Aims. Improvements in the evaluation of outcomes following peripheral nerve injury are needed. Recent studies have identified muscle fatigue as an inevitable consequence of muscle reinnervation. This study aimed to quantify and characterize muscle fatigue within a standardized surgical model of muscle reinnervation. Patients and Methods. This retrospective cohort study included 12 patients who underwent Oberlin nerve transfer in an attempt to restore flexion of the elbow following brachial plexus injury. There were ten men and two women with a mean age of 45.5 years (27 to 69). The mean follow-up was 58 months (28 to 100). Repeated and sustained isometric contractions of the elbow flexors were used to assess fatigability of reinnervated muscle. The strength of elbow flexion was measured using a static dynamometer (KgF) and surface electromyography (sEMG). Recordings were used to quantify and characterize fatigability of the reinnervated elbow flexor muscles compared with the uninjured contralateral side. Results. The mean peak force of elbow flexion was 7.88 KgF (. sd. 3.80) compared with 20.65 KgF (. sd . 6.88) on the contralateral side (p < 0.001). Reinnervated elbow flexor muscles (biceps brachialis) showed sEMG evidence of fatigue earlier than normal controls with sustained (60-second) isometric contraction. Reinnervated elbow flexor muscles also showed a trend towards a faster twitch muscle fibre type. Conclusion. The assessment of motor outcomes must involve more than peak force alone. Reinnervated muscle shows a shift towards fast twitch fibres following reinnervation with an earlier onset of fatigue. Our findings suggest that fatigue is a clinically relevant characteristic of reinnervated muscle. Adoption of these metrics into clinical practice and the assessment of outcome could allow a more meaningful comparison to be made between differing forms of treatment and encourage advances in the management of motor recovery following nerve transfer. Cite this article: Bone Joint J 2019;101-B:867–871

We compared the quantitative electromyographic activity of the elbow flexors during four exercises (forced inspiration, forced expiration, trunk flexion and attempted elbow flexion), following intercostal nerve transfer to the musculocutaneous nerve in 32 patients who had sustained root avulsion brachial plexus injuries. Quantitative electromyographic evaluation of the mean and maximum amplitude was repeated three times for each exercise. We found that mean and maximum elbow flexor activity was highest during trunk flexion, followed by attempted elbow flexion, forced inspiration and finally forced expiration. The difference between each group was significant (p < 0.001), with the exception of the difference between trunk flexion and attempted elbow flexion. Consequently, we recommend trunk flexion exercises to aid rehabilitation following intercostal nerve transfer

Seven pectoralis major transfers in children suffering from bilateral paralysis of elbow flexion due to arthrogryposis or to trauma are reported. A technique is described in which the muscle is mobilised from the clavicle to allow the tendon of insertion to be attached to the biceps tendon at the elbow. The biceps tendon was found to be present and could be mobilised forwards in all the arthrogrypotic elbows. Subjectively, the results were considered by patients or parents to be very good in six cases and fair in one. Elbow flexion power against gravity and against some resistance was achieved in all patients except one. The overall function was very good in one elbow, good in two, fair in three and poor in only one. The merits of the various procedures described for the restoration of elbow flexion in arthrogryposis are discussed. It is concluded that total pectoralis major transfer by the method described here has given the best results

The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level. Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss

We present the long-term results of pectoralis major transfer to restore elbow flexion in seven patients (ten procedures). The early results in all the patients were encouraging but with longer follow-up a gradual and progressive flexion deformity was observed with a decrease in the arc of flexion in eight elbows, reaching ≥ 90° in all cases. The results of pectoralis major transfer deteriorate with time due to the development of a recalcitrant flexion deformity of the elbow. With bilateral involvement we now recommend that the procedure be undertaken on one side only to allow the hand to reach the mouth for feeding, while the opposite side remains in extension for perineal toilet

We have reviewed 50 patients at a mean period of 2.7 years after operations to restore elbow flexion lost as a result of traction injuries of the brachial plexus. A variety of operations were used and, in general, patient satisfaction was high. Objectively, however, the power in the transferred muscles was poor; less than half of the patients had a significant improvement in function. Poor control of the shoulder often compromised the result. Latissimus dorsi and triceps transfers proved most reliable, and some Steindler flexorplasties also gave satisfactory results. Pectoralis major transfers were disappointing and we do not recommend their use in women

