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Transposition of the bicipital tuberosity for treatment of fixed supination contracture in obstetric brachial plexus lesions
T R A N S P O S I T I O N OF T H E B I C I P I T A L T U B E R O S I T Y F O R T R E A T M E N T OF F I X E D S U P I N A T I O N C O N T R A C T U R E I N OBSTETRIC BRACHIAL PLEXUS LESIONS D. EBERHARD
From the Division of Plastic and Reconstructive Surgery, Universityof Vienna Medical School, Austria 2
In nine patients with obstetric brachial plexus lesions (Klumpke type), an impingement of the bicipital tuberosity on the ulna was the main cause for the forearm and hand to be fixed in supination. A surgical technique using reinsertion of the biceps tendon on the bicipital tuberosity is described in detail. It has substantially improved all patients. After a mean follow-up of 29.4 months the hand was in a more functional position than preoperatively in all patients. In seven cases pronation could be increased by contraction of the biceps muscle. By relaxing the biceps muscle and by contraction of the supinator muscle a limited active supination was possible in six cases. Journal of Hand Surgery (British and European Volume, 1997) 22B: 2:261-263
In many cases of lower obstetric brachial plexus lesions (Klumpke type) the forearm and hand are supinated by the action of the biceps muscle unopposed by the pronator teres. Often the supination is not fixed and the hand and forearm can be brought passively into pronation. In association with the supinated position of the forearm, the wrist is held in dorsiflexion because of the extensor muscle imbalance and the effect of gravity. There are several techniques described to deal with this situation (Manfrini and Valdiserri, 1985; Manske et al, 1980; Zancolli, 1976; Zaoussis, 1963). There are other cases where supination is fixed and cannot easily be overcome passively. Causes for supination contracture include contraction of the interosseous membrane, stiffness of the proximal or the distal radioulnar joints or an imbalance of muscular pull on the radius causing a deformity which does not allow the radius to rotate around the ulna. We treated nine patients with supination contracture in whom passive pronation was not possible despite mobilization of the radioulnar joint and longitudinal division of the interosseous membrane. This was due to impingement of the bicipital tuberosity on the ulna. Pronation could only be achieved by overcoming resistance at this point.
supinator muscle, which was usually contracted. The interosseous membrane was divided throughout its length close to the radius and by passive motion the proximal and distal radioulnar joints were mobilized. The bicipital tuberosity was so close to the ulna that pronation could either not be achieved at all or only by overcoming resistance. The forearm went into supination after the tuberosity passed the ulna with a "click". The tuberosity including the attached biceps tendon was removed using a chisel. After this procedure pronation and supination could be done easily. The bicipital tuberosity was reinserted by a compression screw with a washer. The site of reinsertion was selected by the following criteria:
PATIENTS A N D M E T H O D S
In two cases (3 and 8) the pronator teres muscle was reinserted on the radius even though it was paralysed. It was elongated by supination and because of its elasticity a pronating effect was achieved.
1. If no supinator muscle was available the reinsertion was done on the dorsoradial border of the radius. This produced a neutral forearm position on biceps contraction. The muscle would flex the elbow joint without pronation or supination. 2. If the supinator muscle was well developed, it was reinserted by a drill hole into the radius in order to restore active supination. In this case the bicipital tuberosity was reinserted more dorsally on the radius in order to give the biceps a pronating effect when flexing the elbow joint.
Surgical technique
After the diagnosis of supination contracture had been established by clinical examination the deformity of the radius was evaluated by X-ray (patients with severe deformity of the radius were treated by osteotomy and are not discussed here). Under general anaesthesia patients were positioned supine with the upper extremity draped free on a hand table. A midlateral incision was made beginning on the lateral aspect of the arm and extending to the forearm. The radial nerve and its muscle branches were defined. The muscle attachments to the proximal radius were divided. This included the
Patients
Between 1989 and 1993, 23 patients with supination deformities due to obstetric brachial plexus lesions were treated at our department. In nine patients the main obstacle to achieve passive pronation during surgery was the close proximity of the bicipital tuberosity and ulna described above. One patient had already been operated without success elsewhere (case 1). The poor surgical result was due to the fact that the problem of 261
262
THE JOURNAL OF H A N D S U R G E R Y
the bicipital tuberosity as the main obstacle to passive pronation had not been recognized (Fig la). The left arm and forearm were explored as described. After removal of the bicipital tuberosity pronation was easily possible (Fig lb). Figure 2 shows the result after 4 years. Details of the nine patients are given in Table 1. The mean age was 15 years. In all but one case the interosseous membrane was split longitudinally along the radius before removing the bicipital tuberosity. The supinator muscle was disinserted in all cases and reinserted in six patients. In two cases the paralysed pronator teres muscle was reinserted to exploit its elasticity. The reinsertion of the bicipital tuberosity with the biceps tendon was done in pronation between 10 ° and 20 ° in seven cases and in neutral position in two cases. RESULTS The results are listed in Table 1. Active pronation and supination was obtained in five patients and only active
VOL.22BNo. 2 APRIL1997
pronation was retained in three patients. Only passive motion was obtained in one patient. DISCUSSION The shape of the growing skeleton is influenced by the traction of attached muscles. The lack of pull by the paralysed pronator teres muscle is most probably responsible for the radially convex deformity of the radius. In some cases contracture of the interosseous membrane prohibits pronation. On X-ray the parallel arrangement of the bones without narrowing o f the space between them can be seen. In our nine cases the pull of the supinator muscle, which had lost its antagonists and frequently became contracted, caused an approximation between the proximal radius and the ulna. The forearm was permanently supinated and the distance between the radius and ulna became so small that the bicipital tuberosity impinged
Fig 1 (a) Case 1, 2 years after unsuccessful surgery elsewhere. Supination contracture of left forearm with no active or passive pronation possible. (b) After the bicipital tuberosity has been chiselled off, pronation is possible.
