Tendon Transfers

Juntian Wang, MD PGY1

August 30, 2018
Outline
• Introduction and basic principles
• Radial nerve palsy
• Median nerve palsy
• Ulnar nerve palsy
Introduction
• Tendon transfer is useful to restore function after injury to radial /
median / ulnar nerve when surgical repair does not result in useful
function, or nerve repair is not possible
• Cannot restore normal strength, coordination, sensation
• Tendon transfer is possible because of substantial redundancy in
upper extremity tendon anatomy
Basic principles
• Prevention and correction of contracture
• Ensure maximum passive ROM of all joints
• Tissue equilibrium
• Mature wounds, supple joints, soft scars
• Adequate strength
• Match relative strength of donor muscle to replaced muscle (cross-sectional
diameter of muscle belly)
• Amplitude of motion
• 3-5-7 rule for excursion amplitudes: wrist flexors and extensors (33 mm),
finger extensors and EPL (50 mm), finger flexors (70 mm)
Basic principles
• Straight line of pull
• Otherwise, increased force needs to be expended to overcome friction with
surrounding soft tissues
• One tendon-one function
• Single tendon cannot perform two dissimilar active actions
• Synergism
• Wrist extension & finger flexion / wrist flexion & finger extension
• Expendable donor
• Another musculotendinous unit should provide same function as muscle
being transferred
Radial nerve palsy
• Goal: restore lost motor function and powerful grip
• Wrist extension
• Finger (particularly MCP joint) extension
• Thumb (IP joint) extension and abduction

Wrist drop Lack of MCP joint extension

Radial nerve palsy – anatomy
• High vs. low refers to lesion
proximal or distal to deep branch /
posterior interosseous nerve (PIN)
• Radial nerve proper
• Triceps brachii, anconeus,
brachioradialis, ECRL
• Deep branch / PIN
• ECRB (some are innervated by
superficial branch), supinator, EDC,
EDM, ECU, APL, EPB, EPL, EIP
Radial nerve palsy – high
• Results in loss of:
• Muscles innervated by
radial nerve proper
• Muscles innervated by PIN
• Presentation
• Loss of wrist extension
(ECRL, ECRB, ECU)
• Loss of finger extension
(EDC, EIP, EDM)
• Loss of thumb extension Wrist drop
(EPB, EPL)
Radial nerve palsy – low
• Results in loss of:
• Muscles innervated by PIN
• Triceps, anconeus, brachioradialis, ECRL
are preserved
• Presentation: PIN syndrome
• Radial deviation during wrist extension
PIN syndrome
(preserved ECRL, absent ECU)
• Loss of finger extension (EDC, EIP, EDM)
• Loss of thumb extension (EPB, EPL)
Radial nerve palsy – tendon transfers
• Three sets of transfers
• 3/3 use pronator teres (PT) to ECRB to
restore wrist extension
• 2/3 use palmaris longus (PL) to
reroute EPL – other uses FDS III
• FCR / FDS IV / FCU to EDC
• For low radial nerve palsy, PT to
ECRB transfer is unnecessary (ECRL
preserved)

FCR to EDC transfer

Median nerve palsy
• Goal: restore lost motor function
• Thumb opposition
• Thumb flexion
• Index finger flexion
• Sensory loss is the most
important single disability
• Can reduce benefit of tendon
transfer
Median nerve sensory distribution
Median nerve palsy – anatomy
• High vs. low refers to lesion proximal or distal
to origin of anterior interosseous nerve (AIN)
• Median nerve in forearm
• Pronator teres, FCR, PL, FDS
• AIN
• FPL, pronator quadratus, radial half of FDP
• Median nerve in hand
• APB, opponens pollicis, superficial head of FPB, 1st
and 2nd lumbricals

Median nerve anatomy

Median nerve palsy – low
• Results in loss of:
• Thenar muscles innervated by
median nerve
• Presentation
• Loss of thumb opposition (APB,
opponens pollicis, FPB)