We analysed the axis of movement in the normal elbow during flexion in vivo using radiostereometric analysis (RSA). The results show an intraindividual variation in the inclination of the axis ranging from 2.1° to 14.3° in the frontal and from 1.6° to 9.8° in the horizontal plane analysed at 30° increments. The inclination of the mean axis of rotation varied within a range of 12.7° in the frontal and 4.6° in the horizontal plane. In both planes, the mean axes were located close to a line joining the centres of the trochlea and capitellum. The intra- and interindividual variations of the axes of flexion of the elbow were greater than previously reported. These factors should be considered in the development of elbow prostheses

Aims. The conventionally described mechanism of distal biceps tendon rupture (DBTR) is of a ‘considerable extension force suddenly applied to a resisting, actively flexed forearm’. This has been commonly paraphrased as an ‘eccentric contracture to a flexed elbow’. Both definitions have been frequently used in the literature with little objective analysis or citation. The aim of the present study was to use video footage of real time distal biceps ruptures to revisit and objectively define the mechanism of injury. Methods. An online search identified 61 videos reporting a DBTR. Videos were independently reviewed by three surgeons to assess forearm rotation, elbow flexion, shoulder position, and type of muscle contraction being exerted at the time of rupture. Prospective data on mechanism of injury and arm position was also collected concurrently for 22 consecutive patients diagnosed with an acute DBTR in order to corroborate the video analysis. Results. Four videos were excluded, leaving 57 for final analysis. Mechanisms of injury included deadlift, bicep curls, calisthenics, arm wrestling, heavy lifting, and boxing. In all, 98% of ruptures occurred with the arm in supination and 89% occurred at 0° to 10° of elbow flexion. Regarding muscle activity, 88% occurred during isometric contraction, 7% during eccentric contraction, and 5% during concentric contraction. Interobserver correlation scores were calculated as 0.66 to 0.89 using the free-marginal Fleiss Kappa tool. The prospectively collected patient data was consistent with the video analysis, with 82% of injuries occurring in supination and 95% in relative elbow extension. Conclusion. Contrary to the classically described injury mechanism, in this study the usual arm position during DBTR was forearm supination and elbow extension, and the muscle contraction was typically isometric. This was demonstrated for both video analysis and ‘real’ patients across a range of activities leading to rupture. Cite this article: Bone Jt Open 2022;3(10):826–831

The elbow flexor muscles of four men were trained using maximal voluntary isometric contractions. Thirty contractions a day were performed for five weeks. The four men and four control subjects were tested once a week: measurements of the supramaximally stimulated isometric twitch force, the time taken for the twitch force to peak and the tetanic force were carried out; simultaneously, measurements of the force of maximal voluntary isometric contraction and resistance to fatigue were made. The testing sessions produced no training effect on control subjects. Training produced a 20 per cent increase in the force of maximal voluntary isometric contraction after five weeks, but the forces of electrically evoked twitch and tetanus showed no increase. It was concluded that the increase in the force of maximal voluntary isometric contraction must be related to factors other than the force-generating capacity of the muscle fibres themselves

We report the case of an eight-month-old girl who presented with a poliomyelitis-like paralysis in her left upper limb caused by enterovirus 71 infection. She recovered useful function after nerve transfers performed six months after the onset of paralysis. Early neurotisation can be used successfully in the treatment of poliomyelitis-like paralysis in children.

We retrospectively studied the possibility that direct trauma to the biceps muscle might be the cause of poor elbow flexion and supination in 18 consecutive children with birth lesions of the brachial plexus who had delayed or impaired biceps recovery despite neurophysiological evidence of reinnervation. All had good shoulder and hand function at three months of age. Eight recovered a strong biceps after six months, but nine required a pectoralis minor to biceps transfer to augment elbow flexion and supination. One had a delayed but good recovery of the biceps after microsurgical reconstruction of the plexus. All had a clinical ‘pseudotumour’ in the biceps muscle, which was biopsied during pectoralis minor transfer in two patients and showed rupture and degeneration of muscle fibres with a fibro-fatty infiltrate, suggesting previous muscle trauma. Direct muscle trauma is an uncommon but important cause of delayed or impaired biceps recovery after brachial plexus birth injuries. Surgery to reinnervate the biceps muscle will not work if substantial muscle damage is present when a suitable muscle transfer should be considered

