Surgery Spotlight: Median to Radial Nerve Tendon Transfers: PT to ECRB, FCR to EDC, PL to EPL-Standard-Surgery Spotlight: Median to Radial Nerve Tendon Transfers: PT to ECRB, FCR to EDC, PL to EPL-Standard

Surgery Spotlight: Median to Radial Nerve Tendon Transfers: PT to ECRB, FCR to EDC, PL to EPL-Standard

Video Transcription

This tutorial is Tendon Transfers for Radial Nerve Palsy. It will be the left arm and I'm going to be sitting in the axilla.  You can see here that this patient has had an open reduction for a humeral fracture that extended quite distally and no radial nerve function.  He does have a palmaris longus. I'm going to do pronator teres to extensor carpi radialis brevis. There's listers and I'll be taking palmaris to a rerouted extensor pollicis longus  and then flexor carpi radialis over to extensor digitorum communis. So PT to ECRB, EPL from the PL and FCR to EDC.  I'm using multiple incisions. On some smaller arms I can do it with just the one bolar incision  but on this case I'm going to be using an incision on the dorsum that's quite extensive as well to get into ECRB. So the short forms are familiar to you all.  I know pronator teres I'm going to be calling PT or pronator extensor carpi radialis brevis, ECRB.  Now there's the brachioradialis and my first goal is to identify the pronator, pronator teres. I find it by identifying the radial sensory nerve which is right here  and then I move over to find the vessels. Between the vessels and the radial sensory nerve will be the tendon of the pronator teres.  These are two super landmarks to remember to make identification of the pronator teres quick.  So you can see the pronator teres right there, the vessels and the radial sensory nerve and in between those two structures the tendon of the pronator teres.  Next step will be to follow that tendon of the pronator teres to its attachment on the radius  and then extend that tendon by lifting up the periosteum off of the radius as it comes back to join that tendon.  So I need a longer tendon to get into the ECRB, extensor carpi radialis brevis.  So I'll sharply dissect that pronator teres tendon right down to the radius and extend it almost down to the wrist.  Now I'll take an elevator, a curved elevator and sharply dissect that periosteum off the radius. Be careful not to poke too many holes in that periosteum.  So I have a nice long length of periosteum extended off that tendon. You can always throw it away but you can't put it back.  Now I need to mobilize the pronator teres well so that I've got nice excursion of the muscle across the forearm towards the extensor carpi radialis brevis.  The innervation to the pronator teres is much more proximal so I'm not worried about that.  And here I'm lifting that muscle attachment so I've got good glide and good excursion of the pronator teres.  Good, so step one, I'm getting my donors. Here's the flexor carpi radialis FCR and here's the palmaris longus.  Dictating these little videos I can get a little tongue-tied because of the names and the letters.  But palmaris longus, PL, is lifting up and again I want to dissect it well proximally so I've got nice excursion. Now I'm going to get my recipients.  I'm making a longer incision here on the dorsum and I have, especially on women,  just used that volar long incision and then pulled everything back so that I can work under that flap to find the extensor tendons.  But this gentleman's skin is thick and we had to shave off a lot of hair so I think from a cosmetic point of view this isn't going to be a problem  and it certainly makes the surgery easier. Now I'm opening up the fascia and I'm looking for the tendons that I want to re-innervate  or not re-innervate but put tendon transfers into. And the fourth extensor compartment is where I'm going first.  I'll tug on these different tendons so that I know I've got extensor digitorum communis or EDC to the four fingers.  I'll show you the extensor pollicis longus in a few minutes but I'm not going to put the tendon transfer into that.  You want to of course leave the extensor retinaculum intact so you don't get bow stringing and an ineffective transfer.  So you can tug on each of these tendons and get your four tendons to the four fingers.  Index finger.  There are the four tendons coming up there.  Now if you look deeper you can see the extensor pollicis longus. It's the tendon with the most distal muscle belly and you can see muscle all the way down.  Now this is the only tendon that I'm going to divide. I'm going to find it however at the base of the thumb and the radial sensory nerve is not intact here.  So that's something to be grateful for. You can see a branch of the radial sensory nerve in a minute.  So here's extensor pollicis longus, EPL.  A little bit of radial sensory nerve out of the road but it isn't working so that's good news.  As far as us injuring it. Now here's the EPL and I'm going to divide it at the muscle juncture and then I'll deliver it into the distal incision. It's a little easier than normally.  And then I'm going to reroute it over to the volar incision. So I'll use a burlisher. And once again I'm saying I'm lucky that the radial sensory isn't working.  I don't have to worry so much about it. But here comes the EPL into the volar incision.  Now I'm going to look for extensor carpi radialis brevis, ECRB. And of course you don't want to go into longus, you want to go into the brevis  because the brevis inserts at the base of the third metacarpal so you'll get more centralized wrist extension.  I like to do weaves on the transfers to the ECRB and the EDC in case there might ever be some spontaneous re-innervation from proximally over time.  So I want to be able to utilize that potential re-innervation if possible. I mean if you're doing a tendon transfers years out, of course that won't be the case.  Now here's dividing the FCR very distally and make sure you're not dividing the median nerve.  And then the palmaris longus divided distally.  And you'll see our three donor tendons.  Now moving over to the recipients.  And you can understand that you could reflect this flat but it's a lot of work in someone with a big arm. The tourniquet's been deflated and hemostasis has been obtained.  Now we're going to use that tendon passer, sharp pointy tendon passer to set up the wrist extension. So we'll do wrist extension, finger extension, and then thumb extension.  It's a 3-0 Ethabon that we're using and we're doing a fishweave repair which is the strongest repair. It's tight but I can still flex the wrist  so that's the tension that I want on it. I want it set in tight but I want to be able to passively flex the wrist. You can always loosen it up, you can't tighten it up.  So I'm going to be setting it a little bit to the left of the optimum force-tension curve.  Knowing that my physical therapist can help me to loosen it up if need be.  So here we are going through the four tendons, extensor digitorum, communist tendons. These are smaller tendons than what our recipient FCR tendon is.  So you'll see Andrew's made us look pretty tidy as we bring this through. You grab it at the tip, make a big enough spread in the recipient tendons  to let it push through but you can still get an idea. This is a little harder to get that through. So there's my first suture being set up and once again I want it tight  so that the physical therapist can lengthen it if necessary. So the index is a little tighter than the others but I think it's pretty good.  Now I'll continue to set that in with three or four weaves and here's something that might be helpful.  You can split that donor FCR tendon so that you don't have that massive FCR tendon going through these smaller EDC tendons.  So let me just make it a little bit smaller and have that tendon weave now that you've put the first throw through.  Weave distally in this direction and then you can take the other end of it and weave it proximally. Just makes the passing a little easier.  Richard Lieber's done a lot of work on setting tendon transfer tensions, making an attempt to have the tendon transfer set at the maximum point for sarcomere  length for tension, and he noted that the surgeons tend to put the tendons in a little bit tighter than what he'd like, and I think it's for exactly the reasons  we were talking about. So I'll put a single stitch in and then check it. This is the rerouted palmaris longus to EPL, so that it's nice and loose and not too  tight, and I can also flex that thumb into the palm and across to the small finger. So if it feels too tight, I'll loosen it up. If it's too loose, I'll  tighten it up. But once I'm happy with that, then I'll do my weave back and forth to complete that pulvotaft weave. And again, 0-3-0 ethabond is what we use for this.  Post-operatively we keep the wrist extended and the MCPs extended for four weeks and we block the elbow for two weeks. Now just testing that I can have  good range of movement and getting ready for the immobilization as we discussed.

