One-bone forearm osteodesis and biceps re-routing to correct severe supination contracture in a paediatric patient with late obstetric brachial plexus palsy.

PURPOSE: The one-bone forearm arthrodesis has been performed to change the position of the forearm in children with fixed supination deformity due to upper extremity neurologic deficit. In this article, we present a retrospective review of children with late obstetric brachial plexus palsy who underwent palliative surgery to correct severe supination contracture by one-bone forearm osteodesis and biceps re-routing. This technique has not been described previously. MATERIALS AND METHODS: In this retrospective study, four consecutive patients with upper extremity weakness and severe supination contracture who underwent forearm osteodesis in neutral or slight pronation and biceps re-routing. The average age of patients at the time of surgery was 12 years six months (range, 7-14 years). RESULTS: The average follow-up was one year ten months (range, 1 year 6 months to 2 years 7 months). The rotation of the forearm set in neutral (3 patients) and 15° pronation (1 patient). No patients noted adverse effects on the shoulder, elbow or wrist, and none missed having forearm rotation. CONCLUSIONS: One-bone forearm osteodesis and biceps re-routing technique should be considered in some patients with fixed forearm supination deformity and concomitant severe pronation deficit. In this group of patients, repositioning the forearm in a more pronated (or less supinated) position may improve the use of that extremity in activities of daily living. The surgical technique is fairly simple and can be done in a single procedure.

Reconstructive surgery of the amputated ring finger.

PURPOSE: Loss of a fourth digit below the level of the proximal phalanx results in a weakened grip, loss of skilled movements, and the amputation stump is repeatedly traumatized. Transposition of an adjacent fifth digital ray can improve hand function and cosmetic appearance by closing the gap created by the missing digit. Digital ray amputation is not a commonly performed procedure. However, when performed correctly it can dramatically improve hand function and cosmesis. The aim of this study was to evaluate the functional and aesthetic results of the fifth ray radial translation and intercarpal arthrodesis in mutilating ring finger injuries. MATERIALS AND METHODS: In this retrospective study, nine consecutive patients who sustained mutilating ring finger injury were managed by fourth ray amputation with fifth ray transposition between January 2008 and December 2014. There were six males and three females with a mean age of 30.2 ± 12.2 years (age range, 16-56 years) at the time of surgery who underwent delayed fourth ray amputation with fifth ray transposition (after 14 days of injury). Eight cases had undergone previous surgical interventions: three ORIF using intramedullary K-wire fixation, one failed reimplantation, four debridement and application of split thickness skin graft. Primary skin closure of the amputated finger was not considered as previous surgery (one patient). RESULTS: All patients were followed up for a mean period of 17.1 ± 4.1 months (range, 12-24 months). Grip strength and RAS score improved after fourth ray resection. The postoperative grip strength and RAS (score) were not compromised by the associated hand dominance. CONCLUSION: The following conclusions can be made despite the fact that this was a limited study as well as a retrospective analysis: 1-In technical terms, resection of the fourth ray with transposition of the small finger with a wedge-shaped hamate-capitate arthrodesis secured by screw fixation is easier than metacarpal osteotomy/transposition and less liable to post-operative complications. 2-The results of this study suggest that fourth ray resection and transposition of the small finger with a hamate-capitate arthrodesis restores hand function and cosmetics.

Extensor Indicis Proprius Tenodesis to Correct Finger Ulnar Drift Deformity in Rheumatoid Arthritis.

Background: The most frequent deformity of the hand occurring in patients with RA affects the metacarpophalangeal (MCP) joint and it is characterized by a volar subluxation of the proximal phalanges and ulnar drift of the fingers. Methods: The Extensor Indicis Proprius (EIP) tenodesis for correction of ulnar deviation of fingers (II to V) was performed in 10 hands (40 fingers and 5 patients). Results: There was complete correction of the subluxation or dislocation and almost complete correction of the ulnar drift of the metacarpophalangeal joints at the initial postoperative evaluation (three to four months after surgery). However, at final evaluation (eight to twelve months after the operation), all of the digits had some recurrence of ulnar deviation. Conclusion: The EIP tenodesis provides a correct forces vector to maintain the fingers in proper alignment following correction of ulnar deviation.

