Dorsal Splint Research Articles

Short arm splints for wrist stabilization: A mechanical material test and cadaveric radiography study.

Documentation of the wrist stabilizing effect and mechanical properties of common splinting materials is warranted to support evidence-based condition-specific recommendations for wrist immobilization. The objectives of this study were to assess the wrist stabilizing properties of volar and dorsal short-arm splints made of four different materials and evaluate the mechanical properties of the splinting materials. Dorsal and volar short arm splints made of plaster of Paris (PoP) (eight layers), Woodcast (2 mm, rigid vented), X-lite (classic, two layers) or a 3D-printed material (polypropylene) were sequentially mounted on 10 cadaveric arm specimens and fixed in a radiolucent fixture. This enabled the evaluation of maximum wrist flexion and extension relative under an orthogonal load of 42 N via radiographic images. In addition, a three-point bending test was performed on ten sheet duplicates of each of the four splinting materials. When applied as a volar splint, PoP had the highest capability to resist wrist flexion and extension. However, when applied as a dorsal splint, Woodcast exhibited a lower wrist flexion and a similar wrist extension. The 3D-printed splints-both volar and dorsal-showed the highest mean wrist flexion and extension. The mechanical properties of the Woodcast, X-lite and 3D-printed splinting materials were very similar. PoP exhibited distinct properties with a stiffness of 146 (95% confidence interval [CI]: 120-173) N/mm and a deflection at F max of 0.6 (95% CI: 0.5-0.7) mm compared to ≤7.7 (95% CI: 7.4-7.9) N/mm and ≥20 (95% CI: 18-22) mm for the other materials. PoP displayed better wrist stabilizing properties and material stiffness than Woodcast, X-lite and 3D-printed polypropylene. When considering wrist stabilizing properties, PoP may still prove to be the preferred choice for wrist immobilization. Not applicable.

Tarans-Scaphoid Lunate Fracture Dislocation: A Case Report of a Rare Injury

Trans-scaphoid lunate dislocation is an uncommon injury but can be devastating, causing loss of wrist joint movement and function, and compromising grip strength. In this report, we present a case of a 48-year-old man with a history of psychiatric disorder who attempted suicide by jumping from the second floor. He sustained a volar lunate dislocation and scaphoid fracture, with migration of the proximal part of the scaphoid to the volar aspect of the forearm. Open surgical reduction was planned through a dorsal approach: first, the lunate was reduced, then the proximal part of the scaphoid was retrieved from the volar aspect of the forearm and anatomically fixed with a 2.5 mm headless screw. The scapholunate relationship was reduced and fixed with two wires through the scapholunate and scaphocapitate joints. The wound was closed in layers, and the wrist joint was immobilized with a dorsal splint for six weeks. Six weeks postoperatively, the K wires were removed, and the patient started physiotherapy. At three months postoperative follow-up, the wrist joint function was good, with good grip strength and a good range of motion. The gold standard treatment option is open reduction and fixation of the fractured bone and stabilization of the carpal bones in anatomical alignment to reduce possible complications such as median nerve compression, chronic carpal instability, chronic wrist pain, loss of grip strength, wrist arthritis, and carpal collapse.

A Prospective Analysis of Patient Characteristics Affecting the Outcome of Dorsal Splinting for Soft Tissue Mallet Injuries.

Much has been written about the diagnosis and treatment of soft tissue mallet injuries. However, there has been little regarding the characteristics of this injury affecting patients' prognosis. The purpose of this prospective study was to identify factors influencing the outcome of treatment of soft tissue mallet injuries. Patients diagnosed with soft tissue mallet injuries were enrolled prospectively in a protocol of dorsal splinting for 6 to 12 weeks, followed by weaning over 2 weeks and then evaluated at 6, 9, and ≥12 months. Thirty-seven patients (38 digits) completed the study. Treatment success was defined as a final extensor lag of <15° and failure as a final extensor lag of ≥15°. Those failing splint treatment were older compared with those successfully treated. Patient compliance was significantly associated with a successful outcome. Factors that did not significantly affect success included time to treatment, initial injury severity, splinting duration, sex, and ligamentous laxity. Disabilities of Arm, Shoulder, and Hand scores >0 were not associated with treatment failure. Radiographic and clinical extension lag were statistically comparable. This study shows strong association between the success of splint treatment, younger patient age, and compliance with the treatment protocol. Despite this finding, most patients did not report any functional limitations, irrespective of the treatment success. In contrast to prior results, time to treatment and initial extensor lag did not significantly affect treatment success.

