor pollicis longus(FPL), and, occasionally, the flexor digitorum superficialis (FDS) and intrinsic handmuscles. For the sake of economy in these patients, the FDP is prioritized for digitalflexion because its action results in flexion of all of the interphalangeal joints asopposed to the FDS. When muscles are available as donors to be transferred topower grasp, the author usually prioritizes FDP activation as opposed to EDCactivation to provide strength for grasp and hold/manipulation phases, expectingtenodesis finger extension that is passively associated with gravity-produced wristflexion to provide sufficient acquisition and release phases. If the FPL is activated aswell, which is often true if a motor is available to power the FDP because key pinchrestoration is prioritized, grasp is even stronger. Tendon transfers to activate digitalextension are performed when there are sufficient donor muscles available, that is,the patient is in group 4 or higher, and EDC, EPL, and APL activation can beachieved with a single donor motor.


General principles of tendon transfer are often “extended” in this population ofpatients. Regardless of the technique or procedure, ideal patients have supple joints,are motivated, are healthy, and have sufficient cognition to understand, and cooper-ate in their postoperative therapy. Transferring strong muscles that are under volun-tary control is the norm; however, occasionally, muscles with grade 3 strength areused, that is, transfer of the ECRB to FDP through interosseous membrane in group2 patients. Donor muscles must have sufficient amplitude of motion, especiallyconsidering that the excursion for the FDP is approximately 7 cm. Of course, thefunction of the donor muscle must be expendable; and the BR, one of the two radialwrist extensors (ECRL preferred over the ECRB) and pronator teres (PT) meet thiscriterion best. The author preserves the flexor carpi radialis when present (group 5)because, usually, sufficient donor muscles are available to restore meaningful func-tion, and voluntary wrist flexion generally produces better tenodesis digital exten-sion than gravity alone. Use of the ECRB is limited to the previous example;otherwise, the ECRL is the prime wrist extensor used for transfer if the ECRB isunder voluntary control and is of sufficient strength. Sensation is not critical be-cause the goal is restoration of fundamental grasp patterns that can be controlledvisually. If touch, stereognosis, and proprioception were criteria for surgery, almostno tetraplegic patients would qualify for surgery, and this requirement belies expe-rience with the success of surgery. Synergism as achieved with an ECRL to FDPtransfer is ideal but not required.

RESTORATIVE LADDER

The foundation for palmar grasp and release restoration lies in the presence orprovision of wrist extension, which powers the passive tenodesis coupling of wristextension/digital flexion and gravity-produced wrist flexion/digital extension. Onceadequate and voluntary wrist extension is present, a tenodesis grasp and release canbe enhanced as necessary through therapy, orthotics, or surgery. Some patients aresatisfied with tenodesis grasp alone. Most patients desire to become brace free andto have a stronger grasp and key pinch. Restorative or reconstructive surgery isthen based on transferring and tightening tendons along with judicious use of jointstabilization, whether through capsulodesis or arthrodesis.

Patients with group 0 function do not have wrist motion or a suitable donormuscle for transfer into the hand and wrist. As such, restoration of hand function isachievable only through neuroprosthetic implantation, which is primarily used forpatients in groups 0 to 3. In group 1 patients, the BR is available for transfer intothe ECRB, thereby providing wrist extension. Palmar grasp and release is thenenhanced as necessary with orthotics or tendon tenodesis, if necessary. Key pinchrestoration alone is more commonly performed in this group. In group 2 patients,the ECRL is sufficiently strong. Key pinch is still prioritized and powered withtransfer of the BR to FPL, in addition to other thumb-stabilizing procedures. Palmargrasp and release is enhanced as necessary with tenodesis procedures, or can beprioritized over key pinch and restored with a BR to FDP transfer. Some group 2patients retain a present but weak ECRB (BMRC 3 strength). This weak ECRB canbe passed through the interosseous membrane to act as a strong tenodesis transferwithout sacrificing critical wrist extension. In group 3 patients, palmar grasp andrelease can be restored without sacrificing key pinch and is activated by transferringthe ECRL into the FDP; EDC tenodesis is used to “balance” the finger. Two-stageflexor/extensor reconstructions are often performed in patients who function at agroup 3 level or higher but are more commonly used in patients who are at leastgroup 4. In group 4 and 5 patients, options depend on the choice of thumb recon-struction, and available donor motors to power the FDP include the PT and ECRL.At this level, the BR is potentially available to power finger/thumb extension, againdepending on the choice of thumb/key pinch reconstruction. In group 6 patients,

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some digital extension is present, and the EPL alone is activated in addition tofinger flexion. In group 7 patients, only flexion activation is required. In group 8patients, there may be good flexion of the radial digits. In this circumstance, theECRL can be used to power some or all of the FDS. In patients at group 4 level orhigher, and in some patients of higher-level cervical tetraplegia, consideration ofintrinsic balance is included in the surgical plan.

Two-Stage Flexion and Extension Reconstruction

Patients who can undergo restoration of active flexion as well as lateral pinchshould be considered for two-stage reconstructions (group 3 or greater) (Table 2)because joint balancing enhances digital restoration. Unopposed or unbalanced func-tion can result in inefficient function, long-term contractures, and failure of trans-fers, such as finger flexion contractures following isolated activation of the FDP.Either active transfer or, more commonly, tenodesis of the antagonist achieves bal-ance. In this fashion, EDC/EIP tenodesis or activation balances function gainedthrough FDP activation. At the same time, intrinsic reconstruction also achievesdigital balance. The problem is that the rehabilitation for flexion restoration iscontradictory and endangers the rehabilitation for extension restoration; therefore,restoration is performed in two stages, one for flexion and a second for extension.The higher the group level, the more functional the hand. The details of suchprocedural algorithms are found in texts written by House and Zancolli and areoutlined in Table 2.3,7


Table 2. EXAMPLES OF TWO-STAGE FLEXION AND EXTENSION RECONSTRUCTIONS

Zancolli Method (2–6 months between stages) House Method (2–6 months between stages)

1. Extensor reconstructiona. EDC/EPL/APL tenodesis versus BR to EDC/EPL transferb. Thumb CMC arthrodesisc. Zancolli lasso

2. Flexor reconstructiona. BR to FDP transfer versus ECRL to FDP and ECRB/

FPL synchronizationb. BR to FPL versus FPL tenodesisc. PT to FCR for group 4

For groups 4–51. Flexor reconstruction

a. ECRL to FDP transferb. PT to FPL transferc. BR to adductor pollicis/opponens transfer (via FDS graft)

2. Extensor reconstructiona. EDC synchronization and tenodesisb. EPL/APL tenodesisc. Free graft intrinsic index/long tenodesis

For group 61. Flexor reconstruction

a. ECRL to FDP transferb. BR or PT to FPL transferc. Zancolli lasso

2. Extensor reconstructiona. Thumb CMC arthrodesisb. EDC and EPL tenodeses versus BR to EDC/EPL

carpi radialis longus; digitorum communis; carpi radialis brevis;BR � brachioradialis; ECRL � extensor EDC � extensor ECRB � extensor EPL �pollicis longus; pollicis longus; metacarpal; digitorum profundus; pollicis longus;extensor APL � abductor CMC � carpo FDP � flexor FPL � flexor

teres; carpi radialis; digitorum superficialis.PT � pronator FCR � flexor FDS � flexor

TENDON SYNCHRONIZATION

Tendon synchronization is a useful technique whereby all of the FDP or EDC/EIPtendons, respectively, are sutured to each other to create efficiency and economy. It isimpossible to activate flexor or extensor function individually for each digit indepen-dently in the setting of traumatic tetraplegia. In this technique, either the FDP or EDCis transformed into a single tendon unit. In both procedures, the natural cascade of thefingers is ignored, and the synchronization is set such that all the fingers flex andextend level to each other (Fig. 1).

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Figure 1. Synchronization of the flexor digitorum profundus (FDP) and the extensor digitorum commu-nis converts four independent tendons into one “mass” that allows for efficient control of finger motion.Synchronization is performed by tying the tendons in a side to side fashion using at least threehorizontal mattress sutures. At least three sutures are required to control relative translation betweenthe tendons themselves. Note that the fingers are synchronized in a straight, equal fashion, rather thanin the natural cascade. This reverse cascade improves grasp and release ability. The proximal musclewould be transected if a tenodesis procedure were being performed as well.

At least three interrupted nonabsorbable sutures are used to tie the tendons to eachother to create translational control of the mass. This suturing is carried out proxi-mal to the retinaculum on the extensor surface, such that the sutures do not enterthe extensor compartments. With this “reverse cascade,” force is applied through allof the fingers equally and with equal motion, thereby maximizing the size of anobject that can be grasped or manipulated. Synchronization is routinely performedwhen individual finger motion is not already present, that is, at less than group 6function. A minimum of 3 weeks of immobilization is required before sufficienthealing occurs to allow therapy.

TENODESIS TECHNIQUE

Tenodesis refers to tightening tendons to phases of motion, in this case, tighten-ing the extrinsic finger muscles in sync with wrist motion to strengthen or enhancea function that occurs naturally. Finger flexion can be enhanced with wrist extensionby tightening the FDP. Finger extension can be enhanced with gravity-induced wristflexion by tightening the EDC/EIP. Tenodesis procedures are used when donormuscles are absent, and the natural tenodesis effect achieved through the wrist isinadequate. Another circumstance in which tenodesis commonly is applied is whenjoint balancing is necessary. For example, it is desirous to perform tenodesis of theEDC when activating the FDP to prevent late flexion deformities. The problem withtenodesis is that it is generally weak and can stretch with time.

For flexor tenodesis, exposure of the FDP is achieved depending on othersimultaneously performed procedures. This maneuver can be performed through aradial approach (approach of Henry), or a more radial, near-midaxial approach(Fig. 2).


Figure 2. The surgical approaches for most reconstructiveprocedures for palmar grasp and release vary from volarand dorsal combinations to single utilitarian approaches.This view demonstrates two alternative utilitarian exposures.One single straight incision can be created just volar to themidaxial line of the forearm (near-midaxial). Alternatively, asingle “lazy-S” incision can be created in a similar location.Mobilization of full-thickness soft tissue flaps and rotation ofthe forearm provide excellent access to the three forearmcompartments during tetraplegia reconstruction.

Any of these latter approaches are fairly utilitarian because they provide exposurefor other simultaneous procedures, such as key pinch restoration. If EDC/EIP teno-desis or any other extensor-sided procedure is desired, whether at the same settingor in a staged fashion, a lazy-S–shaped or straight radial, near-midaxial incision isideal because access to extensors and flexors is provided through a single approach;otherwise, a separate dorsal approach may be required. Ulnar-sided forearm expo-sures are not useful because the access to muscles and tendons that will be manipu-lated is more limited. FDP synchronization in a reverse cascade is performed, andthe tendons are transected at the musculotendinous junction. The length of tendonrequired for proper tension is estimated because the tendon unit will be anchored tobone via a corticotomy. Wrist extension will pull on the FDP, tensioning the fingersinto flexion. The surgeon must choose the appropriate tension based on factors suchas the patient’s wrist extension strength and motion and passive digital motion. Asimple guideline is to adjust tension such that the fingers are maximally flexed atabout 30 to 45 degrees of extension. In this manner, further wrist extension pro-duces more tension than excursion, adding strength of grasp. Because the corticot-omy is a fixed distance from the radiocarpal joint, shortening the tendon mass bytrimming the proximal edge sharply sets tension. This tension is estimated andcompleted before securing the tenodesis. The corticotomy performed about the dia-physeal/metaphyseal junction must be large enough to accommodate the synchroni-zation mass (1–2 cm diameter). The corticotomy can be created with drill holes andosteotomies or a high-speed burr. Once created, the corticotomy is deepened withcurettes or a burr to create a sizeable cavity large enough to accommodate theproximal FDP tendon unit. Three drill holes are then made proximal to the corticot-omy, leaving a sufficient bone bridge in between and connected to the cavity justcreated. Mimicking the created tenodesis effect using hemostats and temporarysutures allows for final adjustments. Once the tendon mass is appropriately short-ened for proper tension, a locking whipstitch is secured to the outer margins of theproximal synchronization mass using large-caliber nonabsorbable suture (no. 3 or 5).A more centrally placed locking suture is applied as well, leaving four free strandsof suture through which the tendon mass will be anchored. The tendon unit isattached to the volar aspect of the distal radius similar to reattachment of a distalbiceps tendon rupture (Fig. 3A).

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Figure 3. Passive tenodesis procedures. A, For the flexor side, the flexor digitorumprofundus (FDP) is first synchronized, then secured to the volar distal radial surfacethrough a bone tunnel or defect. B, For the extensor side, a similar procedure isperformed using the extensor digitorum communis (EDC �/� the EIP), but proximalto the extensor retinaculum. If necessary, the proximal 1/3 to 1/2 of the retinaculumcan be excised to create room for the synchronized EDC mass in order to avoidadhesions under the fourth dorsal extensor compartment that could reduce the effec-tive excursion achieved during surgery.


The sutures are passed through the cavity and out the proximal drill holes, and thetendon mass is snugged down into the cavity and secured by tying the suturestogether.

Gravity-induced wrist flexion extends the digits, which can be equally affectedvia tenodesis of the EDC. This form of tenodesis is more commonly performedwhen restoring palmar grasp and release when wrist flexion fails to result inadequate finger extension, or when a tendon transfer powers the FDP to achievebetter digital balance. As in the FDP tenodesis, the EDC is synchronized and se-cured proximal to the wrist joint through a corticotomy (Fig. 3B). The corticotomyshould be performed proximal to the extensor retinaculum to prevent postoperativescarring within the dorsal extensor compartments. If significant adhesions alreadyexist with the extensor tendons within the retinaculum, the tendons can be removedfrom the retinaculum and tenodesis performed superficially. The proximal portionof the retinaculum can be removed to avoid adhesions between the tendons nowsynchronized and the fourth dorsal extensor compartment. Tension is set such thatfinger extension is full by about 30 to 45 degrees of flexion and should be individu-alized to the patient. Consideration should be given to EPL/APL tenodesis. Thumbextension is part of palmar grasp release. The wrist and fingers are immobilized ina relaxed neutral position for a minimum of 3 weeks. Afterward, rehabilitation isstarted, consisting of tendon-gliding exercises. Passive motion is not generally usedto avoid stretching the tenodesis.

TENDON TRANSFERS FOR FINGER FLEXION

When activating finger flexion, the typical donor muscle is the ECRL. TheECRL has sufficient excursion and power and is a synergistic transfer. Despite itsavailability, the BR usually used to restore key pinch through transfer into the FPL.In patients having group 4 or greater function, in whom two-stage flexor andextensor reconstruction is often performed, the PT is an available donor muscle andcan be used to power the FDP or, more commonly, thumb motion. For the ECRL,exposure must be extensive enough to allow mobilization of the muscle to reroute itvolarly and to provide sufficient passive excursion to be an effective transfer for theFDP. One can use separate incisions to release, mobilize, and transfer the tendonvolarly, or a longer utilitarian single radial incision, which is especially useful ifother simultaneous procedures are performed.

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The donor muscle is released from its insertion and freed from any fascial orintermuscular connections to maximize excursion. The FDP is identified, and areverse cascade tenodesis is performed. The donor tendon is then routed volarlyaround the radial aspect of the forearm suprafascially and subcutaneously, whenusing the ECRL, and attached to the FDP in the tenodesis zone using a standardPulvertaft weave (the author generally passes the tendon a minimum of three timesthrough the recipient tendon) (Fig. 4).


Figure 4. The extensor carpi radialis longus (ECRL) to flexordigitorum profundus (FDP) transfer. The ECRL is mobilizedand transferred radially to the flexor side of the forearm andtransferred into the FDP. The FDP is initially synchronized,and the ECRL is weaved into the synchronized mass, or justproximal to it. A standard Pulvertaft weave is used to attachthe ECRL into the FDP.

If the PT is chosen, it is released from its long insertion on the radius along with acontinuous strip of periosteum to maximize length for tendon weaving (Fig. 4). Thetendon is then weaved into the FDP tendon unit after it is released and sufficientlyfreed. Regardless of the donor motor chosen, tension is set in a similar fashion. Theresting tension of the transfer is set such that the fingers are flexed with the wrist inabout 30 to 45 degrees of extension. Finger extension with the wrist flexed must bepresent or provided by tenodesis to optimize digital balance and prevent late fingerflexion contractures. The wrist and fingers are immobilized in a relaxed neutralposition for a minimum of 3 weeks. Training exercises are then begun, along withthe use of a removable splint.

TENDON TRANSFERS FOR FINGER EXTENSION

Finger extension is not powered unless there are sufficient donor muscles avail-able. The ideal patient for consideration is in group 5 or higher; group 4 patientscan be considered. In this circumstance, the BR is chosen as the donor muscle; thePT and ECRL are used to power thumb pinch and finger flexion using a two-stagereconstruction. Given the presence of three potentially good donor muscles, one canrely on tenodesis procedures to power finger and thumb extension, use the ECRL topower finger flexion, and use the BR and PT to restore thumb mobility elegantly.Selection of the specific method must be individualized to the patient’s goals anddesires and based on the hand function before surgery. This decision is also basedon the surgeon’s experience. Appropriate descriptions by House and Zancollishould be reviewed, and there is no gold standard.3,7

The BR can be mobilized from the same radial, near-midaxial incision describedearlier. To increase the passive excursion of the BR sufficiently, which is typicallyabout 4 cm, its long expansive tendon must be freed of its more proximal fascialand intermuscular attachments to increase its passive excursion to up to 8 cm(Fig. 5).

