21: Steindler Flexorplasty

Published on 18/04/2015 by admin

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Last modified 18/04/2015

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Procedure 21 Steindler Flexorplasty

Pao-Yuan Lin, Sandeep J. Sebastin, Kevin C. Chung

Indications

image Late presentation of upper trunk brachial plexus palsy (C5-C6; C5-C6-C7) without recovery of elbow flexion.

• Steindler procedure is preferred to a pedicled latissimus dorsi (LD) transfer or free functioning muscle transfer, if the patient has good function of the wrist and finger flexors.
• A pedicled LD transfer or free functioning muscle transfer can be considered if the wrist flexors are weak.
• A pectoralis major–biceps transfer can be considered in patients who have a weak biceps (partial recovery). The pectoralis major cannot replace the function of the biceps but can augment it.

image Arthrogryposis patients lacking elbow flexion.

Examination/Imaging

Clinical Examination

image The patients should have adequate strength in the flexor pronator mass, especially the wrist flexors [flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU)]. This can be assessed by asking the patient to flex the wrist against resistance.

image The patient should have good wrist extension to counteract the possible development of a wrist flexion contracture.

image The patients should have adequate passive flexion of the elbow. If passive flexion of the elbow is limited owing to a tight triceps, then triceps lengthening may be necessary to increase passive range of motion.

Imaging

image Plain radiograph of the elbow should reveal normal elbow articulation.

Surgical Anatomy

image The common flexor-pronator muscles originate from the medial epicondyle. The following muscles are elevated during this procedure: pronator teres, FCR, palmaris longus, FCU, and flexor digitorum superficialis (Fig. 21-1). The flexor digitorum profundus is left in situ (see Fig. 21-1).

image The ulnar nerve must be protected during elevation of the flexor-pronator mass. It may be transposed anteriorly in the submuscular plane.

image The medial (ulnar) collateral ligament of the elbow should be protected during elevation of the flexor-pronator mass. It originates at the posterior distal aspect of the medial epicondyle and inserts into the base of the coronoid process of ulna. It is composed of three bands: anterior, posterior, and transverse (Fig. 21-2).

image

FIGURE 21-1

image

FIGURE 21-2

Positioning

image The patient is positioned supine with the affected extremity on a hand table. The procedure is performed under general or regional anesthesia, and a sterile tourniquet is placed as high up the arm as possible.

Exposures

image A 10-cm longitudinal curvilinear incision centered over the medial epicondyle is made (Fig. 21-3).

image A skin flap is elevated while protecting the medial antebrachial cutaneous nerve. After elevation of the skin flap, one will see the flexor-pronator mass attaching to the medial epicondyle (Fig. 21-4).

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