Problems and solutions in palliative tendon transfer surgery for radial nerve palsy

Palliative tendon transfer procedures for radial nerve palsy are continuing to evolve. The main modifications have concerned the operative techniques and the choice of procedures to adapt surgery to the needs of the patient. A study of all the elements of tendon transfer has been undertaken and has gradually led us to describe two basic methods of transfer either using or not using the flexor carpi ulnaris for transfer. The essential consideration is the avoidance of radial deviation of the wrist by centralizing the insertion of the extensor carpi radialis longus.     

Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury.

Patients with tetraplegia who have "strong" sixth cervical neurologic (C-6) function often can be given active grasp and strong lateral pinch by tendon transfers and tenodeses. Wrist control can be retained by the extensor carpi radialis brevis and flexor carpi radialis and can permit transfer of the extensor carpi radialis longus to provide finger flexion. Either the brachioradialis or pronator teres then is available for transfer to restore adduction-opposition of the thumb with an in situ tendon graft of a paralyzed flexor superficialis rerouted to the thumb through a palmar fascial pulley. The other motor can provide thumb flexion for strong lateral pinch. Extrinsic extension can be provided by tendoeses. With seventh cervical neurologic (C-7) function retained, active digital extension is present and functional expectations are better. Ten hands in seven patients with traumatic tetraplegia from injuries at C-6 or C-7 level have been reconstructed. The average grasp and pinch force after operation was 5.5 and 3.0 Kg., respectively. All patients but one were pleased with the increased function a     

Transfer of extensor carpi radialis longus or brevis for opponensplasty

For the restoration of thumb opposition many types of tendon transfer techniques have been described. The flexor digitorum superficialis (FDS) of the ring finger is commonly selected as a motor. On occasion, however, the quality of the flexor muscles of the fingers or wrist is not good enough for tendon transfer and another available muscle must be selected. In this situation, we have preferred to use an extensor carpi radialis longus (ECRL) or brevis (ECRB) transfer to restore opposition of the thumb. Follow-up examination, at an average 5 years and 10 months after operation, showed that the results of ten of 11 transfers were excellent and the other was good.     

The extensor carpi radialis intermedius tendon

I examined 312 arms from 156 cadavers in the anatomy laboratory of Loma Linda University to find the incidence of the extensor carpi radialis intermedius tendon. I found 29 bodies (12%) that had a good extensor carpi radialis intermedius. In 17 of these 29 bodies, an extra tendon was found bilaterally. Thirty-two extensor carpi radialis intermedius tendons were suitable for transfer operations, and seven were unacceptable. One must be careful to differentiate between a true extensor carpi radialis intermedius tendon and accessory tendinous bands. The relatively high incidence rate and percentage of tendons suitable for transfer operations make this tendon potentially valuable in treating severe quadriplegia with tendon transfers. It can be used successfully for thumb opposition, to motor the flexor pollicis longus, or as a motor for the extensor pollicis longus of the thumb.     

Flexor carpi radialis tendon rupture as a complication of a closed distal radius fracture: a case report

Although extensor pollicis longus tendon ruptures have been noted as a complication of distal radius fractures, flexor tendon ruptures in association with acute fractures of the distal radius are rare. We report a rupture of the flexor carpi radialis tendon as a complication of an acute distal radius fracture that was discovered during operative management of the fracture.     

Restoration of pinch in intrinsic muscles of the hand

The primary intrinsic muscles responsible for key and tip pinch are the adductor pollicis, first dorsal interosseous and flexor pollicis brevis muscles. Numerous conditions can lead to their dysfunction. Non-operative treatment consists of exercises of the compensating extensor pollicis longus and flexor pollicis longus muscles and use of adaptive devices, such as larger grips. Operative treatments include tendon transfers and joint fusions. The most common tendon transfer procedures include transfering of the extensor carpi radialis brevis to the adductor pollicis muscle or transfering of the abductor pollicis longus to the first dorsal interosseous muscle. Both require use of extension tendon grafts. In cases of joint instability or arthrosis, arthrodesis of the thumb and index finger MP or IP joints, alone or in combination, may be indicated.     

