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Multiple tendon transfers for C8 – T1 loss from spinal infarct- Camitz transfer for opposition; ECRL to FDP for finger flexion; Brachioradialis to FPL for thumb flexion

    Overview

    Learn the Multiple tendon transfers for C8 / T1 loss from spinal infarct: Camitz transfer for opposition; ECRL to FDP for finger flexion; Brachioradialis to FPL for thumb flexion surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Multiple tendon transfers for C8 / T1 loss from spinal infarct: Camitz transfer for opposition; ECRL to FDP for finger flexion; Brachioradialis to FPL for thumb flexion surgical procedure.
    Tendon transfers are useful for the restoration of important functional losses. An expendable donor muscle is used for reconstruction of a more useful function. Brand defined the criteria for successful transfer. Each case is unique and the functional deficits should be carefully assessed as well as the strength of potential donors. Patients should be involved in the planning process with pre-operative consultations with the hand therapy team to define the aims of surgery and understand the post-operative rehabilitation requirements.
    This case is a rare situation where a localised spinal cord stroke has damaged the anterior horn cells and caused a permanent loss of the motor outflow at C8 and T1 unilaterally . This lower motor neurone lesion is not amenable to nerve transfer surgery due to the time elapsed since motor loss. The hand remains supple but functionally useless and the patient wishes to restore some function, but understands that normal function is not possible. The case illustrates the assessment process, the techniques involved in tendon transfer surgery that can be applied to other situations and the rehabilitation following surgery.

