DEFINITION

The median nerve can be compromised by any number of causes, including trauma, tumor, chronic compression, or synovitis.

Palsy of the median nerve can result in motor or sensory deficits, or both, within the distribution of this nerve.

 

 

ANATOMY

 

The median nerve enters the forearm between the two heads of the pronator teres muscle.

 

The median nerve travels down the forearm between the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) muscles to enter the carpal tunnel.

 

Along its course, the anterior interosseous nerve branches from the median nerve to provide innervation to the flexor pollicis longus, FDP to the index, and the pronator quadratus muscles.

 

The median nerve proper provides innervation to the flexor carpi radialis, pronator teres, FDS, palmaris longus (PL), and FDP to the long finger.

 

The palmar cutaneous branch arises from the median nerve 5 cm proximal to the wrist joint, crosses the wrist superficial to the transverse carpal ligament, and supplies sensibility to the thenar eminence.

 

Just proximal to the wrist, the median nerve becomes superficial and travels within the carpal tunnel.

 

The recurrent motor branch originates from the central or radial portion of the median nerve during its passage through the carpal tunnel. The recurrent branch usually passes distal to the transverse carpal ligament to innervate the thenar muscles. The nerve can also pass through the transverse carpal ligament (occurs in 5%

to 7% of individuals).8

 

The thenar muscles are the opponens pollicis, flexor pollicis brevis, and abductor pollicis brevis. The flexor pollicis brevis muscle receives dual innervation from both the recurrent branch (superficial head) and the deep motor branch of the ulnar nerve (deep head).

 

The median nerve terminates into multiple sensory branches, which supply sensibility to the thumb, index, long, and ring (radial side) fingers. The sensory branches to the radial side of the index and radial side of the long fingers possess a minor motor component that sends a small branch that innervates the adjacent lumbrical muscle.

 

PATHOGENESIS

 

Most injuries to the median nerve occur at the wrist and affect the thenar muscles. The resultant functional loss is lack of thumb opposition.

 

Compression injuries are most common and are usually attributed to prolonged carpal tunnel syndrome.

 

 

Carpal tunnel compression may also be secondary to tumor, adjacent synovitis, or fracture-dislocation. Penetrating or perforating injuries may directly damage the median nerve.

 

Pediatric causes include lipofibrohamartoma of the median nerve or Charcot-Marie-Tooth disease, a demyelinating process that has a preference for the median and ulnar nerves (FIG 1).6,8

 

High median nerve injuries are rare. Similar causes exist, including trauma and nerve compression.11

 

NATURAL HISTORY

 

With a median nerve compression neuropathy (ie, carpal tunnel syndrome), palsy of the median nerve is insidious in onset and manifestation. Over a period of months to years, patients can progress to decreased median nerve function as well as sensory changes in the dermatome of this nerve.

 

Acute injuries to the median nerve at the wrist or elbow have a traumatic onset followed by abrupt sensory and/or motor changes depending on the extent of injury.

 

 

 

 

FIG 1 • Left hand of 16-year-old boy with Charcot-Marie-Tooth disorder resulting in median nerve palsy. Note inability to oppose thumb with attempt to touch small fingertip. (Courtesy of Shriners Hospital for Children, Philadelphia.)

 

 

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PATIENT HISTORY AND PHYSICAL FINDINGS

 

Compressive neuropathy of the median nerve

 

Patients report pain, numbness, and tingling in the thumb, index, middle, and sometimes ring finger of the affected hand. They frequently describe problems with fine coordination of the hand, notably pinch. Patients often report pain and numbness that awakens them at night.

 

Physical examination findings include thenar muscle wasting and diminished thumb opposition (defined as the combination of palmar abduction, metacarpophalangeal [MCP] joint flexion, and thumb pronation).

 

Additional signs include the Tinel sign; the Phalen sign; the carpal tunnel compression sign; and increased two-point discrimination in the thumb, index, and long fingers.

 

High median nerve neuropathies have similar findings, in addition to loss of forearm pronation and flexion of the thumb, index, and long fingers.

 

Acute median nerve injury

 

 

There is nearly always a wound on the upper extremity, usually on the volar wrist.

