Abstract
Introduction
–Loss of radial nerve function leads to severe weakness of grip and tendon transfer is considered the standard treatment. However; there is continuing debate as to the best combination of tendon transfers in such patients. The aim of this study is to present the results of Flexor carpi radialis (FCR) combination of triple tendon transfer for radial nerve palsy.
Material and methods
It is a retrospective study conducted over 15 years. 58 patients of with irreversible radial nerve paralysis were included. Brands transfer was performed in all cases. The ranges of movement of the wrist, fingers and thumb were evaluated pre-operatively and postoperatively using Bincaz scale.
Results
Total 58 patients were included in the study, 47 were male and 11 female patients with mean age of 35.27 years. Causes of radial nerve palsy were comminuted open humeral fracture (n = 42), penetrating injuries (n = 13) and brachial plexus palsy (n = 3). Mean duration of palsy was 9.37 months (range = 9–12 months). The mean post-operative follow-up was 10 (range = 2–15) years. On evaluation with the Bincaz score, 6 patients had excellent results, 49 patients had good results, and 3 patients had poor results. There were 3 complications in 5 patients, including radial deviation of wrist, inadequate abduction of thumb and restricted wrist flexion. 55 patients (94.82%) were able to return to their normal daily work after ∼8 weeks. Conclusions - Tendon transfer is a standard procedure for radial nerve palsy but potential advantage of one method over the other has not been demonstrated. Brand’s transfer results in an acceptable restoration of hand function.
Keywords: Tendon transfer, Radial nerve paralysis, Flexor carpi radialis, Brands transfer, Wrist drop
1. Introduction
Among all the peripheral nerves of upper limb, radial nerve is most vulnerable to damage.1 Loss of radial nerve function leads to severe weakness of grip as a result of loss of extension of wrist, thumb and metacarpo-phalangeal (MCP) joints of fingers. If radial nerve does not recover after conservative treatment or nerve repair, tendon transfer is considered.2,3 Most of the standard transfers are performed with success however; there is continuing debate as to the best combination of tendon transfers in patients with radial nerve palsy.4 Aim of this study is to present the results of Flexor carpi radialis (FCR, Brands transfer) combination of triple tendon transfer for radial nerve palsy.
2. Material and method
It is a retrospective study conducted from 2003 to 2018 in a tertiary referral centre in Central India. Records of all patients who were operated for tendon transfer for radial nerve palsy during this period were retrieved and analysed. These patients had normal hand function prior to injury with supple hand/wrist joints, stable skeleton, good skin cover with no contracture at the time of tendons transfer. Patients with absent Palmaris longus (PL) tendon or associated injuries of the median or ulnar nerves were excluded from the study. Three tendons were used to restore lost extension of wrist, fingers and thumb. The pronator teres (PT) was transferred to extensor carpi radialis brevis (ECRB) for wrist extension, PL to extensor pollicis longus (EPL) to restore thumb extension and some abduction and FCR to extensor digitorum communis (EDC) to restore fingers extension.
After surgery patients were followed up every month during the first 3 months and then every 3 months for the next 6 months. Postoperatively functional results were assessed by Bincaz scoring system (Table 2). According to this scoring system, results are judged to be excellent with a score above, or equal to, 8 points, good with a score of 6 or 7 points, Fair with 4 or 5 points and poor with 3 or less points.5 Patients were asked about their return to normal activities of daily living/work. Mean post-operative follow-up was 10 (range 2–15) years.
Table 1.
Demographic details of the patients.
