Tendon Transfer Management for Enhanced Function of the Upper Extremity

Tendon Transfer Management for Enhanced Function of the Upper Extremity Deborah A. Schwartz, OTD, OTR/L, CHT [email protected] AOTA 2015 Defin...
Author: Derek Evans
2 downloads 1 Views 180KB Size
Tendon Transfer Management for Enhanced Function of the Upper Extremity Deborah A. Schwartz, OTD, OTR/L, CHT [email protected] AOTA 2015

Definitions: Tendon Transfer Surgery-Attempt to rebalance a hand by repositioning the tendon of a working muscle to take over the function of a now absent or paralyzed muscle Tendon transfer – tendon transected, transferred into another tendon or bone, innervation and vascular supply to donor muscle preserved Free muscle transfer – entire muscle-tendon unit transferred with neurorrhaphy and revascularization Neurotization – implantation of donor motor nerve into denervated vascularized muscle Nerve Transfer- redirection of an intact motor nerve from one muscle to the distal undamaged portion of a nerve from another, effectively bypassing the injured segment of nerve.

Indications: Substitution of function of paralyzed muscle Replace ruptured or avulsed tendon-muscle unit Restore balance to deformed hand Prerequisites: • Analysis of patient’s needs • Bony stability • Adequate soft tissue bed • Mobile joints • Expendable donor muscle

Considerations: Adequate strength -Proportional to cross-sectional area of all muscle fibers (physiologic cross-sectional area) Excursion Direction of Action

Staging of Procedures

Manual Muscle Testing: Grade 5 4

Terminology Normal Good

3 2 1 0

Fair Poor Trace None

Description Full range of motion and full strength Full range of motion against gravity with some resistance Full range of motion against gravity Full range of motion with gravity eliminated Slight contraction without joint movement No evidence of contraction

The Role of Therapy in Tendon Transfers 1. Pre-operative Assessment Interview Evaluations Functional Tests Simulations Patient Questionnaires- COPM, DASH, PRW/HE 2. Pre-operative Conditioning Stretching Orthotic Fabrication Serial Casting Joint Mobilizations Strengthening Program 3. Pre-operative Education Preoperatively, the therapist has the opportunity to discuss and help the patient format realistic goals and expectations from the surgery. The patient should also be made aware of the time frame of post-operative immobilization, post-op regimen and expected timetable of therapy visits and doctor F/U visits. Establish rapport with the patient.

4. Post-operative Rehabilitation

2

Post operative rehabilitation is divided into three phases: Early Phase involves immobilization in a cast for about 3-4 weeks. Intermediate Phase includes thermoplastic orthotic fabrication to continue protection of the transferred muscles. ROM exercises are initiated to isolated joints at first to avoid composite motions and over stretching of the transfers. Gentle Active/ Active assisted motions are performed for short sessions several times a day to reduce joint stiffness. Facilitation Techniques are utilized to activate the transferred muscles. 1. Verbal cues to perform the previous action of the muscle 2. Use of the preoperative postural pattern 3. Tapping, vibration over the muscle belly 4. Performing the function of the transferred muscle while attempting a new function 5. Visual Cues 6. Perform the action simultaneously with both hands 7. Perform on the opposite side 8. Biofeedback and/or NMES to facilitate firing of the muscles.

Late Phase includes strengthening exercises, motion against gravity and increased performance of ADL’S with the involved hand.

1. Median Nerve Tendon Transfers High versus Low Injuries Restoration of Opposition/ Opponensplasty Opposition = Abduction + Pronation + Flexion Function of Opponens Pollicis, Abductor Pollicus Brevis and Flexor Pollicis Brevis

Indications: Low level median nerve palsy Congenital deformities-Hypoplastic thumb Trauma: avulsed tendons and nerves Disease process *most frequently performed transfer in upper extremity Opposition is the ability to bring the thumb up and out of the palm towards the little finger so that the thumb nail is parallel to nail of little finger