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Figure 5. The brachioradialis must be both released and freed from its intramuscular and intrafascialattachments to create sufficient excursion to be a suitable donor motor. A, The brachioradialis is identifiedby the top forceps. The proximity of the median nerve is shown through the bottom forceps. B, Extensivemobilization of the brachioradialis is required to create the sufficient amount of excursion to make it a moresuitable donor motor. The forceps at the top right points to the superficial sensory branch of the radialnerve that should be protected during the dissection.

The incision should reach proximally enough to allow the surgeon to mobilize thismuscle fully. Once freed, it is transferred suprafascially to a synchronized EDC/EIPproximal to the extensor retinaculum (Fig. 6).


Figure 6. Brachioradialis (BR) to extensor digitorum communis (EDC)transfer. The BR is extensively mobilized and routed subcutaneouslyand dorsally into the synchronized EDC. A Pulvertaft weave is used.

The EPL and APL can also be incorporated into this transfer to provide activethumb extension as opposed to a tenodesis. Tension is set such that the fingers areextended with the wrist in about 30 degrees of flexion. The elbow should be flexedabout 70 to 90 degrees as well because the BR crosses two joints. In fact, transfer ofthe BR in general is more effective when the elbow is also stabilized, that is, adeltoid or biceps to triceps transfer. Immobilization is for 3 to 4 weeks. Training isthen begun and is aided by stabilizing the elbow with a brace, especially if asimultaneous elbow extension transfer has been performed, and the patient is notyet able to flex the elbow for fear of overstretching the triceps transfer.

INTRINSICS

Intrinsic reconstruction should be considered in patients undergoing two-stagereconstructions because the restoration of finger flexion and extension could behampered by the lack of intrinsic balance (group 4 patients or higher). Strongcandidates are patients who will have both the finger flexors and extensors acti-vated by tendon transfer. The intrinsic minus hand that can result produces aninefficient and progressively weakening curl grasp. Other situations in which intrin-sic reconstruction should be considered include patients with hyperextensible MCPjoints, which will weaken grasp, and proximal interphalangeal (PIP) joint extensorlags. Patients who exhibit index hyperflexion with the wrist extended may have animpaired key pinch, and this effect could be reversed by intrinsic reconstruction. Afinal patient in whom intrinsic reconstruction should be considered as part of grasprestoration is the rare group 8 patient who is hampered by intrinsic minus handfunction. Two passive tenodesis techniques have been developed to balance theintrinsics, one proposed by Zancolli and one by House. Both techniques are effec-tive, and the relative merits are discussed in the literature.3,7 The author favors theZancolli method but recognizes that postoperative finger stiffness may result; there-fore, in a two-stage reconstruction, the technique should be performed during theflexor phase to minimize scarring.

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Figure 7. Examples of intrinsic reconstruction. A, The Zancolli method. The flexor digitorum sublimus(FDS) is transected between the A1 and A2 pulley, routed over the A1 pulley, and sutured to itself. B, TheHouse method. A graft of palmaris longus is woven into each of the radial lateral bands and central slipsof the index and long finger, and under the extensor communis of the index finger.


The “lasso” method described by Zancolli involves a tenodesis of the FDS tothe A1 pulley, thereby mimicking intrinsic function with wrist extension. Inducingslight MCP joint flexion and preventing interphalangeal hyperflexion with the wristextended improve grasp posturing. Significant PIP lag should be treated simulta-neously by a tenodesis of the central slip and by temporarily pinning the PIP jointin near extension for 2 to 3 weeks. The FDS to each finger is approached by anoblique incision extending from the distal palmar crease to the radial border of theMCP flexion crease. If necessary, the incision for each digit can be extended distallyin a zigzag fashion. The A1 pulley is identified but not transected, but the proximalportion of the A2 pulley can be incised for exposure. The FDS is transected proxi-mal to the chiasm or distal to it if length is required. It is then routed out of theA1/A2 pulley interval. The transected FDS tail is then sewn to itself proximal to theA1 pulley (Fig. 7A).

The alternative method described by House involves tenodesis of the index andlong finger alone. A palmaris longus tendon graft is woven into the radial lateralband/central slip of the index finger and then passed deep through the lumbricalcanal of the index finger, under the index extensor mechanism ulnarly, and deepthrough the lumbrical canal of the long finger, and woven into the radial lateralband/central slip of the long finger (Fig. 7B). This weave now links MCP motion toPIP motion. MCP joint hyperextension is prevented because, when the finger flexeswith the wrist extended, PIP flexion results in MCP flexion. Finger extension is alsoenhanced as both joints extend with EDC tenodesis or activation. Balanced fingerflexion occurs as PIP flexion initiated through an active FDP transfer results in MCPflexion, thereby preventing excessive curling. House recommends that this transferbe performed during the extensor phase of a two-stage reconstruction.3

SURGICAL ALTERNATIVES

Almost no standards exist in approaching restoration in patients with traumatictetraplegia. Although several studies demonstrate the improvements in function andstrength following surgery, few compare one method with another. Most recom-mendations are based on sound knowledge of pathophysiology, anatomy, bio-mechanics, and accrued experience. With regard to tenodesis, any one of a numberof techniques for anchoring the tendon to bone is likely to be effective. Manysurgeons advocate that the tendons be anchored using a “horseshoe” corticotomy.In addition, and depending on the patient’s hand, one can choose to perform flexortenodesis using the FDS. The author prefers a fairly standard, albeit technicallyinvolved method. Another important alternative to strengthen flexor tenodesis canbe performed in group 2 patients with a voluntary but weak ECRB. Because theECRB is not a useful wrist extender in this particular circumstance but retains somefunction and strength, it can be transferred through the interosseous membrane tothe FDP to create a strong FDP tenodesis. This is useful in a patient who mightotherwise be limited to a thumb key pinch restoration, and the presence of a weakbut voluntary ECRB should be determined.

Options exist with regard to the choice of donor muscle for transfer and,perhaps, the priorities for which functions are restored first. The author gives prior-ity to lateral pinch and release and prioritizes activating finger flexion when restor-ing palmar grasp and release. Depending on the patient, these priorities may bechanged, and individualizing treatment to the patient’s goals and needs is one ofthe important concepts in treating tetraplegic patients. For group 4 or higher pa-tients undergoing two-stage reconstruction, various alternative schemes have beenpresented based on the choice of thumb (lateral pinch) restoration.

When activating finger flexion, the ECRL can be transferred into the FDP of theindex and long fingers and the FDS of the little and ring fingers because, occasion-ally, there is excess curling of the ulnar fingers. In such a circumstance, tendonsynchronization would match the FDP of the index and long fingers with the FDSof the ring and little fingers. The FDS can be chosen as the flexor activated inrestoring finger flexion, but one loses the hooking effect on an object achieved bydistal interphalangeal flexion.

With intrinsic reconstruction, especially in the presence of a concurrent PIP lag,the Stiles-Bunnell technique is a useful alternative. In this procedure, the FDS distalto the chiasm is transected, and the slips are woven into the radial lateral band toaddress intrinsic dysfunction by creating simultaneous MCP flexion and PIP exten-sion moments.

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SUMMARY

Restoration of hand function in the setting of traumatic tetraplegia is challeng-ing but extremely rewarding for the patient. Previous outcomes research has dem-onstrated significant gains in function, use, and subjective improvement followingsuch surgery. The key lies in proper patient selection, understanding what goals arereasonable and achievable, and individualizing the surgical plan to fit the patient.

References

1. Gonzalez E, Keith MW: Surgical management ofthe upper limb in tetraplegia. In Lee, Ostrander(eds): The Spinal Cord Injured Patient. DemosMedical Publishing, New York

2. Haque MA, Keith MW, Bednar M, et al: Clinicalresults of ECRB to FDP transfer through theinterosseous membrane to restore finger flexion,in Press

3. House JH, Shannon MA: Restoration of stronggrasp and lateral pinch in tetraplegia: A com-parison of two methods of thumb control ineach patient. J Hand Surg 10A:21–29, 1985

4. Keith MW, Lacey SH: Surgical rehabilitation ofthe tetraplegic upper extremity. Journal of Neu-rology and Rehabilitation 5:75–87, 1991

5. McCarthy CK, House JH, Van Heest A, et al:Intrinsic balancing in reconstruction of the tetra-plegic hand. J Hand Surg 22A:596–604, 1997

6. Peljovich AE, Kucera K, Gonzalez E, et al: Reha-bilitation of the hand and upper extremity intetraplegia. In Mackin EJ, Callahan AD, SkirvenT, et al (eds): Hunter, Mackin, Callaghan Reha-bilitation of the Hand and Upper Extremity, ed5. St. Louis, Mosby, 2002

7. Zancolli EA: Functional restoration of the upperlimb in traumatic quadriplex. In Structural andDynamic Basis of Hand Surgery, ed 2. Philadel-phia, JB Lippincott, 1979, pp 229–262


Allan Peljovich, MD, MPHThe Hand Treatment Center, PC

Suite 1020980 Johnson Ferry Road

Atlanta, GA 30342



Elbow Extension TendonTransferAnn E. Van Heest, MD

Elbow extension transfers provide significant improvement in upper extremityfunction for patients disabled by spinal cord injury. Active elbow extension assiststhe patient in reaching objects above shoulder levels and while lying down, im-proves the ability to drive safely, aids in wheelchair propulsion, permits pressurerelief, and facilitates independent transfer.1,6,25,26 Additionally, active elbow extensionprovides an antagonist to elbow flexion, which allows improved function after handreconstruction that uses the brachioradialis as a tendon transfer.2

Surgical reconstruction of the upper extremity in tetraplegia involves two prior-ities: (1) to establish elbow extension and (2) to establish grasp, pinch, and release.The level of spinal cord injury dictates the muscle deficiencies present and themuscle donors available.

A historical review reveals that surgical reconstruction for the upper extremityis relatively new for patients with spinal cord injury. Before the 1960s, the poorsurvival and poor prognosis after spinal cord injury precluded the need for upperextremity reconstruction. By the 1970s, the surgical management of upper extremityparalysis due to spinal cord injury using tendon transfers became more clarified,including its indications and goals and its differences from tendon transfers forother paralytic events, such as cerebral palsy, peripheral nerve injuries, or polio. Inthe twenty-first century, patients and physicians have become enthusiastic about thebenefits that can be achieved through a well-designed and well-executed surgicalreconstructive plan. In a survey of adult men with spinal cord injury, most wouldhave chosen to restore hand function before bowel, bladder, sexual function, orwalking ability.10



From the Department of Orthopedic Surgery, University of Minnesota; Twin Cities Shriner’s Hospital;and Gillette Children’s Specialtycare Hospital, Minneapolis, Minnesota

PATIENT ASSESSMENT

Patients are candidates for surgical reconstruction of the upper extremity usingtendon transfer surgery based on an assessment of the following elements:

1. Stabilization of return of motor function can be achieved following injury.Motor recovery after spinal cord injury commonly occurs up to 6 monthsafter injury, usually stabilizes by 1 year after injury, but can continue tooccur up to 2 years after injury.5 Reconstructive surgery of the upper extrem-ity is not recommended until the patient’s return of motor strength hasplateaued for at least 2 months; this period usually ranges from 6 to 12months after injury.

2. The patient is stable medically and psychologically. Medical treatment isnecessary for bowel and bladder function, blood pressure control, avoidanceof decubitus ulcers, and eradication of bladder infections. Psychologic stabil-ity implies that the patient has accepted his or her injury, has realisticexpectations of the surgery, and has the mental stamina to complete thepostoperative rehabilitation program.

3. The upper limb must: be free of severe contracture, have no grossly unstablejoints or significant spasticity, and be pain free.

Most spinal cord injury centers have immediate upper extremity range of mo-tion and splinting programs to prevent contracture; however, if a patient presentswith considerable contracture, the limb should be splinted and stretched beforesurgical reconstruction. For elbow tendon transfer, the elbow must be stable. Be-cause many spinal cord injury patients have had concomitant fractures or disloca-tions, a preoperative radiograph of the elbow (including the humerus and forearm)should be obtained. Spasticity can also compromise tendon transfer results, but thisproblem occurs primarily in the forearm and hand when assessing for grasp, pinch,and release reconstructions. Pain in the limb will not be alleviated with tendontransfer, a fact that should be addressed before intervention.

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MOTOR ASSESSMENT

In 1978 the First International Conference on Surgical Rehabilitation of theUpper Limb in Tetraplegia proposed a motor classification for patients with spinalcord injury. This system was modified in 1984 at the Second International Confer-ence and has now become the gold standard (Table 1).

ELBOW EXTENSION TENDON TRANSFER 99

Because of the variability in the number and strength of functioning muscles ateach cervical level, the International Classification requires precise identification ofthe number of muscles functioning below the elbow at grade 4 strength or greater.The system also recognizes the sensibility deficiencies associated with spinal cordinjury and requires classification of hand sensibility as “O” (ocular) for vision as theonly afferent versus “Cu” (cutaneous) if the patient has useful cutaneous sensibility(usually �10 cm two-point discrimination in the thumb). Unfortunately, the Interna-tional Classification does not assess elbow function for the patient’s overall ability toposition the hand in space. Such an assessment is a necessary part of combining thetwo goals of upper limb reconstruction in spinal cord injury, that is, elbow exten-sion and hand function. These goals need to be integrated as part of the overallupper extremity reconstructive plan.

Because of the segmental innervation of the upper extremity from the spinalcord, spinal cord injury produces a predictable pattern of paralysis depending on

Table 1. INTERNATIONAL CLASSIFICATION

Group Muscle Characteristics

0 None1 BR2 BR and ECRL3 BR, ECRL, ECRB4 BR, ECRL, ECRB, PT5 BR, ECRL, ECRB, PT, FCR6 BR, ECRL, ECRB, PT, FCR, finger extensors7 BR, ECRL, ECRB, PT, FCR, fingers and thumb extensors8 Group 7 muscles � partial digital flexors9 Lacks only intrinsics

carpi radialis longus; carpi radialis brevis;BR � brachioradialis; ECRL � extensor ECRB � extensor PT � pronatorteres; carpi radialis.FCR � flexor

Data from McDowell CL, Moberg AE, House JH: Second International Conference on surgical rehabilitation of theupper limb in tetraplegia. J Hand Surg 11A:604–608, 1986.

the level of the injury. As shown in Table 2, the biceps and deltoid are innervatedfrom the spinal cord at a higher level than the triceps. For the typical InternationalClassification level 4 patient, a biceps to triceps or posterior deltoid to tricepstendon transfer can be performed to provide active elbow extension.

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BICEPS TO TRICEPS TENDON TRANSFER

The biceps to triceps tendon transfer uses the biceps as a donor tendon. Theprocedure requires verification that the brachialis will remain as an active elbowflexor (such that elbow flexion will not be lost) and the supinator as an activeforearm supinator (such that forearm supination will not be lost). In reviewing thesegmental motor innervation from the spinal cord (Table 2), the biceps is noted tobe innervated above the same level as the brachialis and the supinator. If the patienthas intact and strong wrist extension, then biceps, brachialis, and supinator functionshould be strong. Additionally, the muscles can be palpated and observed, teachingthe patient to relax the biceps differentially, and still flex the elbow and supinate theforearm, verifying that loss of the donor muscle with the biceps to triceps transferwill not lead to a functional loss. Electromyography or peripheral nerve blocks canbe used to differentiate between biceps and supinator function in patients in whomit cannot be determined clinically.

The biceps to triceps tendon transfer can be performed using a medial12,24 or alateral7,9,21 routing technique. The lateral technique was first described by Frieden-berg in 1954. Two bilateral cases were reported, with complete range of motion inone and a 30-degree extensor lag in the other.

Significant functional improvements were noted. The lateral technique was alsoperformed by Zancolli,27 who reported six cases in 1979 and 13 cases in 198728 withno poor results. No loss of active elbow flexion was noted, although flexor strengthdiminished by 24%. In 1988 Ejeskar7 reported his results using the lateral routingtechnique for biceps to triceps transfer in five patients, including the first complica-tion of radial nerve palsy. The devastating complication of radial nerve palsy wassubsequently noted by others using this technique, and a medial routing is nowpreferred.

Table 2. SEGMENTAL INNERVATION OF UPPER EXTREMITY MUSCLES

Segment

C5 C6 C7 C8 T1

BicepsBrachialis

BrachioradialisSupinator

ECRLECRB

Pronator teresFCR

TricepsEDCEDQ

EIPEPL

Pronator quadratusFDPFPL

FCULumbricals

FDSThenarsAdductor

InterosseiHypothenar

carpi radialis longus; carpi radialis brevis; carpi radialis;ECRL � extensor ECRB � extensor FCR � flexor EDC �digitorum communis; digiti quinti; indicis proprius; pollicisextensor EDQ � extensor EIP � extensor EPL � extensor

longus; digitorum profundus; pollicis longus; carpi ulnaris; digito-FDP � flexor FPL � flexor FCU � flexor FDS � flexorrum superficialis.

Data from Zancolli E: Functional restoration of the upper limbe in traumatic quadriplegia. In Zancolli E (ed):Structural and Dynamic Bases of Hand Surgery, ed 2. Philadelphia, Lippincott, 1979, pp 274–280.

The operative technique preferred by the author uses medial routing. Thepatient is placed supine on the operating table with the limb draped free using asterile tourniquet. An anterior incision (Fig. 1) is used to harvest the biceps tendonfrom its insertion, starting along the medial border of the biceps at the midhumerallevel, extending obliquely across the antecubital fossa, and distally centering overthe biceps insertion on the radial tuberosity.


