Thoracodorsal to triceps nerve transfer (following brachial plexus injury)
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Restoration of triceps function following a brachial plexus injury is increasingly recognised as a desirable aim of reconstructive surgery. Although restoration of elbow flexion is rightly prioritised over other motor functions the triceps must be given consideration wherever feasible.
Active triceps control opens up the potential for more refined elbow flexion, improved active control of elbow extension (compared to mere gravity control) as well as improved shoulder stability. Co-contraction of triceps during elbow flexion also improves fine control of hand position by permitting locking of elbow position. Furthermore the restoration of active extension against gravity increases a persons reach space by 800%.
Historically the results for nerve grafting for elbow extension have been poor. Nerve transfer results have been variable and depend upon the availibility of suitable donor nerves.
For partial plexus injuries involving the upper plexus, intra-plexal donor nerves will be available and I have found the lateral branch of the thoracodorsal nerve to be a suitable donor due to a well matched axon count, a synergistic contraction that readily permits re-learning, and a reliable length with a short re-innervation distance.
The thoracodorsal nerve is also a suitable donor in isolated high radial or distal posterior cord injuries where nerve grafting is deemed unsuitable.
This technique illustrates the key surgical steps required to perform this nerve transfer successfully. Thorough pre-operative examination and investigation, as well as post-operative rehabilitation by therapists experienced in peripheral nerve reconstruction are also integral to the success of this technique.
Another relevant OrthOracle operative technique that readers will find of use is Brachial plexus reconstruction (intercostal to radial nerve transfer)
Some relevant surgical anatomy may also be found by reading the Modified Somsak nerve transfer (medial head of triceps nerve transfer to anterior division of the axillary nerve through a posterior approach)
Author:Tahseen Chaudhry FRCS (Tr & Orth)
Institution: Consultant hand and peripheral nerve surgery, University Hospital, Birmingham, UK.