Repair of flexor carpi radialis tendon laceration at the wrist in a professional ice hockey player

The flexor carpi radialis is a wrist flexor and radial deviator with half the relative strength of flexor carpi ulnaris. In the majority of patients, the flexor carpi radialis tendon is expendable and is routinely used for various reconstructive procedures about the hand and wrist. Isolated flexor carpi radialis lacerations at the wrist are rare. Flexor carpi radialis tendon ruptures, which have been reported in association with distal radius fractures, longstanding osteoarthritis, and percutaneous treatment of scaphoid fractures, are usually treated non-operatively. We report a case of a traumatic laceration of the flexor carpi radialis tendon at the wrist in a professional ice hockey player. Surgical repair and rehabilitation using established principles for intrasynovial flexor tendon repair allowed return to sport at the professional level in 2 months.Tension-free core suture repair was performed with a modified-Kessler, 4-strand repair using a double-stranded 4-0 Supramid suture. A running epitendinous suture was then placed around the circumference of the tendon with 6-0 Prolene. Immobilization of the wrist in 20° of flexion was maintained for 2 weeks. Full active and passive digital motion was allowed immediately postoperatively and continued throughout the rehabilitation. Therapy was initiated at 2 weeks postoperatively with full passive wrist flexion and passive wrist extension to a dorsal block of 20°. At 4 weeks postoperatively, a dorsal splint was fabricated to keep the wrist in neutral. At this time, active extension to a dorsal block of zero and full passive flexion was allowed. Active wrist flexion without resistance was begun at 6 weeks, and full strengthening was allowed at 8 weeks postoperatively. The patient returned to sport at the professional level shortly thereafter. At latest follow-up, the patient has been able to fully participate in professional ice hockey without pain or functional limitation.     

A modified technique of two-staged extensor tendon reconstruction in zones 6–8 in a patient with absent palmaris/plantaris tendons: A case report

IntroductionThe indications for two-staged extensor tendon reconstruction are rare and only 14 previously reported cases were found in the literature. In these cases, silicone rods are inserted in the first stage. Few months later, the palmaris longus / plantaris tendon grafts are usually used to replace the silicone rods.Case reportwe encountered a patient with major defects of the extensor tendons of all fingers extending from the proximal one third of zone 6 to zone 8. The patient had no palmaris or plantaris tendons. We utilized a modified technique of reconstruction using the split flexor carpi radialis as the tendon graft and the flexor carpi ulnaris as the motor tendon. At final follow-up, there was full active extension of the fingers. However, there was limitation of wrist flexion because of the harvesting of both wrist flexors.DiscussionWe describe a modified technique of two-staged extensor tendon reconstruction which may be used in patients with absent palmaris/ plantaris tendons.ConclusionIn patients with absent palmaris/ plantaris tendons and major defects of the extensor tendons of all fingers, the use of split flexor carpi radialis is an adequate alternative for reconstruction and gives a good functional outcome.     

Closed tendon injuries of the hand

Cases of subcutaneous tendon ruptures of the hand were compiled over a period of 10 years; the lesions were all traumatic rather than due to degenerative illness. The 914 injuries fall into two categories: 867 extensor and 47 flexor tendon ruptures. The localisation of the lesions is most often distal. The extensor tendon lesion is accompanied more often by a ruptured bony fragment; the distal flexor tendon is mostly torn-off bony fragment. The extensor tendon ruptures can be subdivided as follows: distal injuries of the extensor aponeurosis in the DIP joint (751 cases), IP joint (31), tractus intermedius (27), ext. carpi radialis longus (5) and brevis (1), ext. carpi ulnaris (6); proximal ruptures of the ext. pollicis longus (42), ext. digitorum communis II and indicis (1 each) and ext. carpi radialis longus and brevis (1 each). The flexor tendon lesions are as follows: distal injuries to flex. digitorum profundus (32 cases), flex. pollicis longus (9), and the opponens pollicis, which is classified under this heading (2). Proximal lesions to flex. pollicis longus (2) and flex. digitorum profundus and superficialis (1 each).     

Reconstruction of the thumb in tetraplegia following spinal cord injury

Functional positioning of the thumb is paramount to the restoration of lateral pinch to the hands in patients with tetraplegia as the result of spinal cord injury. Useful lateral pinch can be provided to patients with at least wrist extension control preserved by use of a combination of flexor pollicis longus tenodesis or transfer and carpometacarpal and inter phalangeal joint stabilization. In patients who retain function in the brachioradialis, extensor carpi radialis longus and brevis, pronator teres, and flexor carpi radialis, strong grasp as well as effective lateral pinch can be restored to the hand by surgery. Thumb control for flexion and extension is provided by tendon transfer to the flexor pollicis longus and tenodesis or transfer to the extensor pollicis longus. Proper positioning for lateral pinch can be accomplished by either arthrodesis of the first metacarpal-trapezial joint or tendon transfer to restore adduction-opposition to the thumb. The surgical concepts presented in this paper have been applied to the functional reconstruction of the hands of more than 50 patients with spinal cord injury during the last 15 years. The patients have been pleased with the significant improvement in function, strength, and speed that has resulted from surgery and have been cooperative advocates as the alternate methods of thumb control have been evaluated.     