Voluntary femoro-tibial subluxations: a benign differential diagnosis in the snapping knee of a child.

Voluntary femoro-tibial subluxation is a rare entity predominantly found in pretoddlers. It presents as a dynamic phenomenon with uni- or bilateral audible snapping of the knee, often in a context of fatigue or irritation at the end of the day. The aim of the study was to observe the evolution and recovery in these patients. Ten children were included. Other causes of dislocating joints and pathologies with snapping of the lateral meniscus were excluded from this study. Six-week immobilisation with a splint at 70° of knee flexion was primarily recommended to all patients. The mean age at onset of symptoms was 10months. Forty percent of the patients presented with bilateral symptoms. Clinically, four patients were hyperlax. In all patients, subluxations could be reproduced passively by rotating the foot externally and advancing the internal tibial plateau anteriorly. Three of the patients were treated with a dorsal splint and experienced significantly less or cessation of symptoms. Two patients underwent surgery, one for a concomitant anterior cruciate ligament (ACL) rupture and meniscus tear that worsened the symptoms, another for concomitant patella dislocation and a meniscus tear. One patient's parents refused treatment and four patients experienced less symptoms at the time of consultation and were not immobilized. Except for the two patients undergoing surgeries, no sequelae were observed. In general, the symptoms got less frequent when the patient began to walk. Voluntary femoro-tibial subluxation in children is a rare and benign condition that often resolves spontaneously without sequelae. The risk of meniscus tear should, however, be considered if subluxations do not cease. IV.

Early Mobilization and Physiotherapy Vs. Late Mobilization and Home Exercises After ORIF of Distal Radial Fractures: A Randomized Controlled Trial.

Background:Volar locking plates have permitted early mobilization, omitting the need for prolonged cast immobilization, after distal radial fractures (DRFs). However, the type of rehabilitation following plate fixation of DRFs remains an unresolved issue. The purpose of this study was to evaluate the effect of physiotherapy after volar plate fixation of DRFs. At a 2-year follow-up, we compared the results of immediate physiotherapy (early mobilization) with those of home exercises following 2 weeks in a dorsal plaster splint (late mobilization).Methods:Patients with an extra-articular DRF scheduled for open reduction and internal fixation (ORIF) with a volar locking plate were evaluated for eligibility for enrollment in the study. The patients were randomized into 2 groups: (1) early mobilization and physiotherapy and (1) late mobilization and home exercise. In the early mobilization group, the plaster splint was removed after 2 to 3 days. During the first 3 months, the patients met with the institution’s physiotherapist every other week. The late mobilization group wore the dorsal splint for 2 weeks and only met with our physiotherapist once, when the splint was removed. This group was provided with a home physiotherapy program and instructed to perform home exercises on their own.Results:One hundred and nineteen patients were included in the study. The 2 groups had similar demographics with respect to age, sex, and baseline values. Seven patients were lost to follow-up. No clinically relevant difference in scores on the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire was found between the 2 groups at any of the follow-up evaluations. The largest difference in the QuickDASH score was found at 6 weeks, when the early mobilization group had a mean score of 30 compared with a mean of 37 in the late mobilization group (p = 0.05).Conclusions:Early mobilization and multiple physiotherapy visits did not improve wrist function compared with standard treatment of 2 weeks in a dorsal plaster splint, a single physiotherapy visit, and home exercises. Early mobilization following ORIF of an extra-articular DRF is safe.Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Effects of surgical and nonoperative treatment on wrist function of patients with distal radius fracture