| S no | Age/sex | Injured hand | Palsy duration (months) | Cause | Previous treatment | Preop exam | Bincaz Scale value in bracket |
Complications |
|---|---|---|---|---|---|---|---|---|
| 1 | 35/M | Right | 10 | Humerus shaft # | No | Poor | Good (6) | – |
| 2 | 31/M | Left | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 3 | 28/M | Right | 9 | Penetrating stab wound | No | Fair | Good (7) | – |
| 4 | 40/M | Right | 11 | Humerus shaft # | No | Poor | Good (6) | – |
| 5 | 36/F | Right | 9 | Penetrating stab wound | Yes | Poor | Excellent (8) | – |
| 6 | 26/M | Right | 9 | Humerus shaft # | No | Poor | Excellent (8) | – |
| 7 | 42/M | Right | 9 | Humerus shaft # | Yes | Poor | Good (6) | – |
| 8 | 32/M | Left | 12 | Humerus shaft # | No | Poor | Good (7) | – |
| 9 | 31/F | Right | 9 | Humerus shaft # | No | Poor | Excellent (9) | – |
| 10 | 33/M | Right | 9 | Brachial palsy | yes | Fair | Good (6) | – |
| 11 | 38/M | Left | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 12 | 27/M | Right | 10 | Penetrating stab wound | Yes | Poor | Good (7) | – |
| 13 | 21/M | Right | 9 | Humerus shaft # | Yes | Fair | Excellent (8) | – |
| 14 | 32/M | Right | 9 | Humerus shaft # | No | Poor | Good (7) | – |
| 15 | 34/M | Left | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 16 | 46/M | Right | 11 | Humerus shaft # | Yes | Poor | Good (6) | – |
| 17 | 30/F | Right | 9 | Penetrating stab wound | No | Poor | Poor (2) | Inadequate thumb abduction |
| 18 | 41/M | Left | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 19 | 48/M | Right | 9 | Humerus shaft # | No | Poor | Poor (2) | Inadequate thumb abduction |
| 20 | 32/M | Right | 10 | Humerus shaft # | Yes | Poor | Good (7) | – |
| 21 | 37/F | Left | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 22 | 31/M | Right | 9 | Penetrating stab wound | Yes | Poor | Good (6) | – |
| 23 | 41/M | Right | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 24 | 45/M | Right | 9 | Humerus shaft # | Yes | Poor | Good (6) | – |
| 25 | 34/M | Right | 12 | Penetrating stab wound | No | Poor | Good (6) | – |
| 26 | 22/M | Right | 9 | Humerus shaft # | No | Poor | Excellent (8) | – |
| 27 | 50/M | Right | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 28 | 39/M | Left | 9 | Humerus shaft # | No | Poor | Good (7) | – |
| 29 | 32/F | Right | 9 | Humerus shaft # | Yes | Fair | Good (6) | – |
| 30 | 29/M | Right | 9 | Brachial plexus palsy | Yes | Fair | Excellent (8) | – |
| 31 | 37/M | Right | 9 | Humerus shaft # | Yes | Poor | Good (6) | – |
| 32 | 33/F | Right | 10 | Humerus shaft # | No | Poor | Good (6) | – |
| 33 | 36/M | Left | 9 | Humerus shaft # | Yes | Fair | Good (6) | – |
| 34 | 34/M | Right | 9 | Penetrating stab wound | No | Poor | Good (7) | – |
| 35 | 42/M | Right | 9 | Humerus shaft # | No | Poor | Good (6) | Marginal necrosis |
| 36 | 32/F | Right | 9 | Humerus shaft # | No | Poor | Poor (3) | Radial deviation – |
| 37 | 26/M | Right | 9 | Penetrating stab wound | Yes | Fair | Good (6) | – |
| 38 | 42/M | Left | 9 | Humerus shaft # | No | Poor | Good (7) | – |
| 39 | 36/M | Right | 11 | Humerus shaft # | No | Poor | Good (6) | – |
| 40 | 34/M | Right | 9 | Penetrating stab wound | No | Poor | Good (6) | Inadequate wrist flexion |
| 41 | 46/M | Right | 9 | Brachial plexus palsy | No | Poor | Good (6) | – |
| 42 | 33/M | Left | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 43 | 30/F | Right | 9 | Penetrating stab wound | No | Poor | Good (7) | – |
| 44 | 36/M | Right | 12 | Humerus shaft # | No | Poor | Good (6) | – |
| 45 | 38/M | Right | 9 | Penetrating stab wound | No | Poor | Good (6) | – |
| 46 | 28/M | Left | 9 | Humerus shaft # | Yes | Fair | Good (6) | – |
| 47 | 42/F | Right | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 48 | 32/M | Right | 9 | Humerus shaft # | Yes | Poor | Good (7) | – |
| 49 | 36/M | Right | 9 | Brachial palsy | No | Poor | Good (6) | – |
| 50 | 41/M | Right | 10 | Humerus shaft # | No | Poor | Good (7) | – |
| 51 | 52/M | Right | 9 | Brachial plexus palsy | No | Poor | Good (7) | Marginal necrosis |
| 52 | 40/F | Right | 9 | Humerus shaft # | No | Poor | Good (6) | – |
| 53 | 32/M | Left | 9 | Penetrating stab wound | No | Poor | Good (7) | – |
| 54 | 38/M | Right | 11 | Humerus shaft # | No | Poor | Good (6) | – |