Dynamic tenodesis of the finger extensors to improve hand function after brachial plexus injury.

The term "plexic hand" refers to hand and wrist involvement in traumatic brachial plexus injuries and to remaining deficits after nerve surgery has been performed. From January 2000 to March 2008, reconstructive surgery (dynamic tenodesis) was performed on seven patients with C5, 6, 7, and 8 nerve root lesions of the brachial plexus to restore wrist and finger extension. This procedure has been used in seven patients (one female). Two patients with a lesion of the brachial plexus sustained a fracture of the affected limb. Preliminary nerve repair operations were required in four cases. One hundred percent (seven) of the patients had improved function following dynamic tenodesis. The extension angle of the wrist joint on grip was 19° on average. The flexion angle of the wrist joint needed to produce MP joint extension was 24.3° on average. A new dynamic extensor tenodesis technique is proposed. The extensor digitorum communis tendons are looped through dorsal carpal retinaculum ligament and sutured to themselves. Our results demonstrate that the extensor dynamic tenodesis procedure is an effective and simple means of restoring grip function for patients with C5, 6, 7, and 8 nerve root lesions.

Treatment of scaphoid nonunions with closed-wedge osteotomy of the distal radius: Report of six cases.

BACKGROUND: The ideal treatment of nonunion of the scaphoid remains unresolved and controversial. It was hypothesized that scaphoid nonunion could be treated successfully using a closed-wedge osteotomy of the distal radius which reduces the inclination of the joint surface and decreases the pressure between the radial and scaphoid surfaces with a reduction of the force applied by the styloid process. We present a preliminary report in six patients with nonunion of the carpal scaphoid using this procedure. The main objective of the osteotomy is to achieve fusion, alleviate pain, and improve function. MATERIALS AND METHODS: Six closed-wedge osteotomies to reduce the inclination of the distal radial surface were performed in patients with scaphoid waist nonunion and a viable proximal pole, without posttrauma osteoarthritis or with moderate posttraumatic osteoarthritis confined to the radio-scaphoid joint. The present series of six patients (all men) were followed for at least 8 months (mean follow-up 14.2 months, range 8-21 months). RESULTS: Solid union was achieved in five patients. Postoperatively, three patients were pain-free, two presented mild pain for heavy work, and one had moderate pain. This type of osteotomy reduced the inclination of the joint surface (radial angulation) 6.2 degrees on average. There was an improvement in joint flexion from a preoperative mean of 40 degrees to 52.5 degrees at last follow-up, in extension from 40.8 degrees to 66.7 degrees , in radial deviation from 15 degrees to 22.5 degrees , and in ulnar deviation from 30.8 degrees to 41.7 degrees . CONCLUSIONS: This preliminary study suggests that a closed-wedge osteotomy of the distal radius could be an alternative approach for patients with scaphoid waist nonunion and a viable proximal pole, without posttrauma osteoarthritis or with moderate posttraumatic osteoarthritis confined to the radio-scaphoid joint. The number of cases was small; however, further studies with a much larger series are needed before routine use of wedge osteotomy in scaphoid nonunion can be recommended.

Restoration of elbow flexion by transfer of the phrenic nerve to musculocutaneous nerve after brachial plexus injuries

Traumatic brachial plexus injuries are a devastating injury that results in partial or total denervation of the muscles of the upper extremity. Treatment options that include neurolysis, nerve grafting, or neurotization (nerve transfer) has become an important procedure in the restoration of function in patients with irreparable preganglionic lesions. Restoration of elbow flexion is the primary goal in treating patients with severe brachial plexus injuries. Nerve transfers are used when spinal roots are avulsed, and proximal stumps are not available. In the present study, we analyze the results obtained in 20 patients treated with phrenic–musculocutaneous nerve transfer to restore elbow flexion after brachial plexus injuries. A consecutive series of 25 adult patients (21 men and 4 women) with a brachial plexus traction/crush lesion were treated with phrenic–musculocutaneous nerve transfer, but only 20 patients (18 men and 2 women) were followed and evaluated for at least 2 years postoperatively. All patients had been referred from other institutions. At the initial evaluation, eight patients received a diagnosis of C5-6 brachial plexus nerve injury, and in the other 12 patients, a complete brachial plexus injury was identified. Reconstruction was undertaken if no clinical or electrical evidence of biceps muscle function was seen by 3 months post injury. Functional elbow flexion was obtained in the majority of cases by phrenic–musculocutaneous nerve transfer (14/20, 70 percent). At the final follow-up evaluation, elbow flexion strength was a Medical Research Council Grade 5 in two patients, Grade 4 in four patients, Grade 3 in eight patients, and Grade 2 or less in six patients. Transfer involving the phrenic nerve to restore elbow flexion seems to be an appropriate approach for the treatment of brachial plexus root avulsion.....(AU)

Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type.

