21: Steindler Flexorplasty

Procedure 21 Steindler Flexorplasty



Pao-Yuan Lin, Sandeep J. Sebastin, Kevin C. Chung



Indications




image Late presentation of upper trunk brachial plexus palsy (C5-C6; C5-C6-C7) without recovery of elbow flexion.


• Steindler procedure is preferred to a pedicled latissimus dorsi (LD) transfer or free functioning muscle transfer, if the patient has good function of the wrist and finger flexors.

• A pedicled LD transfer or free functioning muscle transfer can be considered if the wrist flexors are weak.

• A pectoralis major–biceps transfer can be considered in patients who have a weak biceps (partial recovery). The pectoralis major cannot replace the function of the biceps but can augment it.

image Arthrogryposis patients lacking elbow flexion.



Examination/Imaging



Clinical Examination




image The patients should have adequate strength in the flexor pronator mass, especially the wrist flexors [flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU)]. This can be assessed by asking the patient to flex the wrist against resistance.


image The patient should have good wrist extension to counteract the possible development of a wrist flexion contracture.


image The patients should have adequate passive flexion of the elbow. If passive flexion of the elbow is limited owing to a tight triceps, then triceps lengthening may be necessary to increase passive range of motion.



Imaging




image Plain radiograph of the elbow should reveal normal elbow articulation.



Surgical Anatomy




image The common flexor-pronator muscles originate from the medial epicondyle. The following muscles are elevated during this procedure: pronator teres, FCR, palmaris longus, FCU, and flexor digitorum superficialis (Fig. 21-1). The flexor digitorum profundus is left in situ (see Fig. 21-1).


image The ulnar nerve must be protected during elevation of the flexor-pronator mass. It may be transposed anteriorly in the submuscular plane.


image The medial (ulnar) collateral ligament of the elbow should be protected during elevation of the flexor-pronator mass. It originates at the posterior distal aspect of the medial epicondyle and inserts into the base of the coronoid process of ulna. It is composed of three bands: anterior, posterior, and transverse (Fig. 21-2).


image

FIGURE 21-1


image

FIGURE 21-2



Positioning




image The patient is positioned supine with the affected extremity on a hand table. The procedure is performed under general or regional anesthesia, and a sterile tourniquet is placed as high up the arm as possible.



Exposures




image A 10-cm longitudinal curvilinear incision centered over the medial epicondyle is made (Fig. 21-3).


image A skin flap is elevated while protecting the medial antebrachial cutaneous nerve. After elevation of the skin flap, one will see the flexor-pronator mass attaching to the medial epicondyle (Fig. 21-4).

Only gold members can continue reading. Log In or Register to continue

Related posts:

28: Pronator Teres Rerouting 35: Silicone Metacarpophalangeal Joint Arthroplasty 85: Wrist Denervation 38: Reconstruction for Congenital Thumb Hypoplasia 65: Arthroscopic Treatment for Septic Arthritis 89: Total Wrist Fusion

Stay updated, free articles. Join our Telegram channel
Tags:
Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 21: Steindler Flexorplasty

Full access? Get Clinical Tree
Get Clinical Tree app for offline access