Reanimation of the Paralysed Elbow

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Chapter 32 Reanimation of the Paralysed Elbow

Simon Kay, Catherine Hernon

Introduction

The human elbow joint consists of a semiconstrained articulation between the ulna and the humerus and much less constrained articulations between the radius and the humerus, and the radius and the ulna. In a quadruped the action of extension would be highly valued but in the erect human biped, flexion is paramount, enabling the full range of daily activities including self-maintenance, feeding and occupation. Only when engaged in working above the level of the shoulder does extension become important. Extension is also important in cases where there is some compromise of the lower limbs, specifically where locomotion and transfer depend on elbow extension. As a consequence when considering the paralysed elbow we will look primarily at the restoration of flexion, although we do keep in mind the value of extension and the need to maintain forearm rotation where possible.

Elbow flexion is normally achieved by the activity of three muscles: the biceps brachii, the brachialis and the brachioradialis. Two of these muscles are supplied by the musculocutaneous nerve whose predominant contribution comes from the C6 cervical spinal nerve, while two have some supply from the radial nerve, that of brachialis being partial and that of brachioradialis complete. These contributions are also predominantly from the C6 nerve root. The brachialis muscle passes from the humerus across the anterior elbow joint into the ulnar and serves only as a flexor of the ulnar-humeral articulation, while the biceps inserts into the bicipital tuberosity of the radius and has an additional strong supinating action. Its flexion force is also transmitted to the ulnar through the lacertus fibrosus. Finally the brachioradialis muscle can also serve as a weak supinator or pronator depending upon the position of the elbow. The primary function of all of these muscles, however, is flexion of the elbow.

Conditions resulting in paralysis at the elbow

It is helpful to think of the causes of absent elbow flexion in terms of whether the muscles are present but denervated, or absent. Denervated muscles in clinical practice are most often seen as a result of either adult or congenital brachial plexus palsy or other peripheral nerve injuries. Less commonly progressive neuropathies and spinal injuries may also be encountered.

Absent muscle may result either from trauma destroying or damaging the muscle beyond functional restitution, or from congenital abnormalities including arthrogryposis multiplex congenita.1,2 As we examine the treatment of each of these causes of loss of elbow flexion, a number of treatment techniques will emerge and it will become apparent that all techniques have some application in most conditions. Choosing between these techniques will depend partly upon the repertoire of the surgical team and their experience, and upon patient preference influenced by their age, other conditions, and important factors such as appearance. For such a simple motion, elbow flexion can be remarkably difficult to achieve and it is not uncommon in the senior author’s practice for more than one technique to be employed in a single patient.

Prior to reanimating any elbow, consideration must be given to the passive range of motion. This need not be full or normal; indeed following the restoration of elbow flexion, some degree of contracture is desirable to facilitate the initiation of motion (by virtue of the increased moment arm of muscle action at rest). Similarly full active flexion is not always essential even for feeding. Many children with obstetric brachial palsy develop the ‘trumpet’ sign3 by which in order to get the hand to the mouth the humerus is abducted to 90° or more prior to completion of elbow flexion. This activity compensates for the absence of active external rotation at the shoulder but also excludes gravity from the elbow articulation making flexion easier. It also brings the prehensile radial border of the hand to the mouth in full supination, which is important for those children who have lost pronation.

In dealing with restoration of elbow movement it is important not to consider the elbow in isolation. Too often in adult brachial plexus injury the senior author sees patients in whom elbow flexion has been restored without addressing the instability, or lack of active external rotation, at the shoulder. This results in an elbow that flexes up the anterior chest wall to the anterior neck but does not support a hand that can be positioned in space. Whilst this simple function in a badly paralysed limb can be useful for augmenting brachiothoracic grasp, it is important when planning any brachial plexus reconstruction to consider the implications at the shoulder which may itself be managed by either reanimation or arthrodesis;4,5 a topic that is beyond the scope of this chapter. Furthermore, elbow flexion is valuable in the context of positioning a competent hand in space and so its place in the restoration of function of an upper limb whether from brachial plexus palsy, congenital defects or widespread trauma, must be considered at the outset. A coherent programme with6,7 an appropriate timescale should, therefore, be agreed with the patient at the start of reconstruction and rehabilitation.

Clinical Pearl 32.1

Elbow flexion, although a simple movement, is surprisingly difficult to restore and it is common for patients to require more than one procedure to achieve adequate power and range of movement.

Active elbow flexion is not the only goal in a C5–C6 palsy, and unless lateral (external) rotation is also restored the value of a flexing elbow is dissipated.

Some degree of elbow flexion contracture is desirable when restoring active flexion, since it enhances the initiation of flexion. This is an incidental beneficial side product of the Steindler flexorplasty.

