Motor Nerve Transfers to Restore Extrinsic Median Nerve Function: Case Report

Abstract

Active pronation is important for many activities of daily living. Loss of median nerve function including pronation is a rare sequela of humerus fracture. Tendon transfers to restore pronation are reserved for the obstetrical brachial plexus palsy patient. Transfer of expendable motor nerves is a treatment modality that can be used to restore active pronation. Nerve transfers are advantageous in that they do not require prolonged immobilization postoperatively, avoid operating within the zone of injury, reinnervate muscles in their native location prior to degeneration of the motor end plates, and result in minimal donor deficit. We report a case of lost median nerve function after a humerus fracture. Pronation was restored with transfer of the extensor carpi radialis brevis branch of the radial nerve to the pronator teres branch of the median nerve. Anterior interosseous nerve function was restored with transfer of the supinator branch to the anterior interosseous nerve. Clinically evident motor function was seen at 4 months postoperatively and continued to improve for the following 18 months. The patient has 4+/5 pronator teres, 4+/5 flexor pollicis longus, and 4-/5 index finger flexor digitorum profundus function. The transfer of the extensor carpi radialis brevis branch of the radial nerve to the pronator teres and supinator branch of the radial nerve to the anterior interosseous nerve is a novel, previously unreported method to restore extrinsic median nerve function.

Keywords

Nerve transfers Pronation Nerve injury Median nerve

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References

Abrams

Ziets

Lieber

. Anatomy of the radial nerve motor branches in the forearm. J Hand Surg Am 1997;22: 232–7. doi:10.1016/S0363-5023(97)80157-8.

Apergis

Aktipis

Giota

. Median nerve palsy after humeral shaft fracture: case report. J Trauma 1998;45:825–6. doi:10.1097/00005373-199810000-00040.

Bertelli

. Brachialis muscle transfer to the forearm muscles in obstetric brachial plexus palsy. J Hand Surg Br 2006;31:261–5. doi:10.1016/j.jhsb.2005.11.001.

Bunnell

. Opposition of the thumb. J Bone Jt Surg Am 1938;20: 269–84.

Camitz

. Uber die Behandlung der Oppositionslahmung. Acta Chir Scand. 1929;65:77–81.

Chuang

Borud

. Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy. Plast Reconstr Surg 2002;109:1934–46. doi:10.1097/00006534-200205000-00025.

Davis

. Median nerve palsy. In: Green

, editor. Operative hand surgery. Philadelphia, PA: Churchill Livingstone; 2005. p. 1131–59.

Haugstvedt

Berger

Berglund

. A mechanical study of the moment-forces of the supinators and pronators of the forearm. Acta Orthop Scand 2001;72:629–34. doi:10.1080/000164701317269076.

Huber

. Hilfsoperation bei median Uhlahmung. Dtsch Arch Klin Med 1921;136:271.

10.

Kapandji

. Biomechanics of pronation and supination of the forearm. Hand Clin 2001;17:111–22.

11.

Mackinnon

Novak

. Nerve transfers: new options for reconstruction following nerve injury. Hand Clin 1999;15:643–66.

12.

Mackinnon

Novak

Myckatyn

. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg Am 2005;30:978–85. doi:10.1016/j.jhsa.2005.05.014.

13.

Mackinnon

Roque

Tung

. Median to radial nerve transfer for treatment of radial nerve palsy. Case report. J Neurosurg 2007;107:666–71. doi:10.3171/JNS-07/09/0666.

14.

Manske

McCarroll

Jr Hale

. Biceps tendon rerouting and percutaneous osteoclasis in the treatment of supination deformity in obstetrical palsy. J Hand Surg Am 1980;5:153–9.

15.

Novak

Mackinnon

. Distal anterior interosseous nerve transfer to the deep motor branch of the ulnar nerve for reconstruction of high ulnar nerve injuries. J Reconstr Microsurg 2002;18:459–64. doi:10.1055/s-2002-33326.

16.

Novak

Mackinnon

. Surgical treatment of a long thoracic nerve palsy. Ann Thorac Surg 2002;73:1643–5. doi:10.1016/S0003-4975(01)03372-0.

17.

Novak

Mackinnon

. Treatment of a proximal accessory nerve injury with nerve transfer. Laryngoscope 2004;114:1482–84. doi:10.1097/00005537-200408000-00030.

18.

Ozkan

Aydin

Ozer

. A surgical technique for pediatric forearm pronation: brachioradialis rerouting with interosseous membrane release. J Hand Surg Am 2004;29:22–7. doi:10.1016/j.jhsa.2003.10.002.

19.

Royle

. An operation for paralysis of the thumb intrinsic muscles of the thumb. JAMA 1938;111:612–3.

20.

Seddon

Medaware

Smith

. Rate of regeneration of peripheral nerves in man. J Physiol 1943;102:191–215.

21.

Thompson

. A modified operation for opponens paralysis. J Bone Jt Surg Am 1942;26:632–40.

22.

Timm

O'Driscoll

Johnson

. Functional comparison of pronation and supination strengths. J Hand Ther 1993;6:190–3.

23.

Tung

Mackinnon

. Flexor digitorum superficialis nerve transfer to restore pronation: two case reports and anatomic study. J Hand Surg Am 2001;26:1065–72. doi:10.1053/jhsu.2001. 28427.

24.

Tung

Novak

Mackinnon

. Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries. J Neurosurg 2003;98:313–8.

25.

Tung

Weber

Mackinnon

. Nerve transfers for the upper and lower extremities. Oper Tech Orthop 2004;14:213–22. doi:10.1053/j.oto.2004.06.002.

26.

Weber

Mackinnon

. Nerve transfer in the upper extremity. J Am Soc Surg Hand 2004;4:200–13. doi:10.1016/j.jassh.2004.06.011.