Median to radial nerve transfer after traumatic radial nerve avulsion in a pediatric patient

Restricted access

This case report describes an isolated radial nerve avulsion in a pediatric patient, treated by combination sensory and motor median to radial nerve transfers. After traumatic avulsion of the proximal radial nerve, a 12-year-old male patient underwent end-to-end transfer of median nerve branches to flexor carpi radialis and flexor digitorum superficialis to the posterior interosseous nerve and extensor carpi radialis nerve, respectively. He underwent end-to-side sensory transfer of the superficial radial sensory to the median sensory nerve. Pronator teres to extensor carpi radialis brevis tendon transfer was simultaneously performed to power short-term wrist extension. Within months after surgery, the patient had regained 9–10/10 sensation in the hand and forearm. In the following months and years, he regained dexterity, independent fine-finger and thumb motions, and 4–5/5 strength in all extensors except the abductor pollicis longus muscle. He grew 25 cm without extremity deformity or need for secondary orthopedic procedures. In appropriate adult and pediatric patients with proximal radial nerve injuries, nerve transfers have advantages over tendon transfers, including restored independent fine finger motions, regained sensation, and reinnervation of multiple muscle groups with minimal donor sacrifice.

ABBREVIATIONS ECRB = extensor carpi radialis brevis; FCR = flexor carpi radialis; FDS = flexor digitorum superficialis; PIN = posterior interosseous nerve; PL = palmaris longus; PT = pronator teres; RSN = radial sensory nerve.

Article Information

Correspondence Alison Snyder-Warwick: Washington University School of Medicine, St. Louis, MO. snydera@wustl.edu.

INCLUDE WHEN CITING Published online May 31, 2019; DOI: 10.3171/2019.3.PEDS18550.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A: Presentation of initial axillary injury, before washout; arrow indicates the severed radial nerve. B: Exploration of injury at the axilla; arrow indicates the severed radial nerve. C: Exploration of the axilla, showing an intact branch of the nerve to the triceps muscle. D: Exploration of the antecubital crease; arrow indicates the distal stump of the severed radial nerve. Figure is available in color online only.

  • View in gallery

    Intraoperative dissection of the forearm. A: Proximal dissection. B: Distal dissection. C: Completed transfers: FCR and PL to PIN end-to-end, FDS to ECRB end-to-end, and radial sensory to median end-to-side. BR = brachioradialis; ECRB = nerve to extensor carpi radialis brevis; FCR = nerve to flexor carpi radialis; FDS = flexor digitorum superficialis nerve; median = median nerve; PIN = posterior interosseous nerve; PL = nerve to palmaris longus; PT = pronator teres; RSN = radial sensory nerve. B and C: Modified from Hoben G, Snyder-Warwick A: Principles and applications of nerve transfers, in Chung K (ed): Grabb and Smith’s Plastic Surgery, ed 8. Philadelphia: Wolters Kluwer [in press]. Figure is available in color online only.

References

  • 1

    Bain JRDeMatteo CGjertsen DPackham TGalea VHarper JA: Limb length differences after obstetrical brachial plexus injury: a growing concern. Plast Reconstr Surg 130:558e571e2012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Brown JMTung THMackinnon SE: Median to radial nerve transfer to restore wrist and finger extension: technical nuances. Neurosurgery 66 (3 Suppl Operative):75832010

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Burkhalter WE: Early tendon transfer in upper extremity peripheral nerve injury. Clin Orthop Relat Res (104):68791974

  • 4

    Butler PESims CDRandolph MAMenkes DOnorato JLee WP: A comparative study of nerve healing in adult, neonatal, and fetal rabbits. Plast Reconstr Surg 104:138613921999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Cheah AEEtcheson JYao J: Radial nerve tendon transfers. Hand Clin 32:3233382016

  • 6

    Chim HKircher MFSpinner RJBishop ATShin AY: Reconstruction of pediatric brachial plexus injuries with nerve grafts and nerve transfers. J Hand Surg Am 39:177117782014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Davidge KMYee AKahn LCMackinnon SE: Median to radial nerve transfers for restoration of wrist, finger, and thumb extension. J Hand Surg Am 38:181218272013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Dunnet WJHousden PLBirch R: Flexor to extensor tendon transfers in the hand. J Hand Surg Br 20:26281995

  • 9

    El-Gammal TAAbdel-Latif MMKotb MMEl-Sayed ARagheb YFSaleh WR: Intercostal nerve transfer in infants with obstetric brachial plexus palsy. Microsurgery 28:4995042008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    El-Gammal TAEl-Sayed AKotb MM: Surgical treatment of brachial plexus traction injuries in children, excluding obstetric palsy. Microsurgery 23:14172003

  • 11

    Forli ABouyer MAribert MCurvale CDelord MCorcella D: Upper limb nerve transfers: a review. Hand Surg Rehabil 36:1511722017

