Effect of the Steindler procedure on the median nerve branches to the medial epicondylar muscles

The sub pronator approach to the coronoid process

INTRODUCTION

The aim of our study was to describe a new anteromedial approach that allows exposure of the anteromedial facet of the coronoid process and to characterize the position of the median nerve's motor branches relative to this approach in relation to elbow positioning.

MATERIAL AND METHODS

We performed 16 anteromedial approaches on fresh anatomical specimens. The minimum distance between the medial edge of the trochlea and the second branch of the median nerve was measured in three elbow positions: forearm in supination with the elbow extended, forearm in pronation with the elbow extended, and forearm in supination with the elbow flexed at 90 °. The distance between the joint space and the origin of the first two motor branches of the median nerve was then measured with the elbow extended.

RESULTS

The mean distance between the second motor branch of the median nerve and the medial edge of the trochlea was 13 mm ± 3 mm with the elbow extended and forearm supinated; 5 mm ± 3 mm with the elbow extended and forearm pronated; and 11 mm ± 4 mm with the elbow flexed at 90 ° and forearm supinated. There was a significant difference in distance between the measurement in the pronated position and the two measurements in the supinated positions. However, there was no significant difference between the measurement with the elbow flexed in supination and the elbow extended in supination (p < 0.06).

CONCLUSION

The subpronator approach is a reproducible and reliable approach that allows exposure of the tip of the coronoid process and its anteromedial facet, up to the insertion of the anterior bundle of the medial collateral ligament on the sublime tubercle. We have shown that placing the forearm in supination moves the motor branches at risk of injury away from the surgical site.

LEVEL OF EVIDENCE

V.

Obstetrical brachial plexus injuries: late functional results of the Steindler procedure

We reviewed late functional results of a modified Steindler procedure in patients with obstetrical brachial plexus palsy and poor active elbow flexion. From 1982 to 2005, we reviewed final functional results and complications of 27 cases with flexion weakness of the elbow secondary to obstetrical brachial plexus injury, treated with a modified Steindler procedure. At the end of the follow-up, the mean active elbow flexion was 97° and the mean extensor lag was 10°. In the long-term follow-up, the modified Steindler procedure maintained good results in 67% of the cases in our series, and this percentage raised by 82% when the wrist extensor was present or restored before the Steindler procedure. There were poor results in 19% of the patients, but no major complications.