Tendon Transfer for Wrist Extension

Indications

Wrist in a flexed posture with inadequate wrist extension due to spasticity, paresis, or paralysis. Flexor carpi ulnaris (FCU) or extensor carpi ulnaris (ECU) or both are usually used as donors.

Technique

Harvest ECU tendon via multiple transverse incisions. Begin with 1.5 cm transverse incision over distal ulna. Bluntly dissect through subcutaneous incision to identify sixth extensor compartment. Incise retinaculum and isolate ECU tendon. Palpate muscle-tendon junction ~6 to 8 cm above wrist. Make transverse incision at this level and identify proximal tendon (Fig. 61-1).
Place Allis tissue forceps (Jarit Surgical Instruments, Hawthorne, New York) around tendon and position wrist into extension. Turn forceps to pull tendon in a proximal direction. Incise distal aspect of tendon (Fig. 61-2). Pull cut end of tendon into proximal incision (Fig. 61-3).
Harvest FCU tendon via 1.5 cm transverse incision over volar wrist crease and proximal to pisiform (Fig. 61-4). Bluntly dissect through subcutaneous incision to identify FCU tendon. Mobilize tendon in a circumferential fashion to protect underlying ulnar nerve and artery. Place Allis forceps around tendon and position wrist in flexion. Cut distal end of FCU tendon.
Through a series of transverse incisions, mobilize FCU to midforearm level. Release fascial attachments to ulna to enhance available excursion. Protect adjacent ulnar neurovascular bundle. Pull FCU tendon into proximal incision (Fig. 61-5).
Identify extensor carpi radialis longus (ECRL) and brevis (ECRB) via transverse incision proximal to wrist crease and just distal to the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscle–tendon (M–T) junction. Incise fascia over second compartment and isolate individual tendons.
Create subcutaneous tunnel between the second dorsal compartment and forearm incisions that contain ECU and FCU.
Pass ECU and FCU through subcutaneous tunnel to incision over second dorsal compartment (Fig. 61-6). Weave ECU through ECRL and FCU through ECRB (Fig. 61-7A,B). Use tendon braider and Pulvertaft weave. Suture tenorrhaphy sites using nonabsorbable sutures in a horizontal mattress fashion. Tension tendon transfer to place wrist in ~20 degrees of extension.
Close subcutaneous tissue and skin of all transverse incisions with absorbable suture.