Exterior carpi radialis longus tendinoplasty for thumb basal joint arthritis

Thumb carpometacarpal arthritis has been successfully treated with a combination of trapezium excision, ligament reconstruction, and tendon interposition (most commonly with the flexor carpi radialis [FCR] tendon). We describe a technique using the extensor carpi radialis longus (ECRL) tendon and show, through dissection of 36 cadaver hands, the close relationship between this tendon and the intermetacarpal ligament. Of 16 patients (19 hands) managed with this technique, 95% were satisfied at a mean follow-up of 42 months. We conclude that ligament reconstruction and ECRL tendon interposition constitute a viable treatment option for carpometacarpal joint arthritis, especially when the FCR tendon is unavailable or its use is undesirable.     

Lateral epicondylitis: Open and arthroscopic treatment

Lateral epicondylitis is the most common affliction of the elbow. It occurs in middle-aged individuals and is self-limiting in the majority of cases. The etiology of the condition is not completely understood. Based on clinical, histologic, and imaging data, the tendinous origin of the extensor carpi radialis brevis is the most likely site of pathology. A variety of procedures have been described to treat epicondylitis. Most commonly, the extensor carpi radialis brevis tendon origin is debrided with either open or arthroscopic methods. Both techniques require a thorough understanding of the anatomy of the extensor tendon origin at the humeral epicondyle. Improvement is reported in the majority of cases treated surgically, although residual symptoms persist in a substantial number of patients. Copyright © 2001 by the American Society for Surgery of the Hand     

Extensor tenodesis for plexic hands with C7 to T1 or C8, T1 root avulsions: a new technique

In C7 to T1 or C8, T1 root avulsion palsies, restoration of finger active extension is not possible. Only tenodesis may restore hand opening in active wrist flexion. Many techniques have been described to restore this motion. In routine techniques, extensor tendons are fixed on radius or sutured on dorsal retinaculum. However, in these procedures, progressive tendon lengthening or ruptures may occur and salvage procedure may be difficult to perform. Therefore, we proposed a new extensor tenodesis technique. The extensor digitorum communis tendons are sutured on the paralyzed flexor digitorum superficialis tendons through interosseous membrane. This procedure allows performing a strong tendon to tendon suture more resistant than radius or retinaculum fixation. As other tenodesis techniques, wrist flexion has to be active to obtain hand opening.     

Passive muscle-tendon amplitude may not reflect skeletal muscle functional excursion

PURPOSE: To quantify the gain in muscle mobility with progressive release of surrounding connective-tissue structures and to compare this property with the known architecture of each muscle. METHODS: Each of 5 different muscle tendon units (extensor carpi radialis brevis, extensor carpi radialis longus, flexor carpi ulnaris, flexor digitorum superficialis, pronator teres) was released from its insertion and secured into the jaws of a clamp attached to a servomotor that could be operated under length or force control to simulate the load placed on the tendon by a surgical assistant. A constant load of 5 N was applied to the tendon while the muscle-tendon unit was released surgically from the surrounding tissue in 1-cm increments. Mobility was plotted against release distance and analyzed by linear regression to yield mobility gain, the slope of the regression equation. One-way analysis of variance was used to compare mobility gain among muscles. RESULTS: In contrast to previous results from the brachioradialis muscle in which the mobility gain was large and highly nonlinear, mobility gain was small, consistent, and linear for all muscles studied. The smallest mobility gain was for the flexor digitorum superficialis and was highly linear. The largest gain was for the pronator teres and again was highly linear. In general, the mobility gain for the extensor carpi radialis brevis was similar to that of the extensor carpi radial longus. The flexor carpi ulnaris muscle was difficult to mobilize, and its gain was modest. There was no significant correlation between mobility gain of the forearm muscles during progressive release and the length of their fibers. CONCLUSIONS: The small mobility and complete lack of correlation with fiber length provide strong evidence that mobility gain does not accurately reflect muscle excursion as it is typically described. This calls into question the general practice of tensioning muscles by first passively extending the muscle and then choosing the attachment length as a particular portion of that passive relationship.     

Tendon transfer to reconstruct wrist extension in children with obstetric brachial plexus palsy

This study reports on 20 children with obstetric brachial plexus palsy who underwent a tendon transfer to reconstruct wrist extension. The mean age at the time of tendon transfer was 8 years. There were seven patients with Erb's palsy and the remaining 13 had total palsy. The flexor carpi ulnaris was utilized 15 times and the flexor carpi radialis five times. The transferred tendon was sutured to the tendon of the extensor carpi radialis brevis. The result of the transfer was assessed according to a modified Medical Research Council (MRC) muscle grading system. A good result was obtained in 18 patients (modified MRC grade of 4) and a fair result (modified MRC grade of 3) in two. The choice of tendon transfer to reconstruct the wrist drop deformity in various conditions including adult traumatic brachial plexus injuries is discussed.     

