Restoration of Elbow Flexion for Upper Trunk Brachial Plexus Injuries: Evaluation of Nerve Transfers and Modified Steindler Flexorplasty

@#INTRODUCTION: In patients with delayed presentation between 6 to 12 months, surgical treatment guidelines are not well defined in brachial plexus injury. Still, several authors have agreed that functional outcomes in patients treated within six months from the date of injury have the best results. Nerve transfers are still considered one of the treatment options in the said subset of patients even after six months. In contrast, a primary Steindler flexorplasty, or proximal advancement of the flexor-pronator group, is an ideal technique for elbow flexion with an elapsed time from injury >6 to 9 months. OBJECTIVE: The purpose of this investigation was to compare the clinical outcome s of nerve transfers versus modified Steindler flexorplasty for the restoration of elbow flexion in upper type brachial plexus injuries (BPI). METHODS: A retrospective review of 28 patients who underwent nerve transfers (NT) and 12 patients who underwent modified Steindler flexorplasty (MSF) was done to determine the outcome of treatments. The manual muscle testing using the Medical Research Council scaling system, Visual Analog Scale for pain, active range of motion, and Disabilities of the Arm, Shoulder and Hand form scores were taken as dependent variables. RESULTS: The NT group had a median age of 27.5 years, with 26 men, a median surgical delay of 5.6 months, and a median follow-up of 33 months. Twenty out of 28 patients (71%) had ≥M3 with a median range of 117.6° elbow flexion motion. Median postoperative DASH (n=16) and VAS scores were 29.2 and 3, respectively. For the MSF patients, the median age was 27 years, including ten men, the median surgical delay was 12 months, and the median follow-up was 18.4 months. All the 12 patients had ≥M3, with a median range of motion of 106°. The median postoperative DASH score (n=5) and VAS score were 28.3 and 0, respectively. In the NT group, 73.3% (11/15) achieved ≥M3 elbow flexion if the operation was done in <6 months. CONCLUSION: Nerve transfers and the modified Steindler procedure are still excellent options for successful elbow flexion reanimation in patients with brachial plexus injuries. Our results also showed that those with surgical delays of less than six months had the highest rate of achieving ≥M3 elbow flexion strength in the nerve transfer group.

Unipolar pedicled latissimus dorsi transfer for elbow reanimation in traumatic brachial plexus injuries

Background: Brachial plexus injuries are troubling for the patients socially, economically and emotionally. Elbow joint being a large and vital joint needs to be reanimated so that the patient can carry out his routine work and bring the hand to the mouth. Number of procedures have been defined but latissimus dorsi being a large muscle is the muscle of choice for transfer in cases who present late. Bipolar latissimus dorsi transfers have often been reported but unipolar latissimus dorsi transfer has also been described. Authors have studied the unipolar muscle transfer, it’s surgical technique and results.Methods: In this study 18 patients were studied for demographic data, pre- and post-operative flexion of the elbow and the MRC grade of the corresponding movements. Diagnostic work up in the form of nerve conduction velocity, electromyography and magnetic resonance imaging were carried out and evaluated for their significance in traumatic brachial plexus injuries.Results: In this study 13 patients had avulsion of the C5-6 roots on magnetic resonance imaging. The patients presented after a period of 128.83±56.76 days. Substantial time elapsed and ruled out primary brachial plexus reconstruction or nerve transfers. The average elbow flexion improved from 6.67±5.69 degrees (range: 0-20 degrees) to 86.94±12.38 degrees (range: 65-110 degrees) following unipolar latissimus dorsi transfer. 12 patients (66.67%) developed M4 or M4+ power.Conclusions: Unipolar latissimus dorsi muscle transfer is a reliable method and most of the patients develop adequate strength and satisfactory function at the elbow joint.

Restoration of Elbow Flexion in Traumatic Upper Brachial Plexus Palsy in Adults: Outcome with Intraplexus Distal Nerve Transfers in 78 Patients

Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n » 43), or a fascicle of themedian nerve (group B, n » 16) or a combination of both (group C, n » 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar þ median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer. Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.