    Indications

    INDICATIONS:
    Tendon transfers can be used to reconstruct functional loss due to nerve injury, nerve compression, muscle-tendon loss through trauma, post infective paralysis, inflammatory erosion of tendons as is seen in rheumatoid arthritis or congenital absence of muscles and tendons. In the UK, nerve injury reconstruction is the commonest scenario where tendon transfers are undertaken, however worldwide the management of post-infective paralysis from leprosy is the most common reason to consider tendon transfer surgery.
    Brand defined the criteria for a successful nerve tendon transfer and these will be discussed later. I would recommend for ease of recollection, when considering the option of tendon transfer it is worth considering criteria in 4 separate categories:
    Patient factors:
    The cause of paralysis should be known
    The deficit must be static
    The deficit must be functionally significant
    The patient must be able to comprehend the planned treatment and comply with the post-operative rehabilitation requirements
    Donor muscle factors:
    The muscle should be under voluntary control
    The muscle should have MRC grade 4 or greater power
    The muscle should have an amplitude of excursion similar to the recipient tendon
    The muscle should be phasic with the function of the muscle to be reconstructed
    Surgical bed factors:
    Definitive surgery for the skeleton should be completed
    Absence of infection
    There should be minimal scarring in the bed for the rerouted tendon
    Tendons should be rerouted subcutaneously when possible
    If a change of direction is required for the vector of pull then a pulley must be created
    Target factors:
    The joints to be moved should be supple
    The joints should be stable
    The skin should be sensate (not always necessary – NB Leprosy)
    Direct transfer with overlap of donor and recipient tendon to allow a robust repair – otherwise an interposition tendon graft is required
    In this case the spinal stroke resulted in lower motor neurone paralysis of the muscles innervated by C8 and T1 with relative sparing of proximal C5, C6 and C7 innervated muscles. The deficits resulting are similar to those seen in a lower trunk injury of the brachial plexus with loss of digit flexion and intrinsic function. Digit extension is preserved in this case through C7.
    SYMPTOMS & ASSESSMENT:
    The history and examination should identify the cause of the deficit and confirm that the deficit is static. A functional assessment and review by a hand therapist will help to identify the optimum tendon transfer possibilities. Donor muscle strength should be carefully assessed and documented. Consideration should be given to whether the donor muscle is expendable. In cases of paralysis patients may use functional adaptation of existing muscles to compensate for the missing function.
    The flexibility and stability of the target joints should be assessed.
    The sensation of the target skin should be examined using 2 point discrimination and monofilament pressure threshold assessment.
    Te surgical bed should be assessed for scarring in the line of the tendon transfer and if necessary soft tissue corrective surgery (metalwork removal, skin graft excision, flap resurfacing) should be considered where the tendon transfer will lie in advance of any reconstructive surgery.
    INVESTIGATION:
    Radiographs may be necessary to confirm underlying fracture healing.
    Neurophysiology studies may be used to confirm that there is no recovery to be expected in the target muscle function and to assess the quality of the donor muscle in uncertain cases such as brachial plexus injuries where a recovered muscle may be used as the donor for transfer.
    A pre-operative assessment with a hand therapist is essential to help the patient understand the aim of the surgery, prepare for surgery by optimising the donor function and to anticipate the post-operative regimen, splint age and retraining requirements. The therapist will be able to provide tailored advice regarding activities of daily living and task performance during the recovery phase.
    OPERATIVE ALTERNATIVES:
    Nerve transfers are a viable alternative to tendon transfers in isolated peripheral nerve injuries. Nerve transfer surgery involves the re-innervation of the denervated muscle using an expendable motor branch (nerve transfer) or redundant motor fascicle from within a mixed motor-sensory nerve between motor branch points (highly selective fascicle transfer). The benefits of nerve transfer include re-innervation of the original muscle in tis original bed without change of sarcomere resting length or disturbing the vector of pull. In addition there is no alteration to amplitude of excursion. Control of the newly innervated muscle is achieved through neural plasticity and is optimum is cases where a phasic nerve is use for the transfer (for example a wrist flexor is used for finger extension; a wrist extensor is used for finger flexion). In this case nerve transfer is not possible due to the longstanding nature of the denervation from this lower motor neurone lesion. there is Wallerian degeneration and the motor end plate degeneration and collapse of the intramuscular neural network renders the muscle unreceptive to axonal ingrowth after approximately 9-12 months. In upper motor neurone lesions as seen in some muscle groups below the level of a narrow segment spinal cord injury in the tetraplegic upper limb, there may be preserved neural pathways between the spinal cord and the muscle. In this specific scenario the use of a donor nerve or fascicle under volitional control from above the injury directed to a muscle below the injury may be successful beyond 12 months because denervation only commences from the moment of the nerve transfer. These techniques will be discussed elsewhere in OrthOracle.
    NON-OPERATIVE ALTERNATIVES:
    Functional splints may assist weak muscles or improve the posture of the hand such that preserved muscle function may be optimised. Robotic exoskeletons may be of use in the flail limb for functional assistance. However currently these devices are expensive and not widely available.
    CONTRAINDICATIONS:
    Tendon transfer surgery should not be contemplated in progressive motor paralysis seen in motor neurone disease (amyotrophic lateral sclerosis – ALS) and should be used with caution in disease processes which have stepwise deteriorations over many years (multiple sclerosis, spinal muscular atrophy, hereditary sensory motor neuropathy). In such cases the gains from tendon transfer surgery are likely to be subsequently lost. There are scenarios where function can be improved, for example in case where there is extremely limited function, arthrodesis of the wrist may allow a functional wrist extensor to be used for transfer to finger flexors to enhance the functional status of the limb. I have used this technique in spinal muscular atrophy where no other function existed below the elbow.

    Setup

    The patient uses regular anti-platelet therapy. This must be stopped prior to surgery and the need for bridging anticoagulation to cover the peri-operative period should be discussed with a haematologist.
    The operation is performed under a regional anaesthetic block at the axillary level. An upper arm tourniquet is applied to achieve a bloodless surgical field. I recommend preparation of the whole limb and then use of a sterile tourniquet and an Esmarch bandage for exsanguination. This reduces the ischaemic time and makes it possible to perform this procedure under a single tourniquet application.
    Tendon transfer instruments are essential for this procedure. The tendon passer allows retrieval of tendons through small subcutaneous tunnels and the tendon weave instruments allow completion of a Pulvertaft weave with ease.