  • 12

    Fu SYGordon T: Contributing factors to poor functional recovery after delayed nerve repair: prolonged denervation. J Neurosci 15:388638951995

  • 13

    García-López ANavarro RMartinez FRojas A: Nerve transfers from branches to the flexor carpi radialis and pronator teres to reconstruct the radial nerve. J Hand Surg Am 39:50562014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Gosk JWnukiewicz WUrban M: The effect of perinatal brachial plexus lesion on upper limb development. BMC Musculoskelet Disord 15:1162014

  • 15

    Goubier JNTeboul FPapadogeorgou E: Nerve transfers in children with traumatic partial brachial plexus injuries. Microsurgery 28:1171202008

  • 16

    Ishida OIkuta Y: Analysis of Tsuge’s procedure for the treatment of radial nerve paralysis. Hand Surg 8:17202003

  • 17

    Jonsson SWiberg RMcGrath AMNovikov LNWiberg MNovikova LN: Effect of delayed peripheral nerve repair on nerve regeneration, Schwann cell function and target muscle recovery. PLoS One 8:e564842013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Kobayashi JMackinnon SEWatanabe OBall DJGu XMHunter DA: The effect of duration of muscle denervation on functional recovery in the rat model. Muscle Nerve 20:8588661997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Kruft Svon Heimburg DReill P: Treatment of irreversible lesion of the radial nerve by tendon transfer: indication and long-term results of the Merle d’Aubigné procedure. Plast Reconstr Surg 100:6106181997

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Lowe JB IIISen SKMackinnon SE: Current approach to radial nerve paralysis. Plast Reconstr Surg 110:109911132002

  • 21

    Lowe JB IIITung TRMackinnon SE: New surgical option for radial nerve paralysis. Plast Reconstr Surg 110:8368432002

  • 22

    Mackinnon SERoque BTung TH: Median to radial nerve transfer for treatment of radial nerve palsy. Case report. J Neurosurg 107:6666712007

  • 23

    McDaid PJKozin SHThoder JJPorter ST: Upper extremity limb-length discrepancy in brachial plexus palsy. J Pediatr Orthop 22:3643662002

  • 24

    Monacelli GSpagnoli AMRizzo MISorvillo VQuadrini LScuderi N: Treatment of persistent radial nerve palsy through “tendon minimal transfer” technique. G Chir 32:69722011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Moore AMMacEwan MSantosa KBChenard KERay WZHunter DA: Acellular nerve allografts in peripheral nerve regeneration: a comparative study. Muscle Nerve 44:2212342011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Moore AMWagner IJFox IK: Principles of nerve repair in complex wounds of the upper extremity. Semin Plast Surg 29:40472015

  • 27

    Nikolaou SPeterson EKim AWylie CCornwall R: Impaired growth of denervated muscle contributes to contracture formation following neonatal brachial plexus injury. J Bone Joint Surg Am 93:4614702011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    O’Grady KMPower HAOlson JLMorhart MJHarrop ARWatt MJ: Comparing the efficacy of triple nerve transfers with nerve graft reconstruction in upper trunk obstetric brachial plexus injury. Plast Reconstr Surg 140:7477562017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Pet MALipira ABKo JH: Nerve transfers for the restoration of wrist, finger, and thumb extension after high radial nerve injury. Hand Clin 32:1912072016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Ray WZMackinnon SE: Clinical outcomes following median to radial nerve transfers. J Hand Surg Am 36:2012082011

  • 31

    Ring DChin KJupiter JB: Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am 29:1441472004

  • 32

    Sammer DMChung KC: Tendon transfers: part I. Principles of transfer and transfers for radial nerve palsy. Plast Reconstr Surg 123:169e177e2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33

    Schreiber JJByun DJKhair MMRosenblatt LLee SKWolfe SW: Optimal axon counts for brachial plexus nerve transfers to restore elbow flexion. Plast Reconstr Surg 135:135e141e2015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Seruya MShen SHFuzzard SCoombs CJMcCombe DBJohnstone BR: Spinal accessory nerve transfer outperforms cervical root grafting for suprascapular nerve reconstruction in neonatal brachial plexus palsy. Plast Reconstr Surg 135:143114382015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Skoll PJHudson DAde Jager WSinger M: Long-term results of tendon transfers for radial nerve palsy in patients with limited rehabilitation. Ann Plast Surg 45:1221262000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Tung THMackinnon SE: Nerve transfers: indications, techniques, and outcomes. J Hand Surg Am 35:3323412010

  • 37

    Waters PM: Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B 14:2332442005

  • 38

    Waters PMSmith GRJaramillo D: Glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 80:6686771998

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 34 34 34
Full Text Views 14 14 14
PDF Downloads 16 16 16
EPUB Downloads 0 0 0

PubMed

Google Scholar