Nerve transfer to biceps muscle using a part of ulnar nerve for elbow flexion restoration in acute and delayed upper brachial plexus injury / 中国矫形外科杂志

[Objective]The purpose of this study was to describe mid report the result of the ulnar nerve transfer to biceps muscle to restore elbow flexion after acute and delayed upper brachial plexus injuries.[Methods]Two patients with acute brachial plexus injury (the time between the injury and the operation were six and eight months) and three patients with delayed brachial plexus injury(the time between the injury and the operation were from twevle to eighteen months) underwent nerve transfer using fascicles of the ulnar nerve to the motor branch of the biceis muscle. The average age of the patients was twenty eight and the mean follow-up periods were nine months after the surgery. Patients were evaluated with regard to reinnervation of the biceps, ulnar nerve function, elbow flexion strength, and grip strength.[Results]For the two acute patients, the first sign of biceps muscle contraction were observed within 1 week, the average time required for reinnervation of the biceps after nerve fascicle transfer was within six months. For the three delayed patients, the first sign of bicep muscle contraction was observed in about three month, and the average time required for reinnervation of the biceps was ten months.Hypoesthesia of the ulnar nerve was clinically abserved in three patients, but this symptom disappeared within month with no treatment.Compared with those delayed cases, the acute patients had faster and better recovery of their olbow flexion function.However, all patients achieved grade-3 or better elbow flexion strength according to the grading system of the Medical Research Council.[Conclusion]The author recommend this safe, simple and effective Oberlin procedure for brachial plexus injuries involving the C5、6 or C5~7 nerve roots.

Electromyographic analisys of biceps brachii and erector spinae muscles before and after a fatiguing dynamic test / Análise eletromiográfica dos músculos bíceps do braço e eretores da espinha antes e após um teste isotônico fadigante

The increased number of musculoskeletal injuries can be caused by the lack attention to load level, as well as the posture and time of execution of an overloaded exercise. This way, the objective of this study was to analyze the effect of repetitive barbell biceps curl exercise over biceps brachii and erector spinae muscle electromyographic parameters. Ten healthy male subjects (20,91±1,37 years), without musculoskeletal diseases, performed the biceps curl exercise until fatigue, with 25%, 35% and 45% of 1 repetition maximum. The electromyographic activity of biceps brachii and erector spinae muscles was analyzed during isometric contraction performed before and immediately after fatiguing tests. The muscular fatigue was identified through the increase of root mean square and decrease of median frequency during isometric contractions. The results demonstrated these characteristics of fatigue after fatiguing test (p<0,05) for both muscles, showing a relationship time-load dependent for these electromyographic parameters. No significant differences were found between left and right muscles in the parameters analyzed. The experimental procedures allowed identify the muscular fatigue on biceps brachii muscles and erector spinae activity during barbell biceps curl and the dependence with load and number of repetition...

Recovered latissimus dorsi musculocutaneous flap for reconstruction of flexor of elbow or digits / 中国矫形外科杂志

[Objective]To discuss the result of using latissimus dorsi musculocutaneous flap which function was recovered by repairing the thoracodorsal nerve with nerve transfering for reconstruction of flexor of elbow or digits in brachial plexus injury patients.[Method]From march 2000 to June 2003,eight patients with brachial plexus total roots avulsion were treated by mlutiple donor nerves transfer.The function of latissimus dorsi muscle recorved well but not the biceps muscle in five patients.The function of flex digits did not recover while the latissimus dorsi muscule recorverd well in three patients.All of them had the aid of latissimus dorsi musculocutaneous flap to reconstruct the flexor of elbow or digits.[Result]The patients were followed up for one year to half past three years,all of musculocutaneous flap were survived,the muscle strenght graded 3 to 4 and the active motion of the elbow was over 100 degrees in flexion and 10 degrees to 25 degrees in extension.All the digits can grasp,the fist closure was about 2 cm and the muscle strenght was grade 3 of the involved digits.[Conclusion]It is a good method to reconstruct the flexor of elbow or digits by the recovered latissimus dorsi musculocutaneous flap in brachial plexus total roots avulsion patients.When treating brachial plexus total roots avulsion patients,it is necessary to repair the thoracodorsal nerve.

Ulnar Neuropathy at Elbow after Flap to Graft Conversion Method for Osmidrosis Axillae

Ulnar neuropathy at elbow is the second most common entrapment neuropathy following carpal tunnel syndrome. However, ulnar neuropathy secondary to abnormal strain of the ulnar nerve over the sulcus due to an postoperative osmidrosis axillae position is one of rare causes of ulnar neuropathy at the elbow. Following the operation of osmidrosis axillae, a patient's arm movements were restricted with elbow flexion in order to prevent hematoma from developing at the operation site. In this case presented here, the patient developed ulnar neuropathy 7 day post osmidrosis axillae operation. He had weakness in flexion of the fourth and fifth metacarpophalangeal joints on the right hand, and also weakness in finger straddling, in particular, abduction of the 5th finger on the left hand. Additionally, there was tingling sensation of the fourth and fifth finger and the hypothenar eminence on the left hand. Motor and sensory nerve conduction studies of the left ulnar nerve showed delayed conduction velocities over the left ulnar sulcus. Ulnar neuropathy at the elbow was diagnosed based upon the clinical presentation electrophysiological findings. The patient had been advised to avoid the posture with prolonged flexion of the elbow. The symptoms had been completely resolved spontaneously in 5 months without any surgical intervention. This case has shown that postoperative osmidrosis axillae positon could cause ulnar neuropathy associated with excessive strain of the ulnar nerve during prolonged flexion of the elbow.