    Operation – 1

    The resting posture of the hand demonstrates loss of the normal cascade. Under regional anaesthesia the normal cascade should demonstrate progressive flexion of the digits in a radial to ulnar direction with the thumb held in a mid-palmar abduction and opposition position. Here the hand is flat and the thumb lies in the plane of the palm. This is because of loss of tone and muscle bulk in all the digital flexors and all of the hand intrinsic muscles.
    Isolated loss of intrinsic muscle function would normally result in a clawed posture of the hand (hyperextension of the metacarpophalangeal joints and flexion of the proximal and distal interphalangeal joints) due to unopposed action of the long “extrinsic finger extensors and the “extrinsic” finger flexors. In this case the finger flexors, both flexor digitorum superficial and flexor digitorum profundus are paralysed and so a clawed posture does not develop.
    There is some residual function in the digital extensors through the C7 nerve root, albeit with reduced strength.

    The extension laxity of the metacarpophalangeal joints (MCPJs) is demonstrated in this clinical photograph. Loss of the normal intrinsic action at the digits means that the unopposed long extensors have gradually exerted an extension force across the MCPJs which have developed volar plate attenuation.

    In a case requiring multiple tendon transfers it is imperative to mark all potential surgical incisions to ensure that they are well-placed to access important structures and allow for creation of tunnels for the transfers. Incisions should not run along the direction of the tendon transfer to minimise tendon tether due to adhesions. No narrow skin bridges should be created.
    The volar marking is for exposure of the digital flexors.
    The metacarpophalangeal joint (MCPJ) of the thumb marking on the radial aspect is for the tendon transfer attachment for the opposition transfer.

    On the dorsal aspect of the hand the mark over the index finger MCPJ is for the harvest of the extensor indicis proprius (EIP) tendon which is the opposition transfer tendon that was selected pre-operatively.
    The dorsal wrist marking is for the harvest of the EIP tendon and re-routing to the thumb.

    The volar incision is made ulnar to the flexor carpi radialis (FCR) tendon and the skin flaps are elevate for wide exposure. The median nerve lies in the interval between the FCR and the palmaris longs (PL) tendon and care should be taken to avoid injury to the palmar branch of the median nerve (PBrMN) which lies in the fat between the median nerve and the FCR tendon.

    The deep fascia is incised and the median nerve (M) is identified and protected.

    The ulnar skin flaps are elevated to allow exposure of the digital flexors in the ulnar wound. The flexor digitorum superficial tendons to the ring and small finger are demonstrated (FDS).

    The FDS tendons are retracted radially exposing the flexor digitorum profundus (FDP) tendons in the deep ulnar aspect of the volar wound.

    The FDP tendons are gathered and a tenolysis performed to ensure that they will glide freely after the transfer. There is well organised chronic tenosynovial tissue that tethers the tendons to each other and to surrounding structures. Release of the tissue is essential to ensure glide following the tendon transfer and to ensure that the normal differential glide of the FDP tendons allows restoration of the normal digital flexion cascade.

    The FDP tendons are mobilised to the mouth of the carpal tunnel. Dense adhesions to the FDS tendons must be released in order to allow glide and to ensure that the cascade of the fingers is optimised at the time of the tendon transfer.

    A blue surgical rubber sloop is placed around the tendons to mark them for later transfer (S). The tendons are approximated with several transverse mattress 3’0 Prolene sutures to set the cascade of the fingers after tenolysis. This step ensures that during the later part of the procedure, when the donor tendon transfer is ready for transfer, the cascade of the digits is pre-set and the transfer can be completed to the combined FDP mass without risk of creating differential tension in the FDP in each digit.

    The cascade of the fingers following trans-fixing sutures is confirmed. The small finger should be most flexed, however it is important that palmar contact of the small finger does not prevent adequate flexion of the radial digits as the function will be one of “mass action” after the single tendon transfer to digital flexors. Independent finger flexion will not be possible.

    In the radial aspect of the volar wrist wound, the Flexor Pollicis Longus (FPL) tendon is identified and lifted in a tendon hook retractor.

    The FPL tendon is mobilised with tenolysis until gentle retraction demonstrates full flexion of the thumb interphalangeal joint.