Specific circumstances of lost elbow flexion and methods of treatment

Acute denervation

Because two nerves supply the three muscles responsible for elbow flexion, complete neurogenic loss of flexion is only usually associated with injuries to the upper trunk of the brachial plexus especially proximal to Erb’s point at the C5–C6 level. Isolated paralysis of the anterior compartment of the arm may result from an injury to the musculocutaneous nerve distally either through traction or more commonly as a result of a penetrating injury including iatrogenic causes. As with any acute denervation of the muscle the underlying principle is early restoration of nerve continuity. Where there has been a penetrating wound the diagnosis is obvious and exploration is mandatory wherever possible. Problems most commonly arise in the closed injury where the temptation is to ‘wait and see’. A full discussion of the indications for brachial plexus surgery is not appropriate here but we make some observations. The principle of ‘wait and see’ rests on the concept that a neurapraxia may be responsible for loss of nerve function and that this may be fully recoverable. Furthermore, some will argue, that even if the injury is a Sunderland Grade II or III8,9 surgical exploration would reveal a nerve in continuity and that given that the prognosis is uncertain, resection and grafting would not be appropriate. This is all well and good, but against this must be considered the fact that loss of nerve continuity even at the axonal level results in distal end-organ decay and proximal central cell death, and that these consequences are inversely related to the period since injury. For these reasons some surgeons set an arbitrary time of 3 months to assess if recovery is occurring. This would be appropriate particularly if one is able to monitor the progression of a Hoffman–Tinel phenomenon or there is strong circumstantial evidence (from history of low kinetic energy transfer or evidence from scans of thecal integrity) that a neurapraxia is likely. Recovery from a true neurapraxia is not sequential from proximal to distal but is sudden and anatomically more random as the functional conduction blocks recover.

In addition to the necessary investigations of electromyography (which can be useful in identifying neurapraxia) and nerve conduction studies10 (which are less useful because of the difficulty in achieving compound nerve axon potentials or sensory nerve axon potentials in the deeply placed musculocutaneous nerve), in the absence of scan evidence of avulsion, exploration of the upper trunk in the acute phase after injury in experienced hands can be invaluable. If the brachial plexus is explored within a week of injury the nature, extent and severity of the damage are immediately apparent. In the rare case that a lesion in continuity is so innocuous as to leave doubt about resection and repair, nothing is lost after a simple exploration and one can revert to a ‘wait and see’ policy. However in the vast majority of cases we have explored in such circumstances, the indication for treatment has been unequivocally apparent.11 This principle of open exploration at an early stage (especially in the first week before fibrosis clouds the picture) has guided us over 20 years in the management of upper trunk injuries and infraclavicular injuries to the brachial plexus. The only exception to this in adults has been the prolonged crush injury resulting from dislocation of the shoulder and delayed relocation where early exploration is unlikely to yield useful information since traction and disruption is not the cause of injury and the consequences of localized compression can be difficult to conclude from direct inspection.

The circumstances of Narakas12–14 type I and type II obstetric brachial palsies are similarly specific and the restoration of elbow flexion in these children by primary nerve grafting is the subject of considerable debate and at present there is no universally accepted protocol. The senior author’s own practice is to follow the multiple movement scale as developed in Toronto.15 At 12 weeks, if there is a low score then exploration should be undertaken. At this time the parents are told that the first part of the procedure will be simple exploration of the upper trunk or even the whole brachial plexus and that we will only proceed to surgical repair where the appearance indicates a very low probability of spontaneous or substantial recovery. This judgement requires experience.

Summary Box 32.1

Acute denervation of the muscles of elbow flexion is best treated by early restoration, with nerve grafting (usually employing the sural nerve), as the most appropriate method. Controversy, however, still exists in relation to the indications for exploration and the timings.

In some cases of adult brachial plexus injury (and some cases of congenital brachial plexus injury) C5 and C6 roots are avulsed16–19 and no orthotopic restoration is possible. Here in the acute circumstance nerve transfers must be employed. The principle of a nerve transfer is that an undamaged distal nerve stump which is connected to the muscle in the normal way may be reanimated by neurosynthesis with a competent centrally connected proximal stump of a nerve that was serving another purpose. Clearly, as with tendon transfers, the donor nerve (that is the proximally connected one) must have a function that can be spared. Much has been written on this subject since Sir Herbert Seddon20–22 first described this procedure using intercostal nerves, although the indications in elbow flexion are now quite clear. As stated previously in the case of paralysis of the shoulder and elbow a clear decision must be made about the management of the shoulder whether by nerve transfers (such as the accessory nerve to the suprascapular nerve or the radial nerve to the axillary nerve) or by arthrodesis, at the same time that a management plan is made for the elbow. A number of nerve transfers have been advocated for the elbow and the author’s preferences are given below.

