pre and post operative management in tendon transfer

Pre and Post Operative Physiotherapy Management In Tendon Transfer of Hand

By Dr. Rajal Sukhiyaji (M.PT. in Sports Science)

Contents• Definition• Principles of tendon transfer• Prerequisites for tendon transfer• Treatment goals• Indications, Contraindications, Precautions• Radial nerve palsy ( Purpose, Preoperative

requirements, Tendon transfer, Post operative Management, Different splint)

• Ulnar nerve palsy• Median nerve palsy• Post operative complication• Evaluation time• Recent advances• References

Definition :-•Tendon transfer is a surgical procedure

that involves moving the insertion of a tendon muscle unit from one location to another location.

•A tendon transfer can be used to restore grasp, improve the position of the hand in space, and to prevent deformity, dislocations and contractures.

General Principles Of Tendon TransferThree important principles should be

emphasized

1) The transfer should not significantly decrease the remaining function of the hand.

2) The transfer should not create a deformity if significant return of function occurs following a nerve repair.

3) The transfer should be phasic or capable of phase conservation.

Fundamental principles of muscle-tendon units include the following:

1) Correction of contracture 2) Adequate strength 3) Amplitude of motion 4) Straight line of pull 5) One tendon, one function 6) Synergism 7) Expendable donor 8) Timing of tendon transfer

Prerequisites for tendon transfer•The patient must be a suitable candidate.

•All joints must be fully passively mobile.

•All skin and soft tissue in the vicinity of the transfer must be pliable and mobile.

•The muscle-tendon unit to be transferred must be sufficiently strong to perform its new function in its altered position.

Treatment Goals Preoperative goals

A) Achieving and maintaining full PROM and AROM if possible.

B) Achieving maximum strength of the donor muscle and antagonist muscles

C) Maintaining supple, soft tissue by minimizing scar, edema, and adhesions and resolving intrinsic/extrinsic muscle tightness. Use gel, elastomer molds, kinesiotape, and so on.

D. Complete comprehensive evaluation, including sensory testing, functional assessments, ROM measurements, strength testing, and photographs for postoperative comparison.

E. Educate the patient about the therapy process, splinting demands, and realistic postoperative expectations.

F. Establish good communication with the surgeon, schedule postoperative therapy. Review operative report when available.

Postoperative goals

A.Protect transferred tendon.

B. Maintain ROM of uninvolved joints and involved joints.

C. Control postoperative edema and pain.

D. Control scar tissue (skin and subcutaneous) and prevent adhesions to decrease drag on transfer.

E. Progress patient to functional use of hand.

Indications• Poliomyelitis

• Paralysis of muscle

• Nerve injury (peripheral or brachial plexus)

• Injured (ruptured or avulsed) tendon or muscle

• Balancing deformed hand e.g. cerebral palsy or rheumatoid arthritis

• Some congenital abnormalities

• Prompt consideration of tendon transfers is indicated if,

(a) The prognosis for neurologic recovery is poor even with nerve repair,

(b) Muscles have been destroyed, or

(c) Nerve grafts have been required to restore nerve continuity.

Contraindications

1. Contracture of joints or skin that would limit movement.

2. Lack of a suitable muscle or muscles for transfer.

3. A progressive neuropathy, e.g. nerve damage following radiation therapy.

4. Complicating medical conditions, e.g. muscle spasm or circulatory inadequacy.

PrecautionA. Acceptance of less than full PROM before transfer.

B. Overestimation of donor muscle strength

C. “Drag” along transfer route secondary to scar

D. Technical failures (e.g., rupture of juncture, too loose or too tight)

E. Be mindful of stretching out transfer. Wait until 6 weeks after surgery before addressing tightness of transfer.

Radial Nerve Palsy• The classic ‘wrist drop’ result.

• When the wrist cannot be stabilized in extension, the power of the long flexors is minimized, thereby seriously impairing grip function.

• Where the radial nerve is irreparable, the following functions will need to be restored:1. Wrist extension.

2. Finger extension (at the MCP joints).

3. Thumb extension and abduction.

Purpose

• It is impossible for the patient with this condition to open the hand to grasp objects; therefore, the transfer of normally functioning muscle–tendon units is frequently used to overcome the deficit.

• The radial nerve supplies all of the wrist extensors and finger extensors, including the thumb.

Preoperative requirements1. The wrist must be passively mobile in extension.

2. The MCP joints must be passively mobile in extension.

3. The thumb web space must be normal.

4. There must be a full range of forearm supination/pronation and also elbow flexion/extension.

5. Minimize edema if present.

Tendon transfer for radial nerve palsy

1)Flexor carpi radialis transfer• PT to ECRB for wrist extension

• Flexor carpi radialis (FCR) to EDC for finger MP extension

• Palmaris longus (PL) rerouted to EPL for thumb extension

2)Flexor carpi ulnaris transfer• PT to ECRB for wrist extension

• FCU to EDC for finger MP extension

• PL to rerouted EPL for thumb extension

3)Boyes transfer (Superficialis transfer)• PT to ECRL and ECRB

• Flexor Digitorum Superficialis (FDS) III to EDC

• FDS IV to Extensor Indicis and EPL

• FCR to APL and EPB

Flexor carpi ulnaris (FCU) transfer for radial nerve palsy using pronator teres (PT), FCU and palmaris longus (PL) as motors.

