Results of wrist extension reconstruction in C5-8 brachial plexus palsy by transferring the pronator quadratus motor branch to the extensor carpi radialis brevis muscle.

OBJECT The objective of this study was to report the results of pronator quadratus (PQ) motor branch transfers to the extensor carpi radialis brevis (ECRB) motor branch to reconstruct wrist extension in C5-8 root lesions of the brachial plexus. METHODS Twenty-eight patients, averaging 24 years of age, with C5-8 root injuries underwent operations an average of 7 months after their accident. In 19 patients, wrist extension was impossible at baseline, whereas in 9 patients wrist extension was managed by activating thumb and wrist extensors. When these 9 patients grasped an object, their wrist dropped and grasp strength was lost. Wrist extension was reconstructed by transferring the PQ motor to the ECRB motor branch. After surgery, patients were followed for at least 12 months, with final follow-up an average of 22 months after surgery. RESULTS Successful reinnervation of the ECRB was demonstrated in 27 of the 28 patients. In 25 of the patients, wrist extension scored M4, and in 2 it scored M3. CONCLUSIONS In C5-8 root injuries, wrist extension can be predictably reconstructed by transferring the PQ motor branch to reinnervate the ECRB.

The median nerve consistently drives flexion of the distal phalanx of the ring and little fingers: Interest in finger flexion reconstruction by nerve transfers.

Surgeons believe that in high ulnar nerve lesion distal interphalangeal joint (DIP) flexion of the ring and little finger is abolished. In this article, we present the results of a study on innervation of the flexor digitorum profundus of the ring and little fingers in five patients with high ulnar nerve injury and in 19 patients with a brachial plexus, posterior cord, or radial nerve injury. Patients with ulnar nerve lesion were assessed clinically and during surgery for ulnar nerve repair we confirmed complete lesion of the ulnar nerve in all cases. In the remaining 19 patients, during surgery, either the median nerve (MN) or the anterior interosseous nerve (AIN) was stimulated electrically and DIP flexion of the ring and little fingers evaluated. All patients with high ulnar nerve lesions had active DIP flexion of the ring and little fingers. Strength scored M4 in the ring and M3-M4 in the little finger. Electrical stimulation of either the MN or AIN produced DIP flexion of the ring and little fingers. Contrary to common knowledge, we identified preserved flexion of the distal phalanx of the ring and little fingers in high ulnar nerve lesions. On the basis of these observations, nerve transfers to the AIN may provide flexion of all fingers.

Transfer of the distal terminal motor branch of the extensor carpi radialis brevis to the nerve of the flexor pollicis longus: an anatomic study and clinical application in a tetraplegic patient.

BACKGROUND: In tetraplegics, thumb and finger motion traditionally has been reconstructed via orthopedic procedures. Although rarely used, nerve transfers are a viable method for reconstruction in tetraplegia. OBJECTIVE: To investigate the anatomic feasibility of transferring the distal branch of the extensor carpi radialis brevis (ECRB) to the flexor pollicis longus (FPL) nerve and to report our first clinical case. METHODS: We studied the motor branch of the ECRB and FPL in 14 cadaveric upper limbs. Subsequently, a 24-year-old tetraplegic man with preserved motion in his shoulder, elbow, wrist, and finger extension, but paralysis of thumb and finger flexion underwent surgery. Seven months after trauma, we transferred the brachialis muscle with a tendon graft to the flexor digitorum profundus. The distal nerve of the ECRB was transferred to the FPL nerve. RESULTS: The branch to the ECRB entered the muscle in its anterior and proximal third. After sending out a first collateral, the nerve runs for 2.4 cm alongside the muscle and bifurcates intramuscularly. A main branch from the anterior interosseous nerve, which entered the muscle 3 cm from its origin on the radius, innervated the FPL. The ECRB and FPL nerves had similar diameters (∼1 mm) and numbers of myelinated fibers (∼180). In our patient, 14 months after surgery, pinching and grasping were restored and measured 2 and 8 kg strength, respectively. CONCLUSION: Transfer of the ECRB distal branch to the FPL is a viable option to reconstruct thumb flexion.

Transfer of axillary nerve branches to reconstruct elbow extension in tetraplegics: a laboratory investigation of surgical feasibility.