Oberlin transfer

In 1994, Dr Christophe Oberlin23 described the transfer of fascicles of the ulnar nerve to the nerve supplying biceps brachialis. The theory was that fascicles of the ulnar nerve in the upper arm could be isolated using a neuro-stimulator in the case of the C5–C6 injury (where the hand remained competent) and that these fibres which originate from C8 or T1 could be transferred to the nerve to biceps brachialis and so reinnervate that muscle (Fig. 32.1). This is indeed the case and this is a most effective transfer. We would, however, make a number of observations. First, we are sceptical that fascicles to individual hypothenar muscles can be isolated in the mid-proximal arm. This does not detract from the value of the transfer but can be confusing for surgeons newly undertaking this procedure. Second, the median or the ulnar nerve can be used for this transfer and it is likely that the radial nerve can also be used under certain circumstances. The appeal of this transfer lies in the fact that the neurosynthesis is conducted close to the hilum of the muscle and reinnervation is prompt, mitigating the effects of distal target organ decay. This is our preferred nerve transfer in the arms of adults where orthotopic nerve repair is not possible and a good hand exists. We have never found a significant donor defect in the hand.

image

Figure 32.1 (A,B) The Oberlin transfer. Here the nerves of the arm are exposed and this operative microscope view shows the fascicle of ulnar nerve isolated (lower left (A) ) and repaired to the nerve to biceps (upper right (A) ) to reinnervate that muscle. (B) shows the final neurosynthesis reinforced with fibrin glue.

Intercostal nerve transfer

Sir Herbert Seddon made the discovery that intercostal nerves which are both sensory and motor could be transferred onto nerves in the arm with resultant function. This technique subsequently fell into some disrepute, although it has been resurrected in the past 20 years and we have found it extremely valuable in certain cases. The protocol for such transfers was well described by Chuang24,25 and our practice described here is based upon his work.

Once the musculocutaneous nerve in which orthotoptic repair is not possible has been isolated, its distal stump is prepared as far as possible by dissecting the nerve into the apex of the axilla to the retroclavicular portion where it forms the terminal branch of the upper trunk as the lateral head of the median nerve separates from it. Transected at that point, the distal stump of the musculocutaneous nerve can then be delivered into the axilla. Some surgeons have advocated skeletonizing that nerve into its sensory and motor component to avoid pushing motor fibres distally into the sensory territory after neurosynthesis. Dr Julia Terzis has proposed an alternative and ingenious solution which is to connect the lateral cutaneous nerve of the forearm (the terminal branch of the musculocutaneous nerve) to the nerve to brachioradialis making use of such misdirected fibres to reanimate another elbow flexor.7,26 This technique has the advantage that it does not damage the musculocutaneous nerve further.

The intercostal nerves are then harvested and we prefer to harvest nerves III, IV and V which must be exposed to the midclavicular line. The technique of nerve harvest is complex but every effort must be made to preserve the function of the motor nerves (which can be identified with neurostimulation). They can be separated from the sensory branches which emerge in the mid-lateral line (and which may be used for sensory reanimation of the hand in a severe brachial plexus palsy). These three intercostal nerves are then very carefully co-apted to the musculocutaneous nerve without tension. This not only requires some architectural ingenuity but also that the nerves be delivered to the midaxillary line in the intercostal spaces. It is not necessary to resect ribs either in the adult or child; nor is it necessary to breach the pleura. Bleeding should be anticipated and controlled where possible with vasopressor drugs such as adrenaline rather than by cautery until the nerves have been delivered, as these very fragile nerves can be easily damaged.

This neurosynthesis takes place in the axilla and on-table manipulation of the arm will show how vulnerable this suture line is to shoulder position. At least one of our cases has almost certainly suffered from disruption of the neurosynthesis by a well-meaning attendant abducting the arm for wound care. We now prevent this by suturing the arm to the chest wall for 3 weeks. Recovery from this nerve transfer can be monitored in adults and older children by the ‘squeeze test’ in which squeezing of the biceps brachialis produces pain in the chest wall.

As with Chuang’s regimen, when the squeeze test becomes positive we institute a regimen of heavy physical activity to the point of breathlessness several times a day. The belief is that this has a trophic effect upon the muscle that has decayed and while there is no laboratory evidence for this, the results have been impressive clinically. In the successful case the patient gradually learns to separate the movement of breathing and isolate the function of those nerves supplying the musculocutaneous territories. In time excellent restoration of elbow flexion may result. This is especially the case in children who (as with so many rehabilitation functions) recover, redirect and strengthen this movement without coaching.