Thumb opposition
Median nerve palsy – low
• Biomechanics of thumb opposition
• Thumb opposition requires combination of
abduction, flexion, pronation
• APB is prime muscle
• Opponens pollicis and FPB produce some
opposition
• FPB has been found to have ulnar innervation
• Therefore, thumb abduction and opposition
Thenar muscle anatomy
are frequently preserved after isolated median
nerve injury due to ulnar nerve function
Median nerve palsy – low; tendon transfers
• Restore thumb opposition
• Biomechanics of tendon transfer
• Pulley on ulnar border of wrist should be
utilized to maximize thumb opposition
(parallel to APB)
• 4 standard opponensplasties (to APB)
1. FDS of ring finger
2. EIP
3. Abductor digiti minimi (ADM)
4. PL
Pulley system around ulnar aspect of wrist
Median nerve palsy – high
• Results in loss of:
• Thenar muscles innervated by median nerve
• Muscles innervated by AIN and remainder of
median nerve
• Presentation
• Loss of thumb opposition (APB, opponens
pollicis, FPB) Abnormal OK sign

• Loss of thumb flexion (FPL)

• Loss of index finger flexion (FDP)
• Working part of FDP can provide full but weak
range of middle finger flexion
Median nerve palsy – high; tendon transfers
• If high median nerve laceration is repaired, extrinsic muscle function
can be restored
• Transfers to restore thumb and index finger flexion not required
• Restore index finger and thumb flexion
• Brachioradialis is generally used to restore FPL function
• Adequate index finger flexion can be attained using side-to-side transfer to
functioning FDP tendons
• In rare cases, ECRL transfer can be used
• Restore thumb opposition
Ulnar nerve palsy
• Goal: restore lost motor function
• Thumb adduction
• Finger abduction (index finger)
• Reverse claw hand deformity

Claw hand deformity

Ulnar nerve palsy – anatomy
• High vs. low depends on whether lesion is proximal
or distal to origins of motor branches to FCU and
ring and little finger FDP muscles
• Ulnar nerve in forearm
• Muscular branches – FCU and ulnar half of FDP muscles
• Ulnar nerve in hand
• Deep branch – 3rd and 4th lumbricals, all interossei,
adductor pollicis, hypothenar muscles (ODM, ADM,
flexor digit minimi brevis)
• In some cases, FPB
Ulnar nerve anatomy
Ulnar nerve palsy – low
• Results in loss of:
• Muscles in hand innervated by ulnar nerve
• Presentation: claw hand deformity
• Loss of MCP joint flexion and PIP joint
extension (lumbricals)
• In lower injuries, innervation to ring and
little finger FDP is preserved
• Consequently, patients present with ring
and little finger MCP joint hyperextension,
PIP joint flexion, and unopposed DIP joint
flexion (FDP)

Claw hand deformity

Ulnar nerve palsy – low
• Presentation
• Froment sign – thumb IP joint flexion when
pinching paper between thumb and index finger
• Loss of adductor pollicis and dorsal interosseous
function
• Unopposed FPL function
• Wartenberg sign – little finger abduction
• Loss of palmar interosseous function
• Unopposed extensor digiti minimi (EDM) function
• Inability to cross index and middle fingers
• Loss of interosseous function

Froment (a/b) and Wartenberg (c/d) signs

Ulnar nerve palsy – low; tendon transfers
• Restore thumb-index pinch, correct finger
clawing, restore normal pattern of finger flexion
• ECRB or FDS to adductor pollicis
• APL or EIP to 1st dorsal interosseous for index finger
abduction
• Correct claw hand deformity
• Static procedure (capsulodesis, tenodesis) is sufficient
if correcting MCP joint hyperextension results in IP
joint extension
• Dynamic procedure (tendon transfer) is required
otherwise

MCP joint flexion enabling IP joint extension

Ulnar nerve palsy – low; tendon transfers
• Correct claw hand deformity (cont.)
• FDS or ECRL to lateral bands of ulnar digits (where lumbricals, dorsal and
palmar interossei insert)
• This enables DIP extension
• Tendons must be passed palmar to transverse metacarpal ligament to enable
flexion at MCP joints
Ulnar nerve palsy – high
• Results in loss of:
• Muscles in hand innervated by ulnar nerve
• Remainder of muscles innervated by ulnar nerve
• Presentation
• Paradoxically, claw hand deformity tends to be less severe
• Loss of ring and little finger DIP flexion (FDP)
Ulnar nerve palsy – high; tendon transfers
• Prioritize restoring intrinsic muscle
function (e.g. treat as a low ulnar
nerve palsy)
• Restore little finger flexion
• Suture FDP tendons of ring and little
fingers to FDP tendon of middle
finger; index finger FDP is left free
• Transfer of FCR to FCU may restore
strong flexion and ulnar deviation
of wrist
Tenodesis of ring/little FDP to middle FDP
Key points