SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
Article
Correlation
between
the
elbow
flexion
and
the
hand
and
wrist
flexion
after
neurotization
of
the
fascicles
of
the
ulnar
nerve
to
the
motor
branch
to
the
biceps
夽
Ricardo
Boso
Escudero,
Marcelo
Rosa
de
Rezende,
Erick
Yoshio
Wataya
∗,
Fernando
Vicente
de
Pontes,
Álvaro
Baik
Cho,
Marina
Justi
Pisani
UniversidadedeSãoPaulo,FaculdadedeMedicina,HospitaldasClínicas,SãoPaulo,SP,Brazil
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r
t
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e
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o
Articlehistory: Received13April2016 Accepted20July2016 Availableonline4May2017
Keywords:
Brachialplexus/injuries Brachialplexus/surgery Brachialplexus neuropathies/etiology Brachialplexus neuropathies/surgery Nervetransfer Rehabilitation
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Objective:Gain in elbow flexion in patients with brachial plexus injury is extremely important.Thetransferofafasciclefromtheulnarnervetothemotorbranchofthe muscu-locutaneousnerve(Oberlinsurgery)isatreatmentoption.However,insomepatients,gain inelbowflexionisassociatedwithwristandfingerflexion.Thisstudyaimedtoassessthe frequencyofthisassociationandthefunctionalbehaviorofthelimb.
Methods:Case–controlstudy of18patientswhounderwenttheOberlinsurgery.Group1 includedpatientswithoutdisassociationofrangeofelbowflexionandthatofthefingersand wrist;Group2includedpatientsinwhomthisdisassociationwaspresent.Inthefunctional evaluation,theSollermanandDASHtestswereused.
Results:Itwasobservedthat38.89%ofthepatientsdidnotpresentdisassociationofelbow flexionwithflexionofthewristandfingers.Despitetheexistenceofafavorabledifferencein thegroupwithdisassociationofthemovement,whentheSollermanprotocolwasappliedto thecomparisonbetweenbothgroups,thisdifferencewasnotstatisticallysignificant.With theDASHtest,however,therewasastatisticallysignificantdifferenceinfavorofthegroup ofpatientswhomanagedtodisassociatethemovement.
Conclusion: Theassociationofelbowflexionwithflexionofthewristandfingers,inthe groupstudied,wasshowntobeafrequentevent,whichinfluencedthefunctionalresultof theaffectedlimb.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
夽
StudyconductedattheUniversidadede SãoPaulo,FaculdadedeMedicina,HospitaldasClínicas,DepartamentodeOrtopediae Traumatologia,GrupoCirurgiadaMãoeMicrocirurgiaReconstrutiva,SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:erick.wataya@gmail.com(E.Y.Wataya).
http://dx.doi.org/10.1016/j.rboe.2017.04.006
Correlac¸ão
da
flexão
do
cotovelo
com
a
flexão
da
mão
e
do
punho
após
neurotizac¸ão
dos
fascículos
do
nervo
ulnar
para
ramo
motor
do
bíceps
Palavras-chave: Plexobraquial/lesões Plexobraquial/cirurgia Neuropatiasdoplexo braquial/etiologia Neuropatiasdoplexo braquial/cirurgia Transferênciadenervo Reabilitac¸ão
r
e
s
u
m
o
Objetivo:Oganhodaflexãodocotoveloempacientescomlesãonoplexobraquialédesuma importância.Acirurgiadetransferênciadefascículodonervoulnarpararamomotordo nervomusculocutâneo(cirurgiadeOberlin)éumaopc¸ãodetratamento.Contudo,oganho daflexãodocotovelo,emalgunspacientes,vemassociadoàflexãodopunhoedosdedos.O objetivodestetrabalhoéavaliarafrequênciadessaassociac¸ãoeocomprometimento fun-cionaldomembro.
Métodos: Estudotipocaso-controlede18pacientessubmetidosàcirurgiadeOberlin.No Grupo1foramincluídosospacientesquenãoapresentavamdissociac¸ãodoganhodaflexão docotovelocomadosdedosedopunho;noGrupo2,ospacientesemquehaviadissociac¸ão. OstestesdeSollermaneDisabilitiesoftheArm,ShoulderandHand(Dash)foramusadosna avaliac¸ãofuncional.