Fig 2
(a) Case 1, 4 years after operation. The forearm is in a neutral position. Slight pronation is possible when the elbow is flexed. (b) When the biceps is relaxed some supination is possible.
TRANSPOSITION OF THE BICIPITAL TUBEROSITY
263
on the ulna. To our knowledge this observation is not described in the literature. We found the bicipital tuberosity to be a cause of supination contracture in nine of 23 cases. This seems to be a high incidence. An explanation might be that the average age of our patients was rather high (15 years). Apparently the narrowing between the radius and ulna develops over time, when the supination contracture has persisted for many years.
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References
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Manfrini M, Valdiserri L (1985). Proximal radio-ulnar arthrorisis in the treatment of supination deformity resulting from obstetrical paralysis. Italian Journal of Orthopedic Traumatology, 11: 309-313. Manske P R, McCarroll H R, Hale R (1980). Biceps tendon rerouting and percutaneous osteoclasis in the treatment of supination deformity in obstetrical palsy. Journal of H a n d Surgery, 5: 153-159. Zancolli E (1976). Paralytic supinafion contracture of the forearm. Journal of Bone and Joint Surgery, 49A: 1275-1284. Zaoussis A L (1963 ). Osteotomy of the proximal end of the radius for paralytic supination deformity in children. Journal of Bone and Joint Surgery, 45B: 523 527.
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Received: 19 January 1996 Accepted after revision: 8 July 1996 D. Eberhard MD, Ludwig-Boltzmann Institute for Experimental Plastic Surgery, Waehringer Guertel, 18-20A-1090, Vienna, Austria. © 1997 The British Society for Surgery of the Hand
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From the Division of Plastic and Reconstructive Surgery, Universityof Vienna Medical School, Austria 2
In nine patients with obstetric brachial plexus lesions (Klumpke type), an impingement of the bicipital tuberosity on the ulna was the main cause for the forearm and hand to be fixed in supination. A surgical technique using reinsertion of the biceps tendon on the bicipital tuberosity is described in detail. It has substantially improved all patients. After a mean follow-up of 29.4 months the hand was in a more functional position than preoperatively in all patients. In seven cases pronation could be increased by contraction of the biceps muscle. By relaxing the biceps muscle and by contraction of the supinator muscle a limited active supination was possible in six cases. Journal of Hand Surgery (British and European Volume, 1997) 22B: 2:261-263
In many cases of lower obstetric brachial plexus lesions (Klumpke type) the forearm and hand are supinated by the action of the biceps muscle unopposed by the pronator teres. Often the supination is not fixed and the hand and forearm can be brought passively into pronation. In association with the supinated position of the forearm, the wrist is held in dorsiflexion because of the extensor muscle imbalance and the effect of gravity. There are several techniques described to deal with this situation (Manfrini and Valdiserri, 1985; Manske et al, 1980; Zancolli, 1976; Zaoussis, 1963). There are other cases where supination is fixed and cannot easily be overcome passively. Causes for supination contracture include contraction of the interosseous membrane, stiffness of the proximal or the distal radioulnar joints or an imbalance of muscular pull on the radius causing a deformity which does not allow the radius to rotate around the ulna. We treated nine patients with supination contracture in whom passive pronation was not possible despite mobilization of the radioulnar joint and longitudinal division of the interosseous membrane. This was due to impingement of the bicipital tuberosity on the ulna. Pronation could only be achieved by overcoming resistance at this point.
supinator muscle, which was usually contracted. The interosseous membrane was divided throughout its length close to the radius and by passive motion the proximal and distal radioulnar joints were mobilized. The bicipital tuberosity was so close to the ulna that pronation could either not be achieved at all or only by overcoming resistance. The forearm went into supination after the tuberosity passed the ulna with a "click". The tuberosity including the attached biceps tendon was removed using a chisel. After this procedure pronation and supination could be done easily. The bicipital tuberosity was reinserted by a compression screw with a washer. The site of reinsertion was selected by the following criteria:
PATIENTS A N D M E T H O D S
In two cases (3 and 8) the pronator teres muscle was reinserted on the radius even though it was paralysed. It was elongated by supination and because of its elasticity a pronating effect was achieved.