Figure 1. An anterior incision (heavy line) isused starting along the medial border of thebiceps at the midhumeral level, extendingobliquely across the antecubital fossa, and dis-tally centering over the biceps insertion on theradial tuberosity. (From Kuz J, Van Heest A,House J: Biceps–to–triceps transfer in tetra-plegic patients: report of the medial routingtechniques and follow-up of three cases. JHand Surg [Am] 24:165–170, 1999)

The musculocutaneous nerve is identified and protected as dissection is carrieddown onto the biceps muscle belly, freeing it from its fascial insertions medially andlaterally. As the biceps tendon is dissected down onto its insertions, the lacertusfibrosus is dissected off the forearm fascia and preserved as a second tail of tendonfor subsequent weaving. The biceps tendon is sharply dissected off its radial tuber-osity insertion and is tagged with a No. 5 nonabsorbable locked grasping suture.The lacertus fibrosus is tagged with a No. 0 nonabsorbable locked grasping suture,as shown in Figure 2.

102 VAN HEEST

BT

BA

Pronator teres

MCN

Figure 2. The bicipital tendon and lacertus fibrosus have beenharvested off their insertion and tagged, with careful protectionof the musculocutaneous nerve (MCN). BT � biceps tendon;BA � biceps aponeurosis. (From Kuz J, Van Heest A, HouseJ: Biceps–to–triceps transfer in tetraplegic patients: report ofthe medial routing techniques and follow-up of three cases. JHand Surg [Am] 24:165–170, 1999)

A second posterior incision is made over the distal one third of the triceps andlaterally past the tip of the olecranon (Fig. 3).


Figure 3. A second posterior incision (heavy line) ismade over the distal one third of the triceps and later-ally past the tip of the olecranon. The incision is basedlaterally to allow an adequate skin bridge from the an-terior incision, and to avoid a wound directly over theolecranon that may be subject to pressure and break-down. (From Kuz J, Van Heest A, House J: Biceps–to–triceps transfer in tetraplegic patients: report of themedial routing techniques and follow-up of three cases.J Hand Surg [Am] 24:165–170, 1999)

The incision is based laterally to allow an adequate skin bridge from the anteriorincision and to avoid a wound directly over the olecranon that may be subject topressure and breakdown. A subcutaneous tunnel is made medially from the anteriorwound to the posterior wound in a line of pull that would be straight and free forthe biceps transfer into the triceps insertion. The biceps tendon is passed superficialto the ulnar nerve from the anterior wound, into the posterior wound, and woveninto the triceps tendon. Length will usually allow two to three weaves with the endof the biceps tendon placed into a drill hole into the olecranon. A 4-mm unicorticaldrill hole is placed on the tip of the olecranon to receive the terminal end of thebiceps tendon. Two small drill holes are placed through the opposite cortex to allowthe No. 5 grasping suture to be passed out on Keith needles, tying the No. 5grasping suture over bone (Fig. 4).

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BA

BT

Bone tunnelentrance

Figure 4. The biceps tendon is woven two or three timesthrough the triceps tendon, delivering the distal end to thetip of the olecranon. A 4-mm unicortical drill hole is placedon the tip of the olecranon to receive the terminal end ofthe biceps tendon. Two small drill holes are placed throughthe opposite cortex to allow the No. 5 grasping suture to bepassed out on Keith needles, tying the No. 5 grasping su-ture over the bone. The transfer is tensioned to allow 90� ofelbow flexion. When proper tension has been achieved withtest sutures, a final suturing is done, including interweavingof the lacertus fibrosus through the biceps-to-triceps weavesin order to interlock the position. (From Kuz J, Van Heest A,House J: Biceps–to–triceps transfer in tetraplegic patients:report of the medial routing techniques and follow-up ofthree cases. J Hand Surg [Am] 24:165–170, 1999)

The transfer is tensioned to allow up to 90 degrees of elbow flexion. When propertension has been achieved with test sutures, a final suturing is done, includinginterweaving of the lacertus fibrosus through the biceps to triceps weaves to “inter-lock” the position. The incisions are then closed in layers.

Postoperatively, after surgery the elbow is casted in about 30 degrees of flexionfor 3 weeks. A flexion-blocking splint is then used on a full-time basis to preventelbow flexion beyond 45 degrees, which is progressively increased by 15 degreesper week. Initially, the biceps is trained to extend the elbow with gravity eliminatedusing a “powder board” (a horizontal board to eliminate gravity and “powdered”to eliminate friction). The medially routed biceps can be palpated along the medialhumerus to assess for control and allow patient feedback. If muscle control isachieved, strengthening against resistance begins at 8 to 10 weeks, with the patientwearing the splint for protection only (e.g., transfers). When sufficient strength andrange of motion have been achieved, use of the splint is discontinued. Excellentantigravity strength can be achieved, allowing significant improvement in transfers,driving, pressure relief, and use of the arms when supine (Fig. 5).


Figure 5. Medially routed biceps can be seen as the patientactively extends his elbow while lying supine. (From Kuz J, VanHeest A, House J: Biceps–to–triceps transfer in tetraplegic pa-tients: report of the medial routing techniques and follow-up ofthree cases. J Hand Surg [Am] 24:165–170, 1999)

POSTERIOR DELTOID TO TRICEPS TRANSFER

The posterior deltoid to triceps transfer uses the posterior third and the poste-rior half of the middle third of the deltoid muscle as a donor, with an interposi-tional tendon graft bridging to its insertion into the triceps tendon as shown inFigure 6A–C.

106 VAN HEEST

Figure 6. Posterior deltoid to triceps transfer. The posterior one third of the deltoid is harvested with itsperiosteal insertion off the deltoid tubercle, with careful protection of the axillary nerve and of the insertionof the middle and anterior deltoid insertions (A). Toe extensors are used as intercalary grafts withintertendinous weaves through both the deltoid insertion and the triceps tendon (B). The fascia lata is usedas intercalary graft with a large surface area sewn onto the deltoid tendon, and woven distally through thetriceps tendon and into bone tunnels in the olecranon (C).

The posterior deltoid is easily tested by supporting the limb in 90 degrees ofshoulder abduction and testing strength of shoulder extension while palpating theposterior deltoid, verifying bulk and selective control. Scapular stabilization andcontrol are necessary to maximize the effectiveness of the transfer.

The procedure is performed with the patient in a supine position with theshoulder forequarter draped free. A deltoid incision is made from the tip of theposterior corner of the acromion distally to the deltoid tubercle insertion. Dissectionalong the posterior border of the deltoid down to its insertion onto the humerus isdeveloped. The demarcation between the posterior and middle one third of thehumerus is then defined, usually, best delineated in the proximal aspect of themuscle. The axillary nerve courses about 5 cm distal to the acromion on the deepsurface of the deltoid. The axillary nerve is protected as the plane between the

posterior and the posterior half of the middle third of the deltoid is developeddown to the deltoid insertion. The insertion of the anterior deltoid is protected,whereas the posterior portion is harvested in a full-thickness manner including theperiosteal attachment. A separate triceps incision is made over the distal one thirdof the humerus with exposure of the triceps tendon. A subcutaneous tunnel is madeconnecting the two incisions for placement of the interpositional graft.

Several alternatives have been described for the interpositional graft bridgingthe posterior deltoid to the triceps. As originally suggested by Moberg,19 toe exten-sors from the second, third, and fourth toes allow at least three weaves at eachattachment site. Alternative graft materials include fascia lata,11 tibialis anterior,13,15

extensor carpi ulnaris,14 or Dacron.16 Additionally, a method described by Castro-Sierra and Lopez-Pita3 uses the central one third of the triceps as the graft. In thismethod, a 1-cm strip from the central one third of the triceps is harvested from itsperiosteal insertion in a retrograde manner, mobilizing it proximally to allow suffi-cient length for a woven end-to-end anastomosis with the posterior deltoid. Thegraft is tensioned with the shoulder in 30 to 40 degrees of abduction and noforward flexion so that the elbow can flex 30 to 60 degrees with moderate flexion.

Posterior deltoid to triceps transfers have been compromised by several fac-tors.22,23 The most common problem following this procedure has been elongation ofthe tendon graft.4,20 Friden and collegues8 used intraoperative stainless steel suturesin six patients to measure tendon elongation, which averaged 2.3 cm over a 2-yearperiod. They employed a postoperative armrest to maintain the elbow in 20 degreesof flexion and prevent shoulder adduction. Using this armrest in five subsequentpatients, tendon elongation using the same markers averaged 0.8 cm. Modificationof the postoperative rehabilitation plan to prevent tendon elongation may be neces-sary to maintain strength.

SUMMARY

At the First and Second International Conferences on surgical rehabilitation ofthe upper limb in tetraplegia,17,18 the consensus among surgeons was that, for thetetraplegia patient with paralysis of elbow extension, the first and “fundamentalintervention” for reconstruction of the limb is tendon transfer for elbow extension.This article describes the posterior deltoid to triceps transfer, which has been usedextensively over the last 30 years, and the medially routed biceps to triceps transfer,which has been described more recently.

References

1. Betz RR: Upper extremity management. In BetzRR, Mulcahy MJ (eds): The Child with a SpinalCord Injury: Symposium: Phoenix, Arizona,December 8–11, 1994. Rosemont, IL, AmericanAcademy of Orthopaedic Surgeons, 1996, pp373–458

2. Brys D, Waters RL: Effect of triceps functionon the brachioradialis transfer in quadriplegia.J Hand Surg 12A:237–239, 1987

3. Castro-Sierra A, Lopez-Pita A: A new surgicaltechnique to correct triceps paralysis. Hand 15:42–46, 1983

4. DeBenedetti M: Restoration of elbow extensionpower in the tetraplegic patient using the Mo-berg technique. J Hand Surg 4A:86–89, 1979

5. Ditunno JFJ, Stover SL, Freed MM: Motor andsensory recovery following incomplete tetraple-gia: A multi-center study. Arch Phys Med Re-habil 73:4431–4436, 1992

6. Dunkerley AL, Ashburn A, Stack EL: Deltoidtriceps transfer and functional independence ofpeople with tetraplegia. Spinal Cord 38:435–441, 2000

7. Ejeskar A: Upper limb surgical rehabilitation inhigh-level tetraplegia. Hand Clin 4:585–599,1988

8. Friden J, Ejeskar A, Dahlgren A, et al: Protec-tion of the deltoid to triceps tendon transferrepair. J Hand Surg 25A:144–149, 2000

9. Friedenberg ZB: Transposition of the bicepsbrachii for triceps weakness. J Bone Joint Surg36A:656–658, 1954

10. Hanson RW, Franklin MR: Sexual loss in rela-tion to other functional losses for spinal cordinjured males. Arch Phys Med Rehabil 57:291–293, 1976

11. Hentz VR, Brown M, Keoshian LA: Upperlimb reconstruction in quadriplegia: Functional


assessment and proposed treatment modifica-tions. J Hand Surg 8A:119–131, 1983

12. Kuz JE, Van Heest AE, House JH: Biceps-to-triceps transfer in tetraplegic patients: Reportof the medial routing technique and follow-upof three cases. J Hand Surg 24A:161–172, 1999

13. Lacey SH, Wilber RG, Peckham PH, et al: Theposterior deltoid to triceps transfer: A clinicaland biomechanical assessment. J Hand Surg11A:542–547, 1986

14. Lamb DW, Chan KM: Surgical reconstructionof the upper limb in traumatic tetraplegia: Areview of 41 patients. J Bone Joint Surg 65B:291–298, 1983

15. LeClerq S, McDowell CL: Fourth InternationalConference on surgical rehabilitation of the up-per limb in tetraplegia. Ann Chir Main MembSuper 10:258–260, 1991

16. McDowell CL, House JH: Tetraplegia. In GreenDP, Hotchkiss RN, Pederson WC (eds): Green’sOperative Hand Surgery, ed 4. New York,Churchill Livingstone, 1999

17. McDowell CL, Moberg AE, House JH: SecondInternational Conference on surgical rehabilita-tion of the upper limb in tetraplegia. J HandSurg 11A:604–608, 1986

18. McDowell CL, Moberg EA, Smith AG: First In-ternational Conference on surgical rehabilita-tion of the upper limb in tetraplegia. J HandSurg 4A:604–608, 1979

19. Moberg E: Surgical treatment for absent single-hand grip and elbow extension in quadriple-gia. J Bone Joint Surg 57A:196–206, 1975

20. Moberg EA, Lamb DW: Surgical rehabilitationof the upper limb in tetraplegia. Hand 12:209–213, 1980

21. Moberg E, McDowell CL, House JH: Third In-ternational Conference on surgical rehabilita-tion of the upper limb in tetraplegia (quadri-plegia). J Hand Surg 14A:1064–1066, 1989

22. Rabischong E, Benoit P, Benichou M, et al:Length-tension relationship of the posteriordeltoid to triceps transfer in C6 tetraplegic pa-tients. Paraplegia 31:33–39, 1993

23. Raczka R, Braun R, Waters RL: Posterior del-toid-to-triceps transfer in quadriplegia. ClinOrthop 187:163–167, 1984

24. Revol M, Briand E, Servant JM: Biceps-to-tri-ceps transfer in tetraplegia: The medial route. JHand Surg 24B:235–237, 1999

25. Richards RR: Soft Tissue Reconstruction in theUpper Extremity. New York, Churchill Living-stone, 1995

26. Smith RJ: Tendon Transfers of the Hand andForearm, ed 1. Boston, Little, Brown, 1987, p337

27. Zancolli E: Functional restoration of the upperlimbs in traumatic quadriplegia. In Zancolli E(ed): Structural and Dynamic Bases of HandSurgery, ed 2. Philadelphia, Lippincott, 1979,pp 229–262

28. Zancolli EA: Tetraplegia. In McFarlane RM(ed): Unsatisfactory Results in Hand Surgery.The Hand and Upper Limb. New York,Churchill Livingstone, 1987, pp 274–280


Ann E. Van Heest, MDDepartment of Orthopaedic Surgery

420 Delaware Street SEMMC 492

Minneapolis, MN 55455


108 VAN HEEST

Tendon Transfers DuringIndex Finger PollicizationGary M. Lourie, MD

HISTORICAL PERSPECTIVE

The creation of an opposable thumb through pollicization of the index fingerremains one of the most demanding yet rewarding procedures performed by thehand surgeon. Over 130 years ago, the challenge to reconstruct the deficient thumbbegan with Huguier,5 who reported on the deepening of the web space between adamaged index finger and partial thumb amputations. Significant efforts by Nicola-doni,12 Luksch,10 Joyce,6 and Guermonprez4 in the early 1900s advocated the princi-ple of distant pedicle flaps to reconstruct the deficient thumb. Before World War II,“osteoplastic” reconstruction provided the technique of staged pedicle coveragefollowed by corticocancellous grafting for bony support.

The overwhelming upper extremity trauma seen in World War II sparkedintense progress in hand reconstruction. In 1949 Gosset3 was one of the first sur-geons to recommend transfer of an index finger on its neurovascular pedicle toreconstruct the deficient hand. Littler9 and others refined the index finger neurovas-cular pedicle transfer in thumb reconstruction. These principles gradually foundtheir way into reconstructive schemes for the congenitally deprived thumb.



From the Department of Orthopaedics, Emory University, The Hand Treatment Center, Atlanta, Georgia

The misguided use of thalidomide in Europe accelerated the need for polliciza-tion as a sudden overwhelming population of children were born with congenitaldeficiencies of the upper and lower extremities. Buck-Gramcko1 published 100 casesof pollicization of the index finger. With significant contributions by Littler,9 Rior-dan,13 and others, this procedure has become the technique of choice in reconstruc-tion of congenital hypoplasia or complete absence of the thumb (Figs. 1A, and B).

110 LOURIE

Figure 1. A and B, Postoperative pollicization utilizing principles of Buck-Gramcko.

POLLICIZATION GOALS

Strict adherence to the principles of pollicization is vital and requires creationof a scar-free first web space, adequate skeletal shortening, preservation of theneurovascular pedicle, proper positioning, and intrinsic tendon transfer to motorand stabilize the created thumb. The goal is to provide a sensate, stable, opposablethumb for prehensile pinch and grasp. This article discusses the details of intrinsictendon transfer at the time of pollicization.

TECHNIQUE

The technique of tendon transfer in pollicization of the index finger has evolvedas the overall reconstructive method has advanced. Gosset’s initial procedure ofreconstruction following traumatic thumb loss recommended transfer of the extensorpollicis longus to the index lateral band and the extensor pollicis brevis to thecentral slip.3 Also primarily describing reconstruction following traumatic loss, Lit-tler recommended transfer of the first dorsal interossei to provide abduction andretention of the uninjured adductor pollicis to allow continued adduction of thecreated thumb. The first volar interossei was excised, the extensor pollicis longuswas sutured to the extensor digitorum communis to the index finger to provideextension, and the extensor indicis proprius was transferred to the ulnar lateralband.9

Zancolli’s technique provided abduction of the newly created thumb by releas-ing the origin of the first dorsal interossei and then reattaching it to the fascia ofthe hypothenar muscles on the ulnar border of the hand.14 Carroll2 advocatedtransfer of the first dorsal interossei and first volar interossei to the index middlephalanx to restore abduction and adduction, respectively, in the pollicized digit.All of these contributions added greatly to the success in motoring the pollicizeddigit, and additional refinements made by Kleinman,7,8 Manske,11 Riordan,13 andBuck-Gramcko1 have established the current method of choice in tendon transfer.

The success of each step in the pollicization is predicated on adequate comple-tion of the preceding task. Proper placement of the skin incision not only creates ascan-free first web space but also identifies the neurovascular bundles. Identificationof the palmar neurovasular structures helps to visualize the flexor tendons to theindex finger, along with the first dorsal interossei. The common digital artery andnerve to the index finger–middle web space helps to locate the intermetacarpalligament, which, when incised, allows one to visualize the first volar interossei. Thedorsal dissection is equally as important. Proper preservation of the dorsal veinsallows for unimpeded venous outflow of the pollicized digit and identifies theextensor digitorum communis and the extensor indicis proprius tendons. Successfulcompletion of the dissection over the proximal phalanx of the index finger exposesthe radial and ulnar lateral bands along with the intrinsic muscle contribution.

