TENDON TRANSFER FOR UPPER LEVEL

BRACHIAL PLEXUS INJURY

- A SURABAYA EXPERIENCE

ERWIN RAMAWAN
Dept. Orthopaedic and Traumatology
Dr.Soetomo General Hospital /
School of Medicine-Airlangga University
Surabaya - Indonesia
 BACKGROUND
Road traffic accident may lead to brachial
plexus injury, mainly upper level

Modalities of therapies :
Observation ( no operative )
Nerve repair
Nerve graft
Tendon transfer
Brachial plexus injury classification

Upper level / Erb ( C 5,6, + 7 )

Shoulder : abduction ↓; m.deltoid, supraspinatus

int.rotation ↓; m.infraspinatus, teres
minor
Elbow : flexion ↓; m. biceps, brachialis,
brachioradialis
supination ↓; m. supinator
Lower level / Klumke ( C 8,Th1, + C 7 )

Wrist : flexion ↓
Finger : flexion ↓
 claw hand
Tendon transfer treatment
Indication :
– Nerve root avulsion
– Failed nerve repair/nerve graft after 12-24 month
– Conservative cases after > 6 month, which nerve function
improvement cannot be expected
Commonly done for shoulder 1 year & elbow 1,5 year
after trauma without any neurologic improvement
Joint mobility, adequate soft tissue, & good donor
muscle strength should be consider
Good patient compliance
Shoulder
Azis : m.trapezius to proximal humerus
Bateman modified : scapula spine
resection, transfer screw fixation
Saha : release of superior and middle m.
trapesius origin, to get 5 cm longer
Post op : shoulder spica cast application in
900 abduction, neutral rotation, and flexion
of scapula
8/54 off cast  start exercise
Elbow
Transfer can be obtain from m.latissimus dorsi,
pectoralis major, triceps, sternocleidomastoid, &
flexor pronator mass
Steindler (1918) : flexorplasty, flexor pronator
muscle origin in medial epicondyle (pronator
teres, flexor carpi radialis, palmaris longus,
flexor digitorum sublimis, flexor carpi ulnaris)
transposed 5 cm more proximally
Immobilisation by back slab in flexion for 4-6/54
Case report

Of 7 patients, 6 done in Dr. Soetomo General Hospital, 1 in Budi Mulia Hospital

No Name Age Trauma EMG/NCV result Op Post trauma interval Motor grade

1. Rudi 23 yrs RTA sup.trunk lession S Saha 5 month 4

Steindler 4

2. Suhar 31 yrs RTA sup.trunk lession D Saha 4 yrs 2

3. Dian 19 yrs Fall sup.trunk lession D Saha 14 yrs 2

4. Edi 32 yrs RTA sup.trunk lession D Saha 1 yrs 3

5. Yasir 30 yrs RTA root C5-7 lession D Saha 7 month 2

Steindler

6. Komari 32 yrs RTA root C5-7 lession D Saha 3 yrs 3

Steindler

7. Anton 60 yrs RTA root C5 lession D Saha 6 yrs 2

Patient 1
Mr. R, 23 yrs, RTA,
motorcyclies slipped
and fell 5 months
after trauma, Saha &
Steindler procedure
done excellent result
Patient 2
Mr. S, 31 yrs, RTA,
Saha procedures
done 5 yrs after
trauma, results : fair
Patient 3
Mr. D, 19 yrs, fell, Saha
procedure done 14
yrs after trauma,
result : fair
Patient 4
Mr. E, 32 yrs, RTA,
motorcyclist hit a tree,
Saha procedure done
1 year post trauma,
result : good
Patient 5
Mr. Y, 30 yrs, RTA,
motorcyclist vs car,
Steindler procedure
done 1 year after
trauma, Saha
procedure done 2
years after trauma,
result : fair
Patient 6
Mr. K, 32 yrs, RTA,
motorcyclist vs lorry,
Saha and Steidler
procedure done 1
year after trauma,
result : good
Patient 7
Mr. A, 60 yrs, RTA,
Saha procedures
done 6 yrs after
trauma, result : fair
Conclusion
Saha and Steindler procedure give promising
result
The overall outcome is very much influenced by
pre & post op rehabilitation, including joint
mobility
Good patient compliance / pre & post op
exercise support optimum result
These tendon transfer procedure, no matter how
little, are very satisfying for the invalid