Secondary Repair, Hand

Tendon transfers for wrist and finger

Secondary Surgery - Hand

At the wrist level one of the more frequent deficits that needs to be restored is the wrist extension. The transfers can vary depending of the availability of functioning muscles but they are generally possible even in more extensive paralysis. Restoration of wrist extension is of paramount importance for the hand function and must be a priority objective.

Functional result in a total paralysis after primary repair and after secondary repair by means of a transfer for wrist and finger extension

The palliative surgery at the hand level for lack of finger function is more difficult to carry out, not for technical problems but due to the frequent lack of available muscles to be transposed. This happens in total paralysis where lower roots of the brachial plexus had been avulsed and no possibility of spontaneous recovery can happen. Despite the early microsurgical repair of these roots, the functional results can be sometimes poor and for this reason transfer to recover finger flexion must be performed.

In severe total paralysis when no muscle are available for transfer there is the possibility to performe a tenodesis: it consists of fixing extensor and flexor tendons to the bone (radius) win such away that during eztension of the wrist (red arrows) the flexor are tightened and the extensor are relaxed producing in this way a flexion of the fingers. On the right side we can see that the passive drop of the hand produces a passive extension of the fingers with an opening of the hand

The ideal age to perform these operations is generally around 4 years, as the completion of functional recovery takes more time to occur than in the upper part of the arm.
In selected cases in which no function at all is recovered, especially for elbow flexion, there is still the possibility to transfer with microsurgical techniques a muscle from the thigh. This type of surgery can restore only a unique limited function.

All these type of secondary surgeries (except the last one) take less time to perform as compared to primary microsurgical repair of brachial plexus; it is also necessary to immobilize the affected arm in a cast for a period of 4 to 5 weeks depending of the type of muscular transfer.

Tendon Transfers for wrist and fingers

If there is a lack of wrist and fingers extension after 3 years , there is little hope of further spontaneous recovery . It is the necessary to reconstruct extension with tendon transfers . The muscle used depend on the recovery : if the lower roots have not been paralysed initially , several good muscles can be used : Flexor Carpi Ulnaris , Pronator Teres , Flexor Superficialis ...

In cases of complete paralysis , the distal muscles are weak and the result of the transfers are not so good ;
After transfer , the wrist or fingers are immobilized in extension for 5 weeks . After removal of the splint , the physiotherapy is resumed and a night splint is used for 3 months .