Wrist fusion in peripheral paralysis

In cases of paralysis of the upper limb, wrist fusion is useful in selected indications, especially when there are little to no tendon transfers available to restore finger function and wrist extension. Wrist fusion is particularly useful in the sequelae of brachial plexus lesions and in total paralysis of the radial nerve with hand drop and preserved wrist flexors. Numerous fusion techniques have been proposed. In cases of sequelae of brachial plexus lesions, locking of pronation-supination is associated with the wrist fusion. The use of anatomical plates has dropped the non-union and complication rates.

Biomechanical bases for tendon transfers at the shoulder

Paralysis of the muscles around the shoulder is a debilitating condition that continues to be a very challenging problem. It leads to an inability to position one's hand in space. This greatly compromises the function of the upper limb and can lead to chronic shoulder pain due to inferior glenohumeral subluxation. Management of these complex problems has two main objectives: (i) stabilize the glenohumeral joint to decrease pain related to inferior glenohumeral subluxation; (ii) restore active range of motion in external rotation, abduction, and internal rotation. All the shoulder muscles contract in a coordinated and complex manner to allow the shoulder to move through a complete range of motion. Understanding how the different muscle groups coordinate their contractions and the basic biomechanical principles of tendon transfers is paramount before considering doing a tendon transfer around the shoulder. To function properly, a tendon transfer should have a similar line of pull (similar moment arm), similar tension and similar excursion to that of the muscle it replaces; one tendon transfer should replace only one function and the donor (transferred) muscle should have normal muscle strength (at least M4).

Shoulder arthrodesis in brachial plexus palsy

Long considered as the ultimate surgery for limb salvage in case of brachial plexus palsy, shoulder fusion has seen its indications reduced with the development of more numerous and multiple tendon transfers. This option remains valid and should always be suggested first because of its reliable effects on pain and function. However, it is a demanding surgery, the position of the fusion remains difficult to determine and the complication rate is not negligible.

Transfer of the lateral antebrachial cutaneous nerve to the dorsal branch of the ulnar nerve without nerve graft in case of lower brachial plexus injuries: Anatomical and feasibility study

In the context of lower (C8-T1) brachial plexus injury, transfer of the lateral antebrachial cutaneous nerve (LABCN) to the dorsal branch of the ulnar nerve (DBUN) with an interposed sural nerve graft has been proposed to restore sensitivity on the ulnar side of the hand. The purpose of this study was to assess the feasibility of performing this transfer directly - without interposition of a nerve graft - by intraneural dissection of the DBUN. An anatomical study was performed with 20 upper limbs from adult human cadavers. The LABCN and the DBUN were dissected. The LABCN emerged from the lateral side of the biceps brachii muscle at an average of 2.6±0.4cm from the interepicondylar line and was 13.5±2.6cm long, on average. The DBUN arose from the ulnar nerve 8.2±1.6cm from the styloid process of the ulna. The maximum length of DBUN intraneural dissection relative to the ulnar nerve was 7.5±2.1cm, on average. The LABCN could be transferred to the DBUN in a tension-free manner with end-to-end suturing. Intraneural dissection of the DBUN allows LABCN nerve transfer without interposition of a graft.

Rhomboid nerve transfer to the suprascapular nerve for shoulder reanimation in brachial plexus palsy: A clinical report

Recovery of shoulder function is a real challenge in cases of partial brachial plexus palsy. Currently, in C5-C6 root injuries, transfer of the long head of the triceps brachii branch is done to revive the deltoid muscle. Spinal accessory nerve transfer is typically used for reanimation of the suprascapular nerve. We propose an alternative technique in which the nerve of the rhomboid muscles is transferred to the suprascapular nerve. A 33-year-old male patient with a C5-C6 brachial plexus injury with shoulder and elbow flexion palsy underwent surgery 7 months after the injury. The rhomboid nerve was transferred to the suprascapular nerve and the long head of the triceps brachii branch to the axillary nerve for shoulder reanimation. A double transfer of fascicles was performed, from the ulnar and median nerves to the biceps brachii branch and brachialis branch, respectively, for elbow flexion. At 14 months' follow-up, elbow flexion was rated M4. Shoulder elevation was 85 degrees and rated M4, and external rotation was 80 degrees and rated M4. After performing a cadaver study showing that transfer of the rhomboid nerve to the suprascapular nerve is technically possible, here we report and discuss the clinical outcomes of this new transfer technique.