This nerve transfer is useful in adults but exceptionally valuable in children. In adults we have found that elbow flexion is relatively slow and difficult to sustain. However patients should be able to lift 1 kg. There is no doubt, however, that the movement quickly tires and in some patients is weakened by activities such as talking or drinking while flexing the elbow. We have not observed this limitation in children. This transfer is particularly useful in combination with free functioning muscle transfers again especially so in the younger patient.

Other nerve transfers

Other nerves18,27–35 have also been used to reanimate the musculocutaneous nerve or nerve to biceps brachialis. These included the phrenic nerve which (on the right side easily, and on the left side with some more difficulty) may be harvested endoscopically. This nerve should not be used in small children and certainly never below the age of 3 years, as significant and on occasion fatal respiratory difficulties may ensue. We have been reluctant to use the phrenic nerve generally because of the effect on respiration but where other nerves are not available it has been effective and the adult patient has rarely suffered an identifiable deficit. The phrenic nerve may be used at the same time as three intercostal nerves although a respiratory deficit is more likely.

The spinal accessory nerve can also be used. If the shoulder has been arthrodesed the distal spinal accessory nerve may be spared to reanimate the elbow, although this usually requires an interpositional nerve graft with consequent loss of axonal material at each neurosynthesis. Lastly the cross neck C7 nerve transfer has achieved remarkable popularity since first described by Gu36–38 in China in the early 1990s. The senior author was hesitant to undertake nerve transfers from the undamaged opposite C7 root but after examining the cases of other surgeons, began to undertake this transfer a number of years ago.

In our experience, there has been little if any donor defect. We have, however, subsequently abandoned this nerve transfer as in our hands it has resulted in little functional benefit. Almost all reports of function following this nerve transfer are really reports of muscle activity. This has been demonstrated by several authors.29,39,40 The concern here, however, is that none of our patients (who range from the age of 1 year at the time of transfer to mid-forties) have managed to separate the recovered muscle function from activity of the contralateral limb. It has therefore been a transfer that has clearly resulted in muscle activity, although this activity has in our patients never been translated into day-to-day function or integrated into the activity of the patient. This is in stark contrast to the utility of ipsilateral transfers.

Chronic denervation

There is some debate about what constitutes chronic denervation and from what time after nerve injury orthotopic repair is unlikely to succeed.11,41–45 We have no doubt that 1 year after injury in an adult, motor reinnervation is so unlikely to succeed as to be rarely worth attempting. The difficulty exists between 6 months and a year where some authors will enthusiastically undertake orthotopic or heterotopic repair while others will look to muscle transfers. The commonest circumstance in which this arises is either a patient whose care has been delayed for other reasons (usually other trauma) or the patient in whom repair of the brachial plexus has failed to result in recovery of function. In all cases of chronic denervation where orthotopic or heterotopic repair is inappropriate the afflicted muscle must be replaced or substituted. This can be done conventionally by tendon transfers or less conventionally by free functioning microvascular muscle transplantation.

Tendon transfers

In restoring elbow flexion the normal rules of tendon transfer apply. In particular the donor muscle must be expendable, the transfer must restore a single function operating in a straight line without pulleys and must be of adequate strength and excursion to undertake the activity required. In practice there are few muscle transfers that meet this requirement and in this section we will consider transfer of the pectoralis major, latissimus dorsi and the Steindler transfer of the flexor pronator origin. We will not consider unusual or esoteric transfers such as the sternomastoid prolonged with facia lata, or the pectoralis minor

Pectoralis major

The pectoralis major is a large bulky muscle on the anterior chest wall supplied by the pectoral nerve with root values of C5–T1. It is thus still functioning in many cases where elbow flexion has been lost and can be a very useful transfer. It is, however, a cosmetically important muscle, not only in women, and its deployment for this secondary purpose must be carefully discussed.

There are two main ways of transferring the pectoralis major. Its beautifully vorticeal tendon may be detached from the humerus and elongated distally to be inserted directly into the biceps brachii tendon. This unipolar transfer was first described in 1917.46 It does, however, produce a web across the anterior axillary fold and results in adduction of the humerus at the same time as flexion of the elbow.