 

Physical findings include diminished sensibility in the thumb, index, and long fingers; increased two-point discrimination in those fingers; a positive Tinel sign; and an inability to touch the thumb tip to the small finger (ie, loss of opposition).

 

Depending on the level of injury, patients may display diminished sensibility of the thenar eminence of the thumb, indicating an injury proximal to the palmar cutaneous branch of the median nerve, or a concomitant injury to the palmar cutaneous branch.

 

Higher median nerve neuropathies have similar findings, in addition to loss of forearm pronation and flexion of the thumb, index, and long fingers.

 

Patients with median nerve palsy will not be able to oppose thumb to small finger. There may be some palmar abduction due to function of the abductor pollicis longus or extensor pollicis brevis muscles, but this will be minor. The ulnar-innervated deep head of the flexor pollicis brevis muscle will still function, yielding MCP joint flexion but not true opposition.

 

Inability to make an “OK” sign indicates anterior interosseous nerve injury and high median nerve pathology.11

 

The clinician should ask the patient to try to touch thumb to small finger with the wrist flexed. Due to median nerve palsy, the patient will likely be unable to fully touch the thumb to the small finger.

 

The patient is asked to spread his or her fingers apart and hold them against adduction pressure on the small finger to ensure ulnar nerve function. The examiner feels for resistance and palpates the hypothenar eminence at the same time. There should be resistance to adduction force on the small finger, and firmness of the hypothenar eminence should be appreciated.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Radiographs

 

 

Plain radiographs are helpful in determining the nature of fractures or dislocations after acute trauma to the upper extremity.

 

Specific carpal tunnel radiographic views may demonstrate osteophytes within the carpal tunnel or a hook of the hamate, but they are not routinely performed.

 

Electrodiagnostic studies

 

 

In the setting of compressive neuropathy of the median nerve, nerve conduction studies typically show

increased motor and sensory latencies in the median distribution.

 

In advanced stages of compressive neuropathy, electromyography demonstrates fibrillation potentials in various muscles tested, most commonly the abductor pollicis brevis. These fibrillation potentials indicate denervation of the tested muscle and axonal loss.

 

Advanced high median nerve neuropathy reveals fibrillation potentials in more proximal muscles, such as the flexor carpi radialis and the pronator teres.

 

 

DIFFERENTIAL DIAGNOSIS

Carpal tunnel syndrome Anterior interosseous syndrome Pronator syndrome

Wrist synovitis

Direct injury to the median nerve

Tumor compression of the median nerve Charcot-Marie-Tooth disease

Brachial plexus injury Stroke or other brain injury

 

 

NONOPERATIVE MANAGEMENT

 

Patients with demonstrable carpal tunnel syndrome can undergo a trial of splinting, wrist corticosteroid injection, or both.

 

Work modification is indicated in patients with compressive neuropathy as a result of overuse for both carpal tunnel and pronator syndromes.

 

Anti-inflammatory and immunomodulatory medications are indicated in patients with wrist synovitis secondary to inflammatory arthropathy.

 

SURGICAL MANAGEMENT

 

The chief surgical modality for a low or high median nerve palsy that has not responded to surgery or other interventions is tendon transfer.1,3,8

 

Typically, in a low median nerve palsy, the only function that requires restoration via tendon transfer is thumb opposition, which is a combination of palmar abduction, MCP joint flexion, and thumb pronation.

 

In a high median nerve palsy, the additional loss of flexion of the thumb, index, and long fingers requires tendon transfer. In addition, lack of pronation may require tendon transfer.

 

Preoperative Planning

 

The surgeon must ensure that there is good passive range of motion of the joints to be motored by the tendon transfer.

 

 

 

In long-standing median nerve palsy, the thumb MCP and carpometacarpal joints can become quite stiff. Physical therapy must be implemented to loosen these joints and increase their passive range of motion.3

This can usually be accomplished in 3 to 6 weeks.

 

A thorough assessment of muscle function and strength is made before selecting a transfer, especially in the setting of combined nerve deficits.

