尺侧腕屈肌移位重建屈肘功能

目的分析应用尺侧腕屈肌移位术重建屈肘功能的疗效。方法对16例臂丛上中干损伤(单纯上干损伤7例,上、中干损伤9例),应用尺侧腕屈肌移位术重建屈肘功能。其中3例于术后8~12个月因移位肌腱肌张力松弛,而再次行移位肌肌腱紧缩或止点重新固定术。结果术后随访6~24个月,平均12个月。屈肘肌力恢复至4级12例,3级3例,2级1例。肘关节主动屈曲0°~130°,平均95°;主动伸直-30°~0°,平均-15°;9例在完成屈肘动作时前臂处于旋前位。结论尺侧腕屈肌移位重建屈肘功能方法简单、效果满意,但术后仍存在移位肌腱肌张力松弛、前臂旋前位屈肘及肘关节伸直障碍等问题,需有待进一步改进。     

尺侧腕屈肌及旋前圆肌移位重建前臂旋后功能

目的 探讨尺侧腕屈肌及旋前圆肌移位重建脑性瘫痪前臂旋前畸形患者前臂旋后功能的临床疗效.方法 对脑瘫患者单侧前臂旋前畸形无明显智力障碍的6例,将尺侧腕屈肌转位至桡侧腕短伸肌,旋前圆肌绕桡骨转位重建止点,修复其前臂旋后功能.结果 6例术后随访1～4年,前臂主动旋前由术前10°恢复到术后平均为80°,主动旋后由术前0°恢复到术后平均为60°,旋后肌力由术前0级恢复到术后Ⅳ级,均能完成正常生活和工作,对屈腕功能无明显影响.结论 尺侧腕屈肌及旋前圆肌移位重建脑瘫患者前臂旋后功能可以达到较理想的临床效果.     

劈开桡侧腕屈肌重建伸拇、伸指功能的初步探讨

目的 探讨将前臂桡侧腕屈肌劈开转位重建伸拇、伸指功能的可行性及临床效果.方法 沿桡侧腕屈肌中央肌腱向近心端纵行剖开,形成尺侧部分和肱侧部分同时重建伸拇、伸指功能.术后按照桡神经损伤肌腱移位术的疗效评定标准进行功能评定.结果 本组共3例患者,术后切口均Ⅰ期愈合,获随访12～36个月,疗效优者1例,良者2例,术后患者均未行肌腱松解,伸拇、伸指功能恢复良好.结论 按照骨骼肌"亚部化"的原则,将桡侧腕屈肌劈开后转位,并同时重建两个功能的缺失,与传统的复杂重建术式相比,这一技术的多能性和简易性具有更大的优势.     

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.     

尺侧腕屈肌移位重建屈肘功能

１９８１年５月～１９９２年１１月，连续应用尺侧腕屈肌移位重建屈时功能２１例。经平均３．８年随访，肘关节屈伸活动度最小为７０°，最大为１２０°。肌力最小达Ⅲ级，最大达Ⅴ级。全部病人能满足日常生活工作需要。讨论了在屈时功能重建的同时，需从上肢整体功能考虑肩关节的稳定性及前臂旋转功能。分析了影响疗效的因素，包括肱三头肌肌力不足致伸肘障碍；尺侧腕屈肌肌力小于Ⅳ级者，重建的屈肘活动度较小；肩关节不稳定影响屈肘肌的力量；以及康复治疗的重要性等。提出了相应的提高疗效的措施。     

桡侧腕屈肌移位重建前臂旋后功能

臂丛神经损伤或小儿麻痹后遗症，因肌肉麻痹导致旋后功能障碍，影响手功能的发挥。为了寻找重建旋后功能的动力肌，解剖观察了５０侧成年男尸的桡侧腕屈肌。发现该肌有多源性血管供血，主要来自肱动脉和桡动脉。由正中神经肌支支配肌肉运动；只要保留近侧１／３肌腹便能保证全肌的血液供应及神经支配。根据解剖资料，设计了用桡侧腕屈肌远侧２／３段，经前臂尺侧到桡背侧，将肌腱于前臂极度旋后位，固定在桡骨茎突近端６ｃｍ～１０ｃｍ的桡骨干上。临床应用４例，经平均３．２年随访，旋后功能恢复良好。认为，在尺侧腕屈肌、旋前圆肌麻痹，或需用来重建其它运动功能时，是选择桡侧腕屈肌移位重建前臂旋后功能的最佳适应证     

肘前滑车对屈肘功能重建的力学影响

肘前滑车对屈肘功能重建的力学影响姜广良顾玉东佟刚⒇在肌肉移位重建屈肘功能时，常将止点缝合在肱二头肌腱远侧的肱桡肌上或旋前圆肌止点上；有时为了同时恢复屈指功能而与屈指肌腱缝合〔１，２〕。但屈肘时易产生肘前方弓弦状隆起畸形。有人认为加建肘前滑车可以消除弓...     