3

Numerous Procedures: Transfer of FDS of the Ring to Abductor Pollicis Brevis  Palmaris Longus to APB (Camitz)  ADQM to APB (Huber) Other motors: EIP, EDQM, PL Fabrication of thermoplastic orthosis promoting wide abduction Therapy - emphasis on wide palmar grasp. Facilitate muscle by simultaneously bending tip of Ring finger while bringing thumb up *Can give resistance to Ring finger DIP joint. Opponensplasty: Therapy to promote opposition

2. Radial Nerve Tendon Transfers High versus low injuries Radial Nerve Palsy- denervated extensor muscles Procedure for radial nerve patients: Pronator Teres to Extensor Carpi Radialis Brevis plus additional procedures Goal: Restoration of Wrist Extension Fabrication of a wrist cock up orthosis with pronation strap to maintain forearm position Therapy to promote wrist extension during activities and grasp and release function

3. EIP to EPL Transfer Indications: EPL ruptures secondary to distal radius fractures or patients with Rheumatoid Arthritis

Immobilization in wrist extension and maximum thumb extension for 4 weeks.

4. Restoration of Wrist Extension Indications: Cerebral Palsy - unbalanced wrist due to increased flexor tone

4

Procedure for Cerebral Palsy patients: Possible Donors include Flexor Carpi Ulnaris (FCU) to Extensor Carpi Radialis Longus (ECRL) and/or Extensor Carpi Ulnaris (ECU) to Extensor Carpi Radialis Brevis (ECRB) Radial Nerve Palsy- denervated extensor muscles

Procedure for radial nerve patients: Pronator Teres to Extensor Carpi Radialis Brevis plus additional procedures Restoration of Wrist Extension Early Phase Immobilization in cast in wrist extension, forearm pronation and elbow flexion to 90 to avoid tension on the transfers muscles Fabrication of a wrist cock up orthosis with pronation strap to maintain forearm position Therapy to promote wrist extension during activities and grasp and release function

5. Ulnar Nerve Tendon Transfers High versus Low Injuries: Loss of power grip paralysis of FDP (III and IV) decreased wrist strength Loss of FCU (strongest wrist flexor) Loss of power pinch paralysis of adductor pollicis and first dorsal interosseous impaired thumb stability loss of deep head of FPB

Procedures to treat claw deformity: Early Phase Immobilization in dorsal blocking orthosis for 4 weeks. Begin isolated movements • AROM to enhance tendon gliding• Blocking exercises for FDS and FDP Reinforce lumbrical action. • No passive flexion of IP’s

5

6. Biceps to Triceps Transfer Indications: Tetraplegic population lacks elbow extension due to Spinal Cord injury at C7 level. Factors in Spinal Cord Injuries: Surgery is usually delayed until one year after injury to allow motor function of plateau. Patients must psychologically accept their injury and have a realistic outlook on the functional gains that can be made with surgery. Contraindications of surgery include uncontrolled spasticity and painful paresthesias. Patients must be able to comply with postoperative therapy (no significant brain injury, good family support). Importance of Elbow Extension Functional gains of reach above shoulder level Reach for objects when supine Pressure relief Maximum independence with transfers Positioning of hand in space

Biceps to Triceps Prerequisites: Must have active supinator and brachialis for elbow flexion without biceps. Early Phase Immobilization Well padded long arm cast with elbow in 0-15 degrees of elbow extension Intermediate Phase Orthoses: 1. Flexion Block Splint- Bledsoe Brace prevents elbow flexion initially beyond 15 degrees 2. Elbow extension orthosis for night Therapy to promote active elbow extension Initial AROM in a gravity eliminated plane Late Phase

6

Advance 15 degrees of flexion in splint weekly until patient reaches 90 degrees of flexion and maintains full extension. Discontinue Bledsoe Brace after one week at 90 degrees. Continue night time orthosis for three months Current Evidence and Updates: Wide Awake Surgery Early Mobilization protocols Nerve transfers

