Name:
EIP to EPL Transfer
Description:
EIP to EPL Transfer
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/5a141821-019b-4c64-bed4-0c28b7ad3b0b/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H16M43S
Embed URL:
https://stream.cadmore.media/player/5a141821-019b-4c64-bed4-0c28b7ad3b0b
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/5a141821-019b-4c64-bed4-0c28b7ad3b0b/EIP to EPL Transfer.mp4?sv=2019-02-02&sr=c&sig=V52i8AaGlfk3SFxfpXNlEcfrleBEe2Qc3x8YgbdhAMI%3D&st=2024-12-04T08%3A40%3A26Z&se=2024-12-04T10%3A45%3A26Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. Professor Bijayendra Singh, Consultant Upper Limb & Trauma Surgeon, Medway Hospital. Thank you for watching my channel and the videos. Today, I'm going to present a case of a lady who sustained an injury to her left wrist when she had a fall. She sustained a fracture of her distal radius, which was pretty innocuous and was treated with non operative measure, immobilized in plaster for a short period of time.
BIJAYENDRA SINGH: At about 8/9 weeks, she presented with inability to lift her thumb off the table and her thumb dropped. These are her immediate injury X-rays view and the lateral view, which shows in pretty much a un-displaced fracture, but a little bit of spike on the dorsal side.
BIJAYENDRA SINGH: These are her images at eight weeks showing no further change and good healing of the fractures. These are the two videos showing that she can't lift the thumb up. I can passively lift it up, but then the thumb drops. So Kevin's showing that her thumb is tending to go into the palm.
BIJAYENDRA SINGH: Comparing both sides, you can see how she can demonstrate on the uninjured right hand, but can't do on the left hand. I'm going to demonstrate the extensor indicis to the extensor pollicis tendon transfer for restoration of the extension of the thumb.
BIJAYENDRA SINGH: This is a fairly common, straightforward procedure if done correctly, I'll point to tips and tricks to undertaking this. So patient is supine, arm volar and tourniquet. Mark the anatomical landmarks. I'm trying to feel for,
BIJAYENDRA SINGH: the Listers tubercle, but this can be a bit tricky, especially if the patient has a recent fracture, trace the outline of the UPL tendon and then look at the two tendons over the index finger. The one on the ulnar side is normally the extensor indices tendon and the radial one is the extensor digitorum communis.
BIJAYENDRA SINGH: The first step is to identify the ruptured tendon and so make the incision just proximal to the MCP joint so identify the ruptured APL tendon. It's quite easy and straightforward to identify, but just need to take care to identify the terminal branch of the superficial radial nerve otherwise, this can cause painful neuromas and altered sensation in that side of the thumb.
BIJAYENDRA SINGH: Central dissection, one should be able to identify the APL tendon. Sometimes you may find that this is stuck down, especially if the fracture is reasonably fresh, i.e. within the first three months or so. You can see here I've identified the tendon and then you try and give it a gentle tug. Often it will come off, otherwise it may be a bit of struggle
BIJAYENDRA SINGH: if it is stuck down, like in this case, I'm certain that this is the tendon in question. If that's the case, then you took the second incision, which is on the dorsum of the wrist. This is just proximal to the Listers tubercle, make a reasonable sized incision or you can start with a small one like here.
BIJAYENDRA SINGH: It needs about three to four centimeters incision. Identify the extensor retinaculum, again, this may be a bit adherent and tight but you should be able to identify the APL tendon next to the Listers tubercle.
BIJAYENDRA SINGH: Carefully dissecting, releasing the retinaculum, secure adequate hemostasis as is required and that it can seize the tendon that is stuck down in the scar tissue.
BIJAYENDRA SINGH: Here I now identify the APL tendon and even further tugging onto the distal edge, it's not coming off, but I can see that there is a thin fibrotic and adherent edge at around the Lister's tubercle and as we saw in the clinical evaluation, this was non-functional. I have to cut this sharp at that level.
BIJAYENDRA SINGH: It certainly needs to come out of the groove. Sometimes you have to do further releases. I use a blunt instrument like the McDonally, you can use special tendon gliders to help it along. Often it will need persuasion from both ends to release any of the adherent scar tissue.