BACKGROUND: Loss of elbow flexion due to traumatic palsy of the brachial plexus represents a major functional handicap.Then, the first goal in the treatment of the flail arm is to restore the elbow flexion by primary direct nerve surgery or secondary reconstructive surgery. There are various methods to restore elbow flexion which are well documented in the medical literature but the most known and used is Steindler flexorplasty.This review is intended to detail the author's experience with Steindler flexorplasty to restore elbow flexion in patients with brachial plexus palsy C5-C6-C7 where wrist extensors are paralyzed or weakened. METHODS: We conducted a retrospective follow-up study of 12 patients with absent or extremely weak elbow flexion (motor grade 2 or less), wrist/finger extensor and triceps palsy associated; who had undergone surgical reconstruction of the flail upper limb by tendon transfer (Steindler flexorplasty) and wrist arthrodesis to restore elbow flexion. The aetiology of elbow weakness was in all patients brachial plexus palsy (C5-C6-C7 deficit). Data were collected from medical records and from the information obtained during follow-up visits.Age, sex, preoperative strength (rated on a 0 to 5 scale for the flexors of the elbow, wrist flexors, pronator and triceps), previous surgery, length of follow-up, other associated operative procedures, results and complications were recorded. RESULTS: The results are the follows: Eleven patients were found to have very good or good function of the transferred muscles. One patient had mild active flexion of the elbow despite the reconstructive procedure. There were no major intraoperative complications. Two patients experienced transient, intermittent nocturnal ulnar paresthesias postoperatively. In both patients these symptoms subsided without further surgery. CONCLUSION: Our study suggests that in patients with C5-C6-C7 palsy where the wrist and finger extensors are paralyzed or weaked, the flexor-pronators muscles of the forearm are strong but the triceps is not available for transfer; Steindler flexorplasty to restore elbow flexion should be complemented with wrist arthrodesis.

Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type

Background Loss of elbow flexion due to traumatic palsy of the brachial plexus represents a major functional handicap.Then, the first goal in the treatment of the flail arm is to restore the elbow flexion by primary direct nerve surgery or secondary reconstructive surgery.There are various methods to restore elbow flexion which are well documented in the medical literature but the most known and used is Steindler flexorplasty. This review is intended to detail the author's experience with Steindler flexorplasty to restore elbow flexion in patients with brachial plexus palsy C5-C6-C7 where wrist extensors are paralyzed or weakened. MethodsWe conducted a retrospective follow-up study of 12 patients with absent or extremely weak elbow flexion (motor grade 2 or less), wrist/finger extensor and triceps palsy associated; who had undergone surgical reconstruction of the flail upper limb by tendon transfer (Steindler flexorplasty) and wrist arthrodesis to restore elbow flexion. The aetiology of elbow weakness was in all patients brachial plexus palsy (C5-C6-C7 deficit). Data were collected from medical records and from the information obtained during follow-up visits. Age, sex, preoperative strength (rated on a 0 to 5 scale for the flexors of the elbow, wrist flexors, pronator and triceps), previous surgery, length of follow-up, other associated operative procedures, results and complications were recorded. Results The results are the follows: Eleven patients were found to have very good or good function of the transferred muscles. One patient had mild active flexion of the elbow despite the reconstructive procedure.There were no major intraoperative complications. Two patients experienced transient, intermittent nocturnal ulnar paresthesias postoperatively. In both patients these symptoms subsided without further surgery. ConclusionOur study suggests that in patients with C5-C6-C7 palsy where the wrist and finger extensors are paralyzed....(AU)

Trapezius transfer to treat flail shoulder after brachial plexus palsy.

