Professional Documents
Culture Documents
Techniques in Hand and Amp Upper Extremi
Techniques in Hand and Amp Upper Extremi
http://www.scirp.org/journal/ojo
ISSN Online: 2164-3016
ISSN Print: 2164-3008
Department of Plastic Surgery, John Radcliffe Hospital, Oxford University Hospital NHS Trust, Oxford, UK
Keywords
Anatomy, Pronator Teres, Dissection, Tendon Transfer
1. Introduction
During the 19th century, surgeon first recognised that transferring tendons could re-
store certain functional deficit in extremities, and its advancement was further ampli-
fied by the polio epidemic in Europe at the turn of that century, which saw a significant
raise in patients suffering from limb paralysis. Key surgical pioneers, such as Leo May-
er, Sterling Bunnell, Guy Pulvertaft and Joseph Boyes, expanded tendon transfer sur-
gery, not only to those with paralysis from polio and cerebral palsy, but those with sig-
nificant traumatic limb injuries endured during World War I [1] [2] [3] [4].
In 1921, Robert Jones described the first pronator teres (PT) transfer to wrist exten-
sors for irreparable radial nerve paralysis in infantile hemiplegia, although a detailed
description of indication and outcomes were not published until later by Stelling and
Meyer in 1959, and by Keats in 1970. Pronator teres tendontransfer is most often
used for wrist extensor reconstruction, commonly using the tendon of extensor carpi
radialis brevis (ECRB) as attachment, and for patients with radial nerve palsy, cere-
bral palsy, or tetraplegia, [5]-[10]. The indication is currently limited to selected cases
but offers great functional benefits. It not only improves wrist extension, but grip
strength and dexterity, as well as reduction in power of pronation, which is particular
useful in cases of muscular spasms. The choice of a transfer tendon for reconstruction
of finger extension, is not as straightforward, and the flexor carpi radialis (FCR), the
flexor carpi ulnaris (FCU), and the flexor digitorum superficialis (FDS) are all possible
donors.
In radial nerve injury the greatest functional loss is grip weakness, an early PT to
ECRB transfer (along with nerve repair) is recommended to eliminate the need for an
external splint, as it acts as a dynamic splint during nerve regeneration. Authors have
highlighted that this type of tendon transfer does not interfere with the recovery of
radial nerve injury and supported this approach. The Merle d’Aubigné procedure isone
of the technique used for the treatment of irreversible radial palsy, and describes the
transfer of PT to ECRB and extensor carpi radialis longus (ECRL), FCU to the extensor
pollicis longus (EPL) and extensor digitorum communis (EDC), palmaris longus (PL)
to extensor pollicis brevis (EPB) and abductor pollicislongus (APL) [11]. Riordan’s
tendon transfer simplifies the process by means of the following transfers: PT to ECRB,
FCU to EDC, and PL to EPL [12]. Tendon transfer procedure describes the transposi-
tion of volar tendons to the dorsal aspect through subcutaneous tunnels, which princi-
pally deviates the vector of pull on the extensors from the biomechanical and physio-
logical points of view. We reviewed the literature in English without filter using search
engines: Google scholar, CINAHL, and Pub Med, and used search terms: radial nerve
palsy, tendon transfer, and pronator teres. 74 articles were identified and 19 were deemed
relevant focusing Pronator Teres transfer technique on radial nerve palsy.
322
A. De Leo et al.
2. Anatomy
The word pronator comes from the Latin pronus and translate to “inclined forward
or lying face downward”, which describes the action of pronator teres on the forearm.
The Latin term teres means “round or cylindrical shaped” or “long and round”,
which describes the shape of the muscle. PT is located on the volar aspect of the fo-
rearm, and functions to rotate the forearm palm-down (pronation) with pronator
quadratus (PQ). The muscle originates from two heads (humeral and ulnar) and at-
taches onto the lateral aspect of the radius. The humeral head is larger and shallower,
and begins above the medial epicondyle, at the medial supracondylar ridge with the
other common flexor tendons. The ulnar head originates below the elbow on the
medial aspect of the coronoid process of the ulna. The two heads come together,
cross the forearm diagonally, and insert halfway down the lateral surface of the radius
via a tendon.