| 55 | 33/M | Right | 9 | Penetrating stab wound | No | Poor | Good (6) | Inadequate wrist flexion |
| 56 | 34/F | Right | 9 | Humerus shaft # | No | Poor | Good (7) | – |
| 57 | 28/M | Right | 9 | Humerus shaft # | Yes | Fair | Good (6) | – |
| 58 | 32/M | Right | 9 | Humerus shaft # | No | Poor | Good (6) | – |
We evaluated these patients by Bincaz score (active range of movements at the wrist/metacarpo-phalangeal joints and radial/palmar abduction of thumb at the CMC joint) by goniometer at minimum of 8 weeks follow-up. Radial extension of the thumb was measured in the plane of the palm, as the angle between the line along radial border of the first metacarpal with the IP joint in extension. The palmar abduction was measured in the plane perpendicular to the flat palm, as the angle between the dorsal subcutaneous border of the proximal phalanx of the thumb and the palmar border of the index ray.
3. Surgical technique
Surgery was performed under brachial block with tourniquet control. A volar incision was used to expose PL and FCR tendon. PL was divided as distally as possible at the wrist. EPL was divided proximally, near its musculo-tendinous junction and rerouted towards volar side of wrist. This allows a straight line of pull and abduction of the thumb along with extension. FCR was divided at its insertion and routed in the subcutaneous plane around the radial border of the forearm, the four EDC tendons were dissected just distal to their musculo-tendinous junction and proximal to the extensor retinaculum. A dorsal approach was used to expose and harvest PT at the mid shaft of radius and it was raised by taking 2–3 cm of periosteum to have enough length. PT was routed from the radial side subcutaneously and PT was sutured to the ECRB, FCR with EDC and PL to EPL under tension. (Fig. 1, Fig. 2, Fig. 3, Fig. 4) All tendon repairs were performed ‘end-to-side’ except PL to EPL which was ‘end to end’ using pulvertaft weave using 4/0 non-absorbable nylon sutures (Made by Johnson & Johnson Private Limited, Mumbai India 400 060). Wrist extension was corrected first, followed by correction of the extension of the fingers and finally thumb extension. During suturing wrist was kept in extension between 45° and 60°; thumb and fingers in full extension. After operation, a volar forearm cast was applied for a period of 4 weeks, keeping wrist in 450 extension and MCP joints of fingers in 700 extension, interphalangeal joints in full extension and thumb radially abducted and extended. After 4 weeks supervised physiotherapy was started and a removable splint was used; to keep the wrist, fingers and thumb in post operative position at night and between physiotherapy.
Fig. 1.
Showing the donor tendons.
Fig. 2.
Showing the recipient tendons.
Fig. 3.
Showing repair of tendons by pulvertaft weave.
Fig. 4.
Showing completed repair with skin closure.
4. Results
58 patients with irreversible radial nerve paralysis were included in the study, 47 were male and 11 female patients. Mean age was 35.27 years (range 21–52 years). 46 patients had radial nerve palsy on right side while 12 patients had on left side. 42 Patients had comminuted open humeral fracture, 13 patients had penetrating injuries with irreparable damage to radial nerve while 3 patients had brachial plexus palsy. Mean duration of palsy was 9.37 months (range from 9 to 12 months). 16 patients underwent radial nerve exploration and repair but did not recover. On evaluation with the Bincaz score, 6/58 patients had an excellent result, 49/58 patients had good results, (Fig. 5, Fig. 6, Fig. 7, Fig. 8) and 3/58 patients had poor results (Table 1). There were 3 complications in 5 patients, radial deviation of wrist (n = 1), inadequate abduction of thumb (n = 2) and restricted wrist flexion (n = 2). There were no adhesion, stiffness, lack of dexterity, and decreased muscle power. There was marginal necrosis of skin flap in two patients which got healed with conservative treatment. 2 patients with restricted wrist flexion became better with physiotherapy in 6 weeks time. 55/58 patients (94.82%) were able to return to their normal daily work after ∼8 weeks. 3/58 patients with poor results had difficulty in their routine work.