1. If no supinator muscle was available the reinsertion was done on the dorsoradial border of the radius. This produced a neutral forearm position on biceps contraction. The muscle would flex the elbow joint without pronation or supination. 2. If the supinator muscle was well developed, it was reinserted by a drill hole into the radius in order to restore active supination. In this case the bicipital tuberosity was reinserted more dorsally on the radius in order to give the biceps a pronating effect when flexing the elbow joint.
Surgical technique
After the diagnosis of supination contracture had been established by clinical examination the deformity of the radius was evaluated by X-ray (patients with severe deformity of the radius were treated by osteotomy and are not discussed here). Under general anaesthesia patients were positioned supine with the upper extremity draped free on a hand table. A midlateral incision was made beginning on the lateral aspect of the arm and extending to the forearm. The radial nerve and its muscle branches were defined. The muscle attachments to the proximal radius were divided. This included the
Patients
Between 1989 and 1993, 23 patients with supination deformities due to obstetric brachial plexus lesions were treated at our department. In nine patients the main obstacle to achieve passive pronation during surgery was the close proximity of the bicipital tuberosity and ulna described above. One patient had already been operated without success elsewhere (case 1). The poor surgical result was due to the fact that the problem of 261
262
THE JOURNAL OF H A N D S U R G E R Y
the bicipital tuberosity as the main obstacle to passive pronation had not been recognized (Fig la). The left arm and forearm were explored as described. After removal of the bicipital tuberosity pronation was easily possible (Fig lb). Figure 2 shows the result after 4 years. Details of the nine patients are given in Table 1. The mean age was 15 years. In all but one case the interosseous membrane was split longitudinally along the radius before removing the bicipital tuberosity. The supinator muscle was disinserted in all cases and reinserted in six patients. In two cases the paralysed pronator teres muscle was reinserted to exploit its elasticity. The reinsertion of the bicipital tuberosity with the biceps tendon was done in pronation between 10 ° and 20 ° in seven cases and in neutral position in two cases. RESULTS The results are listed in Table 1. Active pronation and supination was obtained in five patients and only active
VOL.22BNo. 2 APRIL1997
pronation was retained in three patients. Only passive motion was obtained in one patient. DISCUSSION The shape of the growing skeleton is influenced by the traction of attached muscles. The lack of pull by the paralysed pronator teres muscle is most probably responsible for the radially convex deformity of the radius. In some cases contracture of the interosseous membrane prohibits pronation. On X-ray the parallel arrangement of the bones without narrowing o f the space between them can be seen. In our nine cases the pull of the supinator muscle, which had lost its antagonists and frequently became contracted, caused an approximation between the proximal radius and the ulna. The forearm was permanently supinated and the distance between the radius and ulna became so small that the bicipital tuberosity impinged
Fig 1 (a) Case 1, 2 years after unsuccessful surgery elsewhere. Supination contracture of left forearm with no active or passive pronation possible. (b) After the bicipital tuberosity has been chiselled off, pronation is possible.
Fig 2
(a) Case 1, 4 years after operation. The forearm is in a neutral position. Slight pronation is possible when the elbow is flexed. (b) When the biceps is relaxed some supination is possible.
TRANSPOSITION OF THE BICIPITAL TUBEROSITY
263
on the ulna. To our knowledge this observation is not described in the literature. We found the bicipital tuberosity to be a cause of supination contracture in nine of 23 cases. This seems to be a high incidence. An explanation might be that the average age of our patients was rather high (15 years). Apparently the narrowing between the radius and ulna develops over time, when the supination contracture has persisted for many years.
+++1111++ t
+ + + + + 1 + + +
References
0000
Manfrini M, Valdiserri L (1985). Proximal radio-ulnar arthrorisis in the treatment of supination deformity resulting from obstetrical paralysis. Italian Journal of Orthopedic Traumatology, 11: 309-313. Manske P R, McCarroll H R, Hale R (1980). Biceps tendon rerouting and percutaneous osteoclasis in the treatment of supination deformity in obstetrical palsy. Journal of H a n d Surgery, 5: 153-159. Zancolli E (1976). Paralytic supinafion contracture of the forearm. Journal of Bone and Joint Surgery, 49A: 1275-1284. Zaoussis A L (1963 ). Osteotomy of the proximal end of the radius for paralytic supination deformity in children. Journal of Bone and Joint Surgery, 45B: 523 527.
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O O O
O ~
~
~Z
Received: 19 January 1996 Accepted after revision: 8 July 1996 D. Eberhard MD, Ludwig-Boltzmann Institute for Experimental Plastic Surgery, Waehringer Guertel, 18-20A-1090, Vienna, Austria. © 1997 The British Society for Surgery of the Hand
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I II II