Modified Tsuge technique for functional reconstruction of hands with radial nerve palsy
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Objective To introduce a new method of tendon transfer for treating radial nerve palsy and evaluate the clinical outcomes. Methods Twelve cases of irreversible radial nerve injuries were treated with the modified Tsuge technique to reconstruct the function of wrist, thumb and finger extension since June 2002.Results All 12 cases were follow-up for 2 to 48 months. According to Chen Desong's 1994 criteria for outcome evaluation of tendon transfers in radial nerve palsy, good results were seen in 10 cases and fair results in 2 cases.The overall satisfactory rate was 100%. One of the 2 cases that showed fair results had brachial plexus cut injury and repair 8 years earlier, which yielded weaker donor for tendon transfer. The other case was accompanied by soft tissue defect of the dorsal forearm that required flap coverage and hence postoperative scarring. Conclusion Modified Tsuge tendon transfer is the most suitable, simple and effective method for functional reconstruction in radial nerve palsy.
Key words:
Radial nerve; Hand injuries; Functional reconstruction; Tendon transferKeywords:
Radial nerve
Tendon transfer
Brachial plexus injury
Posterior interosseous nerve
Axillary nerve
Metacarpophalangeal joint
Little finger
Numerical digit
Middle finger
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Background: Rupture of the extensor pollicis longus (EPL) tendon after distal radius fracture is a well-known complication. Two mechanisms have been proposed in the literature: a mechanical irritation of the tendon caused by bony prominence or implant material and direct microcirculatory compromise of the poorly vascularized tendon. Attempts to restore the function of the thumb using tendon graft or tendon repair have been reported with unpredictable results. In this report, we performed extensor indicis proprius (EIP) tendon transfer for extensor pollicis longus tendon rupture in patients with distal radius fracture using two to three small incisions and showed reliable results without functional deficit of the donor finger. Aim and Objectives: To reconstruct the ruptured EPL tendon after distal radius fracture via EI tendon transfer can not only minimize the donor site morbidity but also offer a reliable method. Materials and Methods: Totally 16 patients were recruited in this study from January 2004 to December 2013. In all patients, distal radius fracture with fracture fragment, bony spur or prominent fixation devices were found in the imaging study. EPL tendon rupture was diagnosed and reconstruction was performed with EIP tendon transfer in all cases. The functional outcomes of thumb are evaluated by: range of motion of thumb abduction/adduction (angle between index and thumb), elevated angle between table and MCP joint of thumb; extension lag of IP joint of thumb; opposition distance of thumb tip to the little finger tip and comparing with non-operated hand. Each parameter was scored as zero, one, two, or three points. Results: Among the 16 patients, 8 were follow up postoperatively for longer than 6 months. The parameters for functional outcome of the thumb were monitored and the results of surgery were graded as good, fair, or poor according to the total scores of each parameter. A total score of 7 to 9 points was graded as good, 4 to 6 points as fair, 0 to 3 points as poor. Seven patients showed good results, and 1 patient had poor results. Conclusion: Restoring the EPL tendon function using tendon transfer with extensor indicis proprius tendon to extensor pollicis longus tendon is a simple and reliable method. No obvious functional deficit of the index finger was encountered. All patients were satisfied with the range of motion of thumb, compared to the normal side, but they were still dissatisfied with the muscle power of pinch and grip function. A complete post-operative rehabilitation program is essential to obtain satisfactory outcomes.
Tendon transfer
Distal radius fracture
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The radial nerve is one of the three important nerves of the upper limb which causes the wrist, fingers and thumb extension. Loss of radial nerve function in the hand creates a significant disability with difficulty in grasp and power grip. Injuries to the radial nerve can occur at any point along its anatomical route and the etiology could be either post-traumatic or post-surgical. After irreparable radial nerve injury, the only treatment available is tendon transfer other than arthrodesis. Tendon transfer is a treatment option to compensate for the loss of function of the wrist, fingers and thumb extensions of which the flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) are the most common used donor tendons. FCR tendon transfer provides better functional results than FCU tendon transfer. There is no standard procedure but the surgeon must tailor the tendon transfer procedure according to the patients needs.
Tendon transfer
Radial nerve
Posterior interosseous nerve
Flexor Carpi Ulnaris
Extensor Carpi Ulnaris
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The purpose of this article is to present a case where a double flexor tendon transfer was used to restore thumb, finger and wrist extension in a patient who sustained a complete radial nerve transection secondary to a distal humeral shaft or Holstein-Lewis Fracture. The patient in this case sustained his injury during a motor vehicle collision. He subsequently underwent open reduction and internal fixation (ORIF) with exploration of his radial nerve, which was completely transected. The patient then underwent tendon transfer to restore his thumb, finger and wrist function. Tendon transfers using Flexor Carpi Ulnaris, Flexor Digitorum Superficialis, and Pronator Teres were utilized to restore function. Typically it is not ideal to utilize two flexor tendons, but because the patient lacked a Palmaris Longus it was necessary in this case. When performing such a procedure it is expected that wrist and digital flexion will be negatively impacted which was not seen in this case.
Tendon transfer
Radial nerve
Flexor Carpi Ulnaris
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Objective To introduce the application of extensor digiti minimi tendon transfer(modified Tajima technique)for functional reconstruction of thumb opposition following median nerve palsy.Methods Thumb opponenplasty was done in 11 cases of high median nerve injury with irreversible palsy.Modified Tajima technique was used to transfer the extensor digiti minimi tendon.The proximal band was anchored onto the extensor pollicis longus tendon at the metacarpal neck.The distal band was inserted in the medullary cavity of the proximal phalanx.Results The patients were follow-up for 4 to 38 months with an average of 18.5 months.Thumb opposition was restored in all 11 patients with 100％ success rate.The extension of the donor finger was not affected.Conclusion Modified Tajima method is a simple and reliable method to reconstruct thumb opposition function.
