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