Comprehensive Hand Restoration after Lower Brachial Plexus Injury Using a Staged Approach with Nerve and Tendon Transfers
Amy Kite, M.D., Jonathan Cheng, M.D. and Alana Carrasco, none, University of Texas Southwestern Medical Center, Dallas, TX
Introduction
Isolated C7-T1 root injuries impair function of the median, radial, and ulnar nerves. As a result, patients lose both gross motion and fine manipulation in the digits. We describe the use of staged nerve and tendon transfers, tailored to the individual patient and including re-neurotized musculotendinous units, for restoration of lower brachial plexus palsy. Many of these tendon transfers are inspired by reconstructions typically performed for other neuromuscular conditions including cerebral palsy and tetraplegia.
Methods
2 patients with lower trunk brachial plexus palsy had staged reconstruction with 1) nerve transfers, and 2) tendon transfers using donor muscles which were either preserved, spontaneously recovered, or re-neurotized after the initial injury.
Case 1: 23-year-old female with C7-T1 palsy
Stage 1: Digit flexion nerve transfer - brachialis to AIN
Digit extension nerve transfer - ECRB and supinator to PIN
Stage 2: Finger flexion - FDP side-by-side tenodesis
Opposition - Camitz opponensplasty
Composite grasp - Zancolli tendon transfer
Span grasp - FCR to APL side-by-side tenodesis
Stage 3: Key pinch - split FPL to EPL tendon transfer
Case 2: 5-year-old female with T1 palsy
Stage 1: Digit flexion nerve transfer - supinator to AIN and FDS
ECRB to FDS
Intrinsic nerve transfer - EDQ to deep motor branch of ulnar nerve
Stage 2: Finger flexion - Superficialis to profundus (STP) tendon transfer
Opposition - EPB rerouting around FCR tendon
Composite grasp - Zancolli tendon transfer
Stage 3: Span grasp - FCR to APL side-by-side tenodesis
Key pinch - split FPL to EPL.
Results
All patients had MRC 0 in the related lower trunk brachial plexus distribution at the time of initial nerve transfer reconstruction. Tendon transfers began at 18 months after nerve transfer, to allow for recovery of motor function in injured and re-neurotized musculotendinous units.
Comprehensive hand function was restored in both patients after 3 reconstructive stages, by prioritizing the following elements: digit flexion, digit extension, opposition, composite grasp, span grasp, and key pinch.
We will present an algorithmic approach to reconstruction of lower brachial plexus palsy, with the goal of restoring comprehensive hand function.
Conclusions
Restoring hand function in lower brachial plexus palsy is a daunting undertaking, best performed by peripheral nerve surgeons with broad hand surgery and tendon transfer experience. The ultimate goal is comprehensive hand restoration which addresses digit flexion, digit extension, opposition, composite grasp, span grasp, and key pinch, using all available nerve and tendon transfer donor sources.
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