PurposeTo study the effects of surgical and nonoperative treatment on wrist function in patients with distal radius fracture. MethodsIn total, 97 patients treated for distal radius fracture in the Department of Orthopedic Trauma at the People's Hospital of Peking University from Jan. 2010 to Jun. 2016 were selected for outpatient follow-up, including manipulative reduction and dorsal splint fixation in 24 cases, bivalve cast fixation in 19 cases and open reduction and internal fixation in 54 cases. Evaluation was based on Sartiento's modification of the Gartland and Werley score. Efficacy was assessed with wrist pain as the focus. ResultsThe wrist function scores of the surgical group were better than nonoperative groups. There was no significant difference in wrist function scores between the dorsal splint group and the bivalve cast group. The ulnar wrist pain incidence had no significant difference in surgical and nonoperative groups. The displace rate in dorsal splint group was higher than other groups. ConclusionThe overall effect of surgical treatment of distal radius fracture is better than nonoperative treatment. The ulnar wrist pain incidence has no significant difference in these groups. Dorsal splint fixation is more prone to displace than bivalve cast fixation.

Difference in cortical activation during use of volar and dorsal hand splints: a functional magnetic resonance imaging study.

There have been no studies reported on the difference in cortical activation during use of volar and dorsal hand splints. We attempted to investigate the difference in cortical activation in the somatosensory cortical area during use of volar and dorsal hand splints by functional magnetic resonance imaging (fMRI). We recruited eight healthy volunteers. fMRI was performed while subjects who were fitted with volar or dorsal hand splints performed grasp-release movements. Regions of interest were placed on the primary motor cortex (M1), primary somatosensory cortex (S1), posterior parietal cortex (PPC), and secondary somatosensory cortex (S2). Results of group analysis of fMRI data showed that the total numbers of activated voxels in all ROIs were significantly higher during use of volar hand splint (3,376) compared with that (1,416) during use of dorsal hand splint. In each ROI, use of volar hand splint induced greater activation in all ROIs (M1: 1,748, S1: 1,455, PPC: 23, and S2: 150) compared with use of dorsal hand splint (M1: 783, S1: 625, PPC: 0, and S2: 8). The peak activated value was also higher during use of volar hand splint (t-value: 17.29) compared with that during use of dorsal hand splint (t-value: 13.11). Taken together, use of volar hand splint induced greater cortical activation relevant to somatosensory function than use of dorsal hand splint. This result would be important for the physiatrist and therapist to apply appropriate somatosensory input in patients with brain injury.

The lateral-dorsal transposition flap for closure of a palmar soft tissue defect of the proximal phalanx on the little finger after limited fasciectomy in recurrent Dupuytren's contracture

Closure of a palmar soft tissue defect of the proximal phalanx after limited fasciectomy in recurrent Dupuytren's contracture. A palmar soft tissue defect between the distal flexion crease of the palm and the flexion crease of the proximal interphalangeal joint (PIP) after limited fasciectomy in Dupuytren's contracture. Scars at the lateral-dorsal portion of the proximal phalanx (e.g., after burns). Modified incision after Bruner ("mini-Bruner"). Removal of the involved fascial cord. If necessary, arthrolysis of the PIP. Raising the lateral-dorsal transposition flap from distal to proximal and rotating it into the palmar soft tissue defect of the proximal phalanx. Closure of the donor site with a skin transplant. Dorsal plaster of Paris with extended fingers and compressive dressing in the palm for 2days. Afterwards static dorsal splint and daily physiotherapy. Between 2002 and 2007, a total of 32lateral-dorsal transposition flaps in 30patients with recurrent Dupuytren's disease of the little finger underwent surgery. In a retrospective study, 19patients with 20flaps were available for follow-up evaluation after a mean of 6years. All flaps had healed. The median flexion contracture of the metacarpophalangeal joint was 0° (preoperatively, 20°), and of the PIP 20° (preoperatively, 85°) according to Tubiana stage1 (preoperatively, Tubiana stage3). The median grip strength of both the operated and the contralateral hand was 39kg. The DASH score averaged 11points. Overall, 11patients were very satisfied, 6patients were satisfied, 1patient was less satisfied, and 1patient was unsatisfied.