Post operative ManagementSplint position 1. Elbow in 90 degrees of flexion.2. Forearm in about 30 to 90

degrees of pronation.3. Wrist in 30 to 45 degrees of

extension.4. MCP joints in 10 to 15 degrees of

flexion; PIP joints free or at 20 to 45 degrees flexion. The splint extends just proximal to the PIP joints which are left free to move.

5. Thumb in maximum extension and abduction.

• Week 0 to week 3 or 4: Splint/cast.A. Maintain ROM of uninvolved jointsB. Protective ROM of individual jointsC. Avoid composite wrist and digit flexion.D. Edema managementE. Scar managementF.Desensitization techniques

• Week 3 or 4: Splint. Fabricate splint, according to surgeon’s guidance, which may or may not include the elbow. Position the hand and wrist in same positions as in the original cast.A. ROM: as above.B. Scar management

• Weeks 5 to 6: Muscle reeducation.

• Week 7: Begin dynamic flexion splinting if extrinsic extensor tendon tightness is present.

• Week 8: Discontinue protective daytime splinting; introduce resistive exercises. Begin passive wrist flexion to gain maximum pronator teres length.

• Week 12: Resume unrestricted activities.

Different splints

Ulnar Nerve Palsy• Affect pinch and grip strength and manipulation

and cause difficulty with the approach of objects due to a claw-hand deformity.

• Denervation of the flexor digitorum profundus (FDP) to the ring finger (RF) and small finger (SF) complicates the deficits of intrinsic weakness by further weakening grasp.

•The signs indicative of ulnar nerve palsy are as follows:

•Froment’s sign:

•Jeanne’s sign:

•Duchenne’s sign:

•Wartenburg’s sign:

•Purpose

▫Restore balance and function of a hand▫This may occur as a result of prolonged

compression as in cubital tunnel syndrome, trauma, disease, infectious processes, congenital anomalies, or spastic paralysis.

• Where the Ulnar nerve is irreparable, the following functions will need to be restored:

1) MCP joints Flexion 2) Thumb adduction.

•Preoperative requirements for ulnar nerve lesion

1. The PIP joints must be fully mobile in passive extension and the MCP joints fully mobile in passive flexion.

2. Soft tissues should be free of contracting scar and have adequate circulation.

Tendon Transfer for Ulnar nerve palsyo Suitable muscle-tendon units include:

• Flexor digitorum superficialis, extensor carpi radialis longus, extensor carpi radialis brevis, flexor carpi radialis, brachioradialis and palmaris longus.

• The smaller extensors, i.e. extensor indicis proprius and extensor digiti minimi (quinti) can provide intrinsic function with the transfer of a muscle to two fingers each (original Fowler technique)

• Superficialis transfers are designed to integrate MCP joint and IP joint motion. They do not, result in increased grip strength . The use of a wrist extensor to flex the MCP joints will improve gross power grip.

•Low Ulnar Nerve InjuryA) Intrinsic Rebalancing

1) FDS of middle finger (MF)

2) Zancolli lasso procedure3) Brand transfer of ECRL/ECRB to intrinsics

with tendon graft

B) Restoration of power pinch1) Smith-Hastings procedure ECRB ADP with graft2) FDS of RF ADP

• High Ulnar Nerve Injury 1) ECRL FDP

Post operative management• Splint position

1. Wrist in 45 degrees of extension.

2. MCP joints in 70 degrees of flexion.

3. IP joints in full extension.

4. The thumb remains free

Postoperative day 10 to 14: • Remove postoperative cast, have tension checked

by surgeon, and immobilize patient in splint or recast. ▫A. Fit the patient with a splint ▫B. Gentle AROM and PROM within the restraints

of the splint.

Week 4: • The hand and forearm are maintained in the

described position for the first postoperative month. • Begin AROM out of splint, avoiding composite

extension.

Week 6:

• When the hand is removed from the splint and placed on the table, there will be a slight relaxation of the positions of wrist extension and MCP joint flexion.

• The patient is then asked to actively extend the wrist which should result in some MCP joint flexion. Extension of the IP joints should be maintained during this manoeuvre.

• The hand is returned to the splint after each exercise session until the end of the 6th week.

• The patient should perform this exercise on a 1 to 2 hourly basis with 5 to 10 repetitions during the 1st week of active exercise.

• By the 2nd week, the patient learns to localize the action of MCP joint flexion without having to extend the wrist and practises the movement with the hand in all positions, i.e. palm up and with the hand on the side.

• By the 5th week, emphasis is placed on active flexion and extension of the fingers while maintaining MCP joint flexion. Gentle active wrist flexion is also begun. May introduce light resistance.

Week 6 to 12:

• Progressive resistive exercises. It is important not to fatigue the transfer.

• Light gripping activities are commenced.

• Graded resistance is applied to MCP joint flexion with the IP joints extended, i.e. intrinsic flexion.

