Median and/or Ulnar Nerve Fascicle Transfer for the Restoration of Elbow Flexion in Upper Neonatal Brachial Plexus Palsy

Abstract

Introduction: Transfer of a fascicle of the ulnar and/or median nerve to the musculocutaneous nerve in order to reinnervate the biceps and/or brachialis muscles has a high success rate and a low rate of complications in infants with upper (C5-C6) or extended upper (C5-C7) neonatal brachial plexus palsy.

Step 1 make the incision: Make a longitudinal incision along the midline of the middle third of the medial brachium.

Step 2 mobilize the musculocutaneous nerve: The musculocutaneous nerve is typically found on the undersurface of the biceps muscle.

Step 3 mobilize the median nerve: The median nerve runs along the neurovascular sheath medial to the brachial artery.

Step 4 mobilize the ulnar nerve: The ulnar nerve lies posterior to the intermuscular septum.

Step 5 transfer the donor nerve to the recipient nerve: Cut the donor fascicles distally and the recipient fascicles proximally to facilitate transfer.

Step 6 close the wound: Irrigate the wound, and close it in layers.

Step 7 postoperative protocol: Remove the bandages two weeks postoperatively, and encourage passive range-of-motion exercises.

Results: In our series, thirty-one patients underwent single or combined nerve fascicle transfer; twenty-seven (87%) obtained functional elbow flexion recovery (Active Movement Scale [AMS] score ≥ 6) while twenty-four (77%) obtained full elbow flexion recovery (AMS score = 7). Indications Contraindications Pitfalls & Challenges.

Fig. 1

Postoperative photograph showing the location of the surgical scar in the medial brachium of a patient who underwent combined median and ulnar nerve fascicle transfer. (Reproduced with permission of Cincinnati Children’s Hospital.)

Fig. 2-A

Intraoperative photograph showing the motor branch of the musculocutaneous nerve to the biceps (red vessel loop) and the ulnar nerve (yellow vessel loops). (Reproduced with permission of Shriner’s Hospital.)

Fig. 2-B

Close-up intraoperative photograph of the same area seen in Fig. 2-A, showing the motor branch of the musculocutaneous nerve to the biceps superficial to the brachialis muscle with the biceps muscle being retracted superficial to the red vessel loop. (Reproduced with permission of Shriner’s Hospital.)

Fig. 3

Intraoperative photograph showing a longitudinal epineurotomy along the ulnar nerve (yellow vessel loops) with the appropriate donor fascicle dissected free (red vessel loop). The nerve parallel to the ulnar nerve is the medial antebrachial cutaneous nerve. (Reproduced with permission of Shriner’s Hospital.)

Fig. 4

Intraoperative photograph showing the ulnar nerve donor fascicle (yellow background) cut distally and moved anteriorly to facilitate transfer to the biceps motor branch (red vessel loop). (Reproduced with permission of Shriner’s Hospital.)

Fig. 5

Intraoperative photograph showing the coaptation of the ulnar nerve fascicle to the biceps branch of the musculocutaneous nerve with use of fibrin glue. The ulnar nerve fascicle has been transferred superficial to the medial antebrachial cutaneous nerve in this photograph. (Reproduced with permission of Shriner’s Hospital.)