    The FPL is isolated in a red surgical rubber loop following completion of the tenolysis. The Flexor Carpi Radialis (FCR) tendon is retracted in an ulnar direction and the Brachioradialis (BR) tendon is identified inserting into the radial styloid process forming the floor of the first extensor compartment. A tendon hook is used to mobilise the BR tendon and perform a circumferential tenolysis prior to detachment distally.

    The BR tenolysis is completed.

    The BR tendon is detached from the radial styloid attachment in preparation for transfer.

    A radial incision is made in the proximal forearm and the Brachioradialis (BR) muscle belly is identified.

    The BR muscle and tendon are mobilised and the more deeply placed Superficial Radial Nerve is identified and protected in a rubber sloop.

    The Muscle is mobilised circumferentially and the tendon is delivered to the proximal wound. Care must be taken to ensure no damage to the muscle during this manoeuvre. The distal tenolysis must be complete otherwise the tendon will not retract proximally.

    The superficial radial nerve (SRN) lies deep to Brachioradialis and should be identified and protected in a surgical rubber loop.
    ECRB – Extensor Carpi Radialis Brevis
    ECRL – Extensor Carpi Radialis Longus
    SRN – Superficial radial Nerve
    BR – Brachioradialis

    The Brachioradialis is wrapped in a damp saline-soaked gauze swab to prevent dessication.

    The ECRL tendon is identified radial to the BR tendon in the proximal wound and a tendon hook is used to retract the ECRL and demonstrates extension and radial deviation of the wrist. This distinguishes it from the dorsally placed ECRB tendon which extends the wrist in a neutral position due to its central attachment to the middle finger metacarpal base.

    A small incision is made over the dorsum of the base of the index metacarpal on the radial aspect to allow access to the insertion of the Extensor Carpi Radialis Longus tendon.

    The wound is developed to expose the superficial Extensor Pollicis Longus (EPL) tendon and deep to it the Extensor Carpi Radialis Longus (ECRL) tendon. Superficial radial nerve terminal branches cross this area and should be gently mobilised and retracted to prevent injury.

    Operation – 2

    The ECRL is placed in a rubber sloop to assist retraction and the tendon is divided distally from the attachment at the base of the index metacarpal.

    A full circumferential tenolysis is required otherwise the ECRL tendon cannot be delivered to the proximal wound.

    Gentle retraction of the ECRL tendon in the proximal wound allows delivery of the detached distal tendon end. Care should be taken to prevent inadvertent injury to the muscle belly through excessive retraction if the distal tenolysis is incomplete. Note the BR muscle and tendon wrapped in a swab within the wound.

    The ECRL is delivered and a circumferential release of the muscle belly allows redirection of the muscle-tendon unit for the transfer to the finger flexors.

    The fibrous septum deep to the ECRL muscle is released.

    The septum is released. to allow separation of the ECRL from the more deeply placed ECRB.

    The ECRL and the BR muscle-tendon units are fully mobilised in preparation for transfer to the FDPs and the FPL respectively.

    A transverse incision over the index metacarpo-phalangeal hood allows access to the Extensor Digitorum Comminis (EDC) slip to the index and the more ulnarly located Extensor Indicis Proprius (EIP) tendon.

    There are numerous small veins in the superficial wound that should be mobilised and cauterised with bipolar diathermy. Identify any branches of the superficial radial nerve and protect these with gentle retaction.

    The EIP is mobilised and circumferential tenolysis allows elevation with a tendon hook. Sharp dissection separates the EIP insertion from the EDC index insertion to the extensor hood.

    The EIP is protected in a rubber sloop in preparation for harvest. In this case note the small EIP in comparison to the EDC index. This is unusual and at this juncture raises the possibility that the EIP may be vestigial and too poor for a transfer.

    An incision is made on the dorsum of the distal forearm immediately proximal to the extensor retinaculum and the deep fascia is opened over the 4th extensor compartment to reveal the digital extensor tendons. S self retaining retractor is placed in the wound to allow identification of the anatomy. The EDC tendons should lie superficial to the EIP in the distal forearm and the EIP is usually identified by its low-lying muscle belly. The muscle-tendon junction of the EDC is usually more proximal to the EIP.

