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Brachial Plexus and SPML Specialist
X-ray image of elbow. Pediatric Orthoprdic Andrew E. Price MD

Brachial Plexus Elbow Treatments

Elbow Flexion

The Zancolli procedure does the same trick with the biceps tendon at the elbow. Detached from the radius, it is repositioned on the opposite side to where it was to create pronation. It had produced supination. But what if there is no biceps action at all? Then one can be built. One must work with what is working, as brachial palsies do not pick out single muscles as a rule. For example, the pectoral muscle can be repositioned to become a biceps in certain conditions, but may well be poorly suited in some brachial plexus palsies.

The latissimus dorsi can be detached from the ribs and – pivoting on its attachment at the upper humerus – have the once-rib attachment end attached to the biceps tendon at the elbow. That creates an elbow flexor. That same transfer, if attached to the back of the arm, is used to generate triceps power in conditions wherein triceps substitution is needed.

The finger flexors are in two layers and along with the wrist flexors attach not only in the forearm but also above the elbow at the medial condyle. In a real sense, the finger and wrist flexors are already elbow flexors. They can be recruited as elbow flexors by merely stabilizing the wrist or fingers (as with other muscles). Surgically moving the humeral attachment more proximal increases the leverage of those muscles (which at that level are nearly a single unit). Thus weak elbow flexion can be boosted.

Shoulder_StructureIn the absence of shoulder dislocation, if the external rotation cannot be achieved through the physical therapy program, then surgical release through a subscapularis slide (an advancement of the muscle that blankets the undersurface of the scapula reaching laterally to attaches to the front of the humerus (figure on left)) is performed usually at the age of 18 to 24 months. The child attains, with that, immediate improvement of both function and cosmesis.

If over the course of the ensuing year, the contracture begins to recur, a modified L’Episcopo procedure is performed, where the latissimus and teres major insertions are transferred around to the back of the humerus into the infraspinatus tendon. These muscles are powerful internal rotators of the shoulder that join together in what is called a conjoint tendon which attaches to the front of the arm bone or humerus. This transfer is possible because the shoulder has additional powerful muscles that perform similar movements akin to those of the transferred muscles. This transfer will permanently balance the muscles about the shoulder thus preventing recurrence of the contracture and improving elevation of the shoulder.

Humeral_Derotation When permanent bony incongruence has developed in the glenohumeral joint, in those patients who are seen late, an external rotation osteotomy is performed to optimize the position of the arc of motion and improve function and appearance (Figure on left). When minimal muscle recovery occurs and there is little or no ability to elevate the shoulder some salvage procedures have been proposed, including shoulder fusion and trapezius transfer. In our center, we believe that shoulder fusion is the last resort. The trapezial transfer leaves the patient with limited abduction, a webbed neck and a poor cosmetic appearance.

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