Table 2.
Bincaz score for evaluation of the results of tendon transfer for wrist and digital extension.
|
Points |
3 | 2 | 1 | 0 |
|---|---|---|---|---|
|
Wrist extension |
>290 | 0–290 | 0 | |
|
MCP joint extension |
Full | Loss of extension <100 |
Loss of extension >100 |
|
|
First web space opening |
>390 | 30–390 | <300 | |
|
Patient satisfaction |
Excellent | Good | Fair | Poor |
Fig. 5.
Showing preoperative picture of radial nerve palsy flowing humerus fracture.
Fig. 6.
Post operative result with complete wrist and finger extension.
Fig. 7.
Showing preoperative picture of radial nerve palsy flowing brachial plexus injury.
Fig. 8.
Post operative result with complete wrist extension and finger flexion.
5. Discussion
Radial nerve palsy occurs in 11.8% patients following fracture of the humerus and 4.2% will have iatrogenic injuries after fracture reduction/fixation. Radial nerve palsy primarily Results in loss of motor function which compromises the normal hand function affecting the patient’s quality of life and results in loss of employment.6,7
There is various combination of tendon transfer for radial nerve palsy. Historically 3 types of tendon transfer are most popular, Boyes (PT- ECRB, PL-EPL,FDS-EDC), brands (PT- ECRB, PL-EPL, FCR-EDC) and combination using FCU (PT- ECRB, PL-EPL, FCU-EDC). Indications for tendon transfer for radial nerve palsy include severe injury where neurorrhaphy is not possible, high injuries (Brachial plexus injuries), loss of extensor musculo-tendinous unit, no clinical/EMG signs of recovery after neurorrhaphy at six months, late presentation (>10 months) or severe scaring or muscular atrophy.8
Estimation of precise timing of tendon transfer is difficult because many patients with radial nerve palsy may have clinically acceptable recovery spontaneously or after nerve repair. In patients with closed fractures without any intervention on radial nerve, the time to wait before considering tendon transfer is between 3 and 6 months but in cases of repaired radial nerve more specific time frames can be estimated by calculating the nerve regeneration time and by assessing recovery clinically and by EMG. Immediate tendon transfer can be considered when there is more than 10 cm gap between the nerve ends; and presence of extensive scar/skill loss where repair of radial nerve is not possible.9 Some authors recommend early PT to ECRB end to side transfer (internal splintage) at the time of nerve repair to improve the grip early and to eliminate the need for an external splint.10 Since this is end to side transfer, it does not interfere with recovery of the radial nerve.11
Supracondylar fracture leads to high radial nerve palsy causing paralysis of all extensor muscles resulting in classical dropped hand. Radial nerve palsy can be low, when injury is in the proximal portion of the forearm. In these cases wrist dorsiflexion is preserved due to sparing of ECRL but fingers/thumb extension not possible. In high radial nerve palsy, triple tendons transfer will be required while for low radial nerve palsy restoration of wrist extension may not be required.4,12 When there is no chance for the radial nerve recovery, the transfer should be made end-to-end which results in a straight direction of tension but if there is possibility of nerve recovery than the transfer of all tendons should be made end-to-side so that once recovery is achieved, native tendons can resume their function.8,13
Tendon transfers for radial nerve paralysis have a 100-years history with utilization of various combinations of tendons.4 There is no controversy of using PT for wrist extension and PL for thumb extension however; tendon transfer for extension of the fingers remains controversial.14 PT transfer seems to be the best choice to achieve wrist extension because pronation causes extension of the wrist thus the pronator and wrist extensors are simultaneously contracting muscles. It has adequate power, optimal extension moment arm and pronation action is still preserved by the pronator quadratus muscle.4,15 PL is ideal choice for thumb extension as it is expandable and has sufficient power and exact size match of tendons to extend thumb.