BACKGROUND: After severe brachial palsy involving the shoulder, many different muscle transfers have been advocated to restore movement and stability of the shoulder. Paralysis of the deltoid and supraspinatus muscles can be treated by transfer of the trapezius. METHODS: We treated 10 patients, 8 males and 2 females, by transfer of the trapezius to the proximal humerus. In 6 patients the C5 and C6 roots had been injured; in one C5, C6 and C7 roots; and 3 there were complete brachial plexus injuries. Eight of the 10 had had neurosurgical repairs before muscle transfer. Their average age was 28.3 years (range 17 to 41), the mean delay between injury and transfer was 3.1 years (range 14 months to 6.3 years) and the average follow-up was 17.5 months (range 6 to 52), reporting the clinical and radiological results. Evaluation included physical and radiographic examinations. A modification of Mayer's transfer of the trapezius muscle was performed. The principal goal of this work was to evaluate the results of the trapezius transfer for flail shoulder after brachial plexus injury. RESULTS: All 10 patients had improved function with a decrease in instability of the shoulder. The average gain in shoulder abduction was 46.2 degrees; the gain in shoulder flexion average 37.4 degrees. All patients had stable shoulder (no subluxation of the humeral head on radiographs). CONCLUSION: Trapezius transfer for a flail shoulder after brachial plexus palsy can provide satisfactory function and stability.

Trapezius transfer to treat flail shoulder after brachial plexus palsy

Background: After severe brachial palsy involving the shoulder, many different muscle transfers have been advocated to restore movement and stability of the shoulder. Paralysis of the deltoid and supraspinatus muscles can be treated by transfer of the trapezius. Methods: We treated 10 patients, 8 males and 2 females, by transfer of the trapezius to the proximal humerus. In 6 patients the C5 and C6 roots had been injuried; in one C5, C6 and C7 roots; and 3 there were complete brachial plexus injuries. Eight of the 10 had had neurosurgical repairs before muscle transfer. Their average age was 28.3 years (range 17 to 41), the mean delay between injury and transfer was 3.1 years (range 14 months to 6.3 years) and the average follow-up was 17.5 months (range 6 to 52), reporting the clinical and radiological results. Evaluation included physical and radiographic examinations. A modification of Mayer's transfer of the trapezius muscle was performed. The principal goal of this work was to evaluate the results of the trapezius transfer for flail shoulder after brachial plexus injury. Results: All 10 patients had improved function with a decrease in instability of the shoulder. The average gain in shoulder abduction was 46.2°; the gain in shoulder flexion average 37.4°. All patients had stable shoulder (no subluxation of the humeral head on radiographs). ConclusionTrapezius transfer for a flail shoulder after brachial plexus palsy can provide satisfactory function and stability(AU)

Antecedentes: Después de graves parálisis braquial la participación de los hombros, los músculos diferentes transferencias se han defendido para restaurar el movimiento y la estabilidad del hombro. Parálisis de los músculos deltoides y supraespinoso puede ser tratado mediante la transferencia de la trapezius. Métodos: Se han tratado 10 pacientes, 8 hombres y 2 mujeres, mediante la transferencia de la trapezius al húmero proximal. En 6 pacientes las raíces C5 y C6 se habían injuried; en un C5, C6 y C7 raíces, y 3 se completa las lesiones del plexo braquial. Ocho de los 10 había tenido antes de la reparación de neurocirugía músculo transferencia. Su edad media fue de 28,3 años (rango 17 a 41), la demora media entre la lesión y la transferencia fue de 3,1 años (rango 14 meses a 6,3 años) y la media de seguimiento fue de 17,5 meses (rango 6 a 52), la presentación de informes clínicos y los resultados radiológicos. La evaluación incluye exámenes físicos y radiológicos. Una modificación de la transferencia de Mayer trapezius el músculo se realizó. El principal objetivo de este trabajo fue evaluar los resultados de la transferencia de trapezius mayal hombro después de lesión del plexo braquial. Resultados: Todos los 10 pacientes habían mejorado con la función de una disminución de la inestabilidad del hombro. El promedio de ganancia en el secuestro del hombro fue 46,2 °; la ganancia media de la flexión del hombro en 37,4 °. Todos los pacientes tenían estable hombro (sin subluxación de la cabeza humeral en las radiografías). Conclusión Trapezius transferencia de un mayal hombro después de la parálisis del plexo braquial puede funcionar satisfactoriamente y la estabilidad

Restoration of elbow flexion by transfer of the phrenic nerve to musculocutaneous nerve after brachial plexus injuries.