Resultados: Observou-seque38,89%dospacientesnãodissociavamflexãodecotovelode flexãodepunhoedosdedos.Apesardeexistirumadiferenc¸afavorávelaogrupoque dis-sociavaomovimentoquandoaplicadooprotocolodeSollermannacomparac¸ãoentreos pacientesdosdoisgrupos,essanãosemostrouestatisticamentesignificante.Jánoteste Dash,observou-sediferenc¸aestatisticamentesignificante,favorávelaogrupodepacientes queconseguedissociaromovimento.
Conclusão: Aassociac¸ãodaflexãodocotovelocomaflexãodepunhoedosdedosnogrupo estudadomostrouserumeventofrequente,teveinfluêncianoresultadofuncionaldo mem-broacometido.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Brachialplexusinjuryhasreceivedspecialattentioninthelast decadesbecauseitmainlyaffectsyoungpatients.Treatment oftheseinjuriesischallenging.1,2Currently,theleadingcause ofbrachialplexusinjuryisaresultofhighenergytraumain trafficaccidentsand mainvictimsaremotorcyclists.3,4 The injuryoccursbyatractionforceappliedintheshoulderand neckareas,leadingtotemporaryorpermanentlossof move-mentandofupperlimbsensitivity.
AsrecommendedbyHentzandDoi,5restoringactiveelbow flexioninbrachialplexusinjuriesisapriority,regardlessofthe typeofinjury.Toachievethisgoal,severalsurgicalapproaches havebeendescribed.
Initially, neurological procedures should be prioritized, throughnervereconstructionwithorwithoutgraftsandnerve transfers(neurotization).5,6 Thefirst reportofneurotization usingamotorfascicleoftheulnar nervewas publishedin 1994 by Oberlin et al.,7 for elbow flexion gains. This pro-cedure consists of transferring a motor fascicle from the ulnarnervetothebicepsmotorbranch.Ingeneral,a fasci-clerelatedtotheflexorcarpiulnarisandflexordigitorumis chosen,toavoiddenervationoftheintrinsicmusclesofthe hand.TheOberlinproceduregainednotorietyduetoexcellent resultsinelbowflexion,testedanddemonstratedbyseveral authors.Currently,itisroutinelyusedinhighpartiallesions ofthebrachialplexus,i.e.,lesionsthatdonotaffecttheroots ofC8andT1, whichaccountforapproximately 40%ofthe lesions.8,9
In the literature, the assessment of elbow flexion gain afternervereconstructionhasbeendonemostlybyusingthe BritishMedicalResearchCouncil(BRMC)scale.Thistypeof evaluation,althoughwidelyused,provideslittleorno infor-mation about the quality of muscle recovery in terms of functionalityinworklife.7,10,11
In the evaluation of the present patients, who pre-sented recovery of elbow flexion with force greater or equal to M3after Oberlin surgery, weobserved that some patients presented flexion of the elbow associated with flexion of the wrist and fingers. Despite the effectiveness of elbow flexion, this co-contraction phenomenon leads to flexion of the fingers and wrist, which damages the limb’s functionality, especially for the execution of grip movements.
Therefore,thisstudyaimedtoassessthefrequencywith whichco-contractionofthe elbowflexion/wristandfingers flexionoccursanditsfunctionalrepercussions.
Material
and
methods
Table1–Resultinkgfofthehandgrip.
Affectedside Non-affectedside p-Value
Lateralpinch+SD 6.42±3.0 10.1±2.3 0.002
Pulppinch+SD 3.44±1.7 5.77±1.5 0.004
Three-digitpinch+SD 4.89±2.52 7.77±2.2 0.002
SD,standarddeviation;kgf,kilogramforce.
Patientswhopresentedthefollowingcharacteristicswere excludedfromthestudy:
- Bilateralbrachialplexusinjury - Associatedhumeralfracture
- Thosewhodidnotachieveelbowflexionforcegreaterthan orequalto3ontheBMRCscale.
Patientsweredividedintotwogroups:
- Group1:thosenotabletodissociatethemovementofelbow flexionwiththemovementsofwristandfingersflexion; - Group2:those abletodissociate themovementofelbow
flexionwiththemovementsofwristandfingersflexion;
Patients’ epidemiological data, dateofaccident, date of surgery,traumamechanism,ageattimeofinjury,sex,surgical procedures,typeofinjury,andinjuredsidewerecollected.