The alternative is the Clark47–49 transfer in which the origin of pectoralis major is detached from the lower ribs together with part of the anterior rectus sheath. The muscle can then be isolated by carefully dissecting proximally from the origin preserving the neurovascular pedicle on the under surface and isolating the muscle on that pedicle which is largely innervated by the lateral pectoral nerve. The fibres of the anterior rectus sheath are then used for the repair at the level of the biceps brachialis. A more contemporary modification sees the tendon of pectoralis major also detached and relocated either to the anterior clavicle laterally or more commonly to the coracoid process50,51 (Fig. 32.2). This transfer is very effective in children and can also be very useful in adults. In children the muscle can be harvested through both a short transverse upper abdominal and axillary incisions. So distensible is the skin of the child and so short the distances that the dissection can proceed satisfactorily through these two incisions. In the adult more extensive incisions are needed over the free border of the pectoralis major. These can be just as disfiguring as the loss of the muscle.

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Figure 32.2 (A) In this child with arthrogryposis the pectoralis muscle will be transferred for elbow flexion using a bipolar method. The caudal origin of the muscle is raised through a transverse incision and includes fascia or rectus abdominis. The pectoral nerve and vessels can be identified on the deep surface as dissection proceeds cephalad. (B) The pectoralis muscle has been raised as a bipolar unit including some of the rectus abdominis fascia in its caudal extent. At this point the insertion is detached taking care not to damage the pectoral nerve and vascular supply. (C,D) The muscle has been islanded on its neurovascular pedicle and delivered to the arm. Note the insertion is reattached to the coracoid process, and the origin to the ulna (or biceps tendon if one exists) after tubing the muscle.

Latissimus dorsi25,52–56

In the C5–C6 lesion latissimus dorsi is weakened but not paralysed. It can therefore be used as a transfer to restore elbow flexion, although extreme caution should be exercised in the planning as it can also be a very valuable transfer for external rotation of the shoulder. The loss of this option must be weighed carefully against the benefits to the elbow. Indeed it is worth noting that in common with the pectoralis major transfer, this transfer demands a stable shoulder.

Latissimus dorsi is a huge muscle arising over a wide area of the back and flank and inserting into the medial aspect of the bicipital groove. One of its attractive features is that it can be simply but elegantly pedicled on the thoracodorsal artery, which is highly mobile and has an arc of reach that includes the anterior arm. The difficulty with this transfer is the fact that there is no tendon of origin proximally and that it contains fibres of unequal length. It can be difficult therefore to secure it distally.

The authors have modified their technique in this respect and undertaken a bipolar transfer with the muscle inverted so that the tendon of insertion of latissimus dorsi passes to the tendon of the biceps brachii muscle. The wide origin of the muscle is then re-draped around the lateral third of the clavicle and the shoulder including the spine of the scapula. This has the benefit of adding bulk to the shoulder as well as securing a very diffuse origin and allowing the fibres of latissimus dorsi full rein. The disadvantage of this method is that the scarring to access that amount of the shoulder girdle is considerable. Nonetheless we prefer this inverted bipolar technique for both cosmetic and functional reasons.

Like all of the transfers described the muscle should be carefully tensioned. In practice, we put the muscle in tightly with the elbow flexed beyond 90°. Because this muscle is immediately active, the elbow should be maintained in a flexed position for at least 4 weeks and preferably 6 weeks in the adult. Gentle rehabilitation in a hydrotherapy pool should then begin allowing movement without excessive strain. No strain should be placed upon the weak point of this transfer (the sutured origin of latissimus dorsi muscle) for at least 12 weeks. If these conditions are followed this can be a very effective transfer and where the latissimus dorsi muscle is available and not required for shoulder function this is our preferred transfer for chronic denervation of the elbow.

Steindler flexoplasty57

In some patients with denervation of the three prime flexors of the elbow, it can be observed that flexion is nonetheless achieved by clenching the fist, extending the wrist and allowing those fibres of the common flexor origin that pass anterior to the axis of the elbow joint to contract and flex the elbow. This is the so called Steindler effect, and Steindler’s contribution was to observe that this could be enhanced by moving the common flexor origin proximally so increasing the lever arm of these muscles at the elbow joint. In practice this can be a useful transfer.58–62

It is most important to recognize, however, that before this transfer is undertaken the wrist must either be arthrodesed or have strong extension in order that when the common flexor mass is activated the elbow rather than the wrist flexes. If these conditions are met the transfer can be undertaken by separating the common flexor mass together with the medial epicondyle taking great care to conserve the medial collateral ligament of the elbow joint and the ulnar nerve. This complex is then moved proximally on the arm to a new position on the roughened surface of the humerus, the bone being fixed by a lag screw. Some advocate placing the new origin anteriorly believing that leaving it medially adds to a tendency to pronation of the forearm. Commonly it moves 8–10 cm proximally. The limb is then splinted in flexion until the osteosynthesis is secure.

