Hybrid tendon transfer and nerve transfer reconstruction of high radial nerve palsy surgical technique
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Delayed presentation or failed reconstruction of a radial nerve injury results in a persistent wrist drop with paralysed digital extensors. Salvage options include a standard set of high radial tendon transfers, median to radial nerve transfers of or a combination of the two reconstructive modalities. The benefit of tendon transfer reconstruction for wrist extension is early recovery and improved digital function due to the tenodesis effect. The challenge with tendon transfers for digital extension is the loss of some end range wrist flexion due to the restriction conferred by the tendon crossing the wrist and the loss of finger independence at the MCPJ due to the composite action of the extensor tendon transfer reconstruction to all fingers. Some independence is achievable at the PIPJ and DIPJ with the activation of the hand intrinsic muscles through median and ulnar nerve innervation preservation.
There is emerging interest in the use of nerve transfers to achieve better function, however the technique is technically challenging, has a 6-12 month delay until useful function is restored and the nerve transfer should be performed by 6-9 months from injury otherwise irreversible collapse of the intra-muscular neural plexus ensues. A hybrid reconstruction can be offered using a combination of pronator teres (PT) tendon transfer to the wrist and median to posterior interosseus nerve transfers using fascicles from FCR and PL in the proximal forearm. The approach to the proximal median nerve requires release of the PT superficial (humeral) head and so the hybrid technique involves formal elevation of the PT insertion to the radius in the identical way a traditional tendon transfer would be performed. This facilitates exposure of the median nerve and its motor branches in the forearm.
Author: Dominic Power FRCS Orth, Consultant Hand and Peripheral Nerve Surgeon
Institution: Peripheral Nerve Injury Service, Queen Elizabeth Hospital, Birmingham, UK