Patients were assessed for grip strength and the DASH protocolwasapplied,12,13whichaimstomeasuresymptoms andfunctioninindividualswithmusculoskeletalpathologies intheupperlimbs,withafocusonphysicalfunction, high-lightingsubjectiveaspects;theSollermanetal.test,14which measuresthegripmovementsrequiredforcertainADLs,has amoreobjectivecharacter.
TheDASHscorecontains 30 items regardingthe health statusoftheindividual,highlightingdifficultiesinthe perfor-manceofphysicalactivities,severityofsymptoms,andimpact onsocialconditions.EachitemintheDASHhasfiveresponse options,rangingfrom0(nodifficultyorsymptom)to5 (inabil-itytoperformthetaskorextremesymptomseverity).Total DASHscorerangesfrom0to100;itiscalculatedbyaddingthe scoreofeachitem,subtracting30,anddividingthescoreby 1.2.
TheSollermanscoretakesintoaccountthetimerequired, the level ofdifficulty presented, and the quality in which thetaskisperformed,usingthecorrecthandgripposition. Patientsarescoredonafive-pointscale:from0(taskcannot beperformedatall)to4(taskiscompletedwithoutany diffi-cultywithin20sandwiththeprescribedhandgripofnormal quality).Thetotalscore(0–80)iscreatedbythesumofthe scoresofthedifferentsubtests.
DatawerestoredinanExcelspreadsheetandimportedinto SPSSv.23softwareforMac.Continuousdataweredescribed asmeansandtheirrespectivestandarddeviationsandtested fornormalityusingtheKolmogorov–Smirnovtest.Categorical dataweredescribedasabsolutenumbersandtheir respec-tiveproportions.Fortheparametricdata,Student’st-testwas used,andfornon-parametricdata,theMann–Whitneytest. For associations betweencategoricaldata, chi-squaredtest
wasused.Statistically,analphalessthanorequalto0.05was acceptedasstatisticallysignificant.
ThestudywasapprovedbytheResearchEthicsCommittee, underNo.47713615.2.0000.0068.
Results
Twenty-fivemedicalchartsofpatientswhoagreedto partici-pateinthestudyaftertheOberlinprocedurewerecollected. Ofthese,sevendidnotmeettheinclusioncriteria,duetolack offlexionforce,andwereexcluded.Theremaining18patients underwenttheDASHandSollermantests.
Meanageofpatientswas28.9±8.3years;17weremales andone,female.Ten(55.6%)presentedlesionsoftheC5–C7 rootsandeight(44.4%),lesionsoftheC5–C6roots.
Main trauma mechanism was motorcycle accident,
observedin94.4%ofpatients;adifferenttraumamechanism wasobservedinonlyonepatient(5.6%),fallfromabicycle. Brachialplexusinjuryoccurredmainlyontheleftside(77.8%). In the comparative evaluationofdifferent types ofgrip betweentheaffectedandnormalsides,significantdifferences wereobserved,asshowninTable1.
Itwasobservedthatpatientstook6.63±3.63minto com-pletetheSollermantestontheaffectedsideand3.63±1.8min onthenon-affectedside.Thefinalmeanresultoftheprotocol wasonaverage74.83(95%CI:70.4–79.2)pointsonthe non-affected side,withastandarddeviationof8.87points.The affectedsidepresentedameanof62.55(95%CI:54–71)points, withastandarddeviationof17.17points.
TheDASHtestwasappliedonlyintheinjuredlimb;the meanscorewas51.28±18.3points.
Ofthe18patientswhounderwentfunctionalevaluation, seven(38.89%)werenotabletodissociatetheflexion move-mentoftheelbowfromtheflexionmovementsofthewrist andfingers(Group1)and11(61.11%)wereabletodissociate thesemovements(Group2).15FivepatientsfromGroup1and fivefromGroup2presentedinjuryatC5,C6,andC7.
Mean time between injury and surgery were 6.8±2.0 monthsforpatientsinGroup2and7.6±2.6monthsforGroup 1,whichdidnotdiffersignificantly.
Resultsoftheevaluationofthedifferenttypesofhandgrip betweenGroup1andGroup2aredescribedinTable2.
Table2–Resultinkgfofthehandgrip,withorwithoutdissociation.
Group1 Group2 p-Value
Lateralpinch+SD 5.97±3.6 6.72±2.7 0.626
Pulppinch+SD 3.57±2.0 3.36±1.5 0.807
Three-digitpinch+SD 4.41±2.3 5.20±2.7 0.536
SD,standarddeviation;kgf,kilogramforce.