Postoperative care and rehabilitation after open carpal tunnel surgery

Background Carpal tunnel syndrome is the most commonly diagnosed and treated entrapment neuropathy. The most frequently performed procedure in the surgical treatment is the open release of the flexor retinaculum. Regarding postoperative care, current literature is inconclusive and does not meet the necessary requirements to create a consensus on rehabilitation regimen. Although postoperative splinting is common among hand surgeons and most often applied for 1 week, none of the previous studies have especially assessed the outcome after 7 days of splinting. The aim of this study was to investigate the differences in postoperative rehabilitation following open carpal tunnel release, between a regimen of 1 week dorsal splinting and a light foam bandage for 2 days.

Laterale Supramalleolarlappenplastiken zur Defektdeckung im Sprunggelenks- und Fußbereich

Defect reconstruction by transposition of well-vascularized thin and pliable skin. Defect coverage involving the antero- and dorsolateral distal one third of the lower leg, the dorsolateral and dorsomedial hindfoot and dorsal midfoot. Severe peripheral arterial occlusive disease (PAOD), previous trauma at the anterolateral aspect of the lower leg and foot. Lateral fasciocutaneous supramalleolar flap with orthograde blood flow, fasciocutaneous lateral supramalleolar perforator flap with orthograde blood flow, adipofascial lateral supramalleolar flap with orthograde blood flow, lateral fasciocutaneous supramalleolar flap based on the lateral tarsal artery with retrograde blood flow, lateral fasciocutaneous supramalleolar flap based on the anterolateral malleolar artery with retrograde blood flow according to Oberlin. "Tie over" dressing for grafting site for 5 days (healing of split/full-thickness skin graft), complete immobilization of the lower leg for 7 days in a dorsal plaster splint (ensure that there is no pressure on the flap), progressive increase of range of motion after 1 week, postoperative standardized compression therapy, combined with scar therapy (silicone sheet). Reliable, excellent functional and aesthetic results with thin skin in small to midsize defects. Increasing morbidity of grafting site in larger flaps and risk of neuroma when the superficial peroneal nerve was exposed.

Hand Splinting for Poststroke Spasticity: A Randomized Controlled Trial

Purpose: To determine the effect of volar and dorsal splinting on the spasticity of the wrist flexor muscles in patients who had stroke. Method: Thirty-nine subjects were prospectively randomized to use a dorsal or volar splint or no splint (control group). All the patients underwent home-based exercise program, and the experimental groups used either dorsal or volar hand splints according to their distribution. The primary outcome measure was spasticity assessed clinically by the Modified Ashworth Scale (MAS) and electrophysiologically by H latency and Hmax:Mmax ratio of flexor carpi radialis. Secondary outcome measure was passive range of motion (PROM) of wrist extension. Results: Spasticity parameters (MAS, H latency, Hmax:Mmax ratio) and wrist PROM were not significantly different among the groups. Conclusions: This study failed to demonstrate any statistically significant difference in spasticity or in wrist PROM of both the volar and dorsal splint groups. These splints could be recommended as part of an integrative approach without expecting a major clinical effect rather than as an alternative to other treatment.

Tape versus cast for non-operative treatment of primary patellar dislocation: a randomized controlled trial

We hypothesized that taping results in better short-term functional outcome and comparable redislocation rates. In a prospective randomised clinical trial, 18 patients with a primary patellar dislocation ≥18years old without accompanying fractures or previous surgery to the knee were included. After 1week of dorsal splinting, they were randomized into two groups: taping and cylinder cast immobilization. Physical examination and knee function according to the Lysholm Knee Scoring Scale were taken at 1-, 6- and 12-week and at 1- and 5-year follow-up. We also compared the redislocation rates. Taping resulted in a significantly better Lysholm score at 6 and 12weeks post-dislocation (P<0.05), and also after 5-year follow-up (P<0.01). Knee function was better at 1-year follow-up. There were no cases of recurrent dislocation. Tape bandage immobilization seems superior to a cylinder cast even after 5years.

