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Tendon Transfers for Radial Nerve Palsy

 - Discussion:
    - there are many surgical options for restoring digital extension in radial nerve palsy;
    - as w/ all tendon transfers, consider not only synergistic muscle activity, but also amplitude as well as muscle power and tendon excursion;
            - if surgery must be delayed, consider a stabilizing wrist orthosis; 
    - tensioning tendon transfers
    - low radial nerve palsy:
            - with a low radial nerve injury, there will be loss of EDC, EPL, APL;
            - in low nerve palsy, wrist extension is maintained, where as in high palsy, there is loss of wrist extension;
    - high radial nerve palsy:
            - loss of  EDC, EPL, APL, BR, ECRL / ECRB
            - hand orthosis:
                   - need to prevent web space contracture, and hyper-extension at MP joints;

     - EDC deficit: 
           - ref:  Results After Selective Tendon Transfers Through Interosseous Membrane to Provide Selective Finger and Thumb Extension in Chronic Irreparable Radial Nerve Lesions
     - EPL deficit:
           - brachioradialis transfer:
                 - can only be used in low palsies in which there is at least 4/5 function of the BR;
                 - advantage is that this can be performed thru the same incision as the pronator tranfer and the FCR transfer;
                 - typically this transfer is performed after the FCR to EDC transfer;
           - palmaris longus transfer:
                 - tendon rerouted to EPL;
                 - EPL is released at the myotendinous junction and its insertion into the thumb can be mobilized radially in order to promote some abduction in addition to thumb extension;
                 - palmaris longus has also been used to restore thumb abduciton;
           - flexor carpi radialis split transfer:
                 - split transfer allows independent restoration of finger and thumb extension in the absence of palmaris longus;
                 - if present palmaris longus muscle may also be transferred to restore the function of the abductor pollicis longus;
                 - ref: Independent function in a split flexor carpi radialis transfer. 
     - wrist extension deficit: (ECRL / ECRB)
           - often one of the major complaints following radial nerve injuries, is lack of power grip due to inability to stabilize the wrist;
           - pronator teres transfer to the ECRB has become a standard method for restoring wrist extension;
           - the beauty of this transfer is that the pronator teres will continue to function as a pronator;
           - generally this transfer is performed at the time of nerve repair;
           - make small longitudinal incision over the insertion of the PT tendon on the volar radial aspect of the forearm;
                 - harvest the insertion along with 2 cm of adjacent periosteum;
           - pronator tendon is passed subcutaneously over the brachioradialis tendon until it reaches the ECRB;
           - pronator tendon is woven into ECRB w/ enough tension to hold the wrist in mild extension;
           - ref: Functional Deficit After Transfer of the Pronator Teres for Acquired Radial Nerve Palsy.

    - APL deficit:
           - in a low radial nerve palsy, pronator teres can be transfered to the APL, however, in a high radial nerve palsy the pronator teres is used to restore wrist extension

Early transfer for radial nerve transection.  

Tendon transfers for radial nerve palsy

Apparent weakness of median and ulnar motors in radial nerve palsy

Splinting for radial nerve palsy

An improved splint for radial (musculospiral) nerve paralysis

Analysis of Tsuge's Procedure for the Treatment of Radial Nerve Paralysis.

Independent function in a split flexor carpi radialis transfer.

Immediate Postoperative Active Mobilization Versus Immobilization Following Tendon Transfer for Claw Deformity Correction in the Hand