Biomechanical changes of the wrist flexor and extensor tendons following loss of scaphoid integrity

Loss of integrity of the scaphoid may change the motion center of the entire carpus, and deformities from scaphoid fractures may alter the location of motor tendons of the wrist, thus altering their biomechanics. The goal of this study was to clarify biomechanical changes in these tendons following loss of scaphoid integrity. Excursions and moment arms of the principal flexor and extensor tendons of the wrist were investigated in seven cadaveric upper extremities in intact wrists after simulation of scaphoid waist fracture and after removal of the proximal scaphoid. Excursions of the flexor carpi radialis and ulnaris extensor carpi radialis longus and brevis, and extensor carpi ulnaris tendons were measured with rotary potentiometers during wrist flexion-extension and radioulnar deviation. Simultaneously, wrist joint angulation was recorded. Moment arms of the tendons were derived from tendon excursions and joint motion. After scaphoid fracture, the moment arms of the flexor carpi radialis and extensor carpi ulnaris tendons increased significantly during wrist flexion-extension, whereas the moment arms of the extensor carpi radialis longus and brevis tendons decreased significantly. After proximal scaphoid excision, the moment arms of the extensor carpi radialis longus and brevis tendons again decreased significantly during wrist flexion-extension. The moment arms of the flexor carpi radialis and extensor carpi radialis brevis tendons increased significantly during radioulnar deviation, whereas those of the wrist motors on the ulnar side decreased. These findings indicate the importance of the integrity of the scaphoid in maintaining normal biomechanics of motor tendons of the wrist. An increase in the moment arm of the radial wrist flexor along with a decrease in moment arms of the radial extensors constitutes an etiology for persistent angulation of the scaphoid and the hump-back deformity. In addition, disturbing the biomechanics of the wrist motor tendons predisposes the carpal joints to abnormal loading, potentially contributing to the development of carpal joint degeneration.     

Intraoperative assessment of wrist extensor muscle force

Surgical restoration of hand grasp in the patient with spinal cord injury at the sixth cervical level often involves use of one of the two radial wrist extensors. Because the loss of the remaining wrist function would be devastating, it is important to establish techniques for quantitatively predicting postoperative function before tendon transection. An in situ method has been developed for determining muscle strength during tendon transfer surgery. Buckle transducers are placed on the tendons of the extensor carpi radialis brevis and longus for simultaneous measurement of strength of each individual muscle during voluntary and/or electrically stimulated extension of the wrist. The measured strength of the extensor carpi radialis brevis is examined to determine whether sufficient wrist extension torque would remain if the long wrist extensor is transferred. This technique allows accurate measurement of the force developed in any voluntarily activated muscle that has a long tendon of insertion.     

Evolution of surgery for tetraplegic hands in Japan

In Japan, reconstructive surgery for the tetraplegic hand has developed mainly with Tsuge, Yabe, and their students for a little more than 30 years. They mostly used Zancolli's classification and, consequently, followed his treatment guidelines. Some unique procedures and techniques, however, have been devised based on their own experiences, including a static opponens tenodesis using FCR tendon, a modified lasso procedure to anchor a paralyzed flexor superficialis tendon through A2 pulley rather than A1 pulley, one-stage reconstruction of both extensor and flexor tendons, and the percutaneous functional electrical stimulation (FES) system.     

Architecture of selected wrist flexor and extensor muscles

The architectural features of 25 wrist flexor and extensor muscles were studied. Muscles included the flexor carpi ulnaris, the flexor carpi radialis, the extensor carpi ulnaris, the extensor capri radialis brevis, and the extensor carpi radialis longus. Muscle length, mass, fiber pennation angle, fiber length, and sarcomere length (by use of laser diffraction techniques) were determined. In addition, physiological cross-sectional area and fiber length/muscle length ratio were calculated. The muscles were found to be highly specialized, with architectural features of same muscles very similar. The fiber length/muscle length ratio, muscle length, and pennation angle represented the major differences between muscles. Thus using these parameters in discriminant analysis permitted correct identification of each of the 25 muscles. In terms of size and intrinsic design, these individual muscles were highly specialized for their function.     

A method of restoration of the abduction of the thumb in traumatic tetraplegic patients

A method of restoring extension and abduction of the thumb in traumatic tetraplegia is described. This method includes tenodesis of the abductor pollicis longus, transfer of the distal stump of the extensor pollicis brevis tendon to the flexor carpi radialis tendon, and transfer of the distal stump of the extensor pollicis longus tendon to the brachioradialis tendon. I performed this procedure on 6 hands in 5 patients and monitored each patient for 6 to 12 months. A significant increase in radial abduction of the thumb (0.5 +/- 0.2 cm to 2.8 +/- 0.2 cm) occurred in all hands.