Sieg & Adams, Illustrated Essentials of Musculoskeletal Anatomy (1996)

High Lesion: Proximal to elbow
Recovery of intrinsic function rare due to long distance from site of injury
Trauma
Laceration
Compressive
Cubital Tunnel Syndrome
Other
Peripheral Neuropathy (i.e.
Diabetes)
Charcot-Marie-Tooth disease Gunshot/stab wound Prolonged or repetative compression at Guyon’s Canal
(i.e. bicycling, tennis)
Fracture/dislocation Tumor

sportinjuriesandwellnessottawa.blogspot.com

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Low: Intrinsic musculature
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Palmar Interossei
Dorsal interossei
3 rd and 4 th Lumbricals
Adductor Pollicis
Flexor Pollicis Brevis (deep head)
Flexor Digiti Minimi
Opponens Digiti Minimi
Abductor Digiti Minimi
High: Intrinsic + Extrinsic musculature
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Flexor Digitorum Profundus of Ring and Small
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Flexor Carpi Ulnaris

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Claw hand
 low nerve palsy only
Froment’s Sign
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Jeanne’s Sign
Swan Neck
Boutonniere Deformity

 Decreased grip strengthoften as much as 60-80%
 Key Pinchas much as 70-80%
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Relies on the adductor pollicis, 1 st dorsal interossei, and flexor pollicis brevis for stability and strength
Froment’s Sign
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Hyperflexion of the thumb IP joint during pinch
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Jeanne’s Sign
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Hyperextension of the thumb MP joint during pinch
Dell, P et al, JHT (2005)

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 Ulnar ½ of Ring Finger,
Small finger, hypothenar eminence, and similar on dorsum of hand
 Dorsal sensory branch of the ulnar nerve originates approximately 7 cm proximal to ulnar styloid www.rch.org.au

Objectives
 Prepare patient, physically & psychologically, for surgery
 Enable patient to be as functional as possible prior to surgery

 Objectives:
 Reduce MP joint hyperextension due to normal function of the EDC unopposed by the intrinsic flexors
 Stability of thumb for key pinch
 Hand Based:
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Dorsal Knuckle Bender
Figure 8 or Lumbrical Bar
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Hand based thumb spica for pinch
Thumb MP stabilizer for Jeanne’s sign
 Oval 8 for Froment’s sign

ncmedical.com

 Forearm Based: if high ulnar nerve lesion may need to stabilize forearm
 Ulnar gutter allegromedical.com

 Objective:
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Prevent or reduce PIP joint contractures of ring and small fingers
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Prevent or reduce Boutonniere & Swan Neck deformities
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Reduce pain in thumb due to imbalance in pinch

To reduce PIP contractures prior to surgery www.msdlatinamerica.com

For Boutonniere and Swan Neck

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Increase ability to complete tasks with weak pinch
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Use of adaptive equipment
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Elastic shoelaces
Adaptive light switch
Compensation
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Modified writing position
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Adaptive key pinch for car

 Maintain full PROM for involved joints
 Manual Muscle Testing
 Electrical Stimulation
 Persistent pain management/education
 Patient Education regarding realistic expectations related to function, timing, and rehab needs

Specific Transfers and Indications
Goal to Regain From: Donor Tendon
(working)
To: Recipient
Tendon (deficient)
Adductor pollicis Thumb Adduction FDS, ECRB or ECRL, EIP, or
Brachioradialis
Finger Abduction
(index most important)
APL, ECRL, or EIP 1 st dorsal interossei
Reverse Clawing effect
FDS, ECRL (must pass volar to transverse metacarpal ligament to flex proximal phalanx)
Lateral bands of ulnar digits www.orthobullets.com

 Use of ECRB or ECRL w/ free tendon graft (usually Palmaris Longus) to restore Adductor Pollicis function
 Advantage:
 Strong motor component and avoids sacrificing finger flexor
 Good excursion
 Disadvantage:
 Doesn’t reproduce same line of pull
Dell, P. JHT (2005); http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html

 Objective: provide more stability to index during pinch than strength
 Transfers typically provide 25-
50% of normal pinch strength
Dell, P. JHT (2005); http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html

Procedure Concept
Bunnell Release of A1 & A2 pulleys to allow flexors to bowstring, often combined with tightening of volar capsule
Zancolli Volar plate advanced proximally to produce flexion contracture of
MP
Stiles-Bunnell Splits FDS (usually MF) and transfers to radial lateral bands of RF/SF
Zancolli lasso FDS of MF, passed through A1 pulley and sutured onto self
Fowler Active tenodesis w/ 2 tendon grafts sutured to lateral bands
Must have active wrist flexion to elicit tightening for MP flexion and
IP extension
Brand ECRB or ECRL to radial lateral bands
Dell, P. JHT (2005)

Flexor digitorum superficialis (FDS) tendon transfers for correction of clawing.
The FDS can be sewn to the lateral band (A), to bone
(B), or on itself in the
Zancolli lasso (C).
http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html

