Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type^[*]

Abstract

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.

^*This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

• References

• 1 Steindler A. A Muscle Plasty for the Relief of Flail Elbow in Infantile Paralysis. Interstate Med J 1918; 25: 235-241
• 2 Alnot JY, Abols Y. Réanimation de la flexion du coudepar transferts tendineux dans les paralysies du plexus brachial de l’adulte. Rev Chir Orthop 1984; 70: 313-323 6236496
• 3 Mayer L, Green W. Experiences with the Steindler Flexorplasty at-the Elbow. J Bone Joint Surg (Am) 1954; 36-A: 775-789 13174607
• 4 Kettelkamp DB, Larson CB. Evaluation of the Steindler flexorplasty. J Bone Joint Surg (Am) 1963; 45-A: 513-8 14042147
• 5 Carroll RE. Restoration of flexor power to flail elbow by transplantation of triceps tendon. Surg Gynecol Obstet 1952; 95: 685-8 13005342
• 6 Carroll RE, Gartland JJ. Flexorplasty of the elbow: an evaluation of a method. J Bone Joint Surg (Am) 1953; 35-A: 706-l0 13069560
• 7 Carrol RE, Hill NA. Triceps transfer to restore elbow flexion: a study of fifteen patients with paralytic lesions and arthrogryposis. J Bone Joint Surg (Am) 1970; 52 (2) 239-244 5440001
• 8 Carroll RE, Klelnman WB. Pectoralis major transplantation to restore elbow flexion to the paralytic limb. J Hand Surg (Am) 1979; 4 (6) 501-507 512308
• 9 Clark JMP. Reconstruction of biceps brachii by pectoral muscle transplantation. Br J Surg 1946; 34: 180-l 10.1002/bjs.18003413408
• 10 Tsai TM, Kalisman M, Burns J, Klelnert HE. Restoration of elbow flexion by pectoralis major and pectoralis minor transfer. J Hand Surg (Am) 1983; 8 (2) 186-190 6833728
• 11 Hovnanian P. Latissimus dorsi transplantation for loss of flexion or extension at the elbow: a preliminary report on technic. Ann Surg 1956; 243: 493-9
• 12 Zancolli E, Mitre H. Latissimus dorsi transfer to restore elbow flexion: an appraisal of eight cases. J Bone Joint Surg (Am) 1973; 55 (2) 1265-1275 4758039
• 13 Moneim MS, Omer GE. Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption. J Hand Surg (Am) 1986; l1 (01) 135-139
• 14 Ahmad L. Restoration of elbow flexion by a new operative technique. Clin Orthop 1975; 106: 186 10.1097/00003086-197501000-00028 1126074
• 15 Bunnell S. Restoring flexion to the paralytic elbow. J Bone Joint Surg (Am) 1951; 33-A: 566-7 14850494
• 16 Doi K, Sakai K, Kuwata N, Ihara K, Kawai Sh. Reconstruction of finger and elbow function after complete avulsion of the brachial plexus. J Hand Surg (Am) 1991; l6 (05) 796-803
• 17 Alnot Jy. Elbow flexion palsy after traumatic lesions of the brachial plexus in adults. Hand Clinics 1989; 5: 15-22 2656725
• 18 Segal A, Seddon HJ, Brooks DM. Treatment of paralysis of the flexors of the elbow. J Bone Joint Surg (Br) 1959; 41-B: 44 13620705
• 19 Chen WS. Restoration of elbow flexion by modified Steindler flexorplasty. International Orthopaedics 2000; 24: 43-46 10.1007/s002640050011 10774862
• 20 Brunelli GA, Vigasiol A, Brunelli GR. Modified Steindler procedure for elbow flexion restoration. J Hand Surg (Am) 1995; l6-A: 743-746 10.1016/S0363-5023(05)80424-1
• 21 Brunelli GA, Brunelli GR. A fourth type of brachial plexus lesion: The intermediate (C7) palsy. J Hand Surg (Br) 1991; 16-B: 492-495 10.1016/0266-7681(91)90101-S
• 22 Saul KR, Murray WM, Hentz VR, Delp SL. Biomechanics of the Steindler Flexorplasty Surgery: A Computer Simulation Study. J Hand Surg (Am) 2003; 28-A: 979-986 10.1016/S0363-5023(03)00484-2