One of the pleasing things about this transfer is that no re-education is necessary. Furthermore the transfer invariably produces a flexion contracture at the elbow which facilitates the initiation of elbow flexion. The disappointing thing about this transfer in our hands has been that while it does result in good and quite powerful elbow flexion to well beyond 90°, this flexion requires clenching of the fist in most patients and thus the moment the object held in the hand is released the elbow flexion is lost. This can be circumvented by transferring only the wrist flexors,60–62 although this is a much more difficult and less certain undertaking. In practice we have used the Steindler flexorplasty to augment the initiation of elbow flexion or to strengthen other flexion transfers in the manner alluded to at the beginning of this chapter where more than one solution may be required to restore competent flexion.

Clinical Pearl 32.2

Either latissimus dorsi or pectoralis major may be used to restore elbow flexion. Each is better designed as a bipolar transfer, and the latissimus dorsi may be better inverted. However, latissimus dorsi should not be squandered as it might better be used for restoring lateral rotation at the shoulder. Pectoralis major leaves a significant cosmetic defect.

In arthrogryposis the pectoralis major transfer is effective at restoring active elbow flexion, but does remove useful humeral adductor muscle. A free functioning muscle transfer is, however, possible innervated on intercostal nerve transfers. This imports new neuromotor capacity to the limb.

Free functioning muscle transfer

With the advent of microvascular surgery the ability to transfer whole functioning muscular units has changed the way we have managed reanimation of the elbow. In cases of chronic denervation or muscular absence it is now possible to place a functional vascularized muscular unit into the flexor compartment of the upper arm and reinnervate that in a heterotopic manner. Where trauma has destroyed the muscle, and a free functioning muscle transfer replaces it, the reinnervation can be orthotopic.

A number of muscles have been recommended for this purpose including the rectus abdominus, the latissimus dorsi, the rectus femoris, the gastrocnemius and the gracilis muscle.63–67 We have experience with the gracilis muscle in over 60 cases and feel we can speak about this with most authority. The other muscle transfers can be examined on their merits in the published literature, although we will make brief comments about them here. The gastrocnemius muscle is appealing because of its bulk and the fact that its activity is to a considerable degree supplanted by soleus. However, it is a disfiguring donor site, and even if only one belly of the transfer is taken the damage to the calf is clear and permanent. It has the attraction of a clearly defined neurovascular pedicle and it certainly deserves consideration as a transfer, although the excursion of this muscle is not great.

The rectus femoris muscle can be harvested with relatively little donor morbidity and the anterior thigh scar is surprisingly good. We have every reason to believe that this is a valuable muscle for transfer but have experience with only one case in which it was difficult to match the length of the transfer to the shorter length of the upper arm. Like the gracilis muscle it has an excellent excursion, but has greater cross-sectional area (and so can develop greater force) and greater volume (so greater power and work capacity) than gracilis. The mismatch in length remains a problem, as does the donor site.68–70

The latissimus dorsi muscle from the contralateral side is a satisfactory transfer in some patients, although the neurovascular pedicle comes to lie distally and must be reanimated by nerve transfers in the region of the elbow itself.

The rectus abdominis muscle has been harvested and used for this purpose partly because it is familiar to plastic surgeons who use the myocutaneous flap based upon it for breast reconstruction. It is a segmentally innervated muscle with less excursion than its competitors. Furthermore harvesting the whole width of the rectus abdominis muscle is a substantial undertaking, weakening the abdominal wall. This contrasts to its use in breast reconstruction where part of the longitudinal muscle fibres are preserved. We do not anticipate employing this muscle in the arm.

Gracilis muscle

Our preferred elbow flexor is the gracilis muscle. This muscle of the medial thigh is ideal in so many ways. It is redundant, of reasonable cross-sectional area, of good length and excursion and has a fibrous tendon at either end. Furthermore it has a proximally located reliable neurovascular pedicle with a long nerve (the obturator nerve) to facilitate positioning the neurosynthesis (Figs 32.3, 32.4).

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Figure 32.3 The gracilis muscle. Note the fibrous origin and long tendon, the consistent neurovascular hilum and the length (and so excursion) of the muscle.

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Figure 32.4 Harvest and insetting a free functioning gracilis muscle. (A) The muscle is found posterior to a line joining the pubic tubercle to the medial tibial plateau. (B,C) The identity of the muscle is confirmed by the fact that it lengthens and shortens on knee movement, and has a pedicle found one-third of the length of the thigh below the pubic tubercle. The nerve enters it obliquely to join the transverse vascular pedicle. (D) The muscle is completely islanded on its vascular pedicle prior to transfer. (E) The muscle has been transferred, its origin attached to the coracoid with bone anchors, and its tendon will be woven into that of biceps, in this case of obstetric brachial palsy, prior to revascularization on the brachial vessels and reinnervation with an Oberlin transfer.