A rare variant of a high-humeral origin had been reported by some authors, arising
from an existing supracondylar process of the humerus and a fibrous band extending
between the supracondylar process and the medial epicondyle—the ligament of Struth-
ers. This variation often coexists with a variation of the musculocutaneous nerve [13].
According to anatomical studies PT is innervated by the median nerve with two nerve
branches [14] [15]. The degree of reserved PT function if one head is removed is un-
certain with no published supportive studies, thus PT had been not recommended for
use in functional flap transfer [16].
3. Surgical Technique
Patient position is supine with arm tourniquet inflated up to physiological pressure
around 80 - 100 mmHg. Local an aesthesia marcaine 0.25% with 1:200.000 adrenaline is
infiltrated around skin incision. The PT tendon is approached through a straight skin
incision on the upper lateral aspect of the forearm, and its attachment to the radial shaft
could be traced underneath the brachioradialis (BR) muscle from the volar aspect. An
amount of radial periosteum is usually raised with the PT tendon.
323
A. De Leo et al.
5. Conclusion
The use of PT tendon transfer to restore wrist extensor function is well recognised, and
most commonly performed by transferring the PT onto the ERCB tendon. The fibre
lengths and muscle shape of the two muscles are nearly identical, which suggests com-
parable power capacity and lengthening ability, suitable to inter-exchanging [17]. Aside
from wrist extensors, PT is used for numerous other tendon transfer surgery, as a do-
nor. The transfer of forearm pronator teres tendon to wrist extensors had shown good
incorporation, as pronation is synergistic with wrist extension [18]. Good anatomical
understanding of the PT location is essential to expedite the procedure and limit unne-
cessary tissue dissection. The harvest of the PT tendon is best performed through a sys-
tematic and anatomic approach. There is an inherit risk of new bone formation if a pe-
riosteum strip is retained during PT harvest, thus it is not necessary or advised if
proximal elongation is performed. Contraindications for a PT transfer include partial
or complete denervation of the muscle itself.
References
[1] Mayer, L. (1956) The Physiological Method of Tendon Transplants Reviewed after Forty
Years. Instructional Course Lectures, 13, 116-120.
[2] Bunnell, S. (1946) Reconstructive Surgery to the Hand. Guy’s Hospital Gazette, 60, 293-296.
[3] Pulvertaft, G. (1960) Techniques in Hand Surgery. The Journal of Bone & Joint Surgery,
42A, 907.
[4] Boyes, J.H. (1959) Tendon Transfers in the Hand. Medicine of Japan, 5, 958-969.
[5] Altintas, A.A., Altintas, M.A., Gazyakan, E., Gohla, T., Germann, G. and Sauerbier, M.
(2009) Long-Term Results and the Disabilities of the Arm, Shoulder, and Hand Score Ana-
lysis after Modified Brooks and D’Aubigne Tendon Transfer for Radial Nerve Palsy. Journal
of Hand Surgery, 34, 474-478. http://dx.doi.org/10.1016/j.jhsa.2008.11.012
[6] Moussavi, A.A., Saied, A. and Karbalaeikhani, A. (2011) Outcome of Tendon Transfer for
Radial Nerve Paralysis: Comparison of Three Methods. Indian Journal of Orthopaedics, 45,
558-562. http://dx.doi.org/10.4103/0019-5413.87133
[7] Ropars, M., Dreano, T., Siret, P., Belot, N. and Langlais, F. (2006) Long-Term Results of
324
A. De Leo et al.
Tendon Transfers in Radial and Posterior Interosseous Nerve Paralysis. Journal of Hand
Surgery, 31, 502-506. http://dx.doi.org/10.1016/j.jhsb.2006.05.020
[8] Riordan, D.C. (1983) Tendon Transfers in Hand Surgery. Journal of Hand Surgery, 8, 748-
753. http://dx.doi.org/10.1016/S0363-5023(83)80264-0
[9] Chuinard, R.G., Boyes, J.H., Stark, H.H. and Ashworth, C.R. (1978) Tendon Transfers for
Radial Nerve Palsy: Use of Superficialis Tendons for Digital Extension. Journal of Hand
Surgery, 3, 560-570. http://dx.doi.org/10.1016/S0363-5023(78)80007-0
[10] Kozin, S.H. and Hines, B. (2002) Anatomical Approach to the Pronator Teres. Techniques
in Hand & Upper Extremity Surgery, 6, 152-154.