    The EDC index is separated from the ulnarly placed EDC middle. In the deep part of the wound no EIP is identified.

    The EDC index is isolated in a tendon hook and retracted to demonstrate independent extension of the index MCPJ.

    Traction on the divided distal EIP tendon identifies a muscle-tendon belly outline on the hand overlying the index metacarpal. An incision was made at this site to reveal a rare anatomical variant. There is an absent EIP and instead a Extensor Brevis Manus (EBM) muscle and tendon. This variant was first described in 1758 by Albinus. It is considered a variant of the 4th extensor compartment and the prevalence is estimated at 4%. It typically inserts into the extensor to the index or middle fingers, sometimes to the EIP of the index and in extremely rare cases like this it is associated with absence of the EIP.

    The EBM in this case most likely represents a vestigial EIP muscle-tendon unit due to its insertion in the MCPJ extensor hood to the index and the absence of the EIP.

    The EMB muscle and tendon are mobilised and the tendon is delivered to the proximal wound.

    The EMB muscle-tendon unit mobilised and lying free on a saline soaked gauze swab. This will not have sufficient length or excursion for transfer to the thumb for opposition restoration. The EDC index could be used with section at the mid-dorsum of the hand and buddying of the distal stump to the EDC middle, however for opposition the extensor must be delivered around the ulnar border of the wrist and across the palm to achieve abduction and there would be insufficient length necessitating a tendon graft from Palmaris Longus. In addition use of the EDC index in this situation would result in loss of index finger independent extension.
    The decision was made to undertake a Camitz (Palmaris plus palmar aponeurosis) tenodesis opposition transfer to the Abductor Pollicis Brevis (AbPB) tendon. There was intra-operatiove concern that due to the C8 paralysis there would be no active contraction of the Palmaris Longus (PL). The muscle was explored to establish whether it had the appearance of denervation. In denervated muscle there is a light brown colour to the muscle rather than the deep red-brown seen in an innervated muscle. A denervated muscle will not twitch with gentle mechanical squeeze with forceps.
    The PL was deemed viable and so the decision to perform a Camitz transfer to the AbPB was made intra-operatively.

    The radial and volar aspect of the MCPJ to the thumb is incised to expose the AbPB tendon.

    The AbPB tendon is exposed and an Alms retractor placed in the wound edges to facilitate circumferential tenolysis and the passage of a rubber sloop around the tendon.

    A sloop is placed around the AbPB.

    Traction on the AbPB demonstrates abduction of the thumb.

    the palm is marked to allow wide exposure of the palmar aponeurosis for harvest in continuity with the Palmaris Longus (PL) tendon.

    Operation – 3

    The skin is elevated from the underlying palmar aponeurosis.

    The skin should be elevated with subcutaneous fat at the level of the palmar aponeurosis (PA) to prevent necrosis. The palmar aponeurosis (PA) should be protected so that it can be raised in continuity with the Palmaris Longus (PL).
    The PA is the broad tendon insertion of the PL to the base of the digits and represents a superficial digital flexor of the MCPJ. In primates the MCPJ flexion is achieved using the hand intrinsics and therefore the PL represents a phylogenetically degenerating muscle with a selection advantage and as such the prevalence remains high.

    Once fully exposed the palmar aponeurosis can be seen thinning distally and splitting over the digital flexors to insert at the base of the fingers.

    The palmar aponeurosis is marked in preparation for harvest in continuity with PL.

    PA marked in preparation for elevation in continuity with the PL tendon.

    The PA is elevated from Skoog’s fibres distally (transverse fibres at the distal palmar crease). Care must be taken to avoid injury to the common digital nerves and vessels deep to the PA including proximally the superficial palmar arch.

    The distal PA is detached.

    The PL tendon with PA is raised and mobilised to the thumb. This demonstrates that with palmar aponeurosis lengthening in continuity the PL can be transferred to the AbPB tendon.

