Trapezius Muscle Transfer for Restoration of Elbow Extension in a Traumatic Brachial Plexus Injury

Arm reconstruction

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.

Lower Trapezius Muscle Transfer for Elbow Extension Reconstruction After Failed Nerve Transfer for Tetraplegia

Reconstruction of elbow extension is a first priority in the surgical management of patients with tetraplegia. Traditionally, posterior deltoid and biceps to triceps muscle transfers were used, but in recent years, nerve transfers have become the preferred choice of a few surgeons. However, nerve transfer reconstruction failures exist, often related to poor donor nerves, prolonged intervals between the injury and surgery, and advanced patient age. As a valid surgical alternative in such cases, we propose transferring the lower trapezius muscle to reconstruct elbow extension, because this procedure is already being performed successfully in patients with brachial plexus injury. We report 2 patients in whom a lower trapezius transfer was employed as a successful salvage procedure after failed nerve transfer surgery.

Comparative Study of Intercostal Nerve and Contralateral C7 Nerve Transfers for Elbow Extension After Global Brachial Plexus Avulsion

INTRODUCTION

Elbow extensive reconstruction was essential for the patients with brachial plexus avulsion. Nerve transfer was applied to repair elbow extension, but the ultimate recovery was quite different. The purpose of this study was to compare the effects of elbow extension in patients with global brachial plexus avulsion after repaired by intercostal nerve (ICN) and contralateral cervical 7 (cC7) nerve transfer to the long head branch of triceps and to analyze the possible influencing factors.

MATERIALS AND METHODS

A retrospective review of 24 patients treated with ICN and cC7 nerve transfer for elbow extension in posttraumatic global brachial plexus avulsion was carried out. Two ICNs were used as donors in 17 patients, and cC7 nerve was used in the other 7 patients. We evaluated the recovery of elbow extension by the British Medical Research Council grading system and electromyography. The correlation between age, preoperative interval, and prognosis was analyzed in this study.

RESULTS

Efficiency of elbow extensor strength in the ICN transfer group was 47.06%, and it was 28.57% in the cC7 nerve transfer group, but there was no significant difference (P = 0.653). The effective recovery of electromyography in ICN transfer group was 82.35%, whereas in the group cC7 nerve transfer, it was 28.57%, there was a statistical difference between the 2 groups (P = 0.021). Age and interval were negatively correlated with prognosis.

CONCLUSIONS

Intercostal nerve or cC7 nerve transfer to the long head branch of triceps could reconstruct elbow extension to some extent. Compared with cC7 nerve transfer, ICN transfer had a greater result for elbow extension, but the difference in extension power was not significant, whereas there was difference in electromyography recovery. Patient's age and interval were negatively correlated with the results.