Traumatic brachial plexus injuries are a devastating injury that results in partial or total denervation of the muscles of the upper extremity. Treatment options that include neurolysis, nerve grafting, or neurotization (nerve transfer) has become an important procedure in the restoration of function in patients with irreparable preganglionic lesions. Restoration of elbow flexion is the primary goal in treating patients with severe brachial plexus injuries. Nerve transfers are used when spinal roots are avulsed, and proximal stumps are not available. In the present study, we analyze the results obtained in 20 patients treated with phrenic-musculocutaneous nerve transfer to restore elbow flexion after brachial plexus injuries. A consecutive series of 25 adult patients (21 men and 4 women) with a brachial plexus traction/crush lesion were treated with phrenic-musculocutaneous nerve transfer, but only 20 patients (18 men and 2 women) were followed and evaluated for at least 2 years postoperatively. All patients had been referred from other institutions. At the initial evaluation, eight patients received a diagnosis of C5-6 brachial plexus nerve injury, and in the other 12 patients, a complete brachial plexus injury was identified. Reconstruction was undertaken if no clinical or electrical evidence of biceps muscle function was seen by 3 months post injury. Functional elbow flexion was obtained in the majority of cases by phrenic-musculocutaneous nerve transfer (14/20, 70%). At the final follow-up evaluation, elbow flexion strength was a Medical Research Council Grade 5 in two patients, Grade 4 in four patients, Grade 3 in eight patients, and Grade 2 or less in six patients. Transfer involving the phrenic nerve to restore elbow flexion seems to be an appropriate approach for the treatment of brachial plexus root avulsion. Traumatic brachial plexus injury is a devastating injury that result in partial or total denervation of the muscles of the upper extremity. Treatment options include neurolysis, nerve grafting, or neurotization (nerve transfer). Neurotization is the transfer of a functional but less important nerve to a denervated more important nerve. It has become an important procedure in the restoration of function in patients with irreparable preganglionic lesions. Restoration of elbow flexion is the primary goal in treating patients with severe brachial plexus injuries. Nerve transfers are used when spinal roots are avulsed, and proximal stumps are not available. Newer extraplexal sources include the ipsilateral phrenic nerve as reported by Gu et al. (Chin Med J 103:267-270, 1990) and contralateral C7 as reported by Gu et al. (J Hand Surg [Br] 17(B):518-521, 1992) and Songcharoen et al. (J Hand Surg [Am] 26(A):1058-1064, 2001). These nerve transfers have been introduced to expand on the limited donors. The phrenic nerve and its anatomic position directly within the surgical field makes it a tempting source for nerve transfer. Although not always, in cases of complete brachial plexus avulsion, the phrenic nerve is functioning as a result of its C3 and C4 major contributions. In the present study, we analyze the results obtained in 20 patients treated with phrenic-musculocutaneous nerve transfer to restore elbow flexion after brachial plexus injuries.

The effect of ultrasound on the healing of muscle-pediculated bone graft in scaphoid non-union

The use of pedicled vascularised bone grafts from the distal radius makes it possible to transfer bone with a preserved circulation and viable osteoclasts and osteoblasts. Experiments performed at the basic science level has provided substantial evidence that low-intensity ultrasound can accelerate and augment the fracture healing process. Only an adequate double-blind trial comparing treatment by ultrasound stimulation in patients treated by similar surgical techniques can provide evidence of the true effect of ultrasound. This paper describes the results of such a trial. From 1999 to 2004, 21 fractures of the scaphoid with established non-union treated with vascularised pedicle bone graft were selected for inclusion in a double-blind trial. All patients were males, with an average age of 26.7 years (range 17–42 years) and an average interval between injury and surgery of 38.4 months (range 3 months–10 years). Low-intensity ultrasound was delivered using a TheraMed 101-B bone-growth stimulator (30 mW/cm2, 20 min/day), which was modified to accomplish double-blinding. These modifications did not affect the designated active units. The placebo units were adjusted to give no ultrasound signal output across the transducer. Externally, all units appeared identical but were marked with individual code numbers. Patients were randomly allocated to either an active or placebo stimulation. Follow-up averaged 2.3 years (range 1–4 years). All patients achieved fracture union (active and placebo groups), but compared with the placebo device (11 patients), the active device (ten patients) accelerated healing by 38 days (56±3.2 days compared with 94±4.8 days, p<0.0001, analysis of variance)(AU)