    A subcutaneous tunnel is fashioned with blunt dissection from the proximal aspect of the volar wound in the distal forearm to the proximal radial forearm wound.

    A tendon retriever is used to deliver the ECRL and the BR tendons to the volar wound in preparation for transfer to the digital flexors.

    The BR tendon is seen here delivered to the volar wound. The Pl tendon is seen in the proximal wound.

    This photograph demonstrates the delivered ECRL, BR and the in situ PL tendon in the volar wound.

    There are three donor muscle-tendon units and three targets. First the ECRL will be transferred to the FDP (blue sloop); second the BR will be transferred to the FPL (red sloop); third the PL will be transferred to the AbPB (yellow sloop).

    The proximal FDPs are sectioned at the muscle-tendon junction to allow sufficient length for attachment to the ECRL.

    The FDPs are reflected from the volar wound and the underside is trimmed to remove any residual muscle tissue in preparation for the tendon transfer.

    The tendons are irrigated with saline to prevent dessication. The ECRL is delivered to lie alongside the FDP distal tendon stumps in preparation for transfer.

    A tendon weaver is used to create a tunnel through the combined FDP tendons in the cross-sutured normal digital cascade position.

    The weaver is opened to create a tunnel that is sufficiently wide to deliver the donor tendon.

    The ECRL tendon is delivered to the jaws of the weaver using forceps.

    Care should be taken when drawing the tendon through the recipient tendon tunnel using the weaver to avoid snagging of the tendons with consequent fraying and bunching up.

    The ECRL is delivered through the first FDP tendon tunnel.

    The ECRL is drawn through the FDP and tensioned. A mattress 3’0 Prolene suture can placed across the weave to assess the tension when the tendons are left loosely in the wound.

    In total three Pulvertaft weaves are completed between the ECRL and the FDPs and any residual tendon can be wrapped around in a spiral fashion. Each weave should be held with a 3’0 Prolene mattress suture placed so that the pull of the tendon transfer will not propagate a split in the FDP tunnel and so that the tendons are grasped rather than strangulated.

    The tension and the finger cascade should be checked after each suture placement at the Pulvertaft weave sites.

    Further running cross sutures can be used along the edges of the side to side spiral tendon anastomosis.

    Operation – 4

    Excess redundant tendon is trimmed and sutured flat to minimise the risk of snagging during tendon movement.

    Distal to the tendon anastomosis the flexor retinaculum should be released to allow tendon glide without snagging during finger extension.

    Next attention is turned to the BR to FPL tendon transfer which is performed in the same way using three Pulvertaft weaves. 3’0 Prolene mattress sutures are placed across each weave confirming satisfactory thumb position and digit cascade after each suture is tied.

    The suture should be placed across the junction of the tendon transfer at each recipient tunnel to prevent propagation under tendon contraction. The tendons should be grasped and not strangulated by circumferential sutures which could cause necrosis and rupture.

    The ECRL to FDP and the BR to FPL transfers are completed. The PL tendon is ready for transfer to the thumb AbPB. This transfer is left until last as it is the weakest tendon and the transfer is superficially situated in the wound.

    A tunnel is created in the subcutaneous tissues along the radial border of the thumb metacarpal and thenar eminence. A tendon passer is placed through the tunnel from distal to proximal and the PL is introduced to the jaws using fine toothed forceps.

    The jaws of the tendon passer are closed and maintaining this grasp on the PL the passer is gently and steadily puled from the wound delivering the PL to the distal wound adjacent to the AbPB tendon.

    As the PL is tightened it is important to ensure that its line of pull is as straight as possible so that maximum pull is applied to the AbPB in the transferred position.

    The PL is grasped with a tendon weaver to prevent retraction to the tunnel.

    The thumb is positioned in palmar abduction in preparation for the tendon anastomosis. There is ample tendon length for the transfer using Pulvertaft weaves. The palmar wound is partially closed at this time to prevent later manipulation of the thumb and hand after the PL to AbPB Camitz opposition tendon transfer has been completed. This is a weak transfer and excess manipulation could damage the transfer or result in loss of tension.