BIJAYENDRA SINGH: So I'm now grabbing hold of the end of the tendon so I can provide tension and allowed to pull it across.
BIJAYENDRA SINGH: This also helps me be certain that I'm not pulling on the wrong tendon. Hopefully with one sharp pull, you can see the tendon is out now.
BIJAYENDRA SINGH: You can see the tendon is quite fibrotic degenerate and it loses its shininess. That's how one can differentiate between a normal and a tendonopathic and you have to excise that bit as it's not really a viable tendon. But once I've got the tendon out, make a transverse incision about a centimeter over the index MCP joint just proximal to it,
BIJAYENDRA SINGH: dissecting both the tendons, identifying both the tendons and carefully finding the EIP or the extensive indices propius tendon. Again, before you release it from the distal end, need to go proximally and identify this again.
BIJAYENDRA SINGH: Quite often there is some adhesions in the tendon sheath, especially at the level of the fracture site around the wrist. Always run a blunt instrument like the McDonally in the sheath to release this although the IP has a complete separate origin as a muscle belly, sometimes it can have
BIJAYENDRA SINGH: cross connection with the EDC tendon and may prove difficult to identify. I suggest you spend a few minutes tugging on both the ends of the IP to identify that for sure before releasing it from the distal end.
BIJAYENDRA SINGH: Now I've identified both the ends of the EIP tendon and a gentle tug on the proximal end, and the distal end shows that I have got the right tendon in question. The other way to identify the EIP tendon is that it has muscle belly further more distal than the extensor digitorum communis to identify it should be able to pull the tendon into the proximal most incision fairly easily,
BIJAYENDRA SINGH: but again, if there is adhesions, this may prove to be a bit tricky. And now I've got enough length to get this. Once the tendon has been harvested, it's retrieving forceps, which has got a tooth and make sure that the tendon isn't shredded
BIJAYENDRA SINGH: or damaged. At this stage, then we assess the length that is required and I'll trim any extra bit of tendon, especially from the damaged EPL tendon which has become avascular. There are various techniques of how this can be repaired, but this is the Pulvertaft side to side weave, which has provided me with excellent result. It's a very strong repair.
BIJAYENDRA SINGH: The downside is that it can be a bit bulky, but here the tendons are not that big and hence it's not a major problem. Try and get three or four weaves across making sure that you leave the tendon at 90 degrees to the previous one. Once you're happy with that, then use an non absorbable 2-0, either ethibond or a fiber wire type suture
BIJAYENDRA SINGH: to reinforce the repair. Hydro continues to run through repair on both sides going forward and then
BIJAYENDRA SINGH: from one end of the repair to the other end and then the turn back on the opposite side.
BIJAYENDRA SINGH: Once this repair has been achieved, then trim any excess tendon and tendon on both the sides as to reduce the bulkiness of the repair that finishes the main repair and hopefully should be able to notice the tension in the tendon almost straight away. The wound is closed in layers. Do not repair the retinaculum as there's already scar tissue, don't want more adherence.
BIJAYENDRA SINGH: Generally tend to put 2-0 vicryl or similar tissue suture in the fascia fat followed by non absorbable subcutular sutures.
BIJAYENDRA SINGH: If there's no block you will generally infiltrate with copious amounts of local anesthetic to provide good pain relief. Immobilize the hand and the thumb in below elbow, swallow slab with the thumb in neutral or 10 degrees of extension. The patient's discharged on the same day and then returns to outpatients to be seen by the hand therapists at
BIJAYENDRA SINGH: two weeks. At this stage, as long as the patient is reasonably reliable, can start to mobilize under supervision of the hand therapist or with a splint, avoids any heavy lifting manual stuff for six to eight weeks and physical contact sports for about three months. Thank you for watching this video. For more videos, visit my website.
BIJAYENDRA SINGH: Please leave me a feedback. Thank you. [VIDEO ENDS]
Form Title Download
Form Title Bookmark
Form Title Share
Form Title Cite
