15: Nerve Transfer Techniques for Elbow Flexion in Brachial Plexus Palsy

Published on 19/04/2015 by admin

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Last modified 19/04/2015

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Procedure 15 Nerve Transfer Techniques for Elbow Flexion in Brachial Plexus Palsy

Lynda J. Yang

imageSee Video 13: Nerve Transfers for Elbow Flexion in Brachial Plexus Palsy (Ulnar Fascicle to Musculocutaneous Nerve)

Indications

image Lack of elbow flexion/supination

image Available functional donor nerve with a lesser-valued function (e.g., ulnar fascicle to flexor carpi ulnaris with normal muscle power) in close proximity with recipient nerve/muscle

image Available recipient nerve without distal injury (e.g., intact musculocutaneous nerve branch to biceps in patients with supraclavicular brachial plexus injury)

image Donor and recipient nerves ideally with agonistic functions (e.g., flexion of elbow, wrist)

Examination/Imaging

Clinical Examination

image Examine the involvement of all muscles that contribute to elbow flexion—biceps, brachialis, and brachioradialis—to determine the site of injury (e.g., nerve root versus peripheral nerve).

image Examine the active and passive range of motion at the elbow.

image Examine the integrity of the vascular supply to the arm.

image Examine the integrity of the donor nerve/muscle (e.g., flexor carpi ulnaris).

image Determine whether the biceps muscle is ruptured, because end-organ injury would preclude nerve transfer.

Surgical Anatomy

image Pertinent surgical anatomy includes the neurovascular anatomy in the medial aspect of the arm.

Positioning

image Position the patient supine with the arm extended onto a surgical arm board.

image In patients with decreased shoulder range of motion, an external positioning device can be used to place the arm in abduction and external rotation to reveal the medial aspect of the upper arm (Fig. 15-1).

image

FIGURE 15-1

Exposures

image Ulnar fascicle to musculocutaneous nerve: An incision is made along the medial arm from the pectoralis muscle insertion site to distally, with the incision overlying the path of the neurovascular bundle that lies between the biceps and triceps (see Fig. 15-1).

image Double fascicular nerve transfer for elbow flexion:

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