http://dx.doi.org/10.1097/00130911-200209000-00009
[11] Kruft, S., von Heimburg, D. and Reill, P. (1997) Treatment of Irreversible Lesion of the
Radial Nerve by Tendon Transfer: Indication and Long-Term Results of the Merle d’Au-
bigne Procedure. Plastic and Reconstructive Surgery, 100, 610-618.
http://dx.doi.org/10.1097/00006534-199709000-00010
[12] Riordan, D.C. (1974) Radial Nerve Paralysis. Orthopedic Clinics of North America, 5, 283-
287.
[13] Jelev, L. and Georgiev, G.P. (2009) Unusual High-Origin of the Pronator Teres Muscle
from a Struthers’ Ligament Coexisting with a Variation of the Musculocutaneous Nerve.
Romanian Journal of Morphology and Embryology, 50, 497-499.
[14] Tubbs, R.S., Beckman, J.M., Loukas, M., Shoja, M.M. and Cohen-Gadol, A.A. (2011) Me-
dian Nerve Branches to the Pronator Teres: Cadaveric Study with Potential Use in Neuro-
tization Procedures to the Radial Nerve at the Elbow. Journal of Neurosurgery, 114, 253-
255. http://dx.doi.org/10.3171/2010.3.JNS091301
[15] Tung, T.H. and Mackinnon, S.E. (2001) Flexor Digitorum Superficialis Nerve Transfer to
Restore Pronation: Two Case Reports and Anatomic Study. Journal of Hand Surgery, 26,
1065-1072. http://dx.doi.org/10.1053/jhsu.2001.28427
[16] Chen, G., Jiang, H., Liu, A.T., Zhang, J.L., Lin, Z.H., Dang, R.S., Yu, D.Z., Li, W.P. and Liu,
B.L. (2010) Neurovascular Details about Forearm Muscles: Applications in Their Clinical
Use in Functional Muscular Transfer. Surgical and Radiologic Anatomy, 32, 3-8.
http://dx.doi.org/10.1007/s00276-009-0514-y
[17] Abrams, G.D., Ward, S.R., Friden, J. and Lieber, R.L. (2005) Pronator Teres Is an Appro-
priate Donor Muscle for Restoration of Wrist and Thumb Extension. Journal of Hand Sur-
gery, 30, 1068-1073. http://dx.doi.org/10.1016/j.jhsa.2005.04.016
[18] Fujii, H., Kobayashi, S., Sato, T., Shinozaki, K. and Naito, A. (2007) Co-Contraction of the
Pronator Teres and Extensor Carpi Radialis during Wrist Extension Movements in Hu-
mans. Journal of Electromyography and Kinesiology, 17, 80-89.
http://dx.doi.org/10.1016/j.jelekin.2005.11.013
Abbreviations
Pronator Teres—PT;
Flexor Carpi Radialis—FCR;
Flexor Carpi Ulnaris—FCU;
Flexor Digitorum Superficialis—FDS.
325
Submit or recommend next manuscript to SCIRP and we will provide best service
for you:
Accepting pre-submission inquiries through Email, Facebook, LinkedIn, Twitter, etc.
A wide selection of journals (inclusive of 9 subjects, more than 200 journals)
Providing 24-hour high-quality service
User-friendly online submission system
Fair and swift peer-review system
Efficient typesetting and proofreading procedure
Display of the result of downloads and visits, as well as the number of cited articles
Maximum dissemination of your research work
Submit your manuscript at: http://papersubmission.scirp.org/
Or contact [email protected]