Each musculotendinous structure must be carefully preserved. After properskeletal shortening, these structures will be used for tendon transfer to stabilize andmotor the newly created thumb.

TENDON TRANSFERS DURING INDEX FINGER POLLICIZATION 111

The standard transfers adopted by Buck-Gramcko and refined by others includetransfer of the first dorsal interossei for abduction and transfer of the first volarinterossei for adduction. The extensor digitorum communis to the index fingerserves as the abductor pollicis longus; the extensor indicis proprius becomes theextensor pollicis longus1 (Fig. 2). Anatomic variation can exist, and modification ofthese transfers may be necessary.

112 LOURIE

Figure 2. Bony realignment and tendon transfer used to motor the created thumb. DIP �distal interphalangeal; PIP � proximal interphalangeal; MP � metacarpophalangeal; IP �interphalangeal; CM � carpometacarpal. (From Kleinman WB: Management of thumb hypopla-sia. Hand Clin 6:628–630, 1990.)

The insertions of the first dorsal interossei and the first volar interossei areincised at the level of the proximal phalanx. Careful dissection off the shaft of themetacarpal is necessary to preserve each muscle belly. With proper skeletal shorten-ing, each interossei can be transferred distally into the radial and ulnar lateral bandof the index digit, previously separated from the extrinsic extensor. The lateralbands are passed through the tendinous portion of the interossei and sutured backto allow for abduction (dorsal interossei) and adduction (volar interossei) (Fig. 3).


Figure 3. A and B, Tendon transfers. Radial and ulnar lateral bands routed throughtendinous portion of interossei to provide for abduction and adduction. 1 � volar interossei;2 � dorsal interossei; 3 � radial lateral bond; 4 � metacarpal; asterisk � neurovascularbundles. (From Kleinman WB, Strickland JW: Thumb reconstruction. In Green DP, Hotch-kiss RN (eds): Operative Hand Surgery, ed 3. New York, Churchill Livingstone, 1993,p 2068.)

The extensor digitorum communis will act as the abductor pollicis longus. Theextensor indicis proprius will become the extensor pollicis longus. Buck-Gramcko1

and Kleinman7,8 advocated shortening these two extensors a segment equal to thelength of metacarpal resected. Other surgeons disagree with shortening of the exten-sors and recommend leaving the tendons alone, which allows equilibration andretention of proper excursion over time. This technique has been supported byManske and McCarroll.11

There is no disagreement regarding the flexor tendons. They are not shortenedand will readjust quickly to the effective lengthening caused by the skeletal shorten-ing. The A1 pulley is released, which improves the vector for more efficient flexionof the newly created thumb.

The transferred index digit is stabilized anterior to the index base with two tothree transosseous sutures and, along with the intrinsic transfers, positions thethumb in 40 degrees of abduction, 15 degrees of extension, and initial pronation of160 degrees, which will lessen to a final resting posture of 120 degrees.

114 LOURIE

Figure 4. Stability provided by strategically placed sutures to create newcarpometacarpal joint. Abduction, 40�; extension, 15�; pronation, 120�.(From Kleinman WB: Management of thumb hypoplasia. Hand Clin 6:628–630, 1990.)

ALTERNATIVE TRANSFERS

Kleinman7,8 has found that, in as many as 50% of his cases, the first dorsalinterossei has been hypoplastic and in some cases absent. To allow for abduction inthe pollicized digit, he has recommended detaching and transferring the extensordigitorum communis more distal and volar on the index proximal phalanx (Fig. 5).


Figure 5. Kleinman’s technique to provide for abduction ofthumb in the face of an absent first dorsal interossei. Theextensor digitorum communis is redirected more distal andvolar on the index proximal phalanx. EPL (EIP) � extensorpollicis turns into extensor indicis proprius; AbPL (EDCII).(From Kleinman WB: Management of thumb hypoplasia.Hand Clin 6:628–630, 1990.)

If this maneuver proves inadequate, a staged procedure, such as an opponensplasty,can be performed. This procedure can be accomplished by using the abductor digitiquinti (Huber), the flexor digitorum superficialis of the ring finger, or other provendonors (Fig. 6).

116 LOURIE

Figure 6. Huber transfer. The abductor digiti quinti is mobilized and transfered across the palm toprovide for abduction.

Another technique to provide for adduction of the thumb has been describedby Kleinman.7,8 To simplify dissection about the proximal phalanx, he advocatedleaving the insertion of the first volar interossei intact, detaching the muscle bellyorigin, and transferring it to the periosteum of the third metacarpal. This maneuvernot only precludes the need for extensive dissection of the index proximal phalanxbut can minimize skin incisions dorsally, which protects venous outflow.

SUMMARY

Pollicization of an index finger is an exacting procedure that requires strictattention to detail. Integral to its success is the completion of tendon transfers tobalance, stabilize, and motor the newly created thumb. This article has described themethod of choice for tendon transfer.

ACKNOWLEDGMENTS

The author thanks William B. Kleinman, MD, not only for his guidance on work for this article butalso for his continued commitment to teaching in the field of hand surgery.

References

1. Buck-Gramcko D: Pollicization of the index fin-ger: Method and results in aplasia and hypo-plasia of the thumb. J Bone Joint Surg 53A:1605–1617, 1971

2. Carroll RE: Pollicization. In Green DP (ed): Op-erative Hand Surgery, ed 2. New York,Churchill Livingstone, 1988, pp 2263–2280

3. Gosset J: La pollicization de l’index (techniquechirurgicale). J Chir (Paris) 65:403, 1949

4. Guermonprez F, Derode G: Notes sur les Indi-cations de la Restauration du Ponce. Toulouse,Imprinerie Pinel, 1889

5. Huguier PC: Replacement du pouce par sonmetacarpien, par L’andgradissement du pre-mier espace interosseous: Arch Gen Med(Paris) 1:78, 1874

6. Joyce JL: A new operation for substitution of athumb. J Bone Joint Surg 5:499–504, 1917–1918

7. Kleinman WB: Management of thumb hypo-plasia. Hand Clin 4:617–641, 1990

8. Kleinman WB: Thumb reconstruction. In GreenDP (ed): Operative Hand Surgery. New York,Churchill Livingstone, 1992, pp 2043–2073.

9. Littler JW: On making a thumb: One hundredyears of surgical effort. J Hand Surg 1:35–51,1976

10. Luksch I: Uber eine nene methode zum ersatzdes verlorenen daumens. Verh Dtsch Ges Chir32:22, 1903

11. Manske PR, McCarroll HR Jr: Abductor digitiminimi opponensplasty in congenital radialdysplasia. J Hand Surg 3:552–559, 1978

12. Nicoladoni C: Daumen Plastik. Wien KleinWochenschr 10:663, 1897

13. Riordan DC: Congenital absence of the radius.J Bone Joint Surg 37A:1129–1140, 1976

14. Zancolli E: Transplantation of the index fingerin congenital absence of the thumb. J BoneJoint Surg 42A:658–660, 1960


Gary M. Lourie, MDThe Hand Treatment Center

980 Johnson Ferry RoadSuite 1020

Atlanta, GA 30342



Tendon Transfers for Thumb-in-Palm DeformityMichelle Gerwin Carlson, MD, and Catherine Brooks, OT, CHT

Cerebral palsy is a musculoskeletal deformity caused by a static perinatal braininjury. The extent of involvement of motor function and sensibility is variable.Motor involvement may take the form of spasticity, flaccidity, or athetosis (fluctuat-ing between spasticity and flaccidity). Frequently, spastic involvement of a muscle isaccompanied by flaccidity of its antagonist, often necessitating not only release ofthe spastic muscle but transfers to augment the antagonist.

Identification of upper limb dysfunction usually is noted by 1 year of age. Atthis point normal infant achieves a refined pinch with opposition of the thumb tipto the index finger. Infants with cerebral palsy do not reach this milestone, althoughthey may have a more primitive key pinch (thumb to side of index finger).



Work for this article was supported by a grant from the Tow Foundation and the Farbman Foundation.

From The Hospital for Special Surgery; and The Cornell University Medical College, New York, NewYork

The thumb is responsible for 40% of the function of the hand, and the thumb-in-palm deformity seen in cerebral palsy significantly affects the function of thehand. There are two important aspects of thumb-in-palm deformity: (1) the positionof the thumb in the palm during fisting, and (2) the inability to abduct the thumbwhen opening the hand. This inability to get the thumb out of the palm, with lossof the first web space, when trying to grasp an object is the true obstacle to use ofthe hand (Fig. 1).

120 CARLSON & BROOKS

Figure 1. Thumb adduction during grasp prevents this patient from beingable to hold a bottle. (Courtesy of Michelle Gerwin Carlson, MD, New York,New York)

Even in the setting of an adequate web space, abduction of the thumb is necessaryto allow for visualization of the thumb, especially if the forearm is pronated. Visual-ization is important to assist function in a sensory or functionally limited hand.Abduction of the thumb requires strength in the abducting muscles and relaxationof the adducting muscles. Additionally, the skin of the first web space must beredundant enough to allow abduction. The primary muscle responsible for abduc-tion of the thumb is the extensor pollicis brevis (EPB). This muscle abducts thethumb carpometacarpal (CMC) joint and the metacarpophalangeal (MP) joint. Theextensor pollicis longus (EPL) tendon is responsible for extension of the terminalphalanx in this abducted position. EPL firing alone will produce adduction of thethumb ray owing to its line of pull around Lister’s tubercle.7 For full thumb abduc-tion, the EPL and EPB must function. The abductor pollicis longus (APL), althoughnamed an abductor, has little thumb abduction function and actually is more re-sponsible for wrist radial deviation than thumb abduction.

The adducted posture of the thumb is caused by spasticity in the adductorpollicis and the first dorsal interosseous muscle. In most cases, release of thesemuscles is necessary to improve abduction of the thumb. Additionally, the skin ofthe first web space contracts over time and usually needs to be released. The flexorpollicis longus (FPL) muscle may also be spastic and should be checked for tight-ness.

EXAMINATION OF THE THUMB

Physical examination of the spastic upper extremity can be difficult. Despitetheir best efforts, patients often have difficulty cooperating with the examination.Often, it is helpful for the patient to perform the requested activities with bothextremities simultaneously to ensure that the patient understands the requestedtask.

There are four keys to evaluating the adducted deformity of the thumb: (1)spasticity of the flexors and adductors, (2) flaccidity of the extensors and abductors,(3) hypermobility of the MP joint, and (4) web space skin contracture. The flexorsand adductors are the FPL, the flexor pollicis brevis (FPB), the adductor pollicis,and the first dorsal interosseous. With use, the thumb metacarpal will assume anadducted position if there is spasticity of the adductor and first dorsal interosseous,and the MP joint will flex with spasticity of the FPB. These muscles can be palpatedin the first web space. FPL spasticity should be evaluated with the wrist at neutraland the thumb held radial to the index finger. If the interphalangeal (IP) joint of thethumb sits in a fixed flexed position, the FPL will need to be lengthened also.

Extension and abduction of the thumb are performed by the EPB and EPL.Often, the EPL will function well with the thumb in the adducted position, creatingIP joint hyperextension.

Passive or active MP joint hyperextension should be identified and addressed atthe time of surgery; otherwise, tendon transfers to abduct the thumb ray mayproduce unwanted MP joint hyperextension. Additionally, the skin in the first webspace may similarly become contracted and need to be addressed at the time ofsurgical correction.

OPERATIVE PROCEDURES

Operative treatment is directed at the four causes of deformity previouslydescribed. Spasticity of the thumb intrinsics is present in almost all thumb-in-palmdeformities. Attention should primarily be addressed to the adductor pollicis andfirst dorsal interosseous muscles; less frequently, the FPB is involved. Release of theadductor can be performed at its origin1,4–6,8,11,13 or its insertion.2,4–6,8,12 The FPLshould be lengthened or released if it is spastic.

Augmentation of thumb abduction has been performed using a variety of ten-don transfers, including brachioradialis,9 palmaris longus,6 flexor carpi radialis andflexor carpi ulnaris,6,11 extensor carpi radialis longus and brevis,8 and flexor digito-rum superficialis.1,3 Rerouting of the EPL, FPL abductorplasty, and APL and EPBimbrication also have been described.1,3,7–10 Rerouting of the EPL allows the tendonto become a thumb abductor instead of an adductor and extensor. Of these proce-dures, the author has found rerouting of the EPL tendon, or a brachioradialis toEPB transfer to be the most effective. If the EPL is strong and if good extension ofthe IP joint is possible with the wrist in netural, EPL rerouting is performed asdescribed in the following sections. If the EPL is not strong, brachioradialis to EPBtransfer is performed. One must examine the thumb MP joint prior to transfer;otherwise, the transfer may produce unwanted MP joint hyperextension. A capsulo-desis of the MP joint can be performed at the time of the procedure if necessary.

TENDON TRANSFERS FOR THUMB-IN-PALM DEFORMITY 121

Adductor Release and MP Joint Capsulodesis

Adductor Release

Release of the adductor is performed at its insertion on the ulnar thumb sesa-moid and metacarpal through the first web space. Through a double opposing Z-plasty of the first web space (Fig. 2), the adductor tendon and muscle are releasedfrom their insertion on the metacarpal, extensor hood, and sesamoid, and reattachedproximally to periosteum in the midshaft of the metacarpal with a 4-0 nonabsorb-able braided suture (Fig. 3).


Figure 2. The first web space is opposed through a double opposingZ-plasty incision. This allows for excellent visualization of the adductorand first dorsal interosseous and improvement of the skin contracturein the web space. (Courtesy of Michelle Gerwin Carlson, MD, NewYork, New York)

Figure 3. The adductor is taken down from its insertion on thethumb metacarpal and sesamoid. (Courtesy of Michelle GerwinCarlson, MD, New York, New York)

Subperiosteal release of the first dorsal interosseous from the thumb metacarpal isperformed proximally. Care is taken to avoid injury to the princeps pollicis artery asit ascends from the base of the web space along the ulnar border of the firstmetacarpal. After release of the first dorsal interosseous, the FPL tendon should bechecked with the wrist in a neutral position. If full abduction and extension of thethumb is not possible, the FPL tendon will need to be released, usually by fractionallengthening.

MP Joint Capsulodesis

If there is passive hyperextension of the thumb MP joint of more than 20degrees, a capsulodesis can be performed through this incision. The volar capsule istaken down from its origin on the metacarpal along its ulnar side, leaving itattached to the ulnar sesamoid. The capsule is then pulled down securely andsutured more proximally to the periosteum of the first metacarpal. Performing thiscapsular advancement only on the ulnar side of the MP joint is secure enough toprevent MP joint hyperextension after tendon transfer. The MP joint should be heldin 10 degrees of flexion for 4 weeks after surgery with a 0.035-inch Kirschner wire.


Abduction Augmentation

Abduction augmentation is primarily accomplished by one of two procedures.If the EPL can fully extend the thumb IP joint with the wrist in neutral (either heldactively or passively), it is rerouted to become an abductor. If the EPL is notfunctional with the wrist in neutral, the brachioradialis is transferred to the EPB orrerouted EPL.

EPL Rerouting

Through a transverse incision over the third dorsal compartment, proximal toLister’s tubercle, the retinaculum of the third dorsal compartment is incised. TheEPL is removed from its tunnel and allowed to migrate radially (Fig. 4A and B).


Figure 4. The third dorsal compartment is opened over the extensor pollicis longus tendon toallow it to migrate radially. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

Through a second transverse incision just distal to the first dorsal compartment, adistally based slip of APL is harvested (Fig. 5).


Figure 5. A and B, The most volar slip of the abductor pollicis longus (APL) tendon is transecteddistally to create a radial pulley for the extensor pollicis longus (EPL) tendon. EPB � extensorpollicis brevis. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

A radial pulley is created with the abductor slip as it is wrapped around the EPLtendon, pulling it radially. The abductor slip is sutured to the most volar aspectof the retinaculum of the first dorsal compartment, or radial periosteum (Fig. 6Aand B).


Figure 6. A and B, The extensor pollicis longus (EPL) tendon is rerouted radially and volarlythrough the abductor pollicis longus (APL) pulley. (Courtesy of Michelle Gerwin Carlson, MD, NewYork, New York)

The adequacy of the radial pulley is checked intraoperatively by traction on the EPLat the wrist, producing thumb abduction instead of extension and adduction (Fig.7A and B).


Figure 7. A, Traction on the EPL in its anatomic position produces extension and adduc-tion of the thumb. B, After rerouting of the EPL, traction produces abduction of the thumb.(Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

If hyperextension of the MP joint is noted preoperatively, a capsulodesis of the MPjoint is concurrently performed. The first web space is held in abduction with apercutaneous 0.045-inch Kirschner wire, and a nonremovable thumb spica splint isapplied for 4 weeks.

Postoperatively at 4 weeks, the Kirschner wire is removed, the thumb is placedin a removable thumb spica splint, and therapy is begun. Thumb position in thesplint is midante/retropulsion and not pure opposition in an attempt to encouragemore radial abduction. The splint is worn at all times with the exception of bathingand therapy. Silicone scar management is placed in the web space of the splint fornighttime wear. Scar massage is recommended for 3 to 5 minutes daily for 6 weeks.

