Restoration of Elbow Flexion for Upper Trunk Brachial Plexus Injuries: Evaluation of Nerve Transfers and Modified Steindler Flexorplasty

  • Precious Grace B. Handog
  • Tristram D. Montales
  • Emmanuel P. Estrella
Keywords: brachial plexus injuries, nerve transfers, Steindler, elbow flexion


Introduction. In patients with delayed presentation between 6 to 12 months, surgical treatment guidelines are not well defined in brachial plexus injury. Still, several authors have agreed that functional outcomes in patients treated within six months from the date of injury have the best results. Nerve transfers are still considered one of the treatment options in the said subset of patients even after six months. In contrast, a primary Steindler flexorplasty, or proximal advancement of the flexor-pronator group, is an ideal technique for elbow flexion with an elapsed time from injury >6 to 9 months.

Objective. The purpose of this investigation was to compare the clinical outcome s of nerve transfers versus modified Steindler flexorplasty for the restoration of elbow flexion in upper type brachial plexus injuries (BPI).

Methods. A retrospective review of 28 patients who underwent nerve transfers (NT) and 12 patients who underwent modified Steindler flexorplasty (MSF) was done to determine the outcome of treatments. The manual muscle testing using the Medical Research Council scaling system, Visual Analog Scale for pain, active range of motion, and Disabilities of the Arm, Shoulder and Hand form scores were taken as dependent variables.

Results. The NT group had a median age of 27.5 years, with 26 men, a median surgical delay of 5.6 months, and a median follow-up of 33 months. Twenty out of 28 patients (71%) had ≥M3 with a median range of 117.6° elbow flexion motion. Median postoperative DASH (n=16) and VAS scores were 29.2 and 3, respectively. For the MSF patients, the median age was 27 years, including ten men, the median surgical delay was 12 months, and the median follow-up was 18.4 months. All the 12 patients had ≥M3, with a median range of motion of 106°. The median postoperative DASH score (n=5) and VAS score were 28.3 and 0, respectively. In the NT group, 73.3% (11/15) achieved ≥M3 elbow flexion if the operation was done in <6 months.

Conclusion. Nerve transfers and the modified Steindler procedure are still excellent options for successful elbow flexion reanimation in patients with brachial plexus injuries. Our results also showed that those with surgical delays of less than six months had the highest rate of achieving ≥M3 elbow flexion strength in the nerve transfer group.