桡侧腕屈肌移位重建前臂旋后功能一例

目的总结桡侧腕屈肌移位重建前臂旋后功能的临床疗效。方法 2009年8月收治1例因高处坠落伤致前臂旋后畸形2年的22岁男性患者。患者前臂旋后功能受限,固定于旋转中立位,主动旋后消失,被动旋后正常;屈肘肌肌力3级,屈腕肌肌力正常;肩、腕、掌指及指间活动正常。采用桡侧腕屈肌移位重建前臂旋后功能。结果术后切口Ⅰ期愈合,患者获随访1年。患肢前臂旋后50°,旋后肌力4级,配合肩关节外展、外旋功能,可满足日常生活需要。结论在尺侧腕屈肌、旋前圆肌、肱桡肌功能障碍或已用于重建其他功能时,采用桡侧腕屈肌可较好地重建前臂旋后功能。     

电烧伤后肘关节纤维性强直的解剖学基础与临床治疗

目的　探讨电烧伤后肘关节纤维性强直并神经损伤的较好治疗方法。　方法　取30块健康成人肘关节固定标本,进行解剖学观察。对笔者单位10例电烧伤并发肘关节纤维性强直的患者,采用屈、伸肘功能重建的方法进行治疗,即松解尺、桡侧副韧带的前、后束与延长肱二、三头肌肌腱,同时下移内上髁处前臂屈肌群起点的附着点、前置尺神经,以生物力学观察标准进行疗效评价。　结果　通过对健康成人肘关节的解剖学观察可知,如果尺、桡侧副韧带后束与肱三头肌废用性挛缩,可引起肘关节伸直位强直;如果尺、桡侧副韧带前束与肱二头肌废用性挛缩,可引起肘关节屈曲位强直。10例电烧伤患者的术后功能恢复满意。术后随访1—3年,患者肘关节屈伸范围不变,灵活度加强。结论　重建屈、伸肘功能是治疗电烧伤后肘关节纤维性强直的关键,如同时下移内上髁处前臂屈肌群起点的附着点、前置尺神经,可进一步改善关节屈曲与神经嵌压。     

屈腕肌移位术治疗屈肘肌瘫痪

手术方法第一种方法:肘关节内侧适当切口,将旋前圆肌,挠侧届腕肌、掌长肌,屈指浅肌,尺侧屈腕肌共同附丽点(称屈腕肌)从肱骨内髁上剥离,向远端游离3～4cm。预先从大腿上取好阔筋膜条用丝线缝合与屈腕肌衔接。然后在肱骨远侧1/3处,肱二头肌、     

不可逆臂丛神经不全损伤的功能重建

目的探讨不可逆臂丛神经不全损伤的功能重建疗效，改善患侧上肢功能。方法1984年1月～2003年6月收治79例不可逆臂挑神经不全损伤，行肌肉（肌腱）或关节功能位融合（腱固定）。参考美国肩、肘及手外科学会制定的功能评定标准，随访重建关节的活动范围，日常生活基本动作，包括梳头、洗脸（吃饭）、穿衣、解大小便、持（握、捏）物等项目进行打分，综合评定重建手术的疗效。结果术后54例获随访1～19年，其中良30例，可19例，差5例。提示：①肩关节若不稳定，以肩融合疗效较好；②肘关节只采用动力重建，胸大肌起、止点双极移位较尺侧腕屈肌移位好；肱三头肌移位最差；③伸腕、伸指动力重建较屈指、拇对掌功能重建好；④前臂旋后动力重建尺侧腕屈肌移位好，旋前圆肌重建前臂旋后有待进一步积累病例。结论功能重建术是治疗不可逆臂丛神经不全损伤的有效补救手术。应从上肢功能整体发挥出发，选择最佳方案，以进一步提高疗效。     

Use of quantitative intra-operative electrodiagnosis during partial ulnar nerve transfer to restore elbow flexion: the treatment of eight patients following a brachial plexus injury

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.     

Reconstructive operations for the upper limb after brachial plexus palsy

Limited function due to paralysis following brachial plexus lesions can be improved by secondary operations of the bony and soft tissue. Between April 1994 and December 2000, 109 patients suffering from arm-plexus lesions underwent a total of 144 reconstructive operations guided by our concept of integrated therapy. The average age at the time of surgery was 32 years (range: 15-59). The following operations were performed: shoulder arthrodesis (23), trapezius transfer (74), rotation osteotomy of humerus (9), triceps to biceps transposition (9), transposition of forearm flexors or extensors (8), latissimus transfer (7), pectoralis transfer (1), teres major transfer (1), transposition of flexor carpi ulnaris to the tendons of extensor digitorum (10), and wrist arthrodesis (2). Prospectively, in all patients, the grade of muscle power of the affected upper extremity was evaluated prior to surgery. The follow-up period for all 144 operations was, on average, 22 months (range: 6-74). By means of operative measures, almost all patients obtained an improvement of shoulder function (100%) and stability (>90%), elbow flexion (85%), and hand, finger, and thumb (100%). When muscles malfunction after brachial plexus lesions, one should take into account the individual neuromuscular defect, passive joint function, and bony deformities; different procedures such as muscle transpositions, arthrodeses, and corrective osteotomies can then be performed to improve function of the upper extremity. Each form of operative treatment presents patients with certain benefits and all are integrated into a total treatment plan for the affected extremity.     