The “peg test”: A novel technique for dexterity evaluation in hand immobilized with a splint

Manual dexterity tests are difficult to apply in the clinical practice. They are either destined for specific lesions, or are rather complicated and time-consuming. The aim of this study was to evaluate a new manual dexterity test for hand immobilized with a splint: the “peg test”.Our series included 86 persons (without any hand trauma or disease) of mean age 42 years of which 77 were right-handed. Materials included five pegs, splints immobilizing the DIP joint, a desk and a stopwatch. Each subject moved the pegs from a horizontal to a vertical position using the thumb-ring pinch grip. This was repeated three times without a splint, with a palmar splint, with a simple dorsal splint and with a dorsal splint glued to the nail, then once more without a splint. A time score was recorded for each trial. A point was deduced at each fall of a peg for result analysis. Results showed that a learning curve affected performance, but that dominance and age before learning had no effect. After learning performance diminished with these variables in the following order: without splint, then more so with a glued splint, even more with a simple dorsal splint and most with a palmar one. The peg test fulfills metrological requirements of dexterity tests: test-retest (intra-observer) reliability (reproducibility), inter-observer reliability (both measured by correlation coefficient), and validity of instrument of measurement. Simple, rapid and reliable, it is perfectly adapted to manual dexterity evaluation in hand immobilized with a splint.

Repair of Flexor Carpi Radialis Tendon Laceration at the Wrist in a Professional Ice Hockey Player

The flexor carpi radialis is a wrist flexor and radial deviator with half the relative strength of flexor carpi ulnaris. In the majority of patients, the flexor carpi radialis tendon is expendable and is routinely used for various reconstructive procedures about the hand and wrist. Isolated flexor carpi radialis lacerations at the wrist are rare. Flexor carpi radialis tendon ruptures, which have been reported in association with distal radius fractures, longstanding osteoarthritis, and percutaneous treatment of scaphoid fractures, are usually treated non-operatively. We report a case of a traumatic laceration of the flexor carpi radialis tendon at the wrist in a professional ice hockey player. Surgical repair and rehabilitation using established principles for intrasynovial flexor tendon repair allowed return to sport at the professional level in 2 months.Tension-free core suture repair was performed with a modified-Kessler, 4-strand repair using a double-stranded 4-0 Supramid suture. A running epitendinous suture was then placed around the circumference of the tendon with 6-0 Prolene. Immobilization of the wrist in 20° of flexion was maintained for 2 weeks. Full active and passive digital motion was allowed immediately postoperatively and continued throughout the rehabilitation. Therapy was initiated at 2 weeks postoperatively with full passive wrist flexion and passive wrist extension to a dorsal block of 20°. At 4 weeks postoperatively, a dorsal splint was fabricated to keep the wrist in neutral. At this time, active extension to a dorsal block of zero and full passive flexion was allowed. Active wrist flexion without resistance was begun at 6 weeks, and full strengthening was allowed at 8 weeks postoperatively. The patient returned to sport at the professional level shortly thereafter. At latest follow-up, the patient has been able to fully participate in professional ice hockey without pain or functional limitation.