Integrated EMG of patients with upper limb spasticity after stroke / 中华物理医学与康复杂志

Objective To evaluate quantitatively the spasticity of elbow flexor biceps in stroke patients using integrated EMG (IEMG),and to correlate the IEMG with Ashworth scale.Methods The IEMG data was recorded from the biceps while passively stretch the elbow joint of a group of 90 subjects,and was correlated with the varying levels of Ashworth category(20 cases with grade 0,6 cases gradeⅠ,16 cases gradeⅠ~+,20 cases gradeⅡ,and 18 ca- ses gradeⅢ).Results The IEMG data were positively correlated with simultaneous Ashworth scale categories.The range of IEMG value corresponding to the Ashworth category is as follows:1.3～12.1 (6.7?5.4)?V?s vs Ash- worth grade 0;4.6～12.3 (8.5?3.9)?V?s vs Ashworth gradeⅠ.15.3～28.4(21.8?6.6)?V?s vs Ashworth gradeⅠ~+;37.2～68.9 (53.1?15.6)?V?s vs Ashworth gradeⅡ;82.3～144.1 (113.2?30.9)?V?s vs Ash- worth gradeⅢ.Conclusion The IEMG value can be used to quantify the spasticity of elbow flexor in stroke pa- tients.

Effect of Elbow Flexion on Supination, Pronation and Grip Strengths

OBJECTIVE: This study was designed to investigate the effect of elbow flexion on the maximal strengths of supination, pronation, and grip which are important component of hand function. METHOD: The maximal isometric strength of supination and pronation using BTE work simulator and grip strength using hand-held dynamometer were measured in thirty normal adult subjects. Maximal voluntary contraction for 5 sec was performed at the 0, 45, and 90 degrees of elbow flexion randomly. RESULTS: 1) The maximal isometric strengths of supination and pronation were significantly higher at the 0 degree, and lower at 90 degrees of elbow flexion (p<0.05). 2) The maximal grip strength at the 0 degree of elbow flexion was significantly higher than that of 45 and 90 degrees of elbow flexion (pp<0.05). CONCLUSION: The strengths of supination, pronation, and grip were affected by the elbow flexion, which were higher in the extended position of elbow. Therefore the elbow angle should be considered and individualized treatment program should be designed in hand rehabilitation to improve strength and to minimize the incidence of overuse disorder.

Anatomical Evaluation of Ulnar Nerve according to the Elbow Position

OBJECTIVE: To investigate the anatomy of the ulnar nerve according to the degree of elbow flexion and to obtain optimal elbow position for ulnar nerve conduction study. METHODS: Eleven elbows in nine cadavers were dissected. We estimated the 10 cm elbow segment to be the distance between 2 points, 4 cm distal and 6 cm proximal to the center of the cubital tunnel, which was determined to be the halfway point between the medial epicondyle and olecranon with elbow position in extension and 45o, 90o, 135o flexion. Anatomical measurements of the actual length of ulnar nerve, distance between medial epicondyle and ulnar nerve, and distance between medial epicondyle and olecranon were obtained in each position. The actual length of the ulnar nerve was measured between two points of the ulnar nerve closest to the landmarks of the estimated 10 cm with flexible ligature. RESULTS: The actual lengths of ulnar nerve were 10.23 cm, 10.00 cm, 9.44 cm, and 9.08 cm in elbow extension, and 45o, 90o, 135o flexion, respectively. The difference between actual length and estimated lengths were least in 45o elbow flexion (p=0.0001). The distance between medial epicondyle and olecranon increased with increasing elbow flexion (p=0.0001). However, there was no difference in the distance between medial epicondyle and ulnar regardless of the elbow position. As a result, the ulnar nerve seemed to have migrated anteriorly in the cubital tunnel with increasing elbow flexion. CONCLUSION: This study suggest that the optimal angle in ulnar nerve conduction study would be 45o flexion, under the condition that the distance measurement is through the halfway point between the medial epicondyle and olecranon.