Therapy lasting 3 months postoperatively is recommended. The initial postoper-ative therapy goal is an active attempt by the patient to inhibit any thumb adduc-tion during the performance of proximal exercises. This action is assessed andachieved before active EPL/EPB firing is attempted, usually within 2 weeks aftersplint removal. Therapy then progresses to include light cylindrical grasp and lat-eral or opposed light pinch of 1-inch size objects, with a focus on the use ofbalanced palmar and radial abduction. Squeezing and tight pinch are avoided forthe first 3 weeks of therapy to avoid the thumb adduction pattern. If the patientcannot inhibit involuntary adduction, squeezing and tight grasp are limited in thetherapy program but included as needed for activities of daily living. Three weeksafter cast removal, activities of daily living are encouraged, including tasks withpinch and grasp. Activities of daily living are then progressed as tolerated, and thesplint is discontinued 4 weeks after cast removal.

Brachioradialis to EPB Transfer

A 2-cm transverse incision is made 3 cm proximal to the tip of the radialstyloid. The subcutaneous tissues are spread bluntly with care taken to avoid injuryto the superficial branches of the radial nerve. The brachioradialis tendon is identi-fied and released from its insertion on the distal radius as distal as possible. TheEPB tendon is identified in the distal aspect of the wound as the more ulnar of thetendons in the first dorsal compartment. Its identity can be confirmed with retrac-tion of the two tendons. The APL will only abduct the first metacarpal at the CMCjoint, with no effect at the MP joint. The EPB tendon will extend the MP joint. TheEPB tends to be a small tendon. If it is too small, the rerouted EPL describedpreviously can be used instead. The EPB is transected as proximal as possible, andthe tendon is woven into the brachioradialis tendon in a Pulvertaft fashion (Fig. 8Aand B).



Figure 8. A and B, The brachioradialis tendon is transected distally and the EPB proximally and woven ina Pulvertaft fashion into the brachioradialis. (Courtesy of Michelle Gerwin Carlson, MD, New York, NewYork)

Maximum tension is placed on the two tendons with the wrist in neutral during theweave. The tension can be checked after repair. Wrist dorsiflexion should allow thethumb to rest on the radial aspect of the index finger, and wrist volar flexionshould abduct the thumb.

The postoperative regimen is the same as for EPL rerouting.

SUMMARY

Treatment of the thumb-in-palm disorder usually requires release of the patho-logic adduction and augmentation of thumb abduction. Release of the thumb adduc-tor and first dorsal interosseous along with EPL rerouting or brachioradialis to EPBtransfer reliably provide excellent results in improvement of grasp of the hand (Fig.9A and B).


Figure 9. Release of the adductor and first dorsal interosseous andrerouting of the EPL. A, Preoperatively attempted abduction of thethumb produces adduction of the first metacarpal. B, Postoperativelya 60� web space is maintained actively. (Courtesy of Michelle Ger-win Carlson, MD, New York, New York)

References

1. Gelberman RH: Cerebral palsy. In GelbermanRH (ed): Operative Nerve Repair and Recon-struction. Philadelphia, JB Lippincott, 1991, pp1455–1475

2. Goldner JL: Reconstructive surgery of the handin cerebral palsy and spastic paralysis resultingfrom injury to the spinal cord. J Bone JointSurg 37A: 1141–1154, 1955

3. Goldner JL: Upper extremity tendon transfersin cerebral palsy. Orthop Clin North Am 5:389–414, 1974

4. Goldner JL, Koman LA, Gelberman RH, et al:Arthrodesis of the metacarpophalangeal jointof the thumb in children and adults: Adjunc-tive treatment of thumb-in-palm deformity incerebral palsy. Clin Orthop 253:75–89, 1990

5. Hoffer MM, Perry J, Garcia M, et al: Adduc-tion contracture of the thumb in cerebral palsy:A preoperative electromyographic study. JBone Joint Surg 65A:755–759, 1983

6. House JH, Gwathmey FW, Fidler MO: A dy-namic approach to the thumb-in-palm defor-mity in cerebral palsy: Evaluation and resultsin fifty-six patients. J Bone Joint Surg 63A:216–225, 1981

7. Manske PR: Cerebral palsy of the upper ex-tremity. Hand Clin 6:697–709, 1990

8. Matev I: Surgical treatment of spastic “thumb-in-palm” deformity. J Bone Joint Surg 45B:703–708, 1963

9. McCue FC, Honner R, Chapman WC: Transferof the brachioradialis for hands deformed bycerebral palsy. J Bone Joint Surg 52A:1171–1180, 1970

10. Sakellarides HT, Matza RA, Mital MA: Thesurgical treatment of the different types of“thumb-in palm” deformities in cerebral palsy.J Dev Med Child Neurol 21:116, 1979

11. Swanson AB: Surgery of the hand in cerebralpalsy. Surg Clin North Am 44:1061–1070, 1964

12. Szabo RM, Gelberman RH: Operative treat-ment of cerebral palsy. Hand Clin 1:525–543,1985

13. Zancolli EA, Goldner JL, Swanson AB: Surgeryof the spastic hand in cerebral palsy: Report ofthe Committee on Spastic Hand Evaluation. JHand Surg 8A:766–772, 1983


Michelle Gerwin Carlson, MDHospital for Special Surgery

523 East 72nd StreetNew York, NY 10021


Tendon Transfer for WristFlexion Deformity in CerebralPalsyThomas W. Wright, MD

Patients with cerebral palsy commonly position their wrist in a palmar-flexed,ulnar-deviated, and pronated position (Fig. 1). This position is assumed because ofincreased flexor tone of the wrist and finger flexors when compared with theextensors. Grip is markedly weakened by a wrist in a significant palmar-flexedposition. This deformity may become a fixed contracture if the patient has poormotor control and if no program of passive stretching is initiated. This articlefocuses on the pathophysiology of cerebral palsy–associated wrist flexion deformity,treatment rationale, surgical technique, rehabilitation, complications, and results.The treatment of wrist pronation contracture or the multiple other procedures per-formed for patients with cerebral palsy are not discussed.



From the Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida

Figure 1. A, The typical position of the wrist in a functional patient with cerebral palsyshows a palmar flexed, ulnar deviated, and pronated position. B and C, The Pulvertaftweave tenorrhaphy (long arrow) and the transferred FCU (asterisk). D, The wrist is nearneutral when it is tested against gravity.

134 WRIGHT

Multiple tendon transfers have been proposed for treatment of the wrist flexiondeformity in functional patients with cerebral palsy and other brain injury patients.The transfers proposed include flexor carpi ulnaris (FCU) to extensor carpi radialisbrevis (ECRB) (i.e., the Green transfer),3 FCU to extensor digitorum communis(EDC), pronator teres to ECRB,2 extensor carpi ulnaris (ECU) to ECRB, and brachio-radialis to ECRB.4

The normal pattern of grasp and release is mandatory for a functional hand. Awrist in considerable palmar flexion has inadequate grasp because the finger flexorsare at a mechanical disadvantage from relative shortening. The finger flexors aregenerally strong in patients with cerebral palsy, but, with the wrist in substantialflexion, the fingers will appear to be weak, and the patient will have difficultyholding onto objects. If the wrist is corrected manually or with the use of a splint tothe neutral position, finger flexion will be strong, and, often, the patient will lose hisor her ability to release an object (inadequate release pattern). This problem ofinadequate release is as much a functional concern as weak grasp and must beaddressed at the same time the wrist flexion deformity is corrected. Strategies fortreating this problem are presented herein.

Patients with the most severe deformity may also have a fixed wrist flexioncontracture and not just a deformity secondary to a dynamic imbalance of the wristflexors and finger flexors. The FCU is the largest contributor to the flexed andulnar-deviated wrist position. This fixed deformity is seen predominantly in theseverely involved patient with cerebral palsy. Slow passive stretch with correctionto neutral may not be possible in these patients. Higher-functioning patients gener-ally have a passively correctable deformity that can be positioned in at least neutral.

Two general groups of patients with cerebral palsy are treated for wrist flexiondeformities. One group includes high-functioning patients. The other group containslow-functioning, severely involved patients with cerebral palsy. Treatment of thesetwo groups of patients is different with respect to surgical decision making. Muchof the treatment described herein can also be applied to patients with other types ofbrain injuries and wrist flexion deformities.

EVALUATION

The evaluation of the patient with a wrist flexion deformity secondary tocerebral palsy must take into account the entire patient and not just the deformity.Patients selected for a functional-type tendon transfer should have good cognitiveskills, fair limb placement, and some cortical sensation. The presence of athetosis isnot a contraindication to tendon transfer, but the complication rate may be higher.8Procedures for the severely involved patient with cerebral palsy are entirely differ-ent and are directed at hygiene rather than function.

On examination, the overall posture of the wrist is noted. The medical recordshould include a notation of whether the deformity is passively correctable. Whenthe wrist position is corrected between 20 degrees of palmar flexion and neutral, arethe finger extensors strong enough to extend the fingers (Zancolli type 1)?10 AZancolli type 2 patient cannot extend the metacarpophalangeal (MP) joints with thewrist in neutral but can actively extend the joints with the wrist in greater than 20degrees of palmar flexion. If the MP joints cannot be actively extended in any wristposition, a transfer directed at strengthening the finger extensors may be indicated(Zancolli type 3).10

Radiographs should be obtained at the time of consideration of definitive treat-ment of the wrist to assess for any bony deformity. An association between cerebralpalsy and Kienbock disease has been reported.

Dynamic electromyography is time consuming, difficult in the young child, andnot performed in many centers but may provide valuable information as to thephasic pattern of a particular muscle. In the author’s original evaluation, different

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY 135

patterns of spasticity were found from patient to patient, but, most consistently, theFCU and brachioradialis were active through grasp and release. It is not knownwhether their phasic activity would change with transfer, but this effect is unlikely.

Treatment Plan—Functional Patients

Functional patients who have cerebral palsy with wrist flexion deformity aregood candidates for tendon transfer. In most cases, this transfer must be combinedwith a need for weakening the finger flexors and sometimes the remaining wristflexors. If a transfer is performed without addressing the flexor side, frequently, thepatient will have an inadequate release pattern. In patients with Zancolli type 1deformity (active MP joint extension with the wrist in less than 20 degrees offlexion), weakening of the finger and wrist flexors by fractional lengthening may beall that is required; these cases are the exception. Most functional patients withcerebral palsy have deformities in the category of Zancolli type 2 (active MP jointextension with the wrist in greater than 20 degrees of flexion). These patients aretreated with an FCU to ECRB transfer in addition to fractional lengthening of thefinger flexors and wrist flexors. The FCU transfer has a second beneficial effect ofincreasing supination when routed along the ulnar border of the forearm.1 In Zan-colli type 3 deformity (no active MP joint extension at any position of the wrist), theFCU is transferred to the EDC, and the wrist and finger flexors undergo fractionallengthening.

An alternative transfer for weak wrist extension is the pronator teres trans-ferred to the ECRB. In the author’s opinion, this procedure is a distant secondchoice to the FCU transfer because of the greater strength of the tenorrhaphy,removal of a considerable deforming force, and the supination effect of the FCUtransfer.

136 WRIGHT

Figure 2. A, Wrist flexion deformity in a patient with severe cerebral palsy. B and C, Thepatient underwent a profundus to superficialis transfer, Z-lengthening of flexor carpi radi-alis and flexor carpi ulnaris, and a proximal row carpectomy. Note the markedly improvedwrist and finger posture in this patient postoperatively.


Treatment Plan—Low/Nonfunctional Patients

The treatment of wrist flexion deformities in patients with a low level offunction is directed at hygiene concerns (Fig. 2).

Although most of these patients require no surgery, some patients with severe wristflexion deformities that are fixed contractures may require operation for hygienereasons. The fingers may be positioned in a clenched fist, creating concerns aboutpalm hygiene (this concern is actually less common if the wrist flexion contractureis severe). If the wrist deformity is corrected, the finger in palm position will beexacerbated unless the procedure is combined with a superficialis to profundustendon transfer. Another option is proximal row carpectomy, which obtains a rela-tive lengthening of the flexors of approximately 1 cm. The wrist fixed contracture iscorrected by the proximal row carpectomy, although a wrist fusion may still berequired near skeletal maturity. Wrist flexors are tenotomized or Z-lengthened whena superficialis to profundus transfer is performed (Fig. 3).

138 WRIGHT

Flexor digitorumsuperficialis

Flexor digitorumprofundus tendons

Ulna

Radius

Figure 3. A flexor digitorum superficialis transfer to the flexor digitorum profundus. (From Hisey MS,Keenan MA: Orthopaedic management of upper extremity dysfunction following stroke or brain injury. InGreen DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed. 4. New York,Churchill Livingstone, 1999, pp 287–325; with permission.)

In the author’s experience, in patients requiring surgery for hygiene issues, a proxi-mal row carpectomy combined with a wrist fusion is a more predictable procedurethan a tendon transfer (see Fig. 2B and C).

SURGICAL TECHNIQUE IN FUNCTIONAL PATIENTS

Flexor Carpi Ulnaris to Extensor Carpi Radialis Brevis

The FCU to ECRB transfer is performed in functional patients with cerebralpalsy who have a passively correctable deformity and some active MP joint exten-sion with the wrist positioned in greater than 20 degrees of flexion. These Zancollitype 2 patients are the most common group seen. The FCU to ECRB transfer isperformed under general anesthesia with the arm placed on an arm table. Spasticelbow contractures improve dramatically under anesthesia, making positioning eas-ier. The procedure is performed with an upper arm tourniquet. A long longitudinalincision is started 1 mm proximal to the proximal wrist flexion crease and continuedin a proximal direction over the FCU for the distal one third to one half of theforearm (Fig. 4).


Figure 4. The procedure is performed with an upper arm tourniquet. A long longitudinal incisionis started 1 mm proximal to the proximal wrist flexion crease and continues in a proximaldirection over the flexor carpi ulnaris for the distal one third to one half of the forearm. Extensiveinsertion of the flexor carpi ulnaris (FCU) muscle on surronding fascia. It is mandatory to makethis long incision and dissect the FCU to the proximal edge of the incision. This dissectionobtains the correct line of pull and adequate excursion of the transferred tendon.

The distal FCU tendon is isolated and tenotomized just proximal to the pisiforminsertion. The ulnar neurovascular bundle is encountered radial to the tendon at thewrist level and protected. The dissection is continued in a proximal direction,releasing the FCU muscle and tendon from the fascia and the periosteum of theulna. Because of the extensive insertion of the FCU muscle on surrounding fascia, itis mandatory to make this long incision and dissect the FCU to the proximal edgeof the incision. This dissection obtains the correct line of pull and adequate excur-sion of the transferred tendon.

A second 4-cm oblique incision is made proximal to the extensor retinaculumover the ECRB tendon (Fig. 5).

140 WRIGHT

Figure 5. A second 4-cm oblique incision is then made proximal to the extensor retinaculumover the extensor carpi radialis brevis tendon.

Figure 6. Strong Pulvertaft weave tenorrhaphy. (From Gelberman RH: Cerebral palsy. In Gelber-man RH (ed): Operative Nerve Repair (vol. 2). Philadelphia, JB Lippincott, 1991, pp 1455–1475,with permission.)

The ECRB is ulnar to the extensor carpi radialis longus (ECRL) and is carefullyseparated. The ECRB is a better wrist extender than the ECRL, which is a betterradial deviator. A large window is created in the ulnar forearm fascia adjacent tothe FCU at the proximal edge of the ulnar wound. The FCU is then transferredsubcutaneously using a Bunnell tendon passer. Using a Dieter-Buck Gramco tendonpasser, a Pulvertaft weave is created by passing the FCU through the ECRB (Fig. 6).

Appropriate tensioning of the transfer is performed by placing the wrist in maxi-mum extension, retracting the ECRB proximally, pulling distally on the FCU to itsfull length, and then backing off 1 to 2 mm before passing the suture. A 3-0nonabsorbable suture is passed through both tendons at the tenorrhaphy site in ahorizontal mattress fashion. This preliminary tensioning is tested by holding thewrist horizontal and noting whether the transfer will hold the wrist in near neutralagainst gravity. If the wrist flexes greater than 20 degrees, the transfer is nottensioned tight enough and must be revised. If the wrist is held in dorsiflexion, it isovertensioned and must be adjusted appropriately. Although it is possible to over-tension the transfer and create a dorsiflexed wrist deformity, in the author’s experi-ence, overtension is difficult to achieve. Once the correct tension is obtained, anadditional one or two passes of the FCU tendon through the ECRB are performed,and the tendon is sutured in place. Excess FCU tendon is then cut and removed.Figure 7A shows the volar forearm and the approach for harvesting the FCU. Figure7B shows the dorsum of the forearm and the Pulvertaft weave of the FCU andECRB.


FDS

FDP

FCU

EPL

EPB

ECRB

ECRL

APBL

B

A

Ulnara. and n.

Figure 7. Flexor carpi ulnaris to carpi radialis brevis (ECRB) transfer. A, Volar forearm andthe approach for harvesting the FCU. FDP � flexor digitorium profundus, FDS � flexordigitorum superficilias. B, Dorsum of the forearm and the Pulvertaft weave of the FCU andECRB. EPL � extensor pollicus longus, EPB � extensor pollicus brevis, ECRB � extensorcarpi radialis brevis, ECRL � extensor carpi radialis longus, APBL � abductor pollicusbrevis. (From Gelberman RH: Cerebral palsy. In Gelberman RH (ed): Operative NerveRepair (vol. 2). Philadelphia, JB Lippincott, 1991, pp 1455–1475, with permission.)

142 WRIGHT

Alternatively, the FCU may be transferred through the interosseous membrane,but this route is not recommended. Such a transfer is at greater risk for adhesionformation. This route will also lose the beneficial supination effect that occurs whenthe tendon is transferred around the ulnar border of the forearm.

The FCU to ECRB tendon transfer is almost always performed with a concomi-tant fractional lengthening of the flexors.

Flexor Carpi Ulnaris to Extensor Digitorum CommunisTendon Transfer

The FCU transfer to the EDC tendons (Fig. 8) is performed when there is noactive extension of the MP joints in any wrist position (Zancolli type 3).