TheDASHtest presentedamean score of65.3(95% CI: 55–74)pointsforGroup1,withastandarddeviationof10.3 points, while Group 2presented a mean of 43.25 (95% CI: 31.6–54.9) points, with a standard deviation of 17.3 points (p=0.008).Regardingthesedata,astatisticallysignificant dif-ferencewasobserved(Table3).
Table3presentsthe resultsofthe Sollermanand DASH scores,inwhichasignificantdifferencebetweenthegroups wasobservedonlyforthelatterscore.
Discussion
Theincreasednumber ofmotorcycleaccidentsobservedin recentstatisticsisassociatedwithachangeinhabitsof soci-ety,inwhichtheuseofmotorcyclecombineslowpurchaseand maintenancecostswiththeperspectiveofmoreagilemobility inbigcities.
Inagreement with the literature,3,4,13 the present study populationhad aprofileofyoungpatients (mean29years) andpredominantlymale.Motorcycleaccidentwasshownto bethemajorcausalfactor(94%)ofbrachialplexusinjuries,in linewiththeincreaseduseofthistypeoftransportation.
Whentreatingapatientwithbrachialplexusinjury,itis necessarytoestablish prioritiesinthe orderof reconstruc-tion,consideringthatthereareoftenfewtreatmentoptions, whichshouldbeusedaccordingtothejudgmentoffunctional importance.Theliteratureindicatesatendencytoprioritize shoulderandelbowreconstruction,andespeciallyelbow flex-ion,which hasa primaryfunction mainlyinhigh brachial plexuslesions(C5/C6/C7),wherethefunctionalhand,inorder tobeuseful,requirestheelbowflexionmovementsothatit canreachobjects.5
Inthecasesofhighbrachialplexuslesion,itispossibleto useafascicleoftheulnarnerveforneurotizationinthe mus-culocutaneousnerve,asdescribedbyOberlin;thisprocedure hasexcellentresults,asattestedbynumerousstudies,witha successrateof85–93%,withreturnofstrengthgreaterthanor equaltoM3.1,6
Consideringtheevaluationofthedifferenttypesofhand gripbetweentheaffectedsideandthenormalside,a worsen-ingofthestrengthintheformer(40–50%)wasevident.When applyingSollermantest,14paired,inbothsidesofthesame
patient,asignificantdifferencewasobservedinthetimeto executethehand grips(6.63±3.63minon theaffected and 3.63±1.8minon the non-affected side), aswell as amore favorablefinalscoreonthenon-affected side.Onepossible explanationforthisfactisthat,eveninahighplexuslesion, theremaybesomedegreeofimpairmentoftheinnervation ofthemediannerveandevenoftheulnarnerve,duetothe contribution ofdifferent levelsofrootsintheformationof thesenerves.Therefore,thehandstrengthoftheaffectedside shouldbeconsidered,apriori,asinferiortothatofthenormal side.
Inturn,theDASHscorecharacterizestheoverallfunction ofeachpatient,whichisreducedinrelationshiptothatthe normalpopulation,withameanof51points(variationof18), anexpectedfactduetotheevidentfunctionalimpairmentof theaffectedside.
Regardingtheprimaryobjectiveofthepresentstudy,we observedthatalmost39%ofthepatientswhorecoveredelbow flexion through the Oberlin surgerypresentedthe associa-tionofthismovementwithflexionofthewristandfingers. Theremainder(61%)wereabletodissociatebothmovements. Consideringtheminimumpost-Oberlinfollow-uptimeofone year,theauthorsbelievethattheeventofnon-dissociationof movementbetweentheelbowandthehand/wristwasquite highinthepresentsample,andthereforedeservesattention inrelationtoitspossiblecauses,formsoftreatment,and pre-vention.
One of the factors that could influence the occurrence
of non-dissociation of movement (elbow/hand) would be
the time between the injury and the Oberlin surgery, as wellasthehomogeneousdistributionofcasesthatincluded
C7 or not in both groups. However, a balance of these
possible confounding factors was observed in the groups studied.