The muscle is easily harvested from the anterior thigh through a short incision located over the proximal third of the muscle. We will not describe the technique here save to mention a few useful tips. It is very easy for the novice surgeon to mistake the adductor for the gracilis. Although the gracilis is characteristic in having a transverse vascular pedicle which is joined by an oblique nerve and most importantly is the only muscle on the medial thigh that stretches and relaxes with extension and flexion of the knee. The tendon of gracilis may be safely harvested through a stab incision if the muscle is first tensioned by the assistant and the tendon seen to be bow-stringing at the knee.

We have found the gracilis muscle to be an extremely useful replacement for an absent or chronically denervated elbow flexor mass.71 Everything, however, depends upon successful revascularization, which is easily achieved on the brachial vessels, and successful reinnervation, which is facilitated by the long motor nerve, all of whose fibres end within the muscle. We have most commonly reanimated this on an Oberlin transfer or intercostal nerve transfers (the Oberlin being preferred in adults, the intercostal nerves in children). We have attached the proximal tendinous origin of the gracilis to the coracoid process and woven the distal tendon skeletonized of its adventitial tissues into the biceps muscle and its tendon. In cases where the elbow flexors are absent this tendon of gracilis may be passed through a drill hole in the ulnar and secured on the dorsal surface. In this respect it is worth noting that for any elbow transfer orthotopic repair to the biceps tendon may not be possible. A more distal placement may be the only option. This does have the benefit of producing a flexion contracture of the elbow and facilitating the lever arm of the transfer.

We have reviewed our results of free functioning muscle transfer to the elbow and found that transfers of the gracilis muscle in children, whether on intercostal or Oberlin transfers, are almost universally successful in providing powerful activity and adequate reanimation (Fig. 32.5). As with all transfers, however, they have been less successful in adults, although our improvement rate has been at least as good as and usually better than for pedicled transfers. This transfer has the disadvantage of requiring microsurgical familiarity and should only be conducted in a unit undertaking regular microvascular transfers with a high success rate. However, it is worth noting that should this transfer fail it can simply be repeated using the contralateral gracilis with no significant functional cost to the lower limbs. It is thus rare among free muscle transfers as being totally expendable.

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Figure 32.5 This child presented with a neglected obstetrical palsy. She had no elbow flexion and a free functioning gracilis transfer reinnervated on the intercostal nerves was performed. Note the relatively conservative scarring on the chest wall (A) and hypertrophic scarring on the medial arm (B). At 18 months after transfer she had powerful elbow flexion and extension (C,D), which continued to improve and in her late result flexing with 1 kg, the string of contracting gracilis can be appreciated (E,F)

It has not been our normal practice after the first few cases to undertake a monitoring paddle to monitor the blood supply. This is, however, possible as overlying skin is supplied by the vascular pedicle to the muscle. It does, however, require a further operation to remove this paddle unless the patient is prepared to live with the adverse appearance of this ectopic skin.

The free functioning muscle transfer in chronic denervation of the limb and in some congenital conditions (see below) has tremendous potential advantages. It is cosmetically discrete when compared with either latissimus dorsi or the pectoralis major transfer, and can be undertaken through an axillary incision extended onto the medial upper arm with an additional short incision over the antecubital fossa. Most importantly from a conceptual point of view it also allows the introduction of new nerve tissue into the arm when it is used in conjunction with an intercostal nerve transfer. This is important in brachial plexus injury whether in adult or childhood where neural resources in the arm are scarce. This is especially valuable in conditions where there are few functioning motor units.

Clinical Pearl 32.3

The free gracilis muscle is ideally suited as a flexor of the elbow, commonly reinnervated either from the intercostal nerves (especially in children) or a fascicle of the ulnar nerve (in children or adults).

Muscle absent through trauma

Where muscle has been destroyed by trauma, collateral damage is common. Before any muscle is replaced the indications must be clear. Simple loss of the biceps brachialis muscle in the presence of a functioning brachioradialis may require no treatment and it is only when the collateral damage is such that all elbow flexion is lost that restoration of elbow flexion becomes a priority. As stated previously attention must be given to the passive range of motion of the joint. In addition the condition of the soft tissues overlying where the muscle is to be replaced must be addressed. Pliable healthy skin cover is essential and again this may require microvascular free tissue transfer. In some cases it may be tempting to undertake the transfer of a muscle with a healthy overlying skin paddle to replace the scarred or fibrotic skin. This should be undertaken with caution since even in the most experienced hands this expediency can prove unsatisfactory. It is a principle of reconstructive surgery that just as when a tendon is asked to do two tasks, so when a transfer of composite tissue whether free flap or pedicled is asked to perform two functions, one of them is usually less successful. Whilst we acknowledge that positioning the skin paddle satisfactorily in relation to the muscle can be achieved, we prefer to undertake these as staged procedures, restoring the skin and the passive range of motion before undertaking either tendon transfer or free functioning muscle transfer.