 

When performing an opponensplasty, the donor tendon and attachment site are individualized to the particular patient, his or her injury, his or her needs, and the donor muscle-tendon

 

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availability. The vector of transfer is based about the pisiform to provide the most opposition regardless of the donor chosen. As the attachment site onto the thumb moves more dorsal, the amount of pronation and thumb extension is increased.

 

 

Donor options for opponensplasty include the following: FDS8

 

Abductor digiti minimi (ADM) (Huber)4,5

 

Extensor indicis proprius (EIP)2

 

PL (Camitz). The palmaris transfer is associated with more abduction and less opposition compared to other opposition transfers secondary to its inability to transmit force from the pisiform.3,13

 

Other less common donors include the extensor pollicis longus, extensor carpi ulnaris, extensor carpi radialis brevis, and extensor digitorum quinti.4,5

 

Opponensplasty attachment site options include the following3:

 

 

Abductor pollicis brevis tendon. This yields a great deal of thumb abduction and some opposition.

 

Extensor pollicis brevis or longus tendons. This yields thumb abduction, pronation, and MCP joint extension.

 

Single attachment options

 

 

Riordan's technique involves interweaving the transferred tendon into the abductor pollicis brevis tendon, with continuation onto the extensor pollicis longus tendon distal to the MCP joint.

 

Littler's technique attaches the transferred tendon into the abductor pollicis brevis tendon.

 

Bunnell's method involves passing the tendon through a small drill hole made at the proximal phalanx base from the dorsoulnar to palmar radial direction to provide pronation of the thumb.

 

Dual attachment options

 

 

These are designed to rotate (pronate) the thumb and either passively stabilize the MCP joint or minimize interphalangeal joint flexion.

 

There is a theoretical benefit in patients with combined median and ulnar nerve deficits who lack all thumb intrinsic function.

 

Some authors question the use of dual insertion techniques because the transfer will only function predominantly on the tighter of the two insertion sites.

 

In Brand's technique, one-half is woven through the abductor pollicis brevis tendon and then passed distal to the MCP joint and attached to the extensor pollicis longus tendon.

 

In the Royle-Thompson method, a slip is passed through a drill hole made in the metacarpal neck, from

radial to ulnar, with the metacarpal pulled into as much opposition as possible. This slip is tied to the other half that is initially passed dorsally over the extensor hood at the MCP joint and through a small tunnel in the fascia and periosteum at the base of the proximal phalanx.

 

 

High median nerve palsies require additional restoration of thumb, index, and long finger flexion. On occasion, reestablishment of pronation is required.

 

Flexion of the index and long fingers can be accomplished by side-to-side transfers of the FDP tendons of the index and long to the ring and small. The donor tendons are transected proximal to the wrist and woven into the recipient tendons.

 

Thumb flexion can be restored by transfer of the brachioradialis to the flexor pollicis longus.

 

Loss of pronation can be overcome by rerouting the biceps around the radius, which converts the biceps from a supinator into a pronator.

 

Positioning

 

The patient is positioned supine on the operating table.

 

The affected limb is abducted at the shoulder and placed on an attached hand table or arm board.

 

Approach

 

The surgical approach to opponensplasty for median nerve palsy depends on two factors: the donor tendon and the site of attachment.

 

TECHNIQUES

• Low Median Nerve Transfers

Flexor Digitorum Superficialis Transfer (Authors' Preferred Technique)

Make a palmar transverse skin incision over the first annular pulley of the ring finger.

Identify the A1 pulley and incise it longitudinally. Isolate the FDS tendon from the FDP tendon.

Apply traction to the FDS tendon to flex the proximal interphalangeal joint (TECH FIG 1A) and divide the FDS tendon transversely just proximal to its bifurcation while protecting the FDP tendon.

Make a second zigzag incision at the volar ulnar distal forearm in the region of the flexor carpi ulnaris (FCU) tendon insertion.

Isolate the FCU and the ring finger FDS tendons and protect the ulnar neurovascular bundle.

Divide the radial half of the FCU tendon transversely about 4 cm proximal to its insertion onto the pisiform.

Separate the radial half of the tendon longitudinally from the ulnar half, creating a distally based strip of tendon graft.

Loop the tendon graft distally and pass it through the distal portion of the FCU near the pisiform insertion to create a pulley.

