Tendon Transfers

Question 1

indications for tendon transfer (4)

Answer 1

considered as a restorative option when there is no further recover or nerve regeneration (3-4 months)

1. nerve injuries
2. CP
3. SCI
4. brachial plexus birth palsy

Question 2

key component of tendon transfer

Answer 2

patient must be motivated and have a good understanding of the process

Question 3

goal of tendon transfer

Answer 3

to improve functional outcomes and independence

Question 4

prerequisites for tendon transfer (7)

Answer 4

1. analysis of client’s needs
2. bony stability
3. edema/inflammation subsided
4. adequate soft tissue bed
5. mobile joints
6. expendable donor muscles
7. functional sensation in affected extremity

Question 5

considerations in selecting a donor tendon (4)

Answer 5

1. must have the strength to overcome the strength and passive tension of the antagonist muscle
2. needs to lie in appropriate direction of the desired action
3. travels a straight rout and performs a single function
4. potential excursion of the muscle once it is freed from all connective tissue attachments

Question 6

tendon transfer pre-op othosis: radial nerve palsy

Answer 6

support the wrist and MP joints in extension

Question 7

tendon transfer pre-op orthosis: median nerve palsy

Answer 7

support and position the thumb in opposition and ABduction for fine motor tasks

Question 8

tendon transfer pre-op orthosis: ulnar nerve palsy

Answer 8

MP joints positioned in flexion to prevent clawing and to substitute for lack of intrinsic function

Question 9

evaluation for pre-op treatment of tendon transfer (9)

Answer 9

1. assess ability to follow protocol
2. history
3. examine the extremity
4. sensory status
5. AROM/PROM
6. functional use
7. compensatory movements
8. self-reporting outcome measure
9. MMT

Question 10

treatment prior to tendon transfer (4)

Answer 10

1. might provide orthosis to tight joints
2. strengthening the donor muscle
3. ROM
4. patient education

Question 11

common tendon transfers: median nerve palsy (3)

Answer 11

1. palmaris longus - palmar ABduction
2. FDS (ring) - opposition
3. ADM to APB for opposition

Question 12

common tendon transfers: radial nerve palsy (4)

Answer 12

1. PT to ECRB for wrist extension
2. FDS (middle) to EDC for MP extension and FDS (ring) to EPL and EIP
3. FCR to EDC for MP extension and PL for thumb extension
4. FCU to EDC for MP extension and FCR to APL and EPB for thumb radial ABduction

Question 13

common tendon transfers: ulnar nerve palsy (6)

Answer 13

1. ECRB with graft to intrinsics via lateral bands
2. FDS (middle) inserted onto proximal phalanx
3. FDS (ring and middle) split into slips an inserted into lateral band of each finger or lateral part of P1
4. FDS passed through pulley and sutured back onto itself to improve MP flexion
5. BR extended w/ free graft and passed between MC 3-4 to insert on adductor tubercle of thumb
6. ECRB to ADP at 1st MC to restore power pinch

Question 14

questions for physician: tendon transfers (8)

Answer 14

1. ask for op report
2. which muscles were transferred to which insertion sites
3. were pulleys created to alter the course of pull
4. quality of transferred tendon
5. were grafts needed
6. type of suturing technique
7. how long should tendons be immobilized
8. how was the tension of transferred muscles determined

Question 15

tendon transfer treatment guidelines : early phase (4)

Answer 15

weeks 1 to 4

1. encourage movement of uninvolved digits/joints
2. monitor/treat edema
3. monitor cast for good fit
4. patient education on protocol

Question 16

tendon transfer treatment guidelines : intermediate phase (6)

Answer 16

weeks 4 to 6

1. cast removed/make orthosis
2. scar management
3. modalities
4. begin AROM of isolated joints (gentle AROM/AAROM short sessions several x/day)
5. avoid composite motion and overstretching transferred muscle
6. add facilitation techniques

Question 17

facilitation techniques for tendon transfers (8)

Answer 17

1. place and hold
2. using both hands simultaneously
3. using the donor muscle action
4. resistance to the donor muscle (original action)
5. verbal cues
6. visual and functional cues
7. mirror training
8. NMES

Question 18

tendon transfer precautions (4)

Answer 18

1. no PROM against the transferred muscle
2. no resistance to desired muscle
3. no composite motion that puts tension on the transferred muscle
4. do not overwork the transferred muscle

Question 19

tendon transfer treatment guidelines : late phase (5)

Answer 19

weeks 6 to 12

1. begin adding strengthening
2. work for good quality movement
3. gradually discontinue use of orthosis
4. encourage use of hand into ADLs
5. add PROM in opposite direction of transfer

Question 20

tendon transfer orthosis median nerve - opposition

Answer 20

cast 3-4 weeks
long opponens orthosis with thumb in wide ABduction
wear 24/7, only remove for exercise

Question 21

tendon transfer orthosis radial nerve

Answer 21

cast of at 4 weeks
long arm orthosis with elbow 90 deg flexion, pronation, wrist 30-40 deg extension, MP 0 deg extension, IP free (for EPL IP in full extension)
as ROM control improves decrease daytime wear
12 weeks: night wear only

Question 22

tendon transfer orthosis ulnar nerve

Answer 22

cast 3-4 weeks
forearm based dorsal or volar orthosis with MP flexion
4 weeks: gentle AROM one joint at a time
8 weeks: gentle strengthening
12-14 weeks: full activity

Question 23

Wide Awake tendon transfer surgeries

Answer 23

patient is awake with nerve block and physician can ask for movements to check quality of repair