多组神经移位治疗臂丛C5~C7根性撕脱伤重建肩外展及屈肘功能

目的观察联合应用多组神经移位治疗臂丛上、中干根性撕脱伤重建肩外展及屈肘功能的临床效果。方法我科于2012年4月至2014年4月收治臂丛上、中干根性撕脱伤患者16例,采用副神经斜方肌肌支移位修复肩胛上神经、桡神经肱三头肌长头支移位修复腋神经肌支及尺神经部分束支移位肌皮神经（Oberlin术式）,联合修复臂丛上、中干根性撕脱伤,以恢复肩外展及屈肘功能。术后随访采用臂肩手功能障碍（the disabilities of the arm, shoulder and hand, DASH）评分表评估疗效。结果16例患者中有14例术后得到随访。随访时间为24~28个月（平均为25个月）,患者肩关节外展恢复至75°~90°,恢复时间为9.0~18.0个月（平均为14.0个月）。屈肘恢复至100°~160°,恢复时间为4.0~7.5个月（平均为5.8个月）。DASH评分为8.0~16.0分,平均为14.6分。结论使用多组神经移位联合治疗臂丛上、中干损伤,可较好恢复肩外展及屈肘功能,尺神经部分束支移位修复肌皮神经肱二头肌支对手内在肌功能无明显影响。     

多组神经移位治疗臂丛上、中干根性撕脱伤重建肩外展及屈肘功能

目的 观察联合应用多组神经移位治疗臂丛上、中干根性撕脱伤的临床效果。方法 我科于2012年4月至2014年4月收治臂丛上、中干根性撕脱伤损伤患者16例,采用副神经斜方肌肌支移位修复肩胛上神经、桡神经肱三头肌长头支移位修复腋神经肌支及Oberlin术式,联合修复臂丛上、中干根性撕脱伤,恢复肩外展及屈肘功能。术后随访采用DASH评分表进行手术疗效评估。结果 术后16例患者中14例得到随访。随访24—28个月(平均25个月),患者肩关节外展恢复至75°-90°,恢复时间9-18个月(平均14个月)。屈肘恢复至100°-160°,恢复时间4-7.5个月（平均5.8个月）。DASH评分8-14分,平均14.6分。结论 臂丛上、中干损伤使用多组神经移位联合治疗,可较好恢复肩外展及屈肘功能,尺神经部分束支移位修复肌皮神经肱二头肌支对手内在肌功能无明显影响。     

胸大肌转位重建屈肘功能

目的探讨臂丛神经及肌皮神经损伤后,以胸大肌转位重建屈肘功能的方法.方法应用胸大肌转位代肱二头肌重建屈肘功能共12例.结果本组病人有11例随访,随访时间1～6年,效果满意.结论胸大肌转位是重建屈肘功能的有效方法.     

肩肘关节功能重建10例报告

目的：对因臂丛神经损伤或单纯腋神经麻痹所致难以恢复的三角肌瘫痪及屈肘肌瘫痪的患者进行肩关节外展功能重建和肘关节屈面功能重建。方法：用同侧斜方肌、背阔肌或胸大肌转位重建肩、肘关节功能各5例。结果：肩关节外展功能重建优4例,可1例。屈肘功能重建优4例,良1例。结论：创伤引起神经麻痹所致三角肌及屈肘肌瘫在原神经功能难以恢复的情况下,有选择性地进行肩外展及肘屈曲功能重建,可获较满意效果。     

健侧C7神经根经椎体前通路移位修复臂丛神经损伤疗效的初步观察

目的：观察经椎体前通路行健侧C7神经根移位修复臂丛神经损伤的临床效果。方法：将健侧C7神经根在干股交界处切断，近端游离至椎间孔处，经前斜角肌的深面翻转至椎体前食管后间隙，经4-6股皮神经桥接，修复患侧上干或上干后股。2002年3月-2003年8月，共完成21例手术，其中14例术后随访1年以上。14例中男12例，女2例；年龄17-41岁，平均31岁。手术时间：伤后2～6个月，平均4个月。全臂丛神经撕脱伤5例，上中干撕脱伴下干不全损伤8例，上中干锐器伤1例。结果：14例患者术后随访12～19个月，平均16个月。健侧C7神经根修复患侧上干或C5、C6神经根或上干前后股的10例，9例肩外展及屈肘肌肌力≥3级，1例无效；健侧C7神经根修复患侧上干后股或C5神经根的3例，肩外展肌肌力均≥3级；健侧C7神经根修复C6神经根1例，肱二头肌肌力为0级。结论：健侧C7神经根经椎体前通路移位修复臂丛神经上干的同时重建肩外展及屈肘功能或修复上干后股重建肩外展功能，可取得良好疗效。     

