Restoration of hand function in C7–T1 brachial plexus palsies using a staged approach with nerve and tendon transfer

Abstract

Brachial plexus palsies of C7-T1 result in the complete loss of hand function, including finger and thumb flexion and extension as well as intrinsic muscle function. The task of reanimating such a hand remains challenging, and so far there has been no reliable neurological reconstructive method for restoring hand function. The authors aimed to establish a reliable strategy to reanimate the paralyzed hand. Two patients had sustained C7-T1 complete lesions. In the first stage of the operative procedure, a supinator motor branch to posterior interosseous nerve transfer was performed with brachialis motor branch transfer to the median nerve to restore finger and thumb extension and flexion. In the second stage, the intact brachioradialis muscle was used for abductorplasty to restore thumb opposition. Both patients regained good finger extension and flexion. Thumb opposition was also attained, and overall hand function was satisfactory. The described strategy proved effective and reliable in restoring hand function after C7-T1 brachial plexus palsies.

Surgical Anatomy of the Radial Nerve at the Elbow and in the Forearm: Anatomical Basis for Intraplexus Nerve Transfer to Reconstruct Thumb and Finger Extension in C7 − T1 Brachial Plexus Palsy

“…In our study, we required nerve grafts to anastomose the brachioradialis branch to the PIN, and the brachioradialis could usually be used to reconstruct the intrinsic muscle function. 13 The extensor carpi radialis longus branch could usually be directly anastomosed to the PIN in the present investigation, but this procedure may influence wrist extension, because the extensor carpi ulnaris is paralyzed and the carpi radialis brevis is partially impaired in C7 À T1 palsy. In a patient with several extensor carpi radialis longus branches, it is possible to use one branch to repair the PIN, with less damage to wrist extension.…”

Multiple nerve and tendon transfers: a new strategy for restoring hand function in a patient with C7–T1 brachial plexus avulsions

“…Through this strategy, patients with C7-T1 brachial plexus palsies have recovered finger flexion, finger extension, and thumb opposition, which has led to successful grasping and pinching motions. 13 However, finger flexion strength after brachialis mo-tor branch transfer has only corresponded to Medical Research Council (MRC) Grades M2-M3, lowering the grip strength and practical value of the reconstructed hand. We determined that the need for finger flexion strength was greater than the need for finger extension to ensure grasp strength and stability; thus, finger flexion achieved solely through brachialis motor branch transfer is not sufficient.…”

Estudo anatômico da inervação do músculo supinador para reinervar o nervo interósseo posterior

“…Some authors have reported their clinical results with this nerve transfer. 5 11 22 23 24 Dong et al 5 transferred the motor branch from the radial nerve to the supinator muscle to the PIN in four patients. These patients were followed-up and evaluated every three to four months postoperatively.…”

“…These authors performed such transfer in 10 patients, from which 9 recovered at least M3 muscle strength (full range of motion overcoming gravity and small resistance). Zhang et al 22 transferred one supinator branch to the PIN in two patients. They reported that this procedure proved to be reliable, effective, and quick in restoring finger and thumb extension.…”

“…Alguns autores relataram seus resultados clínicos com essa transferência nervosa. 5 11 22 23 24 Dong et al 5 realizaram a transferência do ramo do motor do nervo radial destinado ao supinador para o NIP em quatro pacientes. Esses foram seguidos e avaliados a cada 3/4 meses pós-operatório.…”