Abstract. Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions

Objectives. Traumatic brachial plexus injury causes severe functional impairment of the arm. Elbow flexion is often affected. Nerve surgery or tendon transfers provide the only means to obtain improved elbow flexion. Unfortunately, the functionality of the arm often remains insufficient. Stem cell therapy could potentially improve muscle strength and avoid muscle-tendon transfer. This pilot study assesses the safety and regenerative potential of autologous bone marrow-derived mononuclear cell injection in partially denervated biceps. Methods. Nine brachial plexus patients with insufficient elbow flexion (i.e., partial denervation) received intramuscular escalating doses of autologous bone marrow-derived mononuclear cells, combined with tendon transfers. Effect parameters included biceps biopsies, motor unit analysis on needle electromyography and computerised muscle tomography, before and after cell therapy. Results. No adverse effects in vital signs, bone marrow aspiration sites, injection sites, or surgical wound were seen. After cell therapy there was a 52% decrease in muscle fibrosis (p = 0.01), an 80% increase in myofibre diameter (p = 0.007), a 50% increase in satellite cells (p = 0.045) and an 83% increase in capillary-to-myofibre ratio (p < 0.001) was shown. CT analysis demonstrated a 48% decrease in mean muscle density (p = 0.009). Motor unit analysis showed a mean increase of 36% in motor unit amplitude (p = 0.045), 22% increase in duration (p = 0.005) and 29% increase in number of phases (p = 0.002). Conclusions. Mononuclear cell injection in partly denervated muscle of brachial plexus patients is safe. The results suggest enhanced muscle reinnervation and regeneration. Cite this article: Bone Joint Res 2014;3:38–47

Aims. Delayed diagnosis is a well-known complication of a Monteggia fracture-dislocation. If left untreated, the dislocated radial head later becomes symptomatic. The purposes of this study were firstly, to evaluate the clinical and radiological results of open reduction of the radial head and secondly, to identify the factors that may affect the outcome of this procedure. Materials and Methods. This retrospective study evaluated 30 children with a chronic Monteggia lesion. There were 18 boys and 12 girls with a mean age of 7.4 years (4 to 13) at the time of open reduction. The mean interval to surgery, after the initial fracture, was 23.4 months (6 to 120). Clinical grading used a Kim modified elbow score: radiological outcome was recorded. The effect of the patient’s age, gender, duration from initial injury, Bado classification, and annular ligament reconstruction were analyzed. The mean follow-up was 42.2 months (15 to 20). Results. The Kim elbow scores evaluated at the last clinic visit were excellent in 23 patients, good in three, fair in two, and poor in two. A majority of the patients were found to have significant improvement of elbow flexion (p < 0.001). Six met the criteria of a fair radiological outcome; four of these were operated on more than 24 months after the initial injury, and three had surgery after the age of 11. Univariate analysis failed to find any factor that was significantly associated with a fair or poor outcome. Conclusion. Good clinical and radiological outcomes can be expected in most patients. Osteoarthritic changes were associated with age > 11 years and/or a delay of treatment of > 24 months. However, no statistically significant factor could be identified which correlated with an unfavourable outcome. Cite this article: Bone Joint J 2018;100-B:1117–24

Aims. Between 2002 and 2011, 81 patients with a traumatic total brachial plexus injury underwent reconstruction by double free muscle transfer (DFMT, 47 cases), single muscle transfer (SMT, 16 cases) or nerve transfers (NT, 18 cases). . Methods. They were evaluated for functional outcome and quality of life (QoL) using the Disability of Arm, Shoulder and Hand questionnaire, both pre- and post-operatively. The three groups were compared and followed-up for at least 24 months. Results. The mean shoulder abduction and flexion were comparable in all groups, but external rotation was significantly better in the DFMT group as were range and quantitative power of elbow flexion. Patients who had undergone DFMT had reasonable total active finger movement and hook grip strength. All groups showed improvement in function at a level greater than a minimum clinically important difference. The DFMT group showed the greatest improvement. Discussion. Patients in the DFMT group had a better functional outcome and QoL recovery than those in the NT and SMT groups. . Take home message: Double free muscle transfer procedure is capable of restoring maximum function in patients of total brachial plexus palsy. Cite this article: Bone Joint J 2016;97-B:209–17