健侧C7神经根椎体前移位治疗臂丛根性撕脱伤

目的报道应用健侧C7神经根椎体前移位修复臂丛神经根性撕脱伤的临床效果。方法将健侧C7于前后股分叉处切断，经颈血管鞘和食管后深层，椎体前面通路移植5～6股腓肠神经与患侧臂丛上干吻合重建臂丛上干功能6例。结果术后6例随访13～18个月，其中1例肩外展肌力、屈肘肌力均恢复至4级；3例肩外展肌力恢复至4级，屈肘肌力恢复至3级；1例肩外展肌力恢复至3级，屈肘肌力恢复至2级；1例肩外展及屈肘肌力均恢复至2级。结论健侧C7经椎体前短通路重建臂丛上干功能，在临床应用上是可行、安全的，具有缩短神经移植长度，缩短神经功能恢复时间的优点。     

健侧C7 神经根经椎体前移位修复臂丛上干损伤的中期临床随访

目的 观察健侧C7 神经根经椎体前通路移位修复臂丛上干损伤重建肩外展、屈肘功能的中期效果.方法 健侧C7 神经根经椎体前通路移位修复臂丛上干损伤患者15例,男14例,女1例;年龄15～43岁,平均30岁.全臂丛撕脱伤7例,上、中干撕脱伴下干不全损伤6例,上、中干损伤2例.健侧C7 神经根经椎体前通路移位到患侧臂丛上干的距离平均(7.6±1.7)cm,8例同时行副神经或膈神经移位单独修复肩胛上神经.结果 随访36～63个月,平均50个月.健侧上肢用力内收时,12例患者的肱二头肌、三角肌、胸大肌锁骨部、冈上肌肌力(8例来自副神经或膈神经的支配)均达到4级,大脑皮层运动支配中枢发生临床转化;另3例肌力为3级或以下,尚未发生大脑皮层运动支配中枢的临床转化.健侧上肢用力内收时,8例肩胛上神经单独修复者的肩外展角度平均78.0°,另7例平均43.1..结论 健侧C7 神经根经椎体前通路移位可用于修复臂丛上千损伤,桥接神经的距离短,重建肩外展及屈肘功能的效果良好,大脑皮层运动支配中枢可发生临床转化.     

Betaman法斜方肌移位术重建肩外展功能

臂丛神经损伤经过神经修复手术后，患者肩外展功能仍不能恢复，甚至仍有肩关节半脱位者，可用肩周附近有功能的肌肉移位重建肩外展功能。1997年7月。2002年12月，我院采用改良Betaman法斜方肌移位术重建肩外展功能，取得较为满意的疗效。     

指浅屈肌翻转移位重建屈肘功能

随着现代交通事故的增加 ,臂丛神经损伤逐渐增多 ,且损害程度往往很重 ,预后不佳 ,仅有部分患者通过各种功能重建手术恢复功能。 1 995年 6月～1 998年 6月 ,我科共收治臂丛神经损伤 32例 ,其中4例为臂丛神经上干损伤 ,腕关节及手活动正常 ,肩、肘功能障碍 ,采用指浅屈肌腱翻转移位重建屈肘功能 ,取得了良好的临床效果 ,报告如下。1　临床资料1 .1　一般资料本组 4例 ,均为男性。年龄 2 2～ 42岁。交通事故伤 3例 ,高空坠落伤 1例。临床均表现为屈肘及肩外展功能障碍 ,被动屈肘活动良好 ,肱二头肌及三角肌肌力为 0 ,前臂旋前位时肘关节无主…     