Mediokarpale Teilarthrodese des Handgelenks mittels Spiderplatte

Pain relief while preserving wrist motion in advanced carpal collapse. Advanced carpal collapse stage II/III due to scaphoid non-union, scapholunate ligament tear, idiopathic radiocarpal osteoarthritis, aseptic osteonecrosis of the scaphoid (Preisser's disease). A relative indication is chronic midcarpal instability. Osteoarthrisis of the lunate. Radiocarpal instability with ulnar translation of the wrist. Dorsal curved incision between the 3rd and 4th dorsal extensor compartment. Partial wrist denervation (posterior interosseous nerve). Raising of a radial pedicled capsule flap. Complete extirpation of the scaphoid without fragmentation. Cartilage removal of all the joint facets for arthrodesis. Reduction of the lunate and temporary fixation with K wires between the triquetrum and capitate and the triquetrum and lunate. Milling the plate hole exactly in central position of the four carpal bones. The plate should not protrude from the bone to avoid impingement with the dorsal limb of the radius. Transferring of spongiosa harvested from the removed scaphoid into the arthrodesis gap. Fixation of the 8-hole plate with 2 screws in each of the four carpal bones. Fluoroscopy of the screw fitting. Control of the correct wrist articulation (motion test). Lavage of the wrist. Suture of the capsule flap. Redon drain, wound closure, dorsal splinting. Dorsal splint for 3 weeks; finger mobilization up to complete fist closure starting on postoperative day 1. From week 4-6, active wrist motion, from week 7-10 with increasing load. Return to work after 11-12 weeks. CT scan in cases of delayed union, abnormal function, or persistence of pain. Between 2002 and 2008, 36 four-corner fusions (32 male, 4 female) with the spider plate were performed in 24 right and 12 left wrists. The mean age of the patients at surgery was 48 years (range 32-71 years). Follow-up examinations were performed in 11 patients. The Krimmer and Rudolf scores were determined: 1 excellent, 7 good, 2 satisfactory, and 1 poor result were found. The mean grip strength was 51% relative to the opposite wrist. The mean range of motion (ROM) for wrist extension/flexion was 56% of the opposite side. Wrist extension/flexion averaged 24/0/32° and ulnar/radial deviation was on average 20/0/19°. Pain during activity was on average 2.2 based on the visual analogue scale (0-10). One delayed bony union due to a screw breakage, which required total wrist fusion, was observed.

Blinded, Prospective, Randomized Clinical Trial Comparing Volar, Dorsal, and Custom Thermoplastic Splinting in Treatment of Acute Mallet Finger

Blinded, Prospective, Randomized Clinical Trial Comparing Volar, Dorsal, and Custom Thermoplastic Splinting in Treatment of Acute Mallet Finger

Zone 2 lacerations of both flexor tendons of all fingers in the same patient

Over an eight-year period, the author has treated five males (mean age of 31 years) with clean-cut zone 2 lacerations of both flexor tendons of all fingers using the same surgical technique (profundus only repair using three 'figure of eight' core sutures and proximal venting of the pulley system) and the same postoperative mobilization programme (a dorsal blocking splint with immediate active motion that allowed full extension at the interphalangeal joints). There were no ruptures of the repaired 20 fingers. At final follow-up (mean of 22 months after surgery), the outcome was considered excellent in 12 fingers, good in four fingers and fair in the remaining four fingers by the Strickland-Glogovac criteria. The outcome was similar in all four fingers for every patient supporting the hypothesis of previous studies that the outcome of repair of clean-cut flexor tendon lacerations in zone 2 is related to the psychological and biologic characteristics of the patient.

A prospective randomized controlled trial comparing circumferential casting and splinting in displaced Colles fractures