Inthecomparativefunctionalassessmentofbothgroups, we observed that the Sollerman test presented a trendof better results in patients who could dissociate movement (Group2),butthisdifferencewasnotstatisticallysignificant. Itisnoteworthythatthistestbasicallyassessesthedifferent handgrips,ratherthanthefunctionofthelimbasawhole. Therefore,theobservedlackofdifferencemaybeduetothe inadequacyofthistesttoanswerthequestionposedbythis study.
Table3–Result,inpoints.
Group1 Group2 p-Value
Sollerman 54.42±24 67.72±8.87 0.173
DASH 65.3±10.3 43.25±17.73 0.8
TheDASH score indicated a statisticallysignificant dif-ference,favorabletoGroup2, despitethesmall number of patients.Thatis,inthistest,thedissociationofmovement (elbow/hand)was shownto beanimportantfactor forthe functionalgainoftheaffectedlimbasawhole.Thisfinding seemsintuitive,sinceinmosthandmovements,suchaswhen approachingalocktoopenadoor,therequiredmovementis thatofelbowflexion,combinedwithfirsttheextensionofthe wristandfingers,thenthegrippingmovement.
Patientsfrom Group1 were onlyable tograb an object
when the forearm was supported and the elbow relaxed,
thus allowinghand grip. Regardless ofthefunctional tests used, afundamental difference was observed betweenthe twogroups,characterizedbytheneedforelbowsupportfor gripping in Group 1, which was not observed in Group 2. Whenassessingthefunctionoftheelbowandofthehand inisolation, similarresultswere observedbetweenthetwo groups.However,whenconsideringthefunctionofthelimb asawhole,asignificantdifferencewasobservedbetweenthe twogroups,evidencedbytheDASHscore.
Regarding the difference observed between both tests usedinthefunctionalassessmentoftheaffectedlimb,itis noteworthythatthe Sollerman testfocuseson the specific evaluationofthedifferent hand grips,differently from the DASHtest, inwhichthe scoretakesintoaccountthe func-tionalaspectofthe limbasawhole,inaddition tohaving demonstratedasignificantdifferencebetweenthetwogroups evaluated.Theauthors believethatsincethepresentstudy assessedthesynchronismoftwodistinctmovements topo-graphically,the DASHscore ismoreaccurate toreflectthe qualityoftheaffectedlimbfunction.
WhiletheresultwithOberlinsurgeryisquitesatisfactory intermsofelbowflexiongain,thepresentstudydemonstrated thatasignificantnumberofpatients(39%)couldnotperform thisdissociation.Thisdatashouldbeconsideredwhen evalu-atingtheresultsoftheOberlinsurgery,sinceitcompromises thefunctionoftheaffectedlimbasawhole.
Theauthorsbelievethatsomefactorsmayinfluencethe presenceorabsenceofelbow/handdissociationafterOberlin surgery,suchasthepatient’slevelofeducationandhis/her adherencetotherehabilitationprotocol.Inthepresentstudy, patientsweresubmittedtoastandardrehabilitation proto-colforelbowflexiongain;intheory,theyshouldrespondina similarwaytotheprocessofmovementdissociation.
Mostofthe studies that reported theresults ofOberlin surgeryonlydescribedtheresultsofelbowflexiongain. How-ever,basedonthepresentstudy,thefunctional gainofthe affectedlimbshould beassessedinaglobalwayand thus includethe presenceorabsence ofmovementdissociation, which,asdemonstrated,hasadirectinfluenceonthefinal functionaloutcomeofthepatient.Theauthorsbelievethat furtherstudiesshouldbeconductedinordertoidentifythe possiblecausal factorsforthemovement associationevent (elbow/hand), so thatprophylactic actionscan be taken in ordertoavoidthisadverseeffect.
Asalimitationofthepresentwork,thesmallsamplesize isnoteworthy.However,thisobservationoftheassociationof theelbowflexionmovementwiththeflexionofthewristand thefingershasbeenaconstantfindingintheauthors’daily
practice,whichnecessitatedastudytoindicatethefrequency ofthiseventandthereforeacteffectivelyinitssolution.
The treatment of patients with brachial plexus injury requiresspecifictherapeuticdecisionsthat,duetothescarcity ofoptions,shouldbeusedcarefully,whichimplieshavinga correctevaluationoftheirresultsforamoreeffective treat-ment.Oberlin surgery isundoubtedly excellent forgaining elbowflexion;itwillbeevenbetteriftheundesirable asso-ciationofelbowflexionwithflexionofthewristandfingers canbesuccessfullyavoidedinthefuture.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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