References for Tendon Transfer Presentation AOTA 2015 Deborah A. Schwartz, OTD, OTR/L, CHT 1. Anesthesia; Investigators from Dalhousie University Zero in on Anesthesia: Wide –Awake Extensor Indicis Proprius to Extensor Pollicis Longus Tendon Transfer. Medical Devices & Surgical Technology Week (Dec 14, 2014): 230. 2. Ashworth S, Kozin SH. Brachial Plexus Palsy Reconstruction: Tendon Transfers, Osteotomies, Capsular Release and Arthrodesis. In Skirven TM, Osterman AL, Fedorczyk JF, Amadio PC. (editors). Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, 2011, Mosby. 792-812. 3. Bezuhly M, Sparkes GL, Higgins A, et al. 2007. Immediate Thumb Extension following Extensor Indicis Proprius to Extensor Pollicis Longus Tendon Transfer Using the Wide Awake Approach. Plastic Reconstructive Surgery. 119:15071512. 4. Birch R, Carlstedt T. 2005. Musculotendinous unit transfers after nerve injury. In Friden J, editor: Tendon Transfers in Reconstructive Hand Surgery. London and New York. FESSH. Taylor and Francis. 51- 68. 5. Botte MJ, Pacelli LL. 2005. Basic principles in tendon transfer surgery. In Friden J, Editor: Tendon Transfers in Reconstructive Hand Surgery. London and New York. FESSH. Taylor and Francis. 29-49. 6. Duff SV, Humpl D. 2011. Therapist’s Management of Tendon Transfers. In Skirven TM, Osterman AL, Fedorczyk JF, Amadio PC, editors: Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA. Mosby. 781-791. 7. Giessler GA, Przybilski M, Germann G et al. 2008. Early Free Active Versus dynamic Extension Splinting after Extensor Indicis Proprius Tendon Transfer to Restore Thumb Extension: a Prospective Randomized Study. Journal of Hand Surgery. 33A, 864-868.

7

8. Hammert WC, Heest AEV, James M A et al. 2010. Tendon Transfers. In Hammert WC, Calfee RP, Bozentka DJ, Boyer MI, editors: ASSH Manual of Hand Surgery. Philadelphia, PA. Wolters Kluwer / Lippincott, Williams and Wilkens. 145-169. 9. Journal of Hand Therapy. 26 (2) ; 175-8. 10. Kang L, Wolfe S. 2011. Traumatic Brachial Plexus Injuries. In Skirven TM, Osterman AL, Fedorczyk JF, Amadio PC, editors: Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA. Mosby. 749-759. 11. Koman LA, Li Z, Patterson Smith B, Tuohy C, Cardoso R. 2011. Upper Extremity Musculoskeletal Surgery in the Child with Cerebral Palsy: Surgical Options and Rehabilitation. . In Skirven TM, Osterman AL, Fedorczyk JF, Amadio PC, editors: Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA. Mosby 1651-1658. 12. Kozin, SH. 2005. Tendon Transfers for Radial and Median Nerve Palsies. Journal of Hand Therapy. 18: 208-215. 13. Lalonde D. 2013. How the wide awake approach is changing hand surgery and hand therapy: Inaugural AAHS sponsored lecture at the ASHT meeting. 14. Leclercq C. 2005. Tenodeses in reconstructive hand surgery. In Friden J, editor: Tendon Transfers in Reconstructive Hand Surgery. London and New York. FESSH. Taylor and Francis. 69 -83. 15. Lieber RL2005. Muscle Architectural and biomechanical considerations in tendon transfer In Friden J, editor: Tendon Transfers in Reconstructive Hand Surgery. London and New York. FESSH. Taylor and Francis. 1-19. 16. Liu Y, Lao J, Gao K. et al. 2013. Functional outcome of nerve transfers for traumatic global brachial plexus avulsion. Injury. 44 (5): 655-60. 17. Lohman H, Coppard BM. 2015. Orthotic Intervention for Nerve Injuries. In: Coppard BM, Lohman H. (editors). Introduction to orthotics; a clinical reasoning and problem solving approach. 4th Ed. St. Louis, MO. Elsevier Mosby, 293-323. 18. Lubahn J, Wolfe TL. 2011. Surgical Treatment and Rehabilitation of Tendon Ruptures and Imbalances in the Rheumatoid Hand. In Skirven TM, Osterman AL, Fedorczyk JF, Amadio PC, editors: Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA, Mosby. 1399-1407. 19. MacDermid JC, Tottenham V. 2004. Responsiveness of the disability of the arm, shoulder, and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy. Journal of Hand Therapy. 17(1); 18-23. 20. McCabe C. 2011. Mirror Visual Feedback Therapy: A Practical Approach. Journal of Hand Therapy. 24: 170-179. 21. Moore AM, Novak CB. 2013. Advances in nerve transfer surgery. Journal of Hand Therapy. 27 (2); 96–105. 22. Moscony AMB. 2007. Common Peripheral Nerve Problems. . In Cooper C, editor: Fundamentals of Hand Therapy. Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. St. Louis, MO. Mosby Elsevier. 201250. 23. Peliovich AE, Bryden AM, Malone KJ, et al. 2011. Rehabilitation of the Hand and Upper Extremtiy in Tetraplegia. In Skirven TM, Osterman AL, Fedorczyk JF, Amadio PC, editors: Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA. Mosby.1684-1705.