Key words:
Median nerve; Wounds and injuries; Tendon transfer; Thumb oppositional function
Tendon transfer
Radial nerve
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A radial nerve palsy complicates 1.8 to 17% (mean 11%) diaphyseal humeral fractures (13.7% in our series of 156 humeral fractures and nonunions treated by external fixation – Tsiagadigui, 2000). In about 75%, it is a primary lesion, related to the fracture before any attempt at treatment. In 60%, the fracture, most commonly with an oblique fracture line, involves the middle third. In children, a supracondylar fracture may be complicated by radial nerve palsy. Most nerve lesions correspond to neurapraxia or axonotmesis, due to traction or compression associated with bone angular deformity. Unfrequently, the nerve is impaled or severed by bone fragments, or may be trapped within the fracture in case of a spiral oblique middle or distal third humeral fracture with lateral displacement of the distal fragment. Iatrogenic injury during internal fixation or entrapment within periosteal callus are occasionally observed. The classical indications for early radial nerve exploration include open fractures requiring surgical debridement, or fractures with vascular compromise, or when the osteosynthesis is done by a plate. In all other cases, we recommend to investigate the integrity of the radial nerve by echography. In the absence of discontinuity, spontaneous neurological recovery is likely to occur and is monitored clinically and by electromyography; prevention of joint contracture is done by physiotherapy and by a wrist splint, maintaining the joint in slight dorsiflexion. In case of persistent palsy, neurolysis is indicated several months after the initial injury, the precise delay depending on the level of the fracture. Palliative treatment by tendon transfers offers in cases of persistent palsy excellent functional results. Tendon transfers may be indicated early after the fracture, in case of an irreparable radial nerve lesion.
Radial nerve
Neurolysis
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Since 1994, the author has been treating irreparable radial nerve palsy with pronator teres to the extensor carpi radialis brevis (for wrist extension) and a single tendon (flexor carpi radialis or ulnaris) transfer to restore finger extension as well as thumb extension/radial abduction. We sought to investigate whether these patients are able to flex the fingers with the thumb in abduction/extension posture. This was a prospective study over a 5-year period, and the results of this transfer in 15 consecutive patients (mean age 28 years) were analyzed. At final follow-up (mean 30 months), all patients had reasonable wrist movement, finger extension, and thumb extension/radial abduction. The overall results were rated excellent in 12 patients and good in the remaining three patients according to the Bincaz scale. More interesting was the ability of all patients to flex their fingers with only mild relaxation of the extended/abducted thumb.
Tendon transfer
Radial nerve
Flexor Carpi Ulnaris
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We present an unusual case of chronic posttraumatic anteromedial dislocation of radial head with direct ulnar nerve entrapment in a child. Ulnar nerve decompression, open reduction of the radial head, and annular ligament reconstruction using a palmaris longus tendon graft were performed, and a satisfactory functional outcome was achieved at the 15-month follow-up. Through a review of literature, we conclude that early diagnosis and management for radial head dislocation are recommended to avoid nerve symptoms. Besides, open reduction and annular ligament reconstruction with a palmaris longus tendon graft would be an alternative surgery during chronic phase.
Entrapment
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Objective To explore a modified procedure for reconstruction of extensor tendon insertion.Methods A total of 13 cases of acute avulsion of the extensor tendon insertion were involved.A 'T ' shaped hole was drilled on the base of the distal phalanx perpendicularly by a 1.0 mm K-wire.3-0 tendon suture woven in the terminal extensor tendon was threaded through the drill holes on the distal phalanx to reattach the tendon insertion.DIP joint was fixed at extension by a K-wire which was removed in 6 weeks.A splint was applied to keep the DIP joint in extension till 8 weeks postoperatively when finger extension-flexion movement resumed.A night splint was used till 10 weeks for added protection.Results Primary wound healing was achieved in 12 cases.Wound dehiscence and extensor tendon exposure were seen in one case with severe dorsal skin damage.Flap transfer solved the problem.Postoperative follow-up period ranged from 4 to 30 months.The mallet deformity was corrected.There was no complaint of pain during finger movement.Active motion of involved fingers was satisfactory.According to the upper extremity functional evaluation criteria issued by the Hand Surgery Society of the Chinese Medical Association,the results were rated as good in 11 cases,fair in 1 case and poor in 1 case.The overall satisfactory rate was 92.3％.Conclusion The modified procedure of extensor tendon insertion reconstruction is convenient and practical.
Key words:
Tendon injuries; Surgical procedures, operative; Mallet finger
Mallet finger
Phalanx
Metacarpophalangeal joint
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Double free-muscle transfer is a technique used to treat patients with total brachial plexus palsy to restore hand prehension. It involves the reconstruction of shoulder stability, the transfer of 2 functioning gracilis muscles, and other complementary procedures to optimize the function of the transferred muscles. Wrist arthrodesis is one of these complementary procedures. Our technique of wrist arthrodesis in these patients is different from the standard technique. In this article, we describe our technique and experience of wrist arthrodesis in patients with complete brachial plexus palsy treated with double free-muscle transfer technique. In our procedure, the plate is fixed from the second metacarpal-and not the third as is the usual practice-to the radius to avoid friction with the extensor digitorum communis tendons. A very small bone graft, prepared from the removed Lister tubercle, is needed because of the very thin articular cartilage in these patients. A short arm splint is used for only 1 week postoperatively to avoid finger stiffness. There were no major complications such as pseudoarthrosis or metal failure in our patients because the affected limb is subjected only to mild stresses.
Brachial plexus injury
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