EDC

FCU

Figure 8. Flexor carpi ulnaristo extensor digitorum commu-nis transfer. (From Gelber-man RH: Cerebral palsy. InGelberman RH: OperativeNerve Repair (vol. 2). Phila-delphia, JB Lippincott, 1991,pp 1455–1475, with permis-sion.)

The FCU is transferred in a similar method as previously described, but is passedthrough all four EDC tendons instead of the ECRB tendon. The dorsal incision is 4to 5 cm proximal to the extensor retinaculum and oblique in orientation. The EDCtendons are exposed and sutured side-to-side with the MP joints in the normalcascade. A Pulvertaft weave is created by passing the FCU through each of the EDCtendons with the EDC tendons pulled proximally, the wrist in maximum extension,and the FCU pulled out to full length and then allowed to shorten 1 to 2 mm.Preliminary suture with a nonabsorbable 3-0 material is performed. The appropriatetension is checked against gravity, which should not allow the wrist to flex beyond20 degrees with the MP joints at 0 degrees. Once the tension is appropriate, asecond pass of the FCU is made through each of the EDC tendons and sutured inplace. Excess FCU is removed. Care must be taken to ensure this tenorrhaphy doesnot bind on the extensor retinaculum. If the transfer impinges on the retinaculum,the proximal half of the retinaculum can be released. Alternatively, the tenorrhaphymay be moved more proximally.

In both of the described FCU transfers, there is almost always a need to weakenthe finger flexors and sometimes the FCR as well. A third volar longitudinal inci-sion about 4 to 6 cm in length is made over the middle third of the forearm.Alternatively, the proximal aspect of the incision for harvesting the FCU may becurved in a radial direction, allowing access to the myotendinous junctions of thefinger flexors. The palmaris longus is encountered and the underlying median nervegently retracted. The palmaris longus tendon is incised and retracted. The myoten-dinous junctions of all the finger flexors are exposed. Each finger flexor tendon thatis tight with the wrist in neutral is lengthened fractionally by carefully cuttingthrough the tendon and not disturbing the surrounding muscle (Fig. 9). A fractionallengthening gains about 3 to 5 mm of length. In the patient who has a severelycontracted finger flexor, a second more proximal cut may be performed to gainadditional length. Occasionally, the FCR may require fractional lengthening, butcare should be taken not to overlengthen. If the FCR is lengthened too much, thewrist may become unbalanced, and a reversed dorsiflexion deformity may be cre-ated. Fractional lengthening of the finger and wrist flexors should be performedbefore the wrist or finger extension transfer so as to not disrupt the tenorrhaphysite.

144 WRIGHT

Ulnarneurovasacularbundle

Ulnarneurovasacularbundle

FCR

FCR

FDS

FDSFCU

FCU

B

A

C

Figure 9. A fractional lengthening. (From Gerwin M: Cerebral palsy. In Green DP,Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York,Churchill Livingstone, 1999, pp 287–325.)


OTHER TRANSFER OPTIONS

In a few patients, the ECU can be transferred to the ECRB. The specific patientwho might benefit from this transfer has a good grasp and release pattern and fallsinto palmar flexion and ulnar deviation during grasp. This patient may also benefitfrom an ECU transfer to the ECRB along with a fractional lengthening of the FCU.

The surgical technique for ECU transfer consists of a dorsal oblique incisionabout 8 cm in length. Through this incision, the ECU and the ECRB can be exposed.The ECU is tenotomized distal to the retinaculum. It is then rerouted to the ECRBwhere a tenorrhaphy is performed with a Pulvertaft weave. A fractional lengtheningof the wrist flexors and possibly the finger flexors may be required.

The pronator teres transfer to the ECRB (Fig. 10) has been reported to providewrist extension with good functional results in two thirds of the transfers.2 Thepronator transfer has the advantage of removing one deforming force, the pronator,and applying this force to the ECRB. The disadvantage is that, unlike in previouslydescribed FCU transfers, it does not alleviate the deforming ulnar deviation force atthe wrist. Also, the strength of the tenorrhaphy site is less than in the FCU to ECRBtransfer.

146 WRIGHT

EDC

ABPL

ABPL

ECRL

ECRL

ECRL

PT

ECRB

ECRB

ECRB

Brachioradialis

SupinatorPronator teresECRB and ECRL

A

B

C

D

Figure 10. Pronator teres time to extensor carpi radialis brevis transfer. (From GelbermanRH: Cerebral palsy. In Gelberman RH (ed): Operative Nerve Repair (vol. 2). Philadelphia, JBLippincott, 1991, pp 1455–1475.)

The technique for pronator teres transfer to the ECRB begins with a 6-cmincision over the pronator insertion in the middle third of the radial forearm. Thesuperficial radial nerve is exposed and gently retracted and the pronator insertionexposed. The pronator teres is elevated along with a strip of periosteum so as tolengthen the tendon. The muscle is circumferentially mobilized in a proximal direc-tion. The tendon with its attached periosteum is then passed superficial to theECRB, and a tenorrhaphy is performed using a Pulvertaft weave. Postoperativerehabilitation is essentially the same as described in the next section.

The brachioradialis has been used as a transfer for wrist extension with goodresults.5 The disadvantage of this transfer is that the dissection to mobilize thebrachioradialis and obtain the appropriate amount of excursion is extensive. Thebrachioradialis is a powerful muscle that is often severely spastic in patients withcerebral palsy. If this transfer is overly tensioned it can create an opposite wristextension deformity. Currently, this transfer is used rarely for a wrist deformitysecondary to cerebral palsy.

The surgical technique for brachioradialis transfer to ECRB consists of an inci-sion along the entire length of the radial forearm. The radial sensory nerve isencountered deep to the brachioradialis and is protected. The brachioradialis iselevated from its insertion on the radial aspect of the distal radius. It is thenmobilized in a proximal direction, past its musculotendinous junction, circumferen-tially around its muscle belly. The fascial attachments must be incised to obtain anysignificant excursion. The brachioradialis is then transferred to the ECRB using aPulvertaft tenorrhaphy.

Surgical Postoperative Rehabilitation

Patients who have undergone an FCU transfer to the ECRB are treated with asplint applied in the operating room with the wrist in 20 to 30 degrees of extension.Two weeks after surgery, the splint is changed to a fabricated cast in this sameposition. Six weeks following surgery, the cast is removed and an orthoplast splintplaced. The splint is worn full-time for an additional month but can be removedseveral times a day for active range of motion of the wrist. Splint wear is weaned toa night splinting program by 3 months after surgery. Some patients with significantflexor tone may require a night splinting program on a long-term basis. This addi-tional splinting may be particularly important during periods of growth.

Patients who have undergone an FCU to EDC tendon transfer are placed in asplint that blocks the MP joints at 0 degrees and holds the wrist in 20 to 30 degreesof extension. Two weeks after surgery, a cast is placed that holds the same positionan additional 2 weeks. Four weeks after surgery, an orthoplast splint is truncatedwith the wrist in extension and a removable MP joint flexion block. The MP jointcomponent of the splint is removed several times a day for active range of motionand training of the transfer. Six weeks after surgery, the wrist splint is removedseveral times a day to perform active range of motion. Composite finger and wristflexion should be avoided. Three months following the procedure, splint wear isweaned to a wrist control splint at night only. In cases with persistent significantflexor tone, it may be necessary to continue night splinting indefinitely.

Most patients undergoing the previous transfers will also have a finger flexorfractional lengthening. In that situation, in addition to the immobilization for thetransfer, the fingers are splinted in full extension to the finger tip. The fingers areheld in full extension for 4 to 6 weeks, at which time the cast is removed, and anorthoplast splint holding the fingers is made. The splint is removed several times aday to initiate active range of motion. If considerable flexor tone is present, a nightsplinting program may be necessary.


AUTHOR’S PREFERRED METHOD OF TREATMENT FOR THEFUNCTIONAL PATIENT WITH CEREBRAL PALSY

The author prefers to use the FCU transfer in all functional patients withcerebral palsy who have wrist flexion deformities and some ability to extend the MPjoints actively at any wrist position (most common group). This procedure is almostalways accompanied by a fractional lengthening of the finger flexors, tenotomy ofthe palmaris longus, and, possibly, a careful fractional lengthening of the FCR. If thepatient has no ability to extend the MP joints actively even with wrist flexion, theFCU is transferred to the EDC. This procedure is rarely needed because, in mostinstances, spasticity of the finger flexors, not pure EDC weakness, overpowers thefinger extensors and limits MP joint extension. Fractional lengthening of the tightfinger and wrist flexors is important.

Patients with a weak grip who drift into palmar flexion when trying to sustaina hard grasp are treated by weakening the flexor side rather than performing atendon transfer. A fractional lengthening of the wrist flexors and possibly the fingerflexors is performed.

COMPLICATIONS

The most significant and common complication of the FCU to ECRB and FCUto EDC transfers is over- or undertensioning the transfer. With undertensioning, thepatient’s ability to extend the wrist to neutral may be compromised, possibly neces-sitating functional wrist bracing or revision of the procedure. The opposite situationof overtensioning is less common in the author’s experience but, when present, is asignificant problem often leading to the need for revision surgery. Thometz and co-workers6 had two extension contractures in a series of 25 wrists that underwent anFCU to ECRB transfer.

RESULTS

Beach and co-workers1 reported on the results of FCU to ECRB transfer. Theyfound that although the total arc of wrist motion did not change, but the arc wasnow centered around neutral rather than flexion. Cosmetic improvement was seenin 88% of patients, 79% had functional improvement, and no patient lost function.Athetosis did not adversely affect the outcome in this series. Thometz and co-workers6 reported on 25 patients with FCU to ECRB transfer with an averagefollow-up of 8 years, 7 months. Mean active wrist extension was 44 degrees andpalmar flexion 19 degrees. There were nine good, five fair, and five poor resultsnoted by the modified Green grading system. Other reported series employing thistransfer have noted an improvement of wrist extension ranging from 34 to 44degrees.6,7 The average resting wrist position after an FCU to ECRB transfer is 11degrees of flexion.1,5,9

148 WRIGHT

The FCU to ECRB transfer (Fig. 11), when routed the usual way around theulnar aspect of the forearm, may improve forearm supination an average of 22degrees.1 This range of motion can be significantly improved by the addition of apronator rerouting.


Figure 11. A–E, A patient who is 9 months postoperative after a flexor carpiulnaris to extensor carpi radialis brevis transfer and fractional lengthening of thefinger flexors. The ability to extend fingers and grasp an object with the wrist inneutral is shown.


Figure 11. (Continued)

150 WRIGHT

SUMMARY

The treatment of wrist flexion deformities secondary to cerebral palsy can begratifying from both an appearance and functional standpoint. The mainstay oftreatment in the functional patient with cerebral palsy who has some active MPextension is the FCU to ECRB transfer with fractional finger flexor lengthening. Forthe low/nonfunctional patient with cerebral palsy, the treatment goal is to improvehygiene and is best served without surgery or by a proximal row carpectomy/wristfusion and profundus to superficialis transfer. Despite the lack of treatment optionsfor the brain injury, a balanced wrist with an improved grasp and release patterncan go a long way toward helping patients with activities of daily living andimproved self-esteem.

References

1. Beach WR, Strecker WB, Coe J, et al: Use ofthe Green transfer in treatment of patients withspastic cerebral palsy: 17 years experience. JPediatr Orthop 11:731–736, 1991

2. Colton CL, Ransford AO, Lloyd-Roberts GC:Transportation of the tendon of the pronatorteres in cerebral palsy. J Bone Joint Surg 58B:220–223, 1976

3. Gerwin M: Cerebral palsy. In Green DP,Hotchkiss RN, Pederson WC (eds): Green’sOperative Hand Surgery, ed 4. New York,Churchill Livingstone, 1999, pp 259–286

4. Green WT, Banks HH: Flexor carpi ulnaristransplant and its use in cerebral palsy. J BoneJoint Surg 44A:1343–1352, 1962

5. McCue FC, Honner R, Chapman WC: Transferof the brachioradialis for hands deformed bycerebral palsy. J Bone Joint Surg 52A:1171–1180, 1970

6. Roth JH, O’Grady SE, Richards RS, et al: Func-tional outcome of upper limb tendon transfersperformed in children with spastic hemiplegia.J Hand Surg 18B:299–303, 1993

7. Thometz JG, Tachdjian M: Long-term follow-up of the flexor carpi ulnaris transfer in spastichemiplegic children. J Pediatr Orthop 8:407–412, 1988

8. Tonkin M, Gschwind C: Surgery for cerebralpalsy. Part 2. Flexor deformity of the wrist andfingers. J Hand Surg 17B:396–400, 1992

9. Wenner SM, Johnson KA: Transfer of the flexorcarpi ulnaris to the radial wrist extensors incerebral palsy. J Hand Surg 13A:231–233, 1988

10. Zancolli EA, Zancolli ER: Surgical managementof the hemiplegic spastic hand in cerebralpalsy. Surg Clin North Am 61:395–406, 1981


Thomas W. Wright, MDDepartment of Orthopaedic Surgery

University of FloridaBox 100246

Gainesville, FL 32610



Superficialis to ProfundusTendon TransferDouglas A. Palma, MD, David A. Fuller, MD,and Mary Ann E. Keenan, MD

Spasticity in the upper extremity can produce severe flexion contractures in thewrist and hand in patients with injury to the upper motor neuron system. Theflexion contractures can lead to difficulties with positioning, dressing, and hygieneand are frequently painful. Skin maceration, pressure ulcerations, and nail deformi-ties are common with advanced deformity. Surgery is the treatment of choice. Aflexor digitorum superficialis (FDS) to flexor digitorum profundus (FDP) tendon(STP) transfer is indicated to treat severe spastic flexion contractures of the hand.The hand is repositioned to relieve pain, improve hygiene, and ease activities ofdaily living for patients and caregivers.

The STP transfer has been advocated as treatment in the nonfunctional handwith a spastic clenched fist deformity. The goal of surgery is to rebalance themuscle forces around the wrist and hand. If the flexor tendons to the fingers andwrist are simply released, with time, the unopposed tone in the extensors canproduce an extension deformity of the fingers and wrist. Over the last 10 years, theauthors have performed over 75 STP transfers and have found the procedure to bean effective, predictable, and safe operation.

NONOPERATIVE MANAGEMENT

Nonoperative treatment of the spastic clenched fist may be useful for early ormild deformity. Passive modalities include stretching, splinting, and custom ortho-ses. These modalities should be performed in conjunction with an experiencedoccupational therapist and can risk pressure ulceration and iatrogenic fracture. Sys-temic medications and local neuromuscular blocking agents such as botulinum toxinA can be helpful in controlling spasticity in a dynamic deformity. Despite appropri-ate nonoperative treatment, deformity can progress over time. Advanced deformitiesdo not respond to nonoperative treatment, including stretching, therapy, splinting,antispasticity medications, or intramuscular injections.



From the Department of Orthopaedic Surgery, Albert Einstein Medical Center; and Thomas JeffersonUniversity, Philadelphia, Pennsylvania (DAP, DAF, MAEK)

PREOPERATIVE EVALUATION

The spastic clenched fist deformity is common in brain injury or stroke. Thispattern results from unmasking of the primitive grasp reflex. The fingers are typi-cally clasped into the palm, and the fingernails may be embedded into the palmarskin. Appropriate access to the palm for washing may also be compromised. Skinmaceration, breakdown, and malodor may occur in the chronically contracted hand.Figure 1 illustrates a full-thickness skin ulceration due to pressure in the hand fromuntreated spastic contractures.

154 PALMA et al

Figure 1. Intraoperative full-thickness skin breakdown and hygiene problems resulting fromsevere flexion contracture. The flexor tendons have already been released to allow fingerextension.

Signs and symptoms of pain may be elicited from the patient when caregiversattempt to pry fingers open to gain palmar access.

The examination begins with an assessment of the passive range of motion.Following this determination, the patient is asked to open and close the fingers andto flex and extend the wrist. If no active wrist or finger extension is seen, one mustassess whether there is active control of finger flexion. The degree of motor controlmay be masked by the severe amount of tone present in the finger flexors. Often, anincrease in the pressure of grasp can be felt during attempted finger flexion, indicat-ing underlying muscle control. Spastic finger flexors may override and mask thepatient’s potential to extend the fingers. A temporary lidocaine nerve block of theflexor muscles can help to identify potential extensor muscle activity. Muscles thatcontribute to the clenched fist deformity include the FDS and FDP. If the proximalinterphalangeal (PIP) joints flex while the distal interphalangeal (DIP) joints remainextended, spasticity of the FDS rather than FDP is suspected. Despite the markedincrease in tone, there often exists some underlying volitional control in either orboth sets of extrinsic finger flexors. The FDP typically has less spasticity and bettervolitional control than the FDS.

The intrinsic muscles may be also be spastic but an intrinsic plus posture (i.e.,combined metacarpophalangeal [MCP] flexion and PIP extension) is often not seenbecause spastic extrinsic flexors dominate by flexing the PIP joints. Some degree ofcontracture of the intrinsic muscles is typical of the chronically clenched fist.

OPERATIVE MANAGEMENT

The patient is positioned supine. A hand table is recommended. Contractures atthe shoulder and elbow can make positioning of the extremity difficult and mayneed to be corrected at the same time. Perioperative antibiotics are recommended asa prophylactic measure against infection. Frequently, the skin in a severe clenchedfist deformity will be colonized with organisms resistant to multiple antibioticsbecause of the patient’s exposure to bacteria in multiple institutions. General anes-thesia and tourniquet hemostasis are routine.

The preoperative position of the wrist and hand in a patient sustaining atraumatic brain injury is depicted in Figure 2.