神经干移位和束组移位术治疗臂丛神经上千损伤的疗效对比

目的:探讨臂丛神经上干损伤后应用神经干移位及神经束组移位术的疗效对比.方法:将20例单纯臂丛神经上千损伤患者分成A、B两组,每组10例.患侧肩均不能外展、外旋、上举;屈肘不能;耸肩及伸肘肌力≥4级.肌电图检查:副神经、膈神经及尺神经功能正常;正中神经轻度受损.患者于伤后3-11个月入院治疗.A组于全麻下行副神经到肩胛上神经、膈神经到肌皮神经、肋间神经到腋神经移位术;13组于全麻下行副神经到肩胛上神经、尺神经束支或正中神经束支到肌皮神经、正中神经束支或尺神经束支到腋神经移位术.结果:术后伤口均Ⅰ期愈合,其中B组2例患者出现手部尺神经轻度损伤症状,2例患者出现正中神经轻度损伤症状,经对症治疗后消失.其余患者未出现与供区神经受损的症状.两组患者均获得随访,分别于术后3、6、9、12个月行肌电图检查,经统计学分析,B组神经传导速度优于A组(P＜0.05).A组患者术后5～6个月出现肩外展及屈肘动作,肌电图可记录到受区肌肉新生电位;术后8～9个月,患者肩外展30～65°,屈肘90～120°,肌力3～4级.B组患者术后3～4个月出现肩外展及屈肘动作,肌电图可记录到受区肌肉新生电位;术后7～8个月,患者肩外展30～65°,屈肘90～120°,肌力3～4级.结论:应用功能相近的供体神经行神经束组移位修复受损的神经具有供区损失小、恢复时间快、功能恢复佳等优点,其效果优于神经干直接修复.     

Surgical technique of pedicled bipolar pectoralis major transfer for reconstruction of elbow flexion in brachial plexus palsy

In Erb (C5-C6) type of palsy due to traumatic brachial plexus injury, function is dependent upon the ability of the arm to maneuver and stabilize the hand for action. Complete loss of power of elbow flexion after brachial plexus injuries is a severe disability. If there is control of the shoulder, elbow flexion is of major importance. Various types of procedures have been described to recover or reanimate elbow flexion for chronic or failed upper type paralysis, including free muscle transfer, unipolar and bipolar pedicled muscle transfer, and various tendon transfers.In this article, we describe the surgical technique of bipolar pectoralis major transfer and our experience with this type of transfer, wherein we prefer to transfer all components of the pectoralis major muscle including the sternocostal and clavicular origins and humeral insertion without a fascial graft by the inclusion of a strip of the rectus abdominis fascia along with the flap.     

多组神经束支部移位治疗臂丛神经上干损伤的近期疗效

目的 通过在各受区神经近入肌点处同时进行多组神经束支部移位,恢复臂丛神经上干损伤后丧失的肩肘功能.方法 2007年2月-9月,收治4例单纯臂丛神经上干损伤男性患者.年龄21～39岁.均为车祸伤.左侧1例,右侧3例.患侧肩关节外展、外旋、上举及屈肘不能;耸肩、伸肘、屈伸腕指肌力≥4级.肌电图检查:副神经、尺神经及肱三头肌长头肌支功能好;正中神经功能轻度受损.患者于伤后3～11个月入院.于全麻下行后路副神经到肩胛上神经、肱三头肌肌支到腋神经、尺神经部分束支到肱二头肌肌支和/或正中神经部分束支到肱肌肌支移位术.结果 术后切口均Ⅰ期愈合,其中1例术后出现手部尺侧麻木症状,经对症处理后症状消失.余患者未出现与供区神经相关的运动、感觉功能受损症状.4例均获随访,随访时间7～12个月.术后3～4个月患侧均出现肩外展、屈肘动作.肌电图显示3组受区肌肉均可记录到新生电位.术后6～7个月,患者肩外展30～65°,屈肘90～120°,肌力3～4级.1例随访12个月患者肩外展、上举、外旋及届肘主动活动度基本正常,三角肌、肱二头肌外形轮廓接近正常.结论 应用功能相近的供体神经进行多组神经束支部移位具有供区损失小、恢复时间快、功能恢复佳等优点.尤其适合因伤后时间长延误治疗及锁骨上探查有风险的臂丛神经上干损伤患者.     

Use of the pedicled latissimus muscle flap for upper-extremity reconstruction

Tissue with a blood supply derived from a single constant vascular pedicle may be raised as a flap and rotated within the reach of its blood supply to cover and reconstruct a variety of complex wounds. The latissimus dorsi muscle makes an ideal pedicled flap because of its long neurovascular pedicle, large size, ease of mobilization, and expendability. It can be rotated, with or without overlying skin, to cover soft-tissue defects involving the shoulder, arm, and elbow, or it can be transferred as an innervated muscle to improve shoulder abduction as well as elbow flexion and extension. The major clinical applications of the pedicled latissimus dorsi muscle flap for upper-extremity reconstruction include use as a bipolar transfer to improve elbow flexion after trauma or brachial plexus injury and as a nonfunctioning myocutaneous transfer for coverage of nerves, bones, and joints after soft-tissue loss due to trauma, tumors, infection, or irradiation.     