• The activity programme is upgraded to restore maximum power grip.

Different splints

Median nerve Palsy• Functional impairment from a median nerve lesion

is primarily the result of lost skin sensibility on the working surfaces of the thumb, index and middle finger, those used for precision manipulation, rather than the loss of muscle function.

• The main function that needs to be replaced is opposition of the thumb.

• Three muscles are used for this function▫Abductor pollicis brevis,▫Opponens pollicis and ▫Flexor pollicis brevis.

Purpose

• Restore balance and function of a hand.

• This may occur through prolonged compression as in carpal tunnel syndrome, trauma, disease, infectious process, congenital anomalies, or spastic paralysis.

•Preoperative Requirements prior to opponensplasty for low level lesion (wrist)

1. Normal or maximal thumb web span.

2. Mobile thumb joints.

3. Full mobility of the unaffected digits.

4. Soft tissues should be free of contracting scar and have adequate circulation.

Tendon transfer for Median nerveLow Median nerve palsy

•Opponensplasty :-

A. FDS of ring finger (RF) or PL to APB : long opponens splint

B. Extensor indicis proprius (EIP) to APB: long opponens splint

C. Abductor digiti minimi (ADM) to APB : hand-based or long opponens

Post operative Management•Splint position • The wrist is immobilized in

neutral extension with the thumb held in full opposition and the IP joint of the thumb held in extension

• The fingers are left free to move. • If the PIP joint has been

tenodesed to prevent hyperextension deformity, it should be splinted in about 45 degrees of flexion during the immobilization period.

Postoperative day 10 to 14: Remove postoperative cast, have tension checked

by surgeon, and immobilize patient in splint. Address wound care, edema reduction, and scar management if indicated.

Week 3: Begin AROM of thumb in splint to activate transfer, six to eight times per day

Week 4: Begin AROM of thumb and other joints out of splint. Focus on activation of transfer. May use light grasp and prehension tasks.

Week 6: Discharge splint for protection and begin unrestricted AROM/PROM. May introduce light resistance.

Week 8: Progressive resistive exercises. Preferably the patient should complete frequent low-resistance exercise sessions rather than occasional higher-resistive exercises. It is important not to fatigue the transfer.

Week 12: Resume unrestricted activities.

High Median Nerve Injury•Flexor Pollicis Longus• Brachioradialis/FDS to FPL: dorsal blocking splint

(possibly long arm splint with elbow in 90 degrees flexion for brachioradialis)

Postoperative day 10 to 14:

Week 3: AROM of MCP/IP within splint to activate transfer, six to eight times per day9

Week 4: AROM out of splint for transfer activation and light prehension

Week 6: Discharge splint; PROM and splinting to decrease tightness if present

Weeks 7 to 8: Progressive resistive exercises

Different splint

Post operative Complication• Scarring of tendon to surrounding structures

• Difficulty activating transfer.

• Transfer too loose or too tight. Wait 6 weeks before doing any PROM or splinting against transfer.

• Rupture of transfer repairs

• Overstretching of transferred tendon

Evaluation Timeline

Postoperative day 10 to 14 (after tension has been checked by surgeon)A. Control of edema and pain, wound careB. ROM of uninvolved joints and protected ROM

of involved joints as allowedC. Splint for protection and immobilization

Week 3: AROM of joints and activation of tendon transfer in splint

Week 4: AROM of all joints with splint removed; nonresistive activities in therapy, NMES for transfer activation

Weeks 6 to 8: Discharge protective splint. AROM/PROM and functional activities, splinting for tightness. Progressive resistive exercises at week 8.

Week 10: Manual muscle testing and functional outcomes

Recent advances

• Flexor digitorum superficialis opposition tendon transfer improves hand function in children with Charcot-Marie-Tooth disease: Case series, December,2013

• Transfer of the flexor digitorum superficialis tendons of the middle and ring fingers to restore extension of fingers and thumb (Boyes' transfer), August,2013

References• Burke, Higgins, McClinton, Saunders, Valdata.

Hand and Upper Extremity Rehabilitation, A Practical Guide, 3rd Edition.

• Judith Boscheinen-Morrin. The hand: fundamentals of therapy – 3rd Edition

• Robert w. Beasley, Tendon Transfers, Ch.-88

• Cynthia Cooper, Fundamentals of hand therapy, Clinical Reasoning and Treatment Guidelines for common diagnosis of Upper Extremity

• Dr Jason Crane, Tendon transfers for nerve injuries of the Upper Limb

• GS Kulkarni, Textbook of Orthopedics and Truma, Volume One.

• Flexor digitorum superficialis opposition tendon transfer improves hand function in children with Charcot-Marie-Tooth disease: Case series. T. Estilow; S.H. Kozin; A.M. Glanzman; J. Burns; R.S. Finkel, January, 2014.

• Transfer of the flexor digitorum superficialis tendons of the middle and ring fingers to restore extension of fingers and thumb (Boyes' transfer). Pillukat T; Blanarsch B; Schädel-Höpfner M; Windolf J; van Schoonhoven J; August, 2013.

THANK YOU