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Modified technique of sternomastoid transfer for elbow flexion
Modified technique of sternomastoid transfer for elbow flexion V. P. Kumar, MBBS, FRCS (Ed), K. Satku, MMed, FRCS (ED), and R. W. H. Pho, FRCS, Singapore, Republic of Singapore
vv
e describe a modification of the transfer of the sternomastoid muscle first described by Bunnell’ to restore elbow flexion in cases of severe brachial plexus injury. Passing the sternomastoid su-
tured to a fascia lata tube under the clavicle eliminated the unsightly skin fold that appears prominently on the side of the neck and chest during muscle contraction (Fig. 1). This simple modification eliminated the bowstringing of the stemomastoid during its action.
Case report From the Department of Orthopaedic Surgery, National University of Singapore, and the Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore. Singapore. Received for publication March 25, 1992.
Aug.
14, 1991; accepted
A 24-year-old man had a flail right upper limb as a result of a brachial plexus injury 3 years before. Investigations con-
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Reprint requests: V. P. Kumar, MBBS, FRCS (Ed), Department of Orthopaedic Surgery, National University Hospital, Lower Kent Ridge Road, Singapore 0511, Republic of Singapore. 3/l/38141
Fig. 1. Diagram showing modified technique for stemomastoid transfer. 812
THE JOURNAL
OF HAND
SURGERY
Fig. 2. Patient with total right brachial plexus palsy with transfer to restore elbow flexion. Note absence of unsightly skin fold during sternomastoid contraction. Elbow flexion of 80 degrees was achieved 8 months after the transfer.
Vol. 17A, No. 5 September 1992
Sternomastoid
firmed a preganglionic avulsion injury of the entire plexus. After a stemomastoid transfer the patient could flex the elbow from 0 to 80 degrees 8 months after surgery (Fig. 2). He had a power grade of 3 + and no unsightly skin folds at the neck or chest wall and was happy with the functional and cosmetic outcome. Technique
We detach the two heads of the sternomastoid from the clavicle through a horizontal supraclavicular incision. A 30 by 4 cm strip of fascia lata is taken from the thigh. The fascia is then tubed longitudinally by means of an absorbable continuous 2-O suture with the deep smooth surface superficial. One end of this tubed fascia is then sutured to the tendinous ends of the two heads of the sternomastoid by burying the latter to a depth of 2 cm within the tube. A channel is created beneath the clavicle by careful dissection with a curved artery forceps protecting the
transfer for elbow flexion
subclavian vessels. The channel is then brought subcutaneously through the subclavius and pectoralis major muscles. A subcutaneous tunnel is next developed to the biceps tendon at the elbow, which is exposed by the standard L-shaped incision. The fascial tube, one end of which was previously sutured to the stemomastoid tendon, is then passed under the clavicle and through the subcutaneous channel to the elbow and sutured to the biceps tendon with the elbow flexed at 90 degrees and the sternomastoid at maximal tension. No. 1 monofilament polypropylene is used in the suture. Postoperatively the elbow is kept flexed 130 degrees in a posterior splint for 4 weeks before mobilization. We routinely fuse the ipsilateral flail shoulder at the same time.
1.
REFERENCE Bunnel S. Restoring flexion to the paralytic elbow. J Bone Joint Surg 1951;33A:566-71.
A new tendon transfer for ulnar clawhand: Use of the palmaris longus extended with the palmar aponeurosis A new tendon transfer for ulnar paralytic clawhand, in which the palmaris longus with distal extensions of the palmar aponeurosis is passed under the transverse carpal ligament and tied to the A-l pulley of the small and ring fingers, is described. Advantages of the procedure are that there is no loss of function and free tendon grafts are not needed. (J HAND SURC 1992;17A:813-5.)
Naoyuki Ochiai, MD, Akira Nagano, MD, Yuji Mikami, MD, Tanefumi Nakagawa, and Seizo Yamamoto, MD, Tokyo, Japan
From the Department of 0rthopaedic Surgery, University of Tokyo, Tokyo, Japan. Received for publication March 10, 1992.
Faculty of Medicine,
Nov. 4, 1991; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Naoyuki Ochiai, MD, Department of Orthopaedic Surgery, Faculty of Medicine, University of Tokyo, 7-3-l. Hongo Bunkyo-ku, Tokyo, I13 Japan. 311138143
MD,
M
any operative procedures have been reported for treatment of ulnar clawhand. The three categories are (1) capsuloplasty,’ (2) tenodesis,*-’ and (3) tendon transfer. ‘. 3.5-8 Surgical technique The ulnar palmar aponeurosis is exposed through a zigzag incision from the wrist to the base of the long finger (Fig. 1). The palmaris longus is dissected, and continuity with the palmar aponeurosis is preserved. In THE JOURNAL OF HAND SURGERY
813
vv
e describe a modification of the transfer of the sternomastoid muscle first described by Bunnell’ to restore elbow flexion in cases of severe brachial plexus injury. Passing the sternomastoid su-
tured to a fascia lata tube under the clavicle eliminated the unsightly skin fold that appears prominently on the side of the neck and chest during muscle contraction (Fig. 1). This simple modification eliminated the bowstringing of the stemomastoid during its action.