带蒂大圆肌双极移位重建产瘫肩外展功能

目的评价带蒂大圆肌双板移位重建分娩性臂丛神经损伤（产瘫）后肩外展功能的疗效及临床应用前景。方法对9例产瘫后肩外展功能障碍的患儿行带血管神经蒂大圆肌双极移位术重建肩外展功能,并经术后1年以上的随访,观察其临床应用效果。结果9例患儿术前肩外展平均11．2°（0°-30°）,术后肩外展平均75．4°（45°～95°）。按照顾玉东的评定标准评价：优3例,良4例,可2例,优良率为77．8％。结论对于产瘫后肩外展功能障碍者,用带血管神经蒂大圆肌双极移位术重建其肩外展功能是有效而值得临床推广的治疗方法。     

Function of the shoulder joint after pectoralis major transfer--tracking movement and its electromyographical study

In 11 cases of pectoralis major transfer, tracking movement was performed in the scapular and sagittal planes for both shoulder joints to compare the tracking movement ability of the operated shoulder and the unoperated shoulder. At the same time, electromyograms were taken of the upper trapezius, the middle deltoideus, the pectoralis major and the rhomboideus to compare the EMG amplitude of the operated shoulder and the unoperated shoulder. For all movement at average values, tracking movement ability was better in the operated shoulder. From these findings, it is thought that pectoralis major transfer increases shoulder stability at the time of movement. The increase in EMG amplitude of pectoralis major of the operated shoulder is considered to result from the action of the transferred pectoralis major, which serves as an effective abductor of the scapula, also taking into account the early occurrence of scapular abduction.     

Trapezius transfer in brachial plexus palsy. Correlation of the outcome with muscle power and operative technique

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Saha's technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique. The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6 degrees (0 to 45) to 34 degrees (5 to 90) at the last review. The mean forward flexion increased from 12 degrees (0 to 85) to 30 degrees (5 to 90). Abduction (41 degrees) and especially forward flexion (43 degrees) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42 degrees of abduction and 56 degrees of forward flexion. Active abduction (28 degrees) and forward flexion (19 degrees) were much less in completely flail shoulders (n = 34). Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished. The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.     

Nerve transfers in children with traumatic partial brachial plexus injuries

Brachial plexus trauma is a rare condition in children except for obstetrical lesions, for which nerve grafting is generally proposed. Two children (9 and 12 years old) with C5 and C6 traumatic brachial plexus avulsion lesions are presented, where elbow flexion and shoulder abduction and external rotation were the functions to be restored. Nerve transfers have been performed. Shoulder abduction was restored by an accessory-to-suprascapular nerve transfer in one patient, while the triceps long head motor branch was transferred to the axillary nerve in both patients. Fascicles of the ulnar and median nerve were transferred respectively to the biceps muscle nerve and the brachialis motor branch. At 11 months follow-up, the elbow flexion scored M4 and the shoulder abduction recovered in both patients. No complications were observed. Nerve transfers currently used in adult patients may be applied in children with traumatic partial brachial plexus palsies.     

Tendon transfer around the shoulder in obstetric brachial plexus paralysis: clinical and computed tomographic study

One hundred nine obstetrical palsy patients with defective shoulder abduction and external rotation had subscapularis release and transfer of teres major to infraspinatus with or without pedicle transfer of the clavicular head of pectoralis major to deltoid. The age at surgery averaged 67 months (11-192) and follow-up averaged 36 months (12-80). Thirty-nine cases had follow-up CT scan of both shoulders.Improvement of abduction averaged 64 degrees and that of external rotation 50 degrees, 100% and 290% gain, respectively. Both negatively correlated with the age at surgery (P < 0.001), and were significantly higher in patients operated younger than 4 years.On computed tomographic scans, the degree of glenoid retroversion positively correlated (P < 0.001) with the age at surgery, and was significantly higher in patients operated older than 4 years. The degree of posterior subluxation showed no significant difference between different ages. There was no significant difference between the operated and normal sides in patients operated younger than 4years with regard to glenoid retroversion and in those operated younger than 2 years with regard to posterior subluxation.The operation is useful for correction of defective shoulder abduction and external rotation in obstetric palsy. It is best performed before the age of 2 to get maximal improvement in motion and prevent secondary bone changes. Between the ages of 2 and 4, it also resulted in significant improvement in motion and prevented glenoid retroversion, but not posterior subluxation. After the age of 4, the improvement in motion was not significant and secondary bone changes were not prevented.