Paralysies de la flexion et de l'extension du coude

Abstract

Palsies affecting elbow flexion result in major disability and therefore warrant routine surgical treatment, even in patients with permanent hand paralysis. When elbow flexion is good, restoring extension which is a classic priority in tetraplegic patients is also extremely useful to patients with peripheral palsies. When the time since the injury is fairly short, “anatomic” flexor or extensor muscles should be given a nerve supply, either by restoring normal anatomic pathways or by nerve transfers. Transferring ulnar nerve fibres to the biceps muscle is now the preferred treatment in patients with satisfactory ulnar nerve function. This technique provides better outcomes than does repair by implantation of grafts from the plexus roots. After 12 to 18 months, the arm muscles can no longer be re-innervated, particularly when the nerve is repaired far upstream from the muscle. Palliative muscle transfer can be used in this situation in patients with transferable muscles. To restore elbow flexion, triceps-biceps transfer is indicated only in patients with co-contractions. Transfer of the medial epicondyle muscles as described by Steindler is preferred when the “anatomic” flexors are grade 2: this procedure assists elbow flexion. Latissimus dorsi transfer is mainly indicated in patients with muscle defects in the anterior arm compartment. To restore elbow extension in patients with damage to the proximal radial nerve, unipolar latissimus dorsi transfer is an excellent procedure because of the synergistic action of this muscle. In patients with tetraplegia, the posterior deltoid muscle can be transferred and prolonged with a tendon graft. The biceps can be transferred to the triceps, particularly in patients with stiffness of the elbow limiting the range of flexion. In patients with massive paralysis and no local transferable muscles, i.e., with long-standing brachial plexus paralysis, the treatment consists in free muscle transfers with re-innervation by transferred local nerves; the muscle used may be the latissimus dorsi from the other side or a gracilis muscle.