 

 

 

 

TECH FIG 1 • A. Isolation of ring finger FDS to be transferred for thumb opposition. (continued)

 

 

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TECH FIG 1 • (continued) B. Ring finger FDS passed through the FCU loop, which now serves as the pulley for the transferred tendon. C. Creation of the subcutaneous tunnel between the ulnar wrist and

thumb incisions through which the FDS tendon will be passed. D. Ring finger FDS tendon shown passing through both the FCU tendon and the subcutaneous tunnel. E. Suture fixation of the FDS tendon to the abductor tendon and extensor hood of the thumb. (Courtesy of Shriners Hospital for Children, Philadelphia.)

 

 

Pull the cut ring finger FDS tendon into the volar ulnar forearm incision and pass it through the constructed pulley (TECH FIG 1B).

 

Make a third incision on the radial aspect of the thumb MCP joint.

 

 

Create a subcutaneous tunnel between this incision and the wrist incision (TECH FIG 1C). Pass the ring FDS tendon through this tunnel to the thumb incision (TECH FIG 1D).

 

Place the thumb into opposition with the small finger.

 

Secure the FDS tendon to the thumb with a 3-0 or 4-0 braided polyester suture (TECH FIG 1E).

 

The attachment sites usually include the abductor tendon +/− the dorsal capsule and extensor pollicis brevis tendon.

Abductor Digiti Minimi Transfer (Huber)

 

Make an oblique or zigzag incision beginning distally on the ulnar border of the small finger proximal phalanx, curving radially along the radial border of the hypothenar eminence.

 

Separate the ADM muscle from the flexor digiti minimi. Dissect the ADM distally to its insertion into the proximal phalanx and lateral band.

 

Protect the ulnar sensory nerve to the small finger.

 

 

Divide the ADM insertion sites, including a portion of the lateral band to increase its overall length. Dissect the muscle proximally to the pisiform (TECH FIG 2A).

 

Release the origin from the pisiform; identify and protect the neurovascular bundle (on the dorsoradial side).

 

 

Make a longitudinal incision on the radial aspect of the thumb MCP joint. Use blunt dissection to create a subcutaneous tunnel in the palm.

 

Pass the ADM through the tunnel to the thumb MCP joint (TECH FIG 2B).

 

Secure the ADM tendon to the thumb using 3-0 or 4-0 braided polyester suture (TECH FIG 2C).

 

 

 

TECH FIG 2 • A. Isolated and dissected ADM muscle-tendon unit to be used for transfer for thumb opposition (Huber transfer). (continued)

 

 

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TECH FIG 2 • (continued) B. Passage of the ADM muscle-tendon unit through the previously created subcutaneous tunnel to the thumb. C. Final position of thumb after suture fixation of the ADM to the thumb. Note opposition and palmar abduction. (Courtesy of Shriners Hospital for Children, Philadelphia.)

Extensor Indicis Proprius Transfer

 

Make a longitudinal incision on the dorsum of the index finger MCP joint.

 

Locate the EIP tendon deep and ulnar to the extensor digitorum communis tendon to the index finger (TECH FIG 3A).

 

Identify the EIP tendon along with the extensor hood.

 

Divide the EIP tendon on the proximal edge of the extensor hood. The EIP tendon can be elongated by taking a 3- to 4-mm slip of extensor mechanism along the proximal phalanx. Repair the rent in the extensor hood with interrupted 4-0 braided polyester suture.

 

Make a longitudinal incision on the dorsoulnar aspect of the wrist, just proximal to the point where the dorsal sensory branch of the ulnar nerve crosses near the ulnar styloid.

 

Carry dissection from this incision in a radial direction until the proximal EIP tendon can be identified (just

distal to the extensor retinaculum) (TECH FIG 3B).

 

The EIP tendon is frequently differentiated from the EDC tendons by its distal muscle belly.

 

 

 

TECH FIG 3 • A. Isolation of EIP tendon ulnar and deep to the extensor digitorum communis tendon to the index finger. B. Wrist incision through which the proximal aspect of the EIP is found and isolated. C. The EIP tendon is brought out through the previously created ulnar wrist incision. D. Passage of EIP tendon through the subcutaneous tunnel between ulnar wrist incision and thumb incision.