    The thumb must be maintained in the abducted position with the wrist in neutral during the tensioning of the Pl to AbPB Camitz opposition tensdn transfer.

    Each weave is secured with a 4’0 Prolene mattress suture.

    Excess tendon is removed and the suture of the transfer is completed and a the distal loose flap is sutured down flat to prevent adhesions and snagging during tendon movement.

    The wound closure is completed with interrupted non-absorbable suture in the volar wound. Avoid stretching the transfers by maintaining the wrist in a neutral position, the fingers flexed and the thumb in the palmar abduction position.

    The dorsal wounds can be closed with 4’0 Monacril absorbable continuous subcuticular sutures.

    The completed transfer prior to dressing application. Note the cascade of the fingers and the posture of the thumb. The thumb will be held in more palmar abduction when the wrist is extended through tenodesis even without good contraction of the Palmaris Longus muscle.

    The dorsal wounds are closed with sub-cuticular Monacril sutures.

    Following dressing application an above elbow Plaster of Paris dorsal slab is applied to prevent digit extension and to maintain a neutral wrist position with the elbow flexed at 90 degrees. Due to the proximal origins of the BR and the ECRL the elbow should be immobilised for 2 weeks post-operatively.
    The tourniquet is released with the arm elevated.

    Post Operative

    Following surgery the arm should be elevated in a high Bradford sling and the patient should be advised that elevation should continue during the first 2 weeks following surgery to reduce swelling, prevent wound healing problems and improve tendon glide.
    The patient should be prescribed analgesic medication and advised to start using medication when the first sensation starts to return to the fingers. Analgesic use should continue as required and is advised prior to dressing changes and hand therapy sessions to ensure maximum tendon glide without pain inhibition.
    The cast should be removed at 2 weeks and suture removed. At this stage thermoplastic splint can be applied to the limb with elbow extension block for two weeks then a final two weeks with forearm wrist and hand dorsal block thermoplastic splint only. Tendon gliding exercises should be commenced with a hand therapist at 2 weeks and continued throughout the period of immobilisation.
    Weaning from the splint commences at six weeks with night weaning from eight weeks and work hardening exercises from 8 weeks.
    If the recruitment of the PL to AbPB tendon transfer is poor, a thumb abduction / opposition hand-based splint can be fitted to allow functional use of the thumb and finger flexion transfers.

    Recommended Reading

    Tendon transfers are a reliable method of restoring function to the paralysed hand. Brand’s criteria help in decision making and adherence to these criteria helps to ensure good functional outcomes. Donor muscles should be tested to ensure that they are of sufficient strength and the joints in the digits to be mobilised should be stable and supple. The patient must understand the rehabilitation programme and the goals should be clearly pre-defined. The donor and recipient matching is important and movements should be phasic wherever possible. Wrist extensors are suitable for finger flexors however the excursion of the respective tendons are slightly different resulting in failure to restore full digit roll up. The use of tenodesis to improve tension in the transfer can help to improve this amplitude mismatch.
    1: Brand PW. Biomechanics of tendon transfers. Hand Clin. 1988 May;4(2):137-54
    2:Brand PW, Beach RB, Thompson DE. Relative tension and potential excursion of muscles in the forearm and hand. J Hand Surg Am. 1981 May;6(3):209-19
    3:Brand PW. Biomechanics of tendon transfer. Orthop Clin North Am. 1974 Apr;5(2):205-30
    4: Brand PW. Tendon transfers for median and ulnar nerve paralysis. Orthop Clin North Am. 1970 Nov;1(2):447-54
    5: An KN, Linscheid RL, Brand PW. Correlation of physiological cross-sectional areas of muscle and tendon. J Hand Surg Br. 1991 Feb;16(1):66-7
    6: Rymer B, Thomas PB. The Camitz transfer and its modifications: a review. J Hand Surg Eur Vol. 2016 Jul;41(6):632-7
    7: Cooney WP. Tendon transfer for median nerve palsy. Hand Clin. 1988 May;4(2):155-65

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