In spinal cord injuries at the C6 level, elbow extension is lost and needs reconstruction. Traditionally, elbow extension has been reconstructed by muscle transfers, which improve function only moderately. We have hypothesized that outcomes could be ameliorated by nerve transfers rather than muscle transfers. We anatomically investigated nerve branches to the teres minor and posterior deltoid as donors for transfer to triceps motor branches. In eight formalin-fixed cadavers, the axillary nerve, the teres minor branch, the posterior deltoid branch, the triceps long and upper medial head motor branches, and the thoracodorsal nerve were dissected bilaterally, their diameters measured and their myelinated fibers counted. To simulate surgery, using an axillary approach in two fresh cadavers, we transferred the teres minor or the posterior deltoid branch to the triceps long head and to the thoracodorsal nerve. The posterior division of the axillary nerve gave off the teres minor motor branch and then the branch to the posterior deltoid, terminating as the superior lateral brachial cutaneous nerve. The diameters of the teres minor motor branch, posterior deltoid, triceps long and upper medial head branches, and the thoracodorsal nerve all were ∼2 mm, with minimal variation. The nerves varied little in their numbers of myelinated fibers, being consistently about 1,000. Via an axillary approach, either the teres minor or the posterior deltoid branch could be transferred directly to the thoracodorsal nerve or to triceps branches without any tension.

Transfer of the teres minor motor branch for triceps reinnervation in tetraplegia.

In a case involving tetraplegia and paralysis of elbow extension, the authors transferred teres minor branches to the nerve of the triceps long head. Surgery was performed bilaterally 9 months after the patient sustained a spinal cord injury. Fourteen months postoperatively, elbow extension was complete (British Medical Research Council Score M4). Harvesting of the teres minor motor branch produced no deficits in shoulder function. In patients with tetraplegia, nerve transfer seems to be a promising new alternative for elbow extension reconstruction.

Tratamento das lesões ligamentares intrísecas do punho com videoartroscopia: estudo em 12 casos / Treatment of intrinsic ligament lesions of the wrist with videoartroscopy: study of 12 cases

Objetivo: Analisar os resultados clínicos do tratamento videoartroscópico das lesões ligamentares escafo-semilu-nar e semilunar-piramidal do punho. Métodos: Foram analisados 12 casos, todos tratados com videoartroscopia de punho, acompanhados pós-operatoriamente por 26,5 meses (± 16,3); todos apresentaram remissão total da sintomatologia e recuperação das suas atividades funcionais. Não houve diminuição da mobilidade do punho e da força de preensão manual. Resultados: Lesões ligamentares intrínsecas do carpo devem ser preferencialmente tratadas com videoartroscopia, pois permite o tratamento efetivo sem agressões maiores aos tecidos não lesados. Os resultados foram gratificantes, tanto para o cirurgião como, principalmente, para o paciente, o que encoraja os autores a persistirem com a técnica adotada. Conclusão: A videoartroscopia é um procedimento que permite o efetivo diagnóstico e a quantificação da extensão das lesões ligamentares escafo-semilunar e semilunar-piramidal, permitindo ao mesmo tempo o tratamento sem a necessidade de agressão maior aos tecidos não lesados, como ocorre nas reparações abertas

Thumb metacarpal vascularized bone graft in long-standing scaphoid nonunion--a useful graft via dorsal or palmar approach: a cohort study of 24 patients.

PURPOSE: Long-standing scaphoid nonunion preferentially is treated by using a vascularized bone graft because of its superiority in achieving bone healing. In the present study nonunion was repaired using a bone graft raised from the thumb metacarpal and vascularized by the first dorsal metacarpal artery. METHODS: Twenty-four patients with scaphoid nonunion for longer than 5 years, without ligament injuries and panarthrosis, had surgery. According to the location of the nonunion and presence of dorsal intercalated segment instability deformity, surgery was performed by either a dorsal or palmar approach. The patients had a final clinical and radiographic evaluation 12 months after surgery. RESULTS: Complete healing was shown in 21 patients but incomplete healing was observed in the remaining 3 patients. After surgery patients had marked pain relief, with an improved range of motion and grasping strength. Anatomic restoration of carpal angles and scaphoid length was observed. None of the patients required additional surgery. Before surgery 15 patients presented radiographic signs of wrist arthrosis. During surgery, however, cartilage erosion on the proximal pole or on the radius articular surface was not confirmed. Despite the presence of radiographic arthrosis, wrist symptoms, motion, and grasping strength improved after surgery. CONCLUSIONS: Long-standing scaphoid nonunion, even in the presence of limited arthrosis, can be treated with surgery and healing promoted by a vascularized bone graft. Because of its versatility for use by dorsal or palmar approach and reliability, the first dorsal metacarpal artery vascularized bone graft represents our method of choice.