Common tendons transferred for fingers extension are wrist flexors (FCU or FCR) and/or FDS. Franke, in 1898 transferred FCU to EDC for fingers extension.16 He and other proponents of FCU transfer argued that the FCU is stronger muscle and has longer excursion which is adequate for finger extension therefore it should be preferred. But FCU is the prime stabilizer of the wrist and its use may leads to restriction of wrist flexion and radial deviation which not only causes aesthetic disability, but reduces grip strength quite significantly. Ulnar deviation which is an important movement necessary for activities such as hammering and throwing is also lost. Another contraindication for use of FCU is low radial nerve (posterior interosseous nerve) injuries where extensor carpi radialis longus is intact and use of FCU for transfer will lead to severe radial deviation at the wrist.14,15
Boyes and later Chuinard proposed use of FDS for finger extension (Boyes transfer). Their argument was that wrist flexors (FCU and FCR) have too small amplitude and power to allow simultaneous extension of the wrist and fingers. They further stated that FDS has better sliding, and this is best suited in patients with wrist arthodesis which preclude tenodesis effect.17,18
Using FDS preserve the FCU, which is an important wrist flexor.14 However, the technique is more demanding with a risk of adhesions if passed through the interosseous membrane.19 Another disadvantage of FDS is out of phase transfer, leading to problematic synergy between metacarpo-phalangeal joint extension by transferred tendon and finger flexion by remaining tendons and causes more difficult post-operative motor training of tendons.20,21
Considering the disadvantages of FCU and FDS, transfer of FCR combination seems to be the logical choice for finger extension. It has excursion equal to EDC, only slightly inferior power, and it can be transferred in straight route to extend fingers which maintains the natural position of the wrist.22
In our study Brands transfer was performed in 58 cases with good Results. There were 3 complications in 5 cases, inadequate thumb abduction in 2 cases, which may be due to the inappropriate direction of the rerouted tendon or adhesions of the tendon. Radial deviation in 1 case due to the pronator teres was transferred to both the wrist extensors. Usually PT should be transferred to only ECRB which is stronger and more medial tendon. There was an inadequate wrist flexion in 2 cases. On evaluation with the Bincaz score, 6 patients had an excellent result, 49 patients had good results, and 3 patients had poor results. Majority of the patients adapted efficiently to daily activities.
When PL is absent either brachioradialis or split FCR or FDS of ring finger can be taken. In our study, PL was present in all cases. In one case we had transferred PT to ECRL and ECRB both; this led to radial deviation of wrist. Subsequently, we have attached PT to ECRB alone in all cases because it is the strongest wrist extensor, and it is placed more medially with minimal chances of radial deviation.4,23
The average movements required for the activities of daily living are 5° flexion, 30° extensions, 10° radial deviations, and 15° ulnar deviations of the wrist. Most of the combination of tendon transfer provide this much movements leading to satisfactory final outcome in majority of patients.24 Therefore the choice of tendon transfers is a matter of surgeon’s preference and there seems to be no difference in final outcome except for complications. Therefore the choice of set of tendon transfer aim at reducing the complications, consideration of patients occupation, type/time of injury and surgeons training and experience.
The limitation of our study is there is no data to compare with other technique of tendon transfer as we have performed all tendon transfer using FCR combination only.
6. Conclusion
Different methods of tendon transfer for radial nerve palsy are used but the potential advantage of one method over the other has not been demonstrated. Our study showed that Brand’s transfer results in an acceptable restoration of wrist, thumb and fingers extension.
Author contribution
Pawan Agarwal- Conceptualization; Formal analysis; Investigation; Methodology; Roles/Writing - original draft; Writing - review & editing. Rajeev Kukrele - Formal analysis; Investigation; Methodology; Roles/Writing - original draft; Writing - review & editing. Dhananjaya Sharma- Formal analysis; Investigation; Methodology; review & editing.
Declaration of competing interest
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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