We evaluated the morphological changes to the ulnar nerve of both elbows in the cubital tunnel by sonography in a total of 237 children, of whom 117 were aged between six and seven years, 66 between eight and nine years, and 54 between ten and 11 years. We first scanned longitudinally in the extended elbow and then transversely at the medial epicondyle with the elbow extended to 0°. We repeated the scans with the elbow flexed at 45°, 90°, and 120°. There were no significant differences in the area of the ulnar nerve, but the diameter increased as the elbow moved from extension to flexion in all groups. More importantly, the ulnar nerve was subluxated anteriorly on to the medial epicondyle by 1.5% to 1.9% in extended elbows, by 5.9% to 7.9% in those flexed to 45°, by 40.0% to 44% in those flexed to 90°, and by 57.4% to 58.1% in those flexed to 120°, depending on the age group. Sonography clearly and accurately showed the ulnar nerve and was useful for localising the nerve before placing a medial pin. Because the ulnar nerve may translate anteriorly onto the medial epicondyle when the elbow is flexed to 90° or more, it should never be overlooked during percutaneous medial pinning

The best method of managing a fracture of the distal humerus in a frail low-demand patient with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for patients in whom open reduction and internal fixation (ORIF) is not possible. Conservative methods of treatment, including the ‘bag of bones’ technique (acceptance of displacement of the bony fragments and early mobilisation), are now rarely considered as they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93 years, 72% women) with a fracture of the distal humerus who had been treated conservatively at our hospital between March 2008 and December 2013, and assessed their short- and medium-term functional outcome. . In the short-term, the mean Broberg and Morrey score improved from 42 points (poor; 23 to 80) at six weeks after injury to 67 points (fair; 40 to 88) by three months. . In the medium-term, surviving patients (n = 20) had a mean Oxford elbow score of 30 points (7 to 48) at four years and a mean Disabilities of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95% reported a functional range of elbow flexion. The cumulative rate of fracture union at one year was 53%. The mortality at five years approached 40%. . Conservative management of a fracture of the distal humerus in a low-demand patient only gives a modest functional result, but avoids the substantial surgical risks associated with primary ORIF or TEA. Cite this article: Bone Joint J 2015;97-B:1132–8

We have compared the functional outcome after glenohumeral fusion for the sequelae of trauma to the brachial plexus between two groups of adult patients reviewed after a mean interval of 70 months. Group A (11 patients) had upper palsy with a functional hand and group B (16 patients) total palsy with a flail hand. All 27 patients had recovered active elbow flexion against resistance before shoulder fusion. Both groups showed increased functional capabilities after glenohumeral arthrodesis and a flail hand did not influence the post-operative active range of movement. The strength of pectoralis major is a significant prognostic factor in terms of ultimate excursion of the hand and of shoulder strength. Glenohumeral arthrodesis improves function in patients who have recovered active elbow flexion after brachial plexus palsy even when the hand remains paralysed

Redisplacement of unstable forearm fractures in plaster is common and may be the result of a number of factors. Little attention has been paid to the influence of immobilisation with the elbow extended versus flexed. We prospectively treated 111 consecutive children from two centres with closed forearm fractures by closed reduction and casting with the elbow either extended (60) in China or flexed (51) in Israel. We compared the outcome of the two groups. There was no statistically significant difference in the distribution of the age of the patients, the site of fracture or the amount of angulation and displacement between the groups. During the first two weeks after reduction, redisplacement occurred in no child immobilised with the elbow extended and nine of 51 children (17.6%) immobilised with the elbow flexed. Immobilisation of unstable forearm fractures with the elbow extended appears to be a safe and effective method of maintaining reduction

Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released. At the latest follow-up, the mean flexion of the elbow improved significantly from 96° (85° to 115°) pre-operatively to 130° (110° to 150°) at final follow-up (p = 0.001). The mean extension improved significantly from 43° (5° to 90°) pre-operatively to 22° (5° to 40°) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p < 0.001). All the patients had normal elbow stability. Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain