title: [Z-plasty and rerouting of the biceps tendon with interosseous membrane release to restore pronation in paralytic supination posture and contracture of the forearm].
abstract: OBJECTIVE
  Reduction of paralytic supination posture and contracture of the forearm. Improved spontaneous posture of the paralyzed arm with a more normal anatomic relationship of ulna and radius. Improvement of the activities of daily living, especially activities requiring active pronation (eating, dressing, writing). Prevention of recurrence or increase of the deformity during the growth period in obstetric brachial plexus palsy. Partly restoration of active pronation.
  
  
  METHODS
  Unopposed supination by the biceps in the presence of paralysis of the pronators as a result of --brachial plexus palsy, --poliomyelitis, --quadriplegia, --paralysis from other causes.
  
  
  METHODS
  Ongoing spontaneous or postoperative nerve regeneration and possible improvement of paralyzed pronators. Posttraumatic or degenerative ankylosis of the elbow joint; the extent of the preoperative passive pronation determines the postoperative result. Insufficient power (< M(4)) of the triceps (inadequate triceps function can lead to a flexion contracture of the elbow).
  
  
  METHODS
  After exposure of the biceps tendon a long Z-plasty is used to lengthen the tendon and allow its distal segment to be rerouted around the neck of the radius mediolaterally. The tendon ends are sutured. The technique allows the biceps to become a pronator instead of a supinator while preserving its original function of elbow flexion. In case of interosseous membrane contracture a release of the membrane is necessary.
  
  
  METHODS
  Immobilization in an upper plaster cast or Gilchrist bandage with the elbow in 90 degrees flexion and the forearm in neutral rotation or pronation, no extension below 90 degrees flexion/no supination for 6 weeks. Passive and active exercises of elbow extension, flexion and pronation until the maximally possible range of motion has been reached (12-18 months); dynamic pronation orthosis, if needed.
  
  
  RESULTS
  Eleven children with obstetric brachial plexus palsy and an average age of 6 years (4-12 years) were operated. In eight cases, besides rerouting of the biceps tendon, a release of the interosseous membrane was performed. Average follow-up time is 36 months (10-55 months). In all patients, an improved and more normal spontaneous posture of the paralyzed forearm resulted: difference of forearm position/increase of pronation 87 degrees (70-100 degrees). 91% of the patients reached an active pronation at least to neutral rotation, 46% were able to pronate up to 30 degrees and more.
authors.affiliation: Klinik für Orthopädie, Unfallchirurgie und Sportmedizin, Klinikum Agnes Karll Laatzen/Klinikum Region Hannover, Laatzen, Germany. oliver.ruehmann@krh.eu
authors.forename: Oliver
authors.initials: O
authors.lastname: Rühmann
authors.forename: Robert
authors.initials: R
authors.lastname: Hierner
mesh_terms: D002675:Child, Preschool; D003286:Contracture / Q000601:surgery*; D005260:Female; D006801:Humans; D011403:Pronation; D019651:Plastic Surgery Procedures / Q000295:instrumentation / Q000379:methods*; D016683:Supine Position; D013709:Tendon Transfer / Q000295:instrumentation / Q000379:methods*; D016896:Treatment Outcome
references.citation: J Bone Joint Surg Br. 1963 Aug;45:523-7
references.pmid: 14058329
references.citation: J Bone Joint Surg Am. 1971 Jan;53(1):137-42
references.pmid: 5540154
references.citation: J Hand Surg Am. 2004 Jan;29(1):22-7
references.pmid: 14751098
references.citation: J Bone Joint Surg Am. 1967 Oct;49(7):1275-84
references.pmid: 6053694
references.citation: Rev Chir Orthop Reparatrice Appar Mot. 1977 Oct-Nov;63(7):687-99
references.pmid: 146889
references.citation: J Hand Surg Am. 2006 Jan;31(1):118-24
references.pmid: 16443116
references.citation: J Hand Surg Br. 1997 Apr;22(2):261-3
references.pmid: 9150002
references.citation: J Hand Surg Br. 2002 Feb;27(1):20-3
references.pmid: 11895340
references.citation: J Hand Surg Am. 1980 Mar;5(2):153-9
references.pmid: 7358957
references.citation: J Bone Joint Surg Am. 1994 Mar;76(3):398-402
references.pmid: 8126045
references.citation: J Bone Joint Surg Am. 1958 Jun;40-A(3):633-43
references.pmid: 13539088