Rühmann Oliver, Hierner Robert
Klinik für Orthopädie, Unfallchirurgie und Sportmedizin, Klinikum Agnes Karll Laatzen/Klinikum Region Hannover, Laatzen, Germany.
Oper Orthop Traumatol. 2009 Jun;21(2):157-69. doi: 10.1007/s00064-009-1703-x.
Reduction of paralytic supination posture and contracture of the forearm. Improved spontaneous posture of the paralyzed arm with a more normal anatomic relationship of ulna and radius. Improvement of the activities of daily living, especially activities requiring active pronation (eating, dressing, writing). Prevention of recurrence or increase of the deformity during the growth period in obstetric brachial plexus palsy. Partly restoration of active pronation.
Unopposed supination by the biceps in the presence of paralysis of the pronators as a result of --brachial plexus palsy, --poliomyelitis, --quadriplegia, --paralysis from other causes.
Ongoing spontaneous or postoperative nerve regeneration and possible improvement of paralyzed pronators. Posttraumatic or degenerative ankylosis of the elbow joint; the extent of the preoperative passive pronation determines the postoperative result. Insufficient power (< M(4)) of the triceps (inadequate triceps function can lead to a flexion contracture of the elbow).
After exposure of the biceps tendon a long Z-plasty is used to lengthen the tendon and allow its distal segment to be rerouted around the neck of the radius mediolaterally. The tendon ends are sutured. The technique allows the biceps to become a pronator instead of a supinator while preserving its original function of elbow flexion. In case of interosseous membrane contracture a release of the membrane is necessary.
Immobilization in an upper plaster cast or Gilchrist bandage with the elbow in 90 degrees flexion and the forearm in neutral rotation or pronation, no extension below 90 degrees flexion/no supination for 6 weeks. Passive and active exercises of elbow extension, flexion and pronation until the maximally possible range of motion has been reached (12-18 months); dynamic pronation orthosis, if needed.
Eleven children with obstetric brachial plexus palsy and an average age of 6 years (4-12 years) were operated. In eight cases, besides rerouting of the biceps tendon, a release of the interosseous membrane was performed. Average follow-up time is 36 months (10-55 months). In all patients, an improved and more normal spontaneous posture of the paralyzed forearm resulted: difference of forearm position/increase of pronation 87 degrees (70-100 degrees). 91% of the patients reached an active pronation at least to neutral rotation, 46% were able to pronate up to 30 degrees and more.
减少麻痹性旋后姿势及前臂挛缩。改善瘫痪手臂的自发姿势，使尺骨和桡骨的解剖关系更正常。改善日常生活活动能力，尤其是需要主动旋前的活动（进食、穿衣、书写）。预防产瘫在生长发育期间畸形的复发或加重。部分恢复主动旋前功能。
由于臂丛神经麻痹、小儿麻痹症、四肢瘫、其他原因导致的麻痹，在旋前肌麻痹时肱二头肌无对抗旋后。
正在进行的自发或术后神经再生以及瘫痪旋前肌可能改善。肘关节创伤后或退行性强直；术前被动旋前的程度决定术后结果。肱三头肌力量不足（M(4) 级以下）（肱三头肌功能不足可导致肘关节屈曲挛缩）。
暴露肱二头肌腱后，采用长Z形成形术延长肌腱，并使其远侧段在内侧和外侧绕过桡骨颈重新定位。缝合肌腱两端。该技术可使肱二头肌成为旋前肌而非旋后肌，同时保留其原有的肘关节屈曲功能。若存在骨间膜挛缩，则需松解骨间膜。
用上肢石膏管型或吉尔克里斯特绷带固定，肘关节屈曲90度，前臂中立位旋转或旋前，屈曲低于90度时不伸展/不旋后6周。进行肘关节伸展、屈曲和旋前的被动和主动锻炼，直至达到最大可能的活动范围（12 - 18个月）；必要时使用动力性旋前矫形器。
对11例平均年龄6岁（4 - 12岁）的产瘫患儿进行了手术。8例除肱二头肌腱重新定位外，还进行了骨间膜松解。平均随访时间为36个月（10 - 55个月）。所有患者瘫痪前臂的自发姿势均得到改善且更正常：前臂位置差异/旋前增加87度（70 - 100度）。91%的患者至少达到主动旋前至中立位旋转，46%的患者能够旋前30度及以上。