El uso de injertos óseos vascularizados pediculado distal de radio hace que sea posible transferir los huesos conservados con una práctica y viable osteoclastos y osteoblastos. Experimentos realizados en la ciencia básica ha proporcionado pruebas de que la baja intensidad de ultrasonido puede acelerar y aumentar el proceso de curación de fracturas. Sólo una adecuada ensayo doble ciego que compararon el tratamiento de estimulación por ultrasonidos en pacientes tratados con técnicas quirúrgicas similares pueden aportar pruebas de los verdaderos efectos de la ecografía. Este artículo describe los resultados de dicho proceso. De 1999 a 2004, 21 de las fracturas de escafoides con la unión no tratados con injerto óseo vascularizado pedículo se seleccionaron para su inclusión en un ensayo doble ciego. Todos los pacientes fueron varones, con una edad media de 26,7 años (rango 17-42 años) y un intervalo promedio entre el perjuicio y la cirugía de 38,4 meses (rango 3 meses-10 años). Ultrasonido de baja intensidad se entregó mediante un TheraMed 101-B, estimulador del crecimiento de los huesos (30 mW/cm2, 20 min / día), que fue modificado para cumplir con doble cegamiento. Estas modificaciones no afectan a los designados unidades activas. El placebo se ajustaron a las unidades no ofrecen ninguna salida de señal de ultrasonido a través del transductor. Externamente, todas las unidades, pero parece idéntico fueron marcados con los números de código. Los pacientes fueron asignados al azar a uno, ya sea activa o placebo estimulación. Seguimiento promedio de 2,3 años (rango 1-4 años). Todos los pacientes alcanzaron la unión de fractura (en activo y placebo), pero en comparación con el placebo dispositivo (11 pacientes), el dispositivo activo (diez pacientes) acelerar la curación por 38 días (56 ± 3,2 días en comparación con 94 ± 4,8 días, p <0,0001 , el análisis de la varianza)

Surgical treatment of brachial plexus injuries in adults

We carried out a retrospective review of 32 consecutive patients (30 adults and two children) with total or partial lesions of the brachial plexus who had surgical repair using nerve grafting, neurotisation, and neurolysis between January 1991 and December 2003. The outcome measures of muscular strength were correlated with the type of lesion, age, preoperative time, length and number of grafts, and time to reinnervation of the biceps. The function of the upper limb was also evaluated. There was a significant correlation between muscular strength after surgical repair and both the preoperative time and the length of the nerve graft. There was also a significant correlation between muscular strength and the number of grafts. Muscular strength was better when the neurolysis was done before six months. When neurosurgical repair and reconstructive procedures were performed, the function of the upper limb was improved(AU)

Se realizó una revisión retrospectiva de 32 pacientes (30 adultos y dos niños), con total o parcial de las lesiones del plexo braquial que habían reparación quirúrgica mediante injerto de nervio, neurotisation, y neurolisis entre enero de 1991 y diciembre de 2003. Las medidas de resultado de la fuerza muscular se correlaciona con el tipo de lesión, la edad, el tiempo preoperatorio, la duración y el número de injertos, y el tiempo para reinnervation de los bíceps. La función de la extremidad superior fue también evaluada. Hubo una correlación significativa entre la fuerza muscular después de la reparación quirúrgica y tanto el tiempo preoperatorio y la duración del injerto de nervio. También hubo una correlación significativa entre la fuerza muscular y el número de injertos. Fuerza muscular fue mejor cuando el neurolisis se hizo antes de seis meses. Cuando la reparación de neurocirugía y de reconstrucción se realizaron los procedimientos, la función de la extremidad superior se mejoró