RADIAL NERVE TENDON REPAIR

1. Journal Club : Tendon transfer in Radial nerve palsy
- By Douglas et al. (2009)
Presenter - Dr. SHUBHANSHU RANJAN KUSHWAHA

2. Radial nerve anatomy and course :-

3. Etiology :-
• MC injured peripheral nerve of upper extremity .
• In the axilla : -crutch palsy / Saturday night palsy
-aneurysm of axillary vessels
•In shoulder : fracture & dislocation of upper end of humerus or by attempting their
reduction
•In radial groove :
- # shaft humerus
- prolonged application of torniquet
•B/W spiral groove & lateral epicondyl :
- supracondylar humerus #
- lateral epicondyl#
• At the elbow :
- elbow dislocation
- # neck radius
- during various operative procedures

4. High Radial Nerve Injury
Wrist , finger & thumb extension as well as
thumb abduction are lost
• total palsy
• Triceps muscle & post.
cutaneous nerve
escapes
• Wrist extension preserved
bcs branch to ECRL arises
prox. to elbow
and thumb
• Sensory loss on dorsum of Ist web space
Low Radial Nerve Palsy
If PIN # proximally -> ECU function lost ->
radial deviation in wrist extension

5. Tendon transfer in radial nerve palsy
WHY ?
 Nerve injury fail to recover or irreparable nerve injury or failed nerve repair
 There are three main goals when treating radial nerve palsy :-
Restoration of finger (MCPJ) extension,
Restoration of thumb extension,
In cases if high radial nerve palsy, restoration of wrist extension
WHEN ?
 If the nerve remains in continuity most surgeons prefer 3-6 months of observation , to
await spontaneous recovery

6. Preferred surgical techniques :-
• 2 incision :
 Radial incision > PT to ECRB coaptation ( PT tendon lie adjacent to ECRB tendon ,
expendability of PT tendon
 Ulner incision > FCR to EDC coaptation in a subcut. tunnel
• Tendon coaptation of thumb and finger tendon transfer is performed prior to wrist .
• Tension is adjusted until wrist flexion of 30 ° produces adequate thumb and finger
extension .

7. Robert Jones described 2 sets of tendon transfers :-
1916 : PT - ECRL and ECRB -> wrist extensio
FCU - EDC III,IV,V -> MCPJ extension
FCR - EDC II , EIP and EPL -> Thumb extension
1921 : PT - ECRL and ECRB -> wrist extension
FCU - EDC III,IV,V -> MCPJ extension
FCR - EDCII,EIP,EPL,APL,EPB -> thumb extension

8. Brandt transfer protocol :-
PT - ECRB -> wrist extension
FCR – EDC -> finger extension
PL - EPL -> thumb extension

9. BOYES transfer protocol :-
PT – ECRB -> wrist extension
Ring finger FDS – EPL and EIP -> thumb & index finger extension
Middle finger FDS – EDC to all four fingers - finger extension
FCR -- APL and EPB -> abduction of thumb

10. Merle d’Aubigne procedure :-
PT – ECRB and ECRL
FCU – EPL + EDC
PL -- EBP and APL

11. Post-op care & rehabilitation :-
• Regardless of which procedure is performed , above elbow cast/splint should be applied post-
operatively .
• Position of cast/ splint ->
• Elbow -> 90° flexion , Forearm -> Pronated , Wrist -> 30 ° extension.
( tension off PT to ECRB transfer)
• Thumb -> abducted and extended , MCPJ – extended
( tension off the transfers to EDC and EIP)
• 1-4 wks – ROM exercise of shoulder and IPJ’s of fingers
• 4-6 wks – mobilisation of single joints ( keeping tension off the transfer)
• Splint should be worn when not performing prescribed exercise.
• At 6 wk – focus on activating the muscles used in tendon transfer.
• At 8wk – strengthening exercises , weaning-off of splint
• At 12 wk – Full activity