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For Brand procedure:
 3 ½ weeks post-op
 Splint:
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Volar routing: Dorsal Blocking splint with wrist in 30 degrees flexion, MP 60 degrees flexion, and IP neutral
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Dorsal routing: Dorsal Blocking splint with wrist in 30 degrees of extension, MP blocked in 60 degrees of flexion, and IP extended
ROM
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AROM w/ in splint 10 minutes every hour
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Passive extension to PIP and DIP
Passive flexion-only if tendon inserted into bone; for insertion into lateral bands: no passive flexion until 6 wks due to risk of stretching out transfer
NMES to facilitate excursion
Scar Management
Indiana Hand Protocol (2001)

 6 weeks post-op
 Splint
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Reduced to MP block with palmar bar in 45 degrees of flexion to be worn at all times
 If PIP extensor lag-continue with dorsal blocking splint
 ROM
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PROM to MPs, PIPs, and DIP joints
All completed within the restrains of the MP block
Indiana Hand Protocol (2001)

 7-8 weeks post-op
 Dynamic flexion initiated prn
 Monitor for PIP extensor lags
 10-12 weeks post-op
 MP blocking splint discontinued if hyperextension not present and minimal (<15 degrees) PIP extensor lag
Indiana Hand Protocol (2001)

To ensure good excursion of long flexors, concentration on blocking exercises and use of NMES to restore flexion of FDS and FDP can be helpful
Indiana Hand Protocol (2001)

 Objective: Restore intrinsic muscle function for pinch strength, power grip, and dexterity
 Options
 Terminal branch of AIN to deep motor branch of ulnar nerve
 Not synergistic but increases pinch/grip strength and decreases clawing
 Branches of Posterior Interosseous Nerve (PIN), EDM and ECU branch, to ulnar nerve

Nerve Transfer
Immobilization
 Elbow/Forearm: 7-10 days
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Post-op dressing
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May change to splint as early as s/p 2-3 days
No further protection after 10 days due to no tension on nerve transfer
If tendon transfer at same time, protocol paradigm shift related to tendon
Moore et al, JHT (2014)

 Tendon Transfer
 Same as for Tendon repair
 Nerve Transfer
 Risk of increased tension on nerve repair site

Tendon and/or Nerve Transfer
 Edema control
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Scar management
Pain management
Range of Motion
Sensory Re-Education
Strengthening
Restore Function

 Objective:
To correct recruitment and restoration of muscle balance and decrease compensatory patterns
 Motor Re-education
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Challenges:
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Alterations in motor cortex mapping (i.e. neuro tag smudging)
Muscle imbalances due to weakness associated with dennervation
May persist due to compensatory movement patterns and persistent weakness of reinnervated muscles
Method:
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Contract muscle from donor nerve/muscle with new muscle until motor pattern established
The more synergistic the action and based on original motor pattern, the more recruitment and establishment of muscle balance

 Cortical Re-mapping
 Graded motor imaging
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Left/Right discrimination
Explicit Motor Imagery
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 Mirror Therapy
Patient Education

VibrationClapping
StereognosisContact particles

Light to deep Touch blog.physiotek.com

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ROM
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PROM
Place and Hold with visualization
AROM through full range
Opposition exercises
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Light object pick-up
Marble cup
3 poker chips
Strengthening
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Graded putty exercises
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Button find
Pushing golf tees in putty
Tearing paper

Putty Exercises for grip and pinch

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Cannon, N, et al. Diagnosis and Treatment manual for Physician and Therapists. Upper Extremity Rehabilitation, 4 th edition.
Indianapolis. 2001.
Davis KD, Taylor KS, Anastakis DJ. Nerve Injury Triggers Changes in the Brain. Neuroscientist. 2011; 17 (4).
Dell PC, Sforzo CR. Ulnar Intrinsic Anatomy and Dysfunction.
Journal of Hand Therapy. April-June 2005; 2:198-207.
Hoard AS, Bell-Krotoskie JA, Mathews R. Application of
Biomechanics to Tendon Transfers. Journal of Hand Therapy. April-
June 1995; 115-123.
Moore AM, Novak CB. Advances in nerve transfer surgery. Journal of Hand Therapy. April-June 2014; 27: 96-105.

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Moseley GL, Butler DS, Beames TB, Giles TJ. The Graded
Motor Imagery Handbook. Adelaide, Australia. Noigroup
Publications. 2012.
Sieg & Adams. Illustrated Essentials of Musculoskeletal
Anatomy, 3 rd Edition. Gainesville, Megabooks, Inc. 1996.
Sultana SS, MacDermid JC, Grewal R, Rath S. The effectiveness of early mobilization after tendon transfers in the hand: A systematic review. Journal of Hand Therapy. October 2013;
26: 1-21.
Wang JHC, Guo Q. Tendon Biomechanics and
Mechanobiology-A minireview of basic concepts and recent advancements. Journal of Hand Therapy. April-June 2012; 7:
133-140.