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EIP to EPL Transfer

intermediate Level

Primary Indication

Rupture of extensor pollicis longus (EPL) tendon, typically following distal radius fracture (attritional rupture at Lister's tubercle), rheumatoid arthritis, or direct laceration, when primary repair is not possible

Danger Structures

  • Extensor digitorum communis to index
  • Superficial radial nerve branches
  • Extensor retinaculum
  • Radial artery
  • Extensor pollicis brevis
  • Posterior interosseous nerve (proximally)

Visual Atlas

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Step-by-Step Technique

1

Position supine with arm on hand table, pronate forearm, apply tourniquet

Surgeon's Tip
EXAM KEY: Two-incision technique minimizes dissection. Alternatively, single longitudinal incision possible.
Danger Zone
  • Inadequate exposure
  • Tourniquet time >2 hours
2

Make transverse incision over dorsal wrist at level of Lister's tubercle

Surgeon's Tip
EXAM KEY: EPL ruptures at Lister's tubercle due to watershed blood supply and mechanical irritation
Danger Zone
  • Cutting additional extensor tendons
  • Superficial radial nerve branches
3

Identify EPL stump in third extensor compartment, assess for potential primary repair

Surgeon's Tip
EXAM KEY: Primary repair usually not possible due to tendon retraction and degeneration at rupture site
Danger Zone
  • Missing retracted proximal stump
  • Misidentifying tendon
4

Extend dissection proximally if needed to find retracted EPL proximal stump

Surgeon's Tip
EXAM KEY: Proximal stump may retract significantly - may need to extend incision
Danger Zone
  • Extensive dissection
  • Damage to other extensors
5

Make second transverse incision over index finger MP joint dorsally

Surgeon's Tip
EXAM KEY: EIP lies ulnar to EDC to index finger at MP joint level - identify both tendons
Danger Zone
  • Cutting EDC instead of EIP
  • Inadequate exposure
6

Identify EIP tendon (ulnar to EDC at index MP joint) - confirm by independent extension

Surgeon's Tip
EXAM KEY: Hold index finger flexed, ask patient to extend - EIP will tighten independently of EDC
Danger Zone
  • Wrong tendon harvest (EDC)
  • Incomplete identification
7

Divide EIP at musculotendinous junction distally, preserve length for transfer

Surgeon's Tip
EXAM KEY: Divide as distally as possible to maximize tendon length for transfer
Danger Zone
  • Dividing too proximally (short graft)
  • Damaging EDC
8

Pass EIP tendon subcutaneously from index MP incision to wrist incision

Surgeon's Tip
EXAM KEY: Create subcutaneous tunnel using hemostat or tendon passer - avoid crossing other tendons
Danger Zone
  • Tendon entanglement
  • Passing too deep
9

Redirect EIP tendon superficial to extensor retinaculum (not through EPL tunnel)

Surgeon's Tip
EXAM KEY: Pass EIP superficial to retinaculum - not through third compartment - allows better gliding
Danger Zone
  • Bowstringing if too superficial
  • Adhesions if through compartment
10

Make third small incision over thumb MP joint if needed to retrieve distal EPL stump

Surgeon's Tip
EXAM KEY: Distal EPL stump may be at IP joint - retrieve and prepare for weave/suture
Danger Zone
  • Inadequate distal stump
  • Skin complications from multiple incisions
11

Suture EIP to distal EPL stump using Pulvertaft weave technique

Surgeon's Tip
EXAM KEY: Pulvertaft weave: pass tendon through 3-4 times, each weave at 90° to last, suture each weave
Danger Zone
  • Inadequate weave (weak repair)
  • Incorrect tension
12

Set tension with wrist in neutral: thumb IP joint should be in slight extension

Surgeon's Tip
EXAM KEY: Tension setting critical - too loose = no thumb extension, too tight = can't flex
Danger Zone
  • Incorrect tension setting
  • Loss of thumb flexion if too tight
13

Test thumb extension with wrist in neutral and flexion - should have full ROM

Surgeon's Tip
EXAM KEY: Check tenodesis effect - thumb should extend with wrist flexion
Danger Zone
  • Over-tensioning limiting flexion
  • Under-tensioning giving weak extension
14

Close wounds, release tourniquet, apply thumb spica splint

Surgeon's Tip
EXAM KEY: Protect transfer in thumb spica with thumb extended, wrist neutral for 4 weeks
Danger Zone
  • Rupture of transfer
  • Wound complications
15

Immobilize for 4 weeks, then protected ROM, strengthening at 8 weeks

Surgeon's Tip
EXAM KEY: Gradual rehabilitation - protected motion 4-6 weeks, active motion 6-8 weeks, strengthening 8-12 weeks
Danger Zone
  • Early rupture from aggressive rehab
  • Adhesions from prolonged immobilization