Early functional recovery of elbow flexion and supination following median and/or ulnar nerve fascicle transfer in upper neonatal brachial plexus palsy.
BACKGROUND
Nerve transfers using ulnar and/or median nerve fascicles to restore elbow flexion have been widely used following traumatic brachial plexus injury, but their utility following neonatal brachial plexus palsy remains unclear. The present multicenter study tested the hypothesis that these transfers can restore elbow flexion and supination in infants with neonatal brachial plexus palsy.


METHODS
We retrospectively reviewed the cases of thirty-one patients at three institutions who had undergone ulnar and/or median nerve fascicle transfer to the biceps and/or brachialis branches of the musculocutaneous nerve after neonatal brachial plexus palsy. The primary outcome measures were postoperative elbow flexion and supination as measured with the Active Movement Scale (AMS). Patients were followed for at least eighteen months postoperatively unless they obtained full elbow flexion or supination (AMS = 7) prior to eighteen months of follow-up.


RESULTS
Twenty-seven (87%) of the thirty-one patients obtained functional elbow flexion (AMS ≥ 6), and twenty-four (77%) obtained full recovery of elbow flexion against gravity (AMS = 7). Of the twenty-four patients for whom recovery of supination was recorded, five (21%) obtained functional recovery. Combined ulnar and median nerve fascicle transfers were performed in five patients and resulted in full recovery of elbow flexion against gravity and supination of AMS ≥ 5 for all five. Single-fascicle transfer was performed in twenty-six patients and resulted in functional flexion in 85% (twenty-two of twenty-six) and functional supination in 15% (three of twenty). Patients with nerve root avulsion were treated at a younger age (p < 0.01), had poorer preoperative elbow flexion (p < 0.01), and recovered greater supination (p < 0.01) compared with patients with dissociative recovery. Younger patients (p < 0.01) and patients with C5-C6 avulsion (p < 0.02) recovered the greatest supination. One patient sustained a transient anterior interosseous nerve palsy after median nerve fascicle transfer.


CONCLUSIONS
Ulnar and/or median nerve fascicle transfers were able to effectively restore functional elbow flexion in patients with nerve root avulsion, dissociative recovery, or late presentation following neonatal brachial plexus palsy. Recovery of supination was less, with greater success noted in younger patients with nerve root avulsion.
Division of Orthopaedic Surgery, University of Cincinnati School of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229. E-mail address for K.J. Little: kevin.little@cchmc.org.
Kevin J
KJ
Little
Shriner's Hospital for Children of Philadelphia, Temple University School of Medicine, 3551 North Broad Street, Philadelphia, PA 19140.
Dan A
DA
Zlotolow
Pediatric Hand Surgery and Microsurgery, Orthopaedic Surgery Department, Institut de Recerca Vall d'Hebron (VHIR), Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain.
Francisco
F
Soldado
Division of Orthopaedic Surgery, University of Cincinnati School of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229. E-mail address for K.J. Little: kevin.little@cchmc.org.
Roger
R
Cornwall
Shriner's Hospital for Children of Philadelphia, Temple University School of Medicine, 3551 North Broad Street, Philadelphia, PA 19140.
Scott H
SH
Kozin
D020516:Brachial Plexus Neuropathies / Q000151:congenital / Q000503:physiopathology / Q000601:surgery*; D004551:Elbow Joint / Q000502:physiology; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008475:Median Nerve / Q000601:surgery*; D016067:Nerve Transfer / Q000379:methods*; D016059:Range of Motion, Articular / Q000502:physiology; D020127:Recovery of Function / Q000502:physiology; D012189:Retrospective Studies; D013484:Supination / Q000502:physiology; D014459:Ulnar Nerve / Q000601:surgery*