Case report From the Department of Orthopaedic Surgery, National University of Singapore, and the Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore. Singapore. Received for publication March 25, 1992.
Aug.
14, 1991; accepted
A 24-year-old man had a flail right upper limb as a result of a brachial plexus injury 3 years before. Investigations con-
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Reprint requests: V. P. Kumar, MBBS, FRCS (Ed), Department of Orthopaedic Surgery, National University Hospital, Lower Kent Ridge Road, Singapore 0511, Republic of Singapore. 3/l/38141
Fig. 1. Diagram showing modified technique for stemomastoid transfer. 812
THE JOURNAL
OF HAND
SURGERY
Fig. 2. Patient with total right brachial plexus palsy with transfer to restore elbow flexion. Note absence of unsightly skin fold during sternomastoid contraction. Elbow flexion of 80 degrees was achieved 8 months after the transfer.
Vol. 17A, No. 5 September 1992
Sternomastoid
firmed a preganglionic avulsion injury of the entire plexus. After a stemomastoid transfer the patient could flex the elbow from 0 to 80 degrees 8 months after surgery (Fig. 2). He had a power grade of 3 + and no unsightly skin folds at the neck or chest wall and was happy with the functional and cosmetic outcome. Technique
We detach the two heads of the sternomastoid from the clavicle through a horizontal supraclavicular incision. A 30 by 4 cm strip of fascia lata is taken from the thigh. The fascia is then tubed longitudinally by means of an absorbable continuous 2-O suture with the deep smooth surface superficial. One end of this tubed fascia is then sutured to the tendinous ends of the two heads of the sternomastoid by burying the latter to a depth of 2 cm within the tube. A channel is created beneath the clavicle by careful dissection with a curved artery forceps protecting the
transfer for elbow flexion
subclavian vessels. The channel is then brought subcutaneously through the subclavius and pectoralis major muscles. A subcutaneous tunnel is next developed to the biceps tendon at the elbow, which is exposed by the standard L-shaped incision. The fascial tube, one end of which was previously sutured to the stemomastoid tendon, is then passed under the clavicle and through the subcutaneous channel to the elbow and sutured to the biceps tendon with the elbow flexed at 90 degrees and the sternomastoid at maximal tension. No. 1 monofilament polypropylene is used in the suture. Postoperatively the elbow is kept flexed 130 degrees in a posterior splint for 4 weeks before mobilization. We routinely fuse the ipsilateral flail shoulder at the same time.
1.
REFERENCE Bunnel S. Restoring flexion to the paralytic elbow. J Bone Joint Surg 1951;33A:566-71.
A new tendon transfer for ulnar clawhand: Use of the palmaris longus extended with the palmar aponeurosis A new tendon transfer for ulnar paralytic clawhand, in which the palmaris longus with distal extensions of the palmar aponeurosis is passed under the transverse carpal ligament and tied to the A-l pulley of the small and ring fingers, is described. Advantages of the procedure are that there is no loss of function and free tendon grafts are not needed. (J HAND SURC 1992;17A:813-5.)
Naoyuki Ochiai, MD, Akira Nagano, MD, Yuji Mikami, MD, Tanefumi Nakagawa, and Seizo Yamamoto, MD, Tokyo, Japan
From the Department of 0rthopaedic Surgery, University of Tokyo, Tokyo, Japan. Received for publication March 10, 1992.
Faculty of Medicine,
Nov. 4, 1991; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Naoyuki Ochiai, MD, Department of Orthopaedic Surgery, Faculty of Medicine, University of Tokyo, 7-3-l. Hongo Bunkyo-ku, Tokyo, I13 Japan. 311138143
MD,
M
any operative procedures have been reported for treatment of ulnar clawhand. The three categories are (1) capsuloplasty,’ (2) tenodesis,*-’ and (3) tendon transfer. ‘. 3.5-8 Surgical technique The ulnar palmar aponeurosis is exposed through a zigzag incision from the wrist to the base of the long finger (Fig. 1). The palmaris longus is dissected, and continuity with the palmar aponeurosis is preserved. In THE JOURNAL OF HAND SURGERY
813