Trapezius Transfer to Restore External Rotation in a Patient with a Brachial Plexus Injury

Abstract

Persistent shoulder paralysis after brachial plexus injury is a challenging and difficult problem to treat1,2. Deltoid and rotator cuff muscle recovery has been reported to be incomplete, resulting in loss of abduction and little to no external rotation3,4. The resulting muscle weakness leads to a “hand-on-belly” internally rotated position that limits positioning of the hand anterior to the coronal plane with elbow flexion. For patients who do not receive timely and successful nerve reconstruction, complete axillary and suprascapular nerve paralysis can result in painful inferior glenohumeral subluxation2. As the majority of periscapular muscles are generally paralyzed, there may be few functioning muscles about the shoulder available for tendon transfer. In these instances, upper trapezius transfer has been attempted to restore shoulder abduction, with variable results reported5-15. Transfers of the latissimus dorsi and/or teres major muscles, which have been described for the treatment of upper plexus (Erb-Duchenne pattern) palsy to improve external rotation and abduction, typically do not function with global injury6. The need to restore external rotation in particular is important because it enables the patient to position the hand away from the body, especially when elbow flexion has been restored. Despite the important need for external rotation, we know of no report describing external rotation transfers for patients with a complete brachial plexus palsy, especially for those who present late. We report the preliminary findings of a novel technique of transferring the middle and lower segments of the trapezius muscle, extended with a tendon allograft, to restore external rotation of the shoulder. The patient was informed that data concerning the case would be submitted for publication, and he consented. A fifty-five-year-old, right-hand-dominant man was seen with residual paralysis in the right shoulder eighteen …