Dept. of Orthopaedics & Traumatology Faculty of Medicine Airlangga University Dr.

Soetomo General Hospital SURABAYA

W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E

Radial nerve palsy associated with fractures of the shaft of the humerus is the most common nerve lesion complicating fractures of long bone (Crenshaw AH. 1992)
(Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD,1996)

Tendon transfers have been used for radial nerve palsy for more than one century (Tubiana, 1991, 2002) when hope of spontaneous or surgical recovery appears to be unlikely.

Nerve grafting may restore sensation and motor function but, even when this procedure is possible, the result is not always good enough to give complete extension of the wrist and digits (Ring et al., 2004)
F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E

W A K E

The main problem for the surgeon is the choice of tendons to transfer In a high radial nerve palsy, three tendons will usually be required to restore each one of three functions: extension of the wrist, extension of the fingers and extensionabduction of the thumb
(Scuderi, 1949; Tubiana, 2002).

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

We observed 5 patients whom have been operated between 2006 - 2007 at Dr.Soetomo Hospital.

4 patients underwent a tendon transfer for radial nerve injury after failure to recover following nerve repair and 1 because high demanding Patients with radial nerve dysfunction after brachial plexus injury were not included

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

In high radial nerve palsy (n = 5), the tendon of pronator teres (PT) was always transferred to achieve wrist extension
The transferred tendon was always attached to the extensor carpi radialis brevis (ECRB) distally
F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E

W A K E

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Extension of the fingers was restored with the flexor carpi ulnaris (FCU). The transferred tendon was sutured to the extensor digitorum communis (EDC)

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

The goal of the transfer to the thumb is as much to allow opening of the first web space as to provide extension of the thumb.

(Dr Mickal Ropars, Orthopaedic and Reconstructive Surgery Unit, Hospital Sud University, France)

Thumb Extension restore by PL to rerouted EPL.

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

patients were immobilised in extension in a volar splint for four weeks. Passive motion was then started. Active motion was allowed from six weeks after surgery

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

The functional results were assessed using the method described by Robert G.Chuinard that modified Zachary methode
Results DF Excellent Good Fair Poor
>50 25 to 50 <25

wrist PF
>30 10 to 30 <10

finger MP Ext
>170 135 to 170 <155

thumb ABD
>40 30 to 40 <30

FT-MPC
0 0 to 1n > 1/2 in No improvement

IP Ext
>180 165 to 180 <165

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Sex,Age,handed: Male, 46 years old,Right Injured hand Right Cause CF humerus [R} Previous treatment ORIF [Plating] 6 years

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Wrist extension

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

MCP Extension/flexion

Thumb Extension

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Sex,Age,handed: Male, 43 years old,Right Injured hand Right Cause Stab lateral and post arm Previous treatment Radial nerve repaire

EMG: no function below triceps (4 months)

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Wrist extension/Flexion

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Thumb extension

MCP extension

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Sex,Age,handed: Female, 24 years old,Right Injured hand Right Cause CF humerus [R] Previous treatment ORIF [Plating] and radial nerve repaire

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Wrist extension/Flexion

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Thumb extension

MCP extension

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Sex,Age,handed: Male, 60 years old,Right Injured hand Right Cause CF humerus [R] Previous treatment ORIF [Plating] 5,5 years

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Wrist extension/Flexion

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

MCP extension

Thumb Extension

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Sex,Age,handed: Male, 38 years old,Right Injured hand left Cause OF humerus[L] Fell down from a train Previous treatment ORIF [Plating] 5 months

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Wrist extension

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

MCP extension

Thumb Extension

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

Results
The functional results were assessed using the method described by Robert G.Chuinard that modified Zachary methode

Results DF Case 1 Case 2 Case 3 Case 4 Case 5 Mean

55

wrist PF
30 30 20

finger MP Ext
180 0 0 0

thumb FT-MPC 40 45 40 45 45 43 ABD

180 180 185

Results IP Ext excellent excellent excellent excellent excellent excellent

80
85

175
180

85 75 76

50 50 36

180 180 179

0 0 0

180 180 181

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

DISCUSSION
In respect of the range of motion of the wrist, we recorded a wider range of wrist extension than flexion abilities in our series This asymmetry between flexion range and extension range may either be explained by the way the tension of the transfer is adjusted during surgery or by the tendon used for the finger extension transfer

Those differences have no functional importance because a range of motion of 20/20 is adequate for normal function (Kruft, 1997).

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

During testing of power of gripping, 1 patient (case 3) had radial deviation 20 degrees compensation during this testing.

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

We use standard (FCU) set of transfer and had excellent results We will use others technique (Tsuge procedure, boyes) for the individual patient rather than to try to adapt all patients to single procedure.

whatever the transfers used, they mostly give efficient results in terms of mobility and subjective satisfaction
F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E

W A K E

1 year post transfer Candidate for tendon transfer

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E

W A K E

F O R E S T

U N I V E R S I T Y

S C H O O L

O F

M E D I C I N E