Our primary objective was to determine the effectiveness of 3 immobilization methods (circumferential casting [CC], volar-dorsal splinting [VDS] and modified sugar-tong [MST] splinting) in maintaining the position of displaced distal radius fractures after successful closed reduction. Our secondary objective was to assess longterm functional outcomes associated with immobilization with fibreglass splinting versus standard CC in patients maintaining initial nonoperative reductions. We conducted a prospective randomized single-blind controlled trial in patients over 18 years of age who presented to the emergency department with a displaced fracture of the distal radius requiring closed reduction. The primary outcome was loss of reduction (defined as radiologic slippage or the need for surgical fixation during the 3-4 week primary immobilization period after initial successful reduction). Secondary outcomes included DASH (disabilities of the arm, shoulder and hand) score, return to work, activities of daily living, wrist pain, range of motion and grip strength assessed at 8 weeks and 6 months. Thirty participants were randomly assigned to receive MST splinting, 31 to receive VDS and 40 to receive CC. Baseline characteristics were similar among groups. Radiographic loss of reduction occurred in 16% (95% confidence interval [CI] 3.1%-28.9%) of participants in the VDS group, 20% (95% CI 7.6%-32.4%) in the CC group and 30% (95% CI 13.6%-46.4%) in the MST splinting group (p = 0.17). Based on multivariate analysis of variance, functional outcomes at 8 weeks were similar among groups (p = 0.89). DASH scores at 8 weeks and 6 months were similar among groups, based on 1-way analysis of variance (p > 0.25). Rates of loss in anatomic position were not statistically significant among the 3 types of dressings used. However, there was a clinically important trend of increased loss of reduction with the use of MST splinting. Functional outcomes at 8 weeks and 6 months were not significantly different between CC, VDS and MDS splinting. Ease of application and familiarity with use should guide clinical decisions when choosing a dressing type for displaced Colles fractures.

Blinded, Prospective, Randomized Clinical Trial Comparing Volar, Dorsal, and Custom Thermoplastic Splinting in Treatment of Acute Mallet Finger

Blinded, Prospective, Randomized Clinical Trial Comparing Volar, Dorsal, and Custom Thermoplastic Splinting in Treatment of Acute Mallet Finger

Verpflanzung des Musculus pectoralis major zur Wiederherstellung der Ellbogenbeugung bei posttraumatischen Armplexusschäden

Active elbow flexion is necessary for bimanual tasks. Reconstruction of powerful active elbow flexion. Reconstruction of missing muscle unit by neurovascular pedicled functional muscle transposition. Treatment of second choice (first choice bipolar latissimus dorsi transfer according to Zancolli & Mitre, transfer of the flexor/pronator muscle onto the distal humerus, or transposition of the triceps onto the biceps): --(Secondary) reconstruction of active elbow flexion in case of lesion of the brachial plexus or musculocutaneous nerve. --Replacement of the elbow flexor muscles in case of primary muscle loss (tumor, trauma). Ongoing spontaneous or postoperative nerve regeneration. Ankylosis of the elbow joint (in case of good shoulder and hand function, one should consider arthrolysis or even total joint replacement). Insufficient power of the pectoralis major muscle (< M(4)). Lesion of the axillary artery involving the thoracoacromial artery. Relative: concomitant lesion of the latissimus dorsi and teres major muscles (loss of glenohumeral adduction [thoracohumeral pinch]. Distal muscle transposition: transposition of the origin--pars abdominalis, pars sternocostalis, pars clavicularis (unipolar or bipolar, partial or complete distal transfer): --Unipolar partial pectoralis major muscle transposition according to Clark. --Bipolar partial pectoralis major muscle transposition according to Schottstaedt et al. --Bipolar complete pectoralis major muscle transposition according to Dautry et al. and Carroll & Kleinmann, respectively, possibly in combination with transfer of the pectoralis minor muscle. --Myocutaneous flap in case of concomitant skin defect at the upper arm level. Proximal tendon transfer: transposition of the tendinous insertion at the humerus of the pectoralis major muscle. Immobilization for 6 weeks in a dorsal upper arm splint, a Gilchrist bandage or a thorax-arm abduction orthesis with the elbow in 90 degrees flexion and supination. Early passive motion depending on pain within the sector 90-140 degrees. Progressive increase of active range of motion after 6 weeks. Protected exercise from "out of the splint" with increasing elbow extension of 10 degrees per week. It is important, that there is still an extension lag of 30-40 degrees at 3 months after transfer, in order to protect the reinnervated muscle and avoid overstretching. Although complete elbow extension should be the aim after 1 year, most patients will keep an extension lag of 20-30 degrees. Physiotherapy must continue for 12-18 months. Postoperative standardized compression therapy, combined with scar therapy (silicone sheet). Meta-analysis of the literature and personal results show functional (very good and good) results in 54-86% of patients. There are only few complications.