The muscle transfer is much along the lines delineated already for chronic denervation. The only additional point we would make is that in the presence of collateral damage from trauma microvascular surgery may be more difficult. Furthermore the temptation to use the donor orthotopic nerve that originally supplied the flexor compartment of the arm (i.e. the musculocutaneous nerve) should be resisted. The two reasons are that the musculocutaneous nerve is a mixed nerve as its name implies, and when co-apted to a purely motor nerve, sensory–motor mismatch may occur. Furthermore it is likely that reconstruction will be undertaken some time after injury and it should be remembered that after 3 months, central decay and central cell death is very common and certainly by a year it is questionable whether any recovery is possible. Of course the residual stump of musculocutaneous nerve may still have some muscle attached allowing stimulation and reliable identification of the motor component. If this is the case and the procedure is undertaken early, it can be an ideal donor nerve.

Absent muscle of congenital origin

A number of congenital conditions can result in absent elbow flexion. These include arthrogryposis, radial dysplasia, and other rare syndromes. In severe arthrogryposis the elbow is commonly held in extension and may only have limited passive flexion. In addition the shoulder lacks abduction and may lack external rotation. Movement in the hand will also be limited.

In radial dysplasia (Fig. 32.6) it is most commonly the wrist, the hand and the elbow that are affected and in this condition it is imperative that before consideration is given to correcting the wrist deformity an evaluation of the elbow is undertaken. In the absence of elbow flexion, correction of the wrist may disadvantage the child significantly.

image

Figure 32.6 (A) This child with severe radial dysplasia has a passive renage of flexion and extension at the elbow but no active movement as may be inferred from the absence of flexion creases. (B) The arm is prepared for a functioning free gracilis transfer which will be revascularized on the brachial vessels and reinnervated on the intercostal nerves. (C) The gracilis transfer is completed and the revascularization can be seen proximally. (D) The final appearance at the end of surgery. The chest wound is from harvest and transfer of the intercostal nerves 3, 4 and 5.

In cases of congenital absence, the restoration of muscle follows much the same options as those with chronic denervation and absence through trauma. However, the principle that underpins our practice is to try to bring new neuronal material into the arm, which in practice usually involves transfers onto the intercostal nerves. We choose these nerves because the spinal accessory nerve is already serving useful function and the phrenic nerve is not available in small children. We do not employ the cross-neck nerve transfer for the reasons given earlier.

If the intercostal nerves are to be used they require a free muscle transfer and indeed in arthrogryposis they may be the only available transfer. This, however, obviously requires that gracilis is present. As such prior to surgery an magnetic resonance (MR) image of the thighs is undertaken. An alternative that we have found very effective and should be considered is the pectoralis major as a bipolar transfer. This may have a disfiguring effect on the child, but can be a very effective transfer. In our unit, current practice is to use a free functioning muscle transfer leaving the potentially disfiguring pectoralis major transfer as a reserve. Obviously this requires that gracilis muscle is present and an MR image of the thigh prior to surgery should be undertaken.

In arthrogryposis prior to flexion transfer, a posterior release of the elbow may be necessary, followed by a course of physiotherapy to achieve 90° or more of flexion. This restored passive range should be stable before any transfer is undertaken.

Conclusion

This overview of restoration of elbow flexion in the paralysed elbow has focused on the commonest problems, and the optimal solutions. In practice, upper limb surgery presents many varied challenges and unusual or surprising circumstances requiring bespoke solutions are sometimes encountered. Each of the techniques used may be combined with another technique to produce the best elbow flexion. The consequences to be considered are many and it is important that any elbow flexion surgery is part of a considered and well-constructed plan that is formed before any surgery begins.

We have not considered reanimation of forearm rotation and nor have we considered reanimation of elbow extension. Forearm rotation has not been considered because it is truly a function of the radioulnar joints requiring a very different set of indications and considerations. The restoration of elbow extension is rarely necessary outside the field of spinal injury, which is itself so specialized as to form a whole different topic. On one occasion we have undertaken free muscle transfers to restore isolated absent function of triceps in a child with obstetric palsy and in another instance in a child with mononeuritis of the radial nerve. Otherwise, in a practice of over 20 years treating a large number of brachial plexus patients, we have rarely had to restore this function.

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