SUPERFICIALIS TO PROFUNDUS TENDON TRANSFER 155

Figure 2. Preoperative spastic hand and wrist with no active function. Thewrist flexors and extrinsic finger flexors are contracted. An intrinsic plus posi-tion is also apparent.

Flexion contractures of the wrist flexors, extrinsic finger flexors, and intrinsic fingerflexors all contribute to the position. The fingers often manifest contractures at thePIP and DIP joints as well, although not seen in this patient.

A volar incision is drawn extending from the palm into the mid forearm asshown in Figure 3.

156 PALMA et al

Figure 3. Intraoperative skin incision.

The incision is made straight across the wrist flexion crease. A simultaneous wristarthrodesis was planned for the patient in Figure 3, eliminating the concern for scarcontracture across the wrist flexion crease. The incision needs to be proximalenough to allow the release of the profundus tendons from their muscles and distalenough to release the carpal tunnel. It is often difficult to incise the palm owing tothe severity of the finger flexion contractures. The entire incision may not be com-pleted until the finger flexor tendons are released.

After incising the skin, the median and ulnar nerves along with the ulnar andradial arteries are identified and protected. The median nerve is often draped acrossthe taut FDS tendons at the level of the wrist, showing stricture indicative of nervecompression. Peripheral compression of the median nerve is typically caused bybowstringing of the superficial finger flexors, which lift the nerve from its bed andcan press it against the proximal edge of the transverse carpal ligament. Figure 4shows a vessel loop around the stenotic median nerve as it crosses over the tightFDS tendons.


Figure 4. Intraoperative flexor digitorum superficialis (FDS) tendons with a bluevessel loop around the median nerve. The median nerve chronically com-pressed by the contracted finger flexors against the transverse carpal ligament.

The four FDS tendons are isolated as distally in the palm as possible and suturedtogether with nonabsorbable material. The authors use a 1-0 braided polyestersuture as shown in Figure 5.

Figure 5. Intraoperative with an clamp around the flexor digitorum superficialis(FDS) tendons that are under tension to the flexor digitorum profundus tendons.The FDS tendons are sutured en masse distally in the wound.

Maximum length of the FDS tendons is desired so that when the transfer is per-formed, there will be adequate length in the transferred tendons. The FDS tendonsare then transected distal to the suture site.

Once the FDS tendons have been cut distally, they can be elevated out of thewound to allow visualization as shown in Figure 6.

158 PALMA et al

Figure 6. Intraoperative flexor digitorum superficialis (FDS) tendons transected andretracted proximally. In the proximal wound, the flexor digitorum profundus (FDP)tendons are sutured en masse before transection.

The four FDP tendons are sutured together proximally using nonabsorbable mate-rial, with all of the fingers placed in a balanced position so that, after the transfer,the fingers will be in an acceptable cascade. Once sutured together, the four FDPtendons are released from their proximal muscles.

After the FDS and FDP tendons have been released, the wrist and fingersshould be brought to a neutral position. Wrist flexors often need to be released orlengthened to bring the wrist to a neutral position. The flexor pollicis longus is alsoreleased from its proximal muscle to allow the thumb to be extended. Skin andneurovascular structures need to be closely observed during this extension maneu-ver. Volar skin can be torn or ischemia created in the digits owing to excessivetension on the soft tissues. The position of the FDS and FDP tendons is shown afterthe straightening maneuver in Figure 7.


Figure 7. Intraoperative transected sutured flexor digitorum superficialis (FDS) andflexor digitorum profundus (FDP) tendons, along with flexor pollicis longus prior totransfer. Fingers and wrist are extended. FPL � flexor pollicis longus

Joint contractures at the PIP and DIP joints often need to be manipulated gently toachieve passive finger extension.

With the wrist positioned in neutral and the fingers fully extended, the lengthand tension of the transfer are estimated. Depending on the length of the transectedtendon stumps, the STP transfer is completed with an end-to-end or side-to-sidetransfer. Some activity of the FDS muscle proximally is to be expected, which willpotentially flex the fingers to a limited extent. To reduce the risk of recurrentdeformity, the muscle activity should be considered when tensioning the transfer.The superficialis and profundus tendons are secured together using a 1-0 nonab-sorbable suture. The tourniquet is often deflated before wound closure to assess thevascularity of the fingers as shown in Figure 8.

160 PALMA et al

Figure 8. Intraoperative completed FDS to flexor digitorum profundus (FDP) transfer. Flexorpollicis longus has been incorporated separately. The tourniquet is deflated to assess vascular-ity and provide hemostasis.

Total tourniquet time is generally about 30 minutes. Electrocautery is used forhemostasis. Drains are not routinely used. The skin is closed with an absorbablesuture in the subcutaneous tissue and a nylon suture in the skin.

The postoperative position of the wrist and hand is shown in Figure 9.

Figure 9. Intraoperative final hand position after closure. Skin is under moderate tension in thisclosure. Metacarpophalangeal joints can be fully extended passively and an intrinsic releasewas not performed.

In addition to the tendon transfer, a carpal tunnel release, ulnar motor neurectomy,and wrist arthrodesis were performed. Postoperative position is maintained with aforearm-based volar plaster splint extending to the finger tips. The wrist is held inabout 15 degrees of extension, and the fingers are fully extended.

POSTOPERATIVE CARE

Postoperative care begins with an overnight stay in the hospital for analgesia,elevation, and neurovascular checks. The patient is usually discharged on the firstpostoperative day unless problems arise. A follow-up examination is scheduledapproximately 14 days after surgery for wound check, removal of sutures, andcasting. A short arm cast with the wrist in neutral and the fingers fully extended isapplied for an additional 4 weeks to allow healing of the arthrodesis. The cast isremoved at 6 weeks, and a removable night splint is worn for an additional 6weeks. Figure 10 shows the hand and wrist at the 6-week follow-up visit.


Figure 10. Six week postoperative view showing healed wounds. The intrin-sic plus position has resolved. The fingers are nicely extended and the wristis in a neutral, stable position. Little chance for recurrence of deformityexists for this hand and wrist.

The intrinsic plus position of flexion at the MCP joint has resolved, with eliminationof the intrinsic tone owing to the ulnar motor neurectomy and the stretching in thecast.

COMPLICATIONS

Complications have included superficial wound infections, abnormal swelling,hardware failures, and pulmonary complications.1–4 Review of the authors’ experi-ence has revealed other complications, including deep infection, arterial laceration,and recurrence of deformity. In addition to the potential complications related to theprocedure, many patients have multiple medical problems. Urinary retention andurinary tract infections are common. Gastrointestinal dysmotility and ileus are alsocommon in this patient population. Pulmonary toilet is essential because thesepatients are at risk for aspiration and pneumonia. Skin integrity elsewhere in thebody, such as the sacrum and heel, needs to be monitored vigorously periopera-

tively. Nutrition should be optimized to promote healing after surgery. Patients areoften on a plethora of medications, and diligence is required to prevent medicationerrors.

DISCUSSION

The authors recommend performing an ulnar motor neurectomy at the sametime as the STP procedure, even if the intrinsic plus position is not evident beforesurgery. Intrinsic spasticity can present after the STP procedure if the ulnar motorneurectomy is not performed. Intrinsic spasticity will compromise the result of theSTP procedure and lead to an intrinsic posture of the hand. If intrinsic spasticity hasbeen present for a prolonged time, the flexion at the MCP joint may be rigid, andrelease of the intrinsics at the same time as the STP procedure may be required.

In addition to the ulnar motor neurectomy, the authors routinely perform awrist arthrodesis to control the position of the wrist. Without stabilizing the wrist,release of the wrist flexors can cause a hyperextension deformity and subluxation ofthe carpus.

A carpal tunnel release is also routinely performed. Release of the carpal tunnelallows maximizing the length of the superficialis tendons for transfer by providingaccess to the tendons distally in the palm. Substantial length is required tostraighten the fingers fully. In addition to achieving greater tendon length, release ofthe carpal tunnel will fully decompress the median nerve and provide pain relief.

Profound swelling can be encountered with such extensive surgery at the wristand hand, making it difficult to close the surgical wounds. The volar wrist skin is atgreatest risk for problems with wound healing because this tissue is often thin andcan be under significant tension. This tension can be lessened by shortening thecarpus at the time of wrist arthrodesis with a proximal row carpectomy.

SUMMARY

The STP transfer is a safe and reliable operation to reposition the hand withadvanced flexion contractures. Surgery is often performed in combination with otherprocedures to provide a permanent and predictable correction of the hand and wristposition. A high rate of satisfaction has been reported by patients and caregivers.

References

1. Botte MJ, Keenan MA, Korchek JI, et al: Modi-fied technique for the superficialis-to-profundustransfer in the treatment of adults with spasticclenched fist deformity. J Hand Surg 12A:639–640, 1987

2. Braun RM, Vise GT, Roper B: Preliminary expe-rience with the superficialis-to-profundus ten-don transfer in the hemiplegic upper extremity.J Bone Joint Surg 56A:466–472, 1974

3. Keenan MA, Korchek JI, Botte MJ, et al: Resultsof transfer of the flexor digitorum superficialis

tendons to the flexor digitorum profundus ten-dons in adults with acquired spasticity of thehand. J Bone Joint Surg 69A:1127–1132, 1987

4. Keenan MA, Waters RL: Surgical treatment ofthe upper extremity after stroke and brain in-jury. In Chapman M (ed): Operative Orthope-dics, ed 2. Philadelphia, JB Lippincott, 1993, pp1529–1544

5. Pomerance JF, Keenan MA: Correction of thesevere spastic flexion contractures in the non-functional hand. J Hand Surg 21A:828–832, 1996


Douglas A. Palma, MDDepartment of Orthopaedic Surgery

Albert Einstein Medical CenterWillow Crest Building, 4th floor

5501 Old York RoadPhiladelphia, PA 19141


162 PALMA et al

Functional Free GracilisTransfer for Upper ExtremityReconstructionMilan Stevanovic, MD, and Frances Sharpe, MD

Functional free muscle transfer was first reported in an animal model by Tamaiand co-workers14 in 1970. This technique was successfully applied in humans byHarii and co-workers6 using a functional free gracilis transfer for reconstruction offacial paralysis in 1976. Manktelow and Zucker8,11 popularized the use of functionalfree muscle transfers for reconstruction of functional deficits, including those of theupper extremity.

PRINCIPLES OF MUSCLE TRANSPLANTATION IN THEUPPER EXTREMITY

When possible, functional loss due to nerve or muscle injury should be recon-structed with a tendon transfer or with functional muscle rotational flaps. Whenthese procedures are not feasible owing to unavailability of an appropriate donor,functional free microneurovascular muscle transfer should be considered.1–5,8,10,12

To perform a successful free microneurovascular muscle transfer, several condi-tions should be met at the recipient site. These conditions include the availability ofan undamaged motor nerve; adequate soft-tissue coverage at the recipient site,especially in the distal portion of the recipient site; full passive range of motion ofthe joint(s) in which function is to be restored; and a clean, infection-free, soft-tissuebed. For reconstruction of finger flexion or extension, the flexor or extensor tendonsshould be intact from 2 cm proximal to the wrist joint to their distal insertions, andthe tendons should glide freely.



From the Department of Orthopedics, Keck School of Medicine, University of Southern California LosAngeles County Medical Center, Los Angeles (MS); and Kaiser Permanente, Fontana (FS), California

MUSCLE SELECTION

Several muscles have been used successfully in upper extremity reconstruction.These muscles include the latissimus dorsi, serratus anterior, rectus femoris, tensorfascia lata, and gracilis. The donor muscle selected for reconstruction should fitcertain criteria. The muscle should have sufficient strength to replace the lost func-tion and adequate excursion to maximize joint range of motion. Other requirementsare a single neurovascular pedicle and tendon origin and insertion of sufficient sizeto allow proper reattachment to the muscle. Adequate antagonist muscle functionmust be present. The hand should be sensate, and the patient must be motivated.When a soft-tissue defect is present, the donor muscle should be of ample size to fillthe area of defect and provide coverage for underlying bone, tendons, and neuro-vascular structures. Whenever possible, the donor muscle should be harvested as amusculofasciocutaneous flap to allow better muscle gliding below the skin. Thedonor muscle should not result in a significant functional or cosmetic deficit at thedonor site.

GRACILIS MUSCLE

The gracilis muscle is a strap muscle that is broad proximally and that tapersdistally, with an average length ranging from 35 to 40 cm. The tendinous portionaverages around 6 cm in length. It is superficially located on the medial aspect ofthe thigh and functions to adduct and medially rotate the thigh. It also acts as aweak knee flexor. It is the weakest of the adductors, and its removal does not resultin significant functional loss.

The muscle origin is from the body of the pubis and adjacent ramus of theischium. Its well-defined tendon inserts into the medial surface of the proximaltibia, distal to the tibial tubercle. The insertion of the gracilis lies between theinsertions of the sartorius (anteriorly) and the semitendinosis (posteriorly). Stimula-tion of the gracilis will shorten the muscle length by over 50%, which producesapproximately 15 cm of muscle excursion.8

The blood supply to the gracilis is through several pedicles. The dominantpedicle enters the muscle between 8 and 12 cm from the muscle origin. The lengthof the pedicle ranges from 4 to 6 cm. The arterial diameter is 1 to 2 mm, and thetwo concomitant veins can range from 1 to 4 mm in diameter. Manktelow describedone case in which the superior pedicle was a double pedicle, with two arteries andfour concomitant veins. In that case, the muscle circulation proximal to the pediclewas supplied by one artery, and the muscle circulation distal to the pedicle wassupplied by the other artery. The gracilis also has two or three more distally lyingsmaller vascular pedicles. These pedicles can be ligated without compromising themuscle because the larger proximal pedicle provides adequate circulation for theentire muscle.

If the muscle is dissected with a skin paddle, only the skin paddle overlyingthe proximal half of the muscle is reliable. The skin paddle is supplied by aconstant single perforating vessel that enters the skin paddle at the level of thedominant muscle vascular pedicle. Because the skin paddle relies on a single perfo-rating vessel, it is more susceptible to injury, particularly from shearing forces. Theskin paddle on the medial thigh is often thick and bulky, and it is easier for thisbulky tissue to produce high shear forces at the fasciocutaneous perforator.

The nerve supply to the gracilis is from a single motor branch of the obturatornerve that enters the muscle immediately proximal to the vascular pedicle. Thenerve branch is composed of two to three fascicles surrounded by an abundance offat tissue. The fascicles can be easily separated from the fat tissue and individuallystimulated. A single fascicle can control 20% to 50% of the anterior portion of themuscle; the remaining portion of the muscle is controlled by the other fascicles. This

164 STEVANOVIC & SHARPE

territorial distinction can be useful when trying to reconstruct independent thumband finger flexion.9

PREOPERATIVE PLANNING

Recipient Site Planning

Before considering functional muscle transplantation, several criteria must bemet with respect to the recipient site. The patient should have sufficient passiverange of motion of the joints for which the function is to be restored; an undamagedmotor nerve with a cross-sectional area similar in size to the motor nerve of thegracilis should be available as a donor; and skin coverage of the distal half of thegracilis and the site of tendon repair should be adequate for tendon gliding toassure a good functional outcome. Only the proximal half of the gracilis can bereliably covered by harvesting the gracilis with an overlying skin paddle. In general,the authors recommend this maneuver to allow for proximal muscle gliding and toenable monitoring of the transferred tissue.

In patients who have sustained a significant soft-tissue injury or a Volkmann’sischemic contracture associated with functional loss, preoperative planning mayinclude angiography or MR angiography with gadolinium to better identify therecipient vessels.

Operating Room Planning

When possible, the procedure should be performed in a two-team approach.Appropriate microsurgical instruments and an operating microscope should beavailable. The room temperature should be between 75 and 80� F, at least until thepatient’s core temperature has stabilized around 98.6� F. A pathologist experiencedin neurohistochemical staining should be available if there is a question regardingthe suitability of the recipient site donor nerve.

SURGICAL TECHNIQUE

Even when a two-team approach is used, the recipient site should be exploredand a suitable recipient artery, vein, and nerve identified. If there is a questionregarding the recipient nerve, further investigation must be performed before har-vesting the gracilis. Investigation may include examination under the microscope,frozen section, or histochemical identification of the sensory and motor fascicles of amixed nerve. These studies may take up to 2 hours. Awake nerve stimulation mayalso be used to distinguish motor from sensory fascicles. This technically demandingprocedure is best indicated for separating motor from sensory fibers for the axillaryand musculocutaneous nerves. When these structures are adequately identified, si-multaneous preparation of the recipient site and dissection of the gracilis muscle canproceed with two surgical teams.

Preparation of the Recipient Site

Preparation of the recipient site begins with elevation of skin flaps. The distaltendons of the muscles in which function is to be restored are identified andevaluated for their ability to glide within their soft-tissue bed. Dissection for thetransplanted gracilis muscle origin is carried out. The operating microscope is thenbrought to the operating field, and the previously identified artery, vein, and nerveare prepared.

FUNCTIONAL FREE GRACILIS TRANSFER FOR UPPER EXTREMITY RECONSTRUCTION 165

Gracilis Muscle Dissection

Dissection of the gracilis begins with identification of the tendon distallythrough either a transverse or a longitudinal incision just proximal to the adductortubercle. The tendon lies between the muscle of the sartorius and musculotendinousregion of the semitendinosus. When the tendon is identified distally, a half-inchPenrose drain is placed below the tendon. Tension is applied to the Penrose drain toallow identification of the muscle proximally and to plan the proximal skin incisionand paddle.