 

 

Divide the distal aspect of the extensor retinaculum over the fourth compartment to mobilize the EIP tendon.

 

 

 

Bring the EIP tendon out through the ulnar wrist incision (TECH FIG 3C). Make another small longitudinal incision on the radial edge of the pisiform. Make a fourth incision over the thumb MCP joint.

 

Create a subcutaneous tunnel from the ulnar wrist incision to the pisiform incision, then on to the thumb MCP joint incision, using blunt dissection.

 

 

Pass the EIP tendon first through the pisiform incision, then on to the thumb incision (TECH FIG 3D). Suture the EIP tendon to the thumb using a 3-0 or 4-0 braided polyester suture.

 

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Palmaris Longus Transfer (Camitz)

 

Confirm the presence of a PL tendon by having the patient attempt to oppose the thumb to the small fingertip with the wrist flexed.

 

Make a longitudinal incision beginning at the distal wrist crease and continuing distally to the proximal palmar crease. This incision may be “zigzagged” at the wrist to prevent scar contracture.

 

Dissect the PL tendon in a proximal to distal direction.

 

 

Take a small (about 1 cm2) patch of palmar aponeurosis along with the PL tendon. Make an incision over the dorsum of the thumb MCP joint.

 

Create the subcutaneous tunnel between the PL tendon and the MCP joint with blunt dissection.

 

Pass the PL tendon through the tunnel to the thumb incision.

 

Secure the PL tendon to the thumb with 3-0 or 4-0 braided polyester suture.

• High Median Nerve Transfers

Brachioradialis Transfer

 

Make a long radial incision from the radial styloid to the brachioradialis muscle belly.

 

Release the brachioradialis tendon from the radial styloid and mobilize it along the forearm to optimize available excursion (TECH FIG 4A).9

 

Identify the flexor pollicis longus tendon deep to the flexor carpi radialis tendon (TECH FIG 4B).

 

Weave the harvested brachioradialis tendon into the flexor pollicis longus using a tendon braider and multiple weaves (TECH FIG 4C).

 

Determine proper tension of the transfer by placing the wrist in flexion and extension and judging tenodesis lateral pinch position and thumb release, respectively (TECH FIG 4D).

 

 

 

TECH FIG 4 • A. Brachioradialis tendon released and mobilized into the proximal one-third of the forearm.

B. Flexor pollicis longus tendon isolated in volar compartment. C. Brachioradialis tendon woven through the flexor pollicis longus tendon. D. Tendon transfer tension is adjusted until there is lateral pinch during wrist extension. (Courtesy of Shriners Hospitals for Children, Philadelphia.)

Biceps Rerouting

 

Biceps rerouting is preferred for supple supination deformities of the forearm to correct the forearm position and to apply a pronation moment.

 

Surgery is performed under general anesthesia. The upper extremity is prepared and draped in the usual sterile fashion. A sterile circular tourniquet (HemaClear, OHK Medical Devices, Grandville, MI) is applied that exsanguinates during application.

 

Design a Z incision with a horizontal limb across the antecubital fossa (TECH FIG 5A).

 

Identify the lateral antebrachial cutaneous nerve lateral to the biceps tendon and protect it (TECH FIG

5B).

 

Isolate the biceps tendon and incise the lacertus fibrosus while protecting the underlying median nerve and brachial artery.

 

Trace the biceps tendon to its insertion into the radial tuberosity by careful dissection and placement of the elbow in flexion and the forearm into supination (TECH FIG 5C).

 

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Plan a Z-plasty of the biceps tendon along its entire length to ensure sufficient tendon length for passage around the radius (TECH FIG 5D).

 

Leave the distal Z-plasty attached to the insertion site and leave the proximal Z-plasty attached to the muscle belly (TECH FIG 5E).

 

Reroute the distal attachment around the radius through the interosseous space to create a pronation force. A curved clamp, such as a Deborah cast clamp or Castaneda pediatric clamp (Pilling Surgical, Inc., Research Triangle Park, NC), facilitates tendon passage (TECH FIG 5F,G).

 

Protect the posterior interosseous nerve during tendon passage.