Dynamic contributions of the flexor-pronator mass to elbow valgus stability

BACKGROUND: Previous studies have indicated that the demands placed on the medial ulnar collateral ligament of the elbow when it is subjected to valgus torque during throwing exceed its failure strength, which suggests the necessary dynamic contribution of muscle forces. We hypothesized that the flexor-pronator mass assists the medial ulnar collateral ligament in stabilizing the elbow against valgus torque. METHODS: Six cadaveric elbows were tested at 30 degrees and 90 degrees of flexion with no other constraints to motion. A full medial ulnar collateral ligament tear was simulated in each elbow. Muscle forces were simulated on the basis of the centroids and physiological cross-sectional areas of individual muscles. The biceps, brachialis, and triceps were simulated during flexor carpi ulnaris, flexor digitorum superficialis, flexor digitorum superficialis and flexor carpi ulnaris, and pronator teres-loading conditions. Kinematic data were obtained at each flexion angle with use of a three-dimensional digitizer. RESULTS: Release of the medial ulnar collateral ligament caused a significant increase in valgus instability of 5.9 degrees +/- 2.4 degrees at 30 degrees of elbow flexion and of 4.8 degrees +/- 2.0 degrees at 90 degrees of elbow flexion (p < 0.05). The differences in valgus angulation between each muscle-simulation condition and the medial ulnar collateral ligament-intact condition were significantly different from each other (p < 0.05), except for the difference between the flexor carpi ulnaris contraction condition and the flexor digitorum superficialis-flexor carpi ulnaris co-contraction condition. This co-contraction provided the most correction of the valgus angle in comparison with the intact condition at both 30 degrees and 90 degrees of elbow flexion (1.1 degrees +/- 1.8 degrees and 0.38 degrees +/- 2.3 degrees , respectively). Simulation of the flexor carpi ulnaris alone provided the greatest reduction of the valgus angle among all individual flexor-pronator mass muscles tested (p < 0.05), whereas simulation of the pronator teres alone provided the least reduction of the valgus angle (p < 0.05). CONCLUSIONS: The flexor-pronator mass dynamically stabilizes the elbow against valgus torque. The flexor carpi ulnaris is the primary stabilizer, and the flexor digitorum superficialis is a secondary stabilizer. The pronator teres provides the least dynamic stability.     

Transposition of local muscles to restore elbow flexion in brachial plexus palsy

Between 1994 and 2001, triceps to biceps transfers were done in 10 men and a transfer of the forearm flexors and extensors (Steindler procedure) in nine. All had suffered from a post-traumatic lesion of their brachial plexus, resulting in loss of elbow flexion. Their mean age at the time of the original accident was 27 years (range 16-50 years) and at the time of muscle transfer 35 years (range 22-56 years), with a mean observation period of 20 months (range 6-51 months). In 16 patients, a neurosurgical procedure had been performed after the trauma, and in 22 patients other reconstructive operations had been done. Transfer of the forearm flexors and extensors resulted in active elbow flexion with a mean of 94 degrees (range 70-130 degrees ). After triceps to biceps transposition a mean of 109 degrees (range 70-140 degrees ) was reached. A mean deficit of passive extension of 12 degrees (range 0-30 degrees ) remained after the Steindler procedure, and of 5 degrees (range 0-10 degrees ) after triceps to biceps transposition. Two complications occurred with the Steindler procedure. The transfer of the triceps muscle to the tendon of the biceps and the transfer of the forearm flexors or extensors on loss of elbow flexion, therefore, resulted in adequate movement and strength. Both procedures involve operating close to the elbow joint and had minimal complications. The triceps to biceps transfer is particularly suitable for co-contraction of triceps and biceps.     

Pressures recorded in ulnar neuropathy

The pressure between the ulnar nerve and the arcade bridging the two heads of the flexor carpi ulnaris muscle was recorded peroperatively in ten patients with electrophysiologically confirmed ulnar neuropathy at the elbow. At rest, with the elbow extended, pressures ranged from 0 to 19 mm Hg but increased in flexion and during isometric contraction of the flexor carpi ulnaris muscle to maximal values above 200 mm Hg.     