After the skin paddle is designed, the proximal dissection is carried out. Theproximal incision and dissection should extend distally to the level of the musculo-tendinous junction. The posterior limb of the skin paddle and the posterior marginof the gracilis should be dissected first because the neurovascular pedicle is locatedanteriorly. During dissection of the skin paddle, the subcutaneous tissue layer isbeveled away from the paddle, creating a wider base for supplying the skin flapand to minimize the risk of injury to the perforating branches. The skin paddleshould be secured to the muscle fascia to prevent shearing injuries to the perforat-ing branches. The anterior limb of the skin paddle and the anterior margin of thegracilis are dissected. To measure the correct resting length of muscle, the thigh isabducted and the knee extended (Fig. 1A). A ruler is used to measure 5-cm incre-ments from the muscle origin to the distal aspect of the musculotendinous junction.These increments are marked with a 4-0 silk suture through the muscle belly.

The gracilis may be supplied by several pedicles. The proximal vascular pedicleis dominant and should be meticulously dissected. The smaller more distally lyingpedicles should be ligated. The motor branch to the gracilis from the obturatornerve always lies proximal to the dominant pedicle. The vascular pedicle and motorbranch are dissected and mobilized to provide maximum length.


The gracilis tendon is released as distally as possible. A retractor or a finger isplaced below the muscle origin to protect the surrounding structures. Using cautery,the muscle origin is released from the pubis. The muscle is mobilized, leaving thepedicle intact, and is allowed to perfuse for 15 to 20 minutes (Fig. 1B).


A

B

Obturator n. branch

Profunda femoris a. & v.

Suture markersGracilis Vascular pedicle

to gracilis m.

Figure 1. A, Measurement of the resting length of the gracilis. B, Harvested gracilis muscle.

Revascularization

When the muscle has been perfused and the vasospasm has resolved, thepedicle is ligated, maintaining maximum pedicle length. The muscle is transferredto the recipient site. Provisional staples or sutures are used to secure the muscle tothe surrounding tissues. The gracilis origin is sutured to the intended recipient siteorigin. The muscle belly is stretched to its resting length, and the position of thevascular repair is assessed. The position of the vascular anastomosis is determinedwith the muscle stretched to its resting length and at its maximally shortenedlength. There should be no traction on the pedicle during either lengthening orshortening of the muscle belly. At the time of wound closure, the pedicle must becarefully evaluated and positioned so that there is no redundancy of the pediclethat would allow it to be kinked. The skin flaps should be carefully positioned so asnot to compress the pedicle. If the skin closure is too tight, and the pedicle is at riskof compression, it is better to change plans for wound closure and consider a skingraft or other closure options.

The arterial repair is performed first either as an end-to-end or an end-to-sideanastomosis, dependent on the recipient vessel. For an end-to-end repair, the au-thors prefer to use a 10-0 nylon suture on a 75 �m needle. For an end-to-side repair,a 9-0 nylon suture is used on a 100 �m needle. The venous repair is performed end-to-end. A concomitant vein is used for the recipient vein. The repair is performedwith 10-0 nylon suture on a 75 �m needle.

Reinnervation

Nerve repair should be carried out as close as possible to the gracilis musclebelly. An epineurial repair is done with 10-0 nylon on a 75 �m needle. Manktelowand colleagues have recommended a fascicular repair with 11-0 nylon suture. Thisrepair may be useful in reconstructing two independently controlled neuromuscularunits; however, the maneuver requires two appropriately sized suitable motor fasci-cles at the recipient site. At times, nerve grafting may be required to reach therecipient nerves. The sural nerve is the most common donor for grafting.

Muscle Position and Tension

When the vascular and neural anastomoses have been completed, the gracilismuscle origin is definitively secured. Adjustments are made to the provisionalfixation to minimize compression or traction on the pedicle and to best recreate theanatomic axis of pull of the muscle function that is to be restored. The origin issecured with a horizontal mattress stitch using nonabsorbable braided 2-0 suture.


A

B

Radial a. (end-to-side)venae comitantes

Ant. interosseous n.

Neurovascularbundle

5 cm

Pull

Medialepicondyle

Flexor pollicislongus tendon

Flexor tendons

Gracilis m.

Flexor tendons

Figure 2. A, Restoration of resting length at the transplant site. B, Transplanted muscle withnew origin and insertion.


The transferred muscle is stretched to its resting length such that the previouslyplaced marker sutures are at 5-cm intervals (Fig. 2A). The distal tendon repair isperformed with the extremity in extension when restoring flexion and in flexionwhen restoring extension. When possible, the distal repair is completed as a Pulver-taft weave using a braided 3-0 nonabsorbable suture (Fig. 2B). In the deltoid recon-struction, the distal repair is often near the musculotendinous junction of the gra-cilis, and the repair may be done directly to bone.

Soft-Tissue Coverage

The transplanted muscle requires a healthy soft-tissue environment so that itcan glide freely in its transposed position. Harvesting a fasciocutaneous skin paddlewith the gracilis provides smooth gliding coverage for the proximal half of themuscle. The distal tendinous portion of the gracilis cannot be covered with the skinpaddle or a skin graft. For reconstruction of the shoulder girdle and arm, the distalgracilis is usually easily covered by local tissue. In the forearm, there is morecommonly soft-tissue deficiency, which may require additional procedures, such aspreoperative soft-tissue expansion or a random fasciocutaneous flap.

Intraoperative and Postoperative Management

During the surgical procedure, the anesthesiologist should closely monitor thepatient’s core temperature, systolic blood pressure, and urinary output. The patientshould not be paralyzed for the procedure, especially when trying to separate thefascicles of the nerve to the gracilis to restore independent function to the thumband fingers. Urinary output should be between 80 and 100 mL/hour. Systolic bloodpressure should not be maintained with vasopressors. Before the microsurgicalanastomosis, the patient may be kept hypotensive. After the vascular anastomosis,the systolic blood pressure should be maintained between 120 and 130 mm Hg.

Postoperatively, the patient is monitored in an intensive care unit, ideally bynursing staff familiar with free-tissue transfers. The room temperature should bemaintained between 75 and 80�F. The patient should be kept without enteral intakebut well hydrated. Urinary output should be between 80 and 100 mL/hour for thefirst 24 hours. The flap should be monitored for temperature and capillary refill.Doppler signal is not always audible through the skin flap. In the first 24 hours, anyfirmness of the skin paddle or purplish petechiae around the edges are signs ofvenous obstruction, and the patient should immediately be taken to the operatingroom for reexploration. These signs, even in the presence of a normal temperatureand capillary refill, are sufficient to warrant emergent surgery. If the surgical anas-tomosis is patent, the dominant perforators to the skin paddle should be examined.If outflow from the skin paddle is compromised, the skin paddle should be re-moved, and the muscle should be skin grafted.

If thrombosis occurs, revascularization of the muscle can be achieved, even with3 hours of ischemia time. Nevertheless, more than 2 hours of ischemia time in afunctional muscle transfer can cause irreparable damage to the muscle function. Ifischemia time exceeds 2 hours, the transposed muscle should be removed andreplaced with a new functional graft.

Postoperative immobilization is continued for 4 weeks. Uninvolved joints arekept supple through active and passive range of motion. At 4 weeks, a therapyprogram of passive stretching of the transferred muscle is initiated. When spontane-ous muscle contraction occurs, the patient is encouraged and directed in activerange of motion and gradual resistive exercises. The authors believe that afterspontaneous muscle contraction occurs, there is a role for muscle stimulation inmuscle reeducation.


FUNCTIONAL RECONSTRUCTION

Functional reconstruction of the anterior deltoid (Fig. 3), biceps (Fig. 4A–C),triceps (Fig. 5), forearm flexors (Fig. 6A–E), and forearm extensors (Fig. 7, Fig. 8A–E) is outlined in Table 1.


(Text continued on page 179)

Deltoidinsertion

Thoracodorsala. & venae comitantes

Gracilis

Axillary n.

Figure 3. Anterior deltoid reconstruction.


Branch ofaccessory n.

Gracilis Thoracoacromiala. & v.

A B

C

Figure 4. A, Biceps reconstruction. B and C, This 32-year-old patient sustained a right-side brachial plexusinjury from a motorcycle accident 3 years before presentation. He underwent brachial plexus explorationand repair 4 months after his initial injury. He had good recovery of hand function, partial recovery ofdeltoid and latissimus function, and no recovery of his musculocutaneous nerve function. He underwent afunctional free gracilis muscle transfer with arterial anastomosis to the thoracoacromial artery and vein, andneural anastomosis to a trapezial branch of the accessory nerve. At 3 years, he recovered 120� of elbowflexion with M-4 strength.


Post. margin ofacromion

Gracilis m.

Latissimusdorsi

Tricepstendon

Thoracodorsal a. & venae comitantesTriceps branch of radial n.

Figure 5. Triceps reconstruction.


Figure 6. A 6-year-old patient underwent resection of a rhabdomyosarcoma of theforearm. The tumor involved the flexor-pronator muscle mass of the proximal fore-arm. Following excision of the flexor muscles, with the exception of the flexorpollicis longus, a functional free gracilis was transferred to provide soft-tissue cov-erage of the proximal forearm and to restore flexor function to the fingers. A, MRimage of the rhabdomyosarcoma. B, Resection of the tumor and flexor-pronatorgroup. C, Transplanted gracilis with skin paddle. Neural anastomosis was per-formed to the motor branch of the flexor digitorum superficialis. Arterial repair wasperformed end-to-side to the ulnar artery and venous repair was an end-to-endrepair to the concomitant vein.

Illustration continued on opposite page


Figure 6 (Continued). D and E, Functional outcome 2 years from initial surgery.


Lateralepicondyle

Radial a. & venae comitantes (end-to-end or end-to-side)Post. interosseous n.

Gracilis m.

Ulna

Figure 7. Forearm extensor reconstruction.


Figure 8. This 26-year-old patient sustained severe left upper extremity injury following amotorcycle accident. He had undergone seven previous surgeries for an open fracture of theradius and ulna. He had loss of extensor function caused by initial injury and a poor soft-tissue envelope. A groin flap was originally used to cover the distal third of the forearm. Twoyears following his original injury, he underwent open reduction and internal fixation of theradial and ulnar nonunions. Simultaneously, a functional free gracilis was performed to pro-vide proximal soft-tissue coverage and to restore wrist and finger extension. A, Nonunionafter eradication of infection. B, Soft-tissue envelope before groin flap. C, Absent wristextension.



Figure 8 (Continued). D, Radiographs 2 years after free gracilis muscle transfer with intervalhardware removal. E, Functional wrist extension 2 years following free gracilis transfer.


Table 1. UPPER EXTREMITY MUSCLE FUNCTION RESTORED WITH FUNCTIONAL FREE GRACILIS

Muscle Origin Insertion Tensioning Recipient Vessels Recipient Nerve

Anteriordeltoid

Distal third of clavi-cle and acromion

Residual of tendinousinsertion on the lat-eral arm or directlyto the humerus

Gracilis stretchedto its restinglength with theshoulder ex-tended

Thoracodorsal artery andconcomitant veins, orthoracoacromial trunkand concomitantveins, or tributaries ofthe cephalic vein

Axillary nerve, or ante-rior branches of thespinal accessorynerve, nerve to pecto-ralis minor (requiresnerve graft)

Biceps Distal portion of theclavicle and acro-mion or coracoidprocess and clavi-pectoral fascia,depending on thelength of the gra-cilis muscle

Distal biceps tendon,if present, or to theradial tuberositythrough bonetunnel

Shoulder and elbowin extension

Thoracodorsal artery andconcomitant veins,thoracoacromial trunkand concomitant veinor tributaries of the ce-phalic vein

Motor fibers of the mus-culocutaneous nerve,intercostal nerves, oranterior branches ofthe spinal accessorynerve

Triceps Posterior aspect ofthe acromion

Triceps tendon or di-rectly to the olecra-non

Shoulder and elbowflexion

Thoracodorsal artery andconcomitant veins,posterior circumflexhumeral, or profundabrachii and concomi-tant veins

Triceps branches of theradial nerve, intercos-tal nerves, branch toteres minor from theaxillary nerve

Forearmflexors

Medial epicondyle ofthe humerus

Flexor digitorum pro-fundus tendons atlevel of the wrist*

Elbow, wrist, andfingers in maxi-mum extension

Radial or ulnar artery asend-to-side or end-to-end anastomosis andconcomitant veins

Anterior interosseousnerve or branchesfrom the mediannerve to the superfici-alis or profundusmuscles

Forearmextensors

Lateral epicondyle ofthe humerus

Extensor digitorumcommunis and ex-tensor pollicis lon-gus tendons at thelevel of the wrist

Wrist and fingerspositioned inmaximum flexion

End-to-end or end-to-side to the radial ar-tery, or ulnar arteryusing a vein graft, orradial recurrent artery

Venous repair to venaecomitantes of the ra-dial artery

Posterior interosseousnerve; if not present,then a single branchof the median nerveto one of the superfi-cialis muscles, withnerve grafting as nec-essary

*If independent thumb and finger flexion is to be reconstructed, the gracilis muscle needs to be longitudinally split and separated into itsautonomously controlled fascicles. Distally, one tendon is repaired to the flexor digitorum profundus, and the other repaired to the flexor pollicis longus.Two separate motor nerve branches should be used.

COMPLICATIONS

Potential complications affecting graft viability include venous or arterialthrombosis, hematoma, and isolated failure of the skin paddle. Any of these compli-cations should be addressed with an emergent return to the operating room. Asdiscussed previously, ischemia time greater than 2 hours results in poor functionaloutcome.7 The transplanted muscle under this circumstance should be removed andreplaced with another transplanted gracilis muscle. This option should be listed inthe informed surgical consent.

Late complications include poor nerve regeneration, adhesions, and tendonrupture. Adhesions and tendon ruptures can be corrected surgically, whereas poornerve regeneration cannot. If the procedure was performed properly and no nervegraft was required, some recovery of muscle function should be seen at 3 months.13

If no recovery is seen by 1 year after transplantation, no useful functional recoverycan be anticipated.

SUMMARY

The authors’ first choice for reconstruction about the shoulder girdle and elbowis a functional rotational latissimus dorsi muscle flap. This procedure has been welldescribed for reconstruction of the deltoid, biceps, and triceps. In the forearm, manydifferent types of tendon transfer have been successfully used, and this operationshould be the primary reconstructive procedure. When these options are not avail-able owing to brachial plexus injury, soft-tissue loss from extensive trauma or tumorresection, or the need for reconstruction of multiple functional deficits, microneuro-vascular free gracilis transfer is an excellent tool for restoration of lost function.

References

1. Chuang D: Functioning free-muscle transplan-tation for the upper extremity. Hand Clin 13:279–289, 1997

2. Chung D, Carver N, Wei F: Results of func-tioning free muscle transplantation for elbowflexion. J Hand Surg 21A:1071–1077, 1996

3. Doi K, et al: Double muscle transfer for upperextremity reconstruction following completeavulsion of the brachial plexus. Hand Clin 15:757–767, 1999

4. Doi K, et al: Limb-sparing surgery with rein-nervated free-muscle transfer following radicalexcision of soft-tissue sarcoma in the extremity.Plast Reconstr Surg 104:1679–1687, 1999

5. Doi K, et al: Reinnervated free muscle trans-plantation for extremity reconstruction. PlastReconstr Surg 91:872–883, 1993

6. Harii K, Ohmori K, Tori S: Free gracilis muscletransplantation with microneurovascular anas-tomoses for treatment of facial paralysis. PlastReconstr Surg 57:133–143, 1976

7. Kuzon W, McKee N, Fish J: The effect of intra-operative ischemia on the recovery of contract-

ile function after free muscle transfer. J HandSurg 13A:263, 1988

8. Manktelow R: Functioning microsurgical mus-cle transfer. Hand Clin 4:289–296, 1988

9. Manktelow R: Muscle transplantation by fascic-ular territory. Plast Reconstr Surg 73:751–755,1984

10. Manktelow R, McKee N: Free muscle trans-plantation to provide active finger flexion. JHand Surg 3A:416–426, 1978

11. Manktelow R, Zucker R: The principles of func-tioning muscle transplantation: Applications tothe upper arm. Ann Plast Surg 22:275–282, 1989

12. O’Brien B, et al: Free microneurovascular mus-cle transfer in limbs to provide motor power.Ann Plast Surg 9:381–391, 1982

13. Stevanovic M, Seaber A, Urbaniak J: Canineexperimental free muscle transplantation. Mi-crosurgery 7:105–113, 1986

14. Tamai S, et al: Free muscle transplants in dogswith microsurgical neurovascular anastomoses.Plast Reconstr Surg 46:219–225, 1970


Milan Stevanovic, MDHand and Microsurgery

Department of OrthopedicsUniversity of Southern California Los Angeles County Medical Center

GNH Room 39002025 Zonal Avenue

Los Angeles, CA 90033



Atlas of the Hand Clinics Copyright © 2006 Saunders, An Imprint of Elsevier Volume 7, Issue 1 (March 2002) Issue Contents: (Pages ix-180)

1 ix-ix Preface Kozin SH

2 1-17 Tendon transfers for thumb opposition Shin AY

3 19-39 Tendon transfers for intrinsic function in ulnar nerve palsy Kalainov DM

4 41-52 Tendon transfer for radial nerve palsy Rettig ME

5 53-66 Tendon transfers for elbow flexion Kozin SH

6 67-77 Tendon transfers for lateral pinch Weiss AA

7 79-95 Tendon transfers for restoration of active grasp Peljovich AE

8 97-108 Elbow extension tendon transfer Van Heest AE

9 109-117 Tendon transfers during index finger pollicization Lourie GM

10 119-131 Tendon transfers for thumb-in-palm deformity Carlson MG

11 133-151 Tendon transfer for wrist flexion deformity in cerebral palsy Wright TW

12 153-162 Superficialis to profundus tendon transfer Palma DA

13 163-180 Functional free gracilis transfer for upper extremity reconstruction Stevanovic M

Documents

Tendon Transfers