 

Place the elbow in 90 degrees of flexion and the forearm in pronation. Repair the rerouted distal tendon back to the proximal tendon that is still attached to the biceps muscle using a tendon weave augmented by nonabsorbable suture (TECH FIG 5H).

 

Close the subcutaneous tissue and skin in routine fashion. Apply a long-arm cast with the elbow in 90 degrees of flexion and the forearm in pronation. The cast is worn for 5 weeks.

 

After 5 weeks of immobilization, the cast is removed and rehabilitation is started. A posterior long-arm orthosis is fabricated with the elbow in a resting position with the forearm pronated and the wrist in neutral or slightly extended (TECH FIG 5I).

 

In a gradual fashion, activities of daily living that require pronation are incorporated into the therapeutic regimen (TECH FIG 5J).

 

 

 

TECH FIG 5 • A. Skin incision for biceps rerouting. B. Isolation of the biceps tendon and lacertus fibrosus. The lateral antebrachial cutaneous nerve is just lateral to the tendon. C. Biceps tendon is traced to its insertion into radial tuberosity. D. Z-plasty of the biceps tendon is planned along its entire length to ensure sufficient tendon length for passage around the radius. E. Z-plasty of entire biceps tendon. The distal Z-plasty is left attached to the insertion site and the proximal Z-plasty is left attached to the muscle belly. F. A curved clamp facilitates tendon rerouting around the radius. G. Tendon is passed through interosseous space and around the radius. (continued)

 

 

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TECH FIG 5 • (continued) H. Distal limb is repaired back to proximal limb using a tendon weave augmented with nonabsorbable suture. I. Two-piece supracondylar orthosis is fabricated following cast immobilization.

J. Activities of daily living that require pronation, such as typing, are incorporated into therapy. The figures are oriented as follows: hand to the left and shoulder to the right. (Courtesy of Shriners Hospital for Children, Philadelphia.)

 

 

 

PEARLS AND PITFALLS
	Tendon ▪ Patients should be carefully examined prior to surgery to determine donor transfer tendons available for transfer and specific thumb motion(s) needed to regain selection function for work and daily activities.     Pulley ▪ Use the FCU or the pisiform when transferring the FDS ring finger tendon.3 construction ▪ Use the pisiform when transferring the EIP tendon. PL transfer does not require a pulley, but it yield primarily palmar abduction not opposition.     Attachment ▪ Commonly, the abductor pollicis brevis tendon; however, if additional pronation site and extension is necessary, then a more dorsal attachment site is performed.     Subcutaneous ▪ Tunnels should be ample size to allow easy passage of transferred tendons. tunnel

 

 

• After suturing the tendon transfer, the thumb should be in full opposition with

the wrist in extension. In flexion, the thumb should relax out of the palm.8

Tendon

transfer tensioning

creation

 

Stiff joints before tendon transfer

• Affected joints, especially in the thumb, must have good passive range of motion before tendon transfer. Otherwise, transfer risks failure due to inability to motor the joints.

 

POSTOPERATIVE CARE

 

A bulky hand dressing and short-arm plaster splint is placed with the wrist in flexion and the thumb in full opposition.

 

Immediate hand therapy commences to maintain motion in the fingers, especially the ring finger after FDS harvest.

 

If the ring finger tends to position into flexion, a proximal interphalangeal joint extension splint is fabricated for night-time wear.

 

In contrast, a ring finger that tends to swan-neck secondary to loss of the FDS tendon requires a silver ring splint to prevent deformity until the remaining FDS scars along the volar aspect of the proximal interphalangeal joint.

 

After 2 to 3 weeks, the plaster splint is removed and therapy is initiated. Longer periods of immobilization may yield scarring of the FDS tendon within the reconstructed pulley. Earlier mobilization under the auspices of a

qualified therapist may be appropriate in the compliant patient.10

 

An Orthoplast splint is fabricated to maintain mild wrist flexion and thumb opposition. The splint is removed four to six times a day to encourage tendon gliding exercises and retraining of the transferred tendon.

 

 

P.886

 

Similar occupational therapy principles are applied after other opposition transfers as described, including the PL, EIP, ADM, and other transfers.