Triceps to biceps transfer to restore elbow flexion in three patients with brachial plexus palsy.

Between April 1994 and April 1998, triceps to biceps transfers were done for three men with post-traumatic lesions of the brachial plexus and consequent loss of elbow flexion. Their mean age at the time of their accidents was 33 years (range 19-41) and at the time of muscle transfer 40 years (28-46), with a mean observation period of 21 months (12-31). The transfer resulted in active elbow flexion in all patients with a mean of 113 degrees (90 degrees-130 degrees) and a degree of strength 4-5 (contraction against resistance) with no remaining deficit of passive extension. Two patients were satisfied with the result of the operation and the other was content. No complications were noted. The transfer of the triceps muscle to the tendon of the biceps muscle on loss of elbow flexion resulted in adequate movement and degree of strength. The triceps to biceps transfer involves operating close to the elbow joint and minimal complications, is cosmetically satisfactory, and is particularly suitable for co-contraction of triceps and biceps.     

TRICEPS TO BICEPS TRANSFER TO RESTORE ELBOW FLEXION IN THREE PATIENTS WITH BRACHIAL PLEXUS PALSY

Between April 1994 and April 1998, triceps to biceps transfers were done for three men with posttraumatic lesions of the brachial plexus and consequent loss of elbow flexion. Their mean age at the time of their accidents was 33 years (range 19-41) and at the time of muscle transfer 40 years (28-46), with a mean observation period of 21 months (12-31). The transfer resulted in active elbow flexion in all patients with a mean of 113° (90°-130°) and a degree of strength 4-5 (contraction against resistance) with no remaining deficit of passive extension. Two patients were satisfied with the result of the operation and the other was content. No complications were noted. The transfer of the triceps muscle to the tendon of the biceps muscle on loss of elbow flexion resulted in adequate movement and degree of strength. The triceps to biceps transfer involves operating close to the elbow joint and minimal complications, is cosmetically satisfactory, and is particularly suitable for co-contraction of triceps and biceps.     

Reconstruction of elbow flexion by transposition of pedicled long head of triceps brachii muscle

A new technique of restored flexion in the elbow joint in an inveterate injury of the brachial plexus is described. The insertion of the long head of the triceps brachii muscle was transferred with an intact nervous and vascular supply to the anterior brachial region and sutured above the radial tuberosity with the insertion tendon of the biceps brachii muscle. The muscle strength three months after surgery according to the muscle test was 4-. Flexion in the elbow joint was possible up to 85 degrees. Extension in the elbow joint was preserved, the muscle strength was 3. Anatomical investigation revealed that the mean length of the nerve of the long head of the triceps was 5.5 cm, the number of terminal branches was 3-4, 70% of the vascular supply was from the brachial artery, the length of the vascular bundle was 3.6 cm. In 33% there was an additional neurovascular hilus which was 2-3 cm distally from the main hilus. The investigation confirms that the neurovascular pedicle of the long head of the triceps brachii muscle is sufficiently mobile and damage by traction during transposition of the insertion tendon is therefore not likely. Transfer of the long head of the triceps brachii muscle in inveterate injuries of the brachial plexus is a suitable alternative for reconstruction of nerves or transfer of other muscles to restore flexion in the elbow joint.     

Effect of radial shortening on muscle length and moment arms of the wrist flexors and extensors

The purpose of this study was to determine the effect of distal radial shortening on muscle length and moment arm of the wrist flexors and extensors. In eight cadaveric upper extremities, distal radius fractures were simulated by an ostectomy. The distal radius was progressively shortened by 2.5, 5.0, 7.5, and 10 mm. Changes in the resting length of the flexor carpi radialis and ulnaris, extensor carpi radialis longus and brevis, and extensor carpi ulnaris muscles were measured with rotary potentiometers at neutral position, flexion, extension, and radial and ulnar deviation of the wrists. The wrists were passively moved through flexion-extension and radioulnar deviation, and tendon excursions and wrist joint angulation were recorded simultaneously. Tendon moment arms were derived from tendon excursions and joint motion. The results showed that either muscle, length or moment arm of the principal wrist flexors and extensors was significantly affected by the radial shortening. Muscle length decreased significantly after radial shortening in all the wrist flexors and extensors except for the extensor carpi ulnaris. The moment arm of the extensor carpi ulnaris tendon decreased significantly during either wrist flexion-extension or radioulnar deviation. The extensor carpi radialis brevis and flexor carpi ulnaris tendons also showed a significant decrease in their moment arms during radioulnar deviation of the wrist. Radial shortening of only 2.5 mm caused statistically significant changes in muscle length and moment arm of the wrist flexors and extensors. Increasing the extent of radial shortening exaggerated the biomechanical changes in the wrist motors. These results validate the importance of normal radial length for wrist kinetics and, from a biomechanical perspective, support complete correction of radial shortening after distal radius fractures.