Video Summary

The tutorial covers the surgical procedure of tendon transfers for radial nerve palsy in a patient's left arm. The approach includes transferring the pronator teres (PT) to the extensor carpi radialis brevis (ECRB), rerouting the extensor pollicis longus (EPL) from the palmaris longus (PL), and transferring the flexor carpi radialis (FCR) to the extensor digitorum communis (EDC). The procedure involves careful dissection and multiple incisions to access and transfer specific tendons. Attention is given to maintaining proper tension and ensuring functional wrist, finger, and thumb extension post-operatively.

Asset Caption

This tutorial describes the following tendon transfers:

(1) pronator teres (PT) to extensor carpi radialis brevis (ECRB),

(2) flexor carpi radialis (FCR) to extensor digitorum communis (EDC), and

(3) palmaris longus (PL) to extensor pollicis longus (EPL). The patient had a left humeral fracture and lost complete radial nerve function. He elected fofor tendon transfers for radial nerve palsy.

Surgeon Susan E. Mackinnon MD, Andrew Yee BS

Source Washington University of St. Louis School of Medicine This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Hand

Nerve

Susan E. Mackinnon MD

Andrew Yee BS; Memben

tendon transfers

radial nerve palsy

surgical procedure

pronator teres

extensor carpi radialis brevis