 

Patients are instructed in other modalities, including scar management, muscle-tendon reeducation, and incorporation of the transfer into activities of daily living.

 

OUTCOMES

In general, opposition transfers are successful: Most patients regain opposition adequate to perform normal daily activities such as writing, buttoning clothes, and other fine manipulation tasks (FIG 2).12

Burkhalter et al2 reported excellent results in 57 of 65 cases of EIP opponensplasty; excellent results were defined as those with 75% function compared to the opposite normal thumb or those with less than a 20-degree difference between the plane of the opposite thumbnail and the plane of the palm with good power.

Jacobs and Thompson,7 using a variety of donor tendons (mainly ring and long finger FDS tendons),

 

pulley designs, and insertion techniques, reported 77 good or excellent, 9 fair, and 17 poor results.

Similar results were obtained with ring and long finger FDS tendons.

In a comparison of FDS versus EIP opponensplasty, Anderson et al1 compared 50 EIP to 116 FDS ring finger opponensplasty cases. Their analysis demonstrated that the EIP opponensplasty was best in supple hands, whereas the FDS opponensplasty was more suitable in less pliable hands.

 

FIG 2 • Postoperative photo of patient from FIG 1. This demonstrates good thumb opposition after ring finger FDS transfer for thumb opposition. (Courtesy of Shriners Hospital for Children, Philadelphia.)

 

 

 

COMPLICATIONS

Suboptimal transfer outcome due to stiff joints

Selection of suboptimal or weak muscle-tendon unit for transfer Incorrect vector of pull due to lack of or poor selection of pulley Rupture of transferred tendon

Tendon adhesions

Loss of grip strength or independent ring finger function after FDS ring finger transfer

Difficulty with muscle-tendon reeducation, especially with tendon transfers that are not synergistic. For example, EIP transfer is more difficult to learn compared to FDS tendon transfer.

 

 

REFERENCES

1. Anderson GA, Lee V, Sundararaj GD. Opponensplasty by extensor indicis and flexor digitorum superficialis tendon transfer. J Hand Surg Br 1992;17(6):611-614.

    

    

2. Burkhalter W, Christensen RC, Brown P. Extensor indicis proprius opponensplasty. J Bone Joint Surg Am 1973;55(4):725-732.

    

    

3. Cooney WP. Tendon transfer for median nerve palsy. Hand Clin 1988;4:155-165.

    

    

4. Davis T. Median nerve palsy. In: Green D, Hotchkiss R, Pederson W, et al, eds. Green's Operative Hand Surgery, ed 5. Elsevier, 2005:1131-1160.

    

    

5. de Roode CP, James MA, McCarroll HR Jr. Abductor digit minimi opponensplasty: technique, modifications, and measurement of opposition. Tech Hand Up Extrem Surg 2010;14(1):51-53.

    

    

6. Estilow T, Kozin SH, Glanzman AM, et al. Flexor digitorum superficialis opposition tendon transfer improves hand function in children with Charcot-Marie-Tooth disease: case series. Neuromuscul Disord 2012;22(12):1090-1095.

    

    

7. Jacobs B, Thompson TC. Opposition of the thumb and its restoration. J Bone Joint Surg Am 1960;42A:1015-1026.

    

    

8. Kozin SH. Tendon transfers for radial and median nerve palsies. J Hand Ther 2005;18:208-215.

    

    

9. Kozin SH, Bednar M. In vivo determination of available brachioradialis excursion during tetraplegia reconstruction. J Hand Surg Am 2001;26(3):510-514.

    

    

10. Rath S. Immediate active mobilization versus immobilization for opposition tendon transfer in the hand. J Hand Surg Am 2006;31(5): 754-759.

     

     

11. Ratner JA, Peljovich A, Kozin SH. Update on tendon transfers for peripheral nerve injuries. J Hand Surg Am 2010;35:1371-1381.

     

     

12. Sundararaj GD, Mani K. Surgical reconstruction of the hand with triple nerve palsy. J Bone Joint Surg Br 1984;66(2):260-264.

     

     

13. Trumble T. Tendon transfers. In: Trumble T, ed. Principles of Hand Surgery and Therapy, ed 1. Saunders, 2000:343-360.