8

24. Pettengill K. 2011. Therapist Management of the Complex Injury. In Skirven TM, Osterman AL, Fedorczyk JF, Amadio PC, editors: Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA. Mosby. 1238- 1251. 25. Rath S. 2009. A Randomized Clinical Trial Comparing Immediate Active Motion with Immobilization after Tendon Transfer for Claw Deformity. Journal of Hand Surgery. 34A: 488–494. 26. Ratner JA, Kozin SH. 2011. Tendon transfers for upper extremity peripheral nerve injuries. In Skirven TM, Osterman AL, Fedorczyk JF, Amadio PC, editors: Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA. Mosby. 771- 780. 27. Ratner JA, Pelijovich A, Kozin SH. 2010. Update on Tendon Transfers for Peripheral Nerve Injuries. Journal of Hand Surgery. 35A 1371-1381. 28. Richer RJ, Peimer CA. 2005. Flexor Superficialis Abductor Transfer with Carpal Tunnel Release for Thenar Palsy. Journal of Hand Surgery. 30A: 506- 512. 29. Rosenthal EA, Elhassan BT. 2011. The Extensor Tendons: Evaluation and Surgical Management. In Skirven TM, Osterman AL, Fedorczyk JF, Amadio PC, editors: Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA. Mosby. 487 -520. 30. Sammer DM, Chung KC. 2009. Tendon Transfers Part I: Principles of Transfer and Transfers for Radial Nerve Palsy. Plastic Reconstructive Surgery. 123:169e177e, 2009. 31. Sammer DM, Chung KC. 2009. Tendon Transfers Part II: Transfers for Ulnar Nerve Palsy and Median Nerve Palsy. Plastic Reconstructive Surgery. 124(3) 212e-221e. 32. Schoeneveld K, Wittink H, Takken T. 2009. Clinimetric Evaluation of Measurement Tools Used in Hand Therapy to Assess Activity and Participation. Journal of Hand Therapy. 22: 221-36. 33. Schwartz DA. 2014. Tendon Transfers. In Cooper C (Ed). Fundamentals of Hand Therapy. Elsevier Mosby. ST. Louis, MO. 438-456. 34. Schwartz DA. 2005. Strategies for Facilitation of Tendon Transfers for Enhanced Wrist Extension in Cerebral Palsy: A Case Report. British Journal of Hand Therapy (HAND). 10:10-16. 35. Sultana SS, MacDermid JC, Grewal R, Rath S. 2013. The effectiveness of early mobilization after tendon transfers in the hand: A systematic review. Journal of Hand Therapy, 2013 Jan-Mar; 26 (1): 1-22. 36. Sunumu IO, Aydeniz A, Turkmen A et al. 2010. Rehabilitation of Tendon Transfers for Radial Nerve Injury: A Report of Two Cases. Turkish Journal of Physical Medicine & Rehabilitation. 56; 91. 37. Van Lede P, van Veldhoven G. 2006. Therapeutic Hand Splints: A Rational Approach. 2nd Edition. Asker, Norway. Volume 2. 38. Yavari M, Abdolrazaghi HA, Riahi A. 2014. A comparative study on tendon transfer surgery in patients with radial nerve palsy. World Journal of Plastic Surgery. January 3(1):47-51.

9

10

Suggest Documents