1. TENDON TRANSFERS AND UPPER LIMB DISORDERS
Aws Khanfar,
MBBS, MRCSI, MFSEM, CHSOrth, FEBOT

2. 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.

3. 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

4. Indications Paralysed muscle
Injured (ruptured or avulsed) tendon or muscle
Balancing deformed hand e.g. cerebral palsy or rheumatoid arthritis
Some congenital abnormalities

5. 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

6. 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

7. General principles Amplitude of the donor muscle ( TENDON EXCURSION)
-. Donor muscle factors
Amplitude of the donor muscle ( TENDON EXCURSION)

8. General principles Power of the donor muscle
Any transferred muscle loses at least one grade of strength, so only Grade 5 muscles are satisfactory

9. 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

10. 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

11. 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

12. Basic Principles of Post Operative Rehabilitation
1. Pro tective phase
Begins at surgery and lasts 3 – 5 weeks
Objectives:-
Protective splinting
Oedema control
Mobilise uninvolved joints

13. Mobilise tendon transfer
2. 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

14. Basic Principles of Post Operative Rehabilitation
3. 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

15. Radial Nerve Palsy
Wrist extension is critical for stability, which is essential for grip and assisting the function of many tendons crossing the wrist

16. Tendon Transfers Well defined and highly effective, aiming to replace
Wrist extension
Finger extension
Thumb extension and abduction
Standard

17. Radial Nerve Palsy Non-Operative Treatment Splintage
Maintenance of full passive ROM in all joints of the wrist/hands and prevent contractures

18. Radial Nerve Palsy Early transfers (“Internal Splintage”)
greatest functional loss is grip strength

19. PT to ECRB

20. FCU to EDC

21. PL to EPL

22. Common Upper limb disorders
Symptoms:
Muscle/tendon problems :
Pain , Swelling ,Weakness
Nerve related :
Tingling/altered sensation , Weakness

23. Tendon problems: Dequervain’s
History:
New, repetitive activity
Pain over thumb side of the wrist
Pain on making a fist,
grasping or holding objects

24. Examination
Swelling
Thickening
Tenderness
Freinklestein test

25. Treatment
Activity modification
NSAID
Splintage – thumb widely abducted
Steroid Injection

26. . Surgical Release

27. 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%

28. Etiology
Multiple microtraumatic events
Disruption of the internal structure of the tendon and degeneration of the cells and matrix

29. 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

30. Non- Operative Treatment options
Topical NSAIDs
Oral NSAIDs
Orthotic devices
Physiotherapy

31. Operative treatment
Surgery to repair the tendon

32. 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

33. Association of CTS in computer workers

34. Symptoms
Pins and needles
Pain
The pain may travel up the forearm.
Numbness of finger
Dryness of the skin
Weakness of muscles

35. AnatomyContents:
Nine flexor tendons
Tendons
Median Nerve

36. Examination
Dry pulps
Wasting of Thenar muscles
Tinels

37.  Investigations
Nerve conduction test

38. Treatment
Night splints
Surgical release

39. Shoulder Impingement syndrome
Pain in shoulder
Increases with activity
Clicking sensation in shoulder
Pain with overhead activities/ reaching for seat belt, wearing cloths

41. Treatment
Pain medication
Activity modification
Physio ,To improve scapular position , Strengthen a specific group of muscles
Injection into shoulder
Surgery