TRANSFER

OF

THE

AFTER

BRACHIAL

WAQAR

From

TRAPEZIUS

AZIZ,

the Christine

FLAIL

PLEXUS

RICHARD

M. Kleinert

FOR

M. SINGER,

Institutefor

INJURY

THOMAS

Hand

SHOULDER

and

W.

Micro

WOLFF

Surgery,

Kentucky

Shoulder
arthrodesis
is often used to freat flail shoulder
after a brachial
plexus iujury, but has a high
complication
rate and entails loss of passive mobffity.
We have reviewed
27 patients
with brachial
plexus
injury treated
by transfer
of the trapezius
to the proximal
humerus
at an average
time from injury of 31.3
months.
Pre-operatively,
all 27 shoulders
were subluxated,
with an average
abduction
of 3.5#{176}.
Postoperatively,
shoulder
abduction
averaged
45.4#{176},
and subluxation
was abolished.
All patients
were satisfied
with their
improvement
in function.
Trapezius
transfer
is recommended
as a simple procedure
that requires
only a brief
period
in hospital,
allows
early
rehabilitation,
and gives a satisfactory
outcome,
while retaining
passive
mobility of the shoulder.
Flail
shoulder
secondary
difficult
to treat. Shoulder

to a brachial
plexus
injury
is
fusion has been accepted
as an

adequate

has

treatment,

(Vastam#{228}ki
improvement
criteria,

but

1987).

of function,
Richards,

a high

However,

complication

using

subjective

and

Waddell

and

of the

irreversibility

factors

against

shoulder

Hudson

Several
muscle
restore
movement
poliomyelitis

(1985)

recently,

the use ofthese

been
reported

monograph,
with transfer
technique

However,
operation
alone

1927,

Harmon

Saha

1939;

some

1932;

(1967)

gave

1986).

details

In

of his

ics), University
of Louisville
School
of Medicine
Christine
M. Kleinert
Institute
for Hand
and
Micro
Abraham
Flexner
Way, Suite 850, Louisville,
Kentucky

1990 British
0301-620X/90/4l09
JBoneJointSurg[Br]

VOL.

be sent

to Dr T. W. Wolff.

Editorial
Society
ofBone
$2.00
1990; 72-B:70l-4.

72-B, No. 4, JULY

1990

to
after

and

Joint

Surgery

to reach

extent
between

a classic
experience

of the
(1954).
for the
transfer

a plateau,

and

of recovery.
The
muscle
transfers

it is difficult

choice
and

for flail

shoulder

secondary

to brachial

PATIENTS
We

treated

27

transfer
average
average
months

of the

months

(range

AND

patients,

age

was

to the

31 .2 years

time
after
injury
to 10 years).
The

some
Surgery,
225
40202,
USA.

and

Nine

at the time

associated

patients

transfer

injury.

four

proximal

female,

humerus.

by
Their

(range
14 to 58), and the
was 3 1 3 months
(range
6
average
follow-up
was 14.6
.

10 patients
(seven
patients

(37%)

of trapezius

had

had

had nerve grafts and

had had other muscle

one
and
but

transfer

procedure,
latissimus
one

were

and all had

pain.

Pre-operative
evaluation
included
radiographic
examinations,
with
EMG
shoulder
subluxation

where

muscle

6 to 46).

Before
the transfer,
brachial
plexus exploration
three had neurolysis).
Nine

unemployed

the

METHODS

23 male

trapezius

plexus

transfers,
and eight had had more than
for example,
brachial
plexus exploration
dorsi transfer
for elbow
flexion.
All
(Orthopaed-

to predict

of other
treatment
lies
an arthrodesis,
which
is

essentially
irreversible
and therefore
unacceptable
there is a possibility
that the patient
may regain
control of the glenohumeral
joint.
We have evaluated
the results of trapezius

1935;

use.

W. Aziz, MD, Fellow in Hand Surgery

R. M. Singer, MD, Former Fellow in Hand Surgery
T. W. Wolff, MD, Assistant
Clinical
Professor
of Surgery

of the

Haas

of the trapezius,
using a modification
originally
described
by Bateman
the absence
of clear
indications
and expecting
too much
from
this

should

found

cases.

Ober

(Karev

has led to its infrequent

Correspondence

years

as

1950; Saha
1967), and, more
procedures
after brachial
plexus

has

injury

were

in these

pain,

a long remobility,
and

transfers
have been advocated
and stability
of the shoulder

(Mayer

1949;

Steindler

procedure
fusion

of

satisfaction

fusion
unsatisfactory.
Technical
difficulties,
habilitation,
complications,
loss of passive
the

rate

absence

have been several

reports
of the success
of
plexus
exploration
and grafting
(Kline
and
1983 ; Millesi
1984), but the results
take several

There

brachial
Judice

(33%)

had

radiological

after
the initial
injury,
prior to the transfer.

physical

and

in 13 patients.
subluxation
of the

and all showed

Shoulder
abduction

some
was
701

w. AZIZ,

702

measured
as the angle between
the trunk
the pre-operative
average
was 3.5#{176}
(range
22 of the 27 having
none).
The
was 4.2#{176}
(range
0#{176}
to 50#{176},
again

R. M. SINGER,

and the arm:

0#{176}
to 30#{176}
with

average
shoulder
flexion
with 22 having
none).
In

The partly

brachial

wound

injuries.

Surgical
technique.
We use a modification
technique
described by Mayer(l927)and
and

amended

the

operating

by Saha

table

(1967).

with

Patients

are

(1954)

positioned

a 45#{176}
foot-down

tilt

on

and

to the humerus

is fixed

screws,

the deltoid

of the surgical
Bateman

fragment
with its trapezius
inserwith two 4.5 mm cortical lag
ensuring
firm bone-to-bone
contact
(Fig. 3). The
is thoroughly
irrigated
with saline solution,
and

the acromioclavicular
tion

plexus

full

deltoid is split longitudinally

to
humerus
(Fig. 2), which
is scored
The arm is then abducted
to 90#{176},
and

detached

expose
the proximal
with an osteotome.

the CS and C6 roots had been injured ; in six

CS, C6, and C7 roots ; and in five there were complete
16 patients

1. W. WOLFF

is sutured

on top ofthe

mobilised

in a soft

abduction

Dotted
ofthe

lines
deltoid.

show

the

line

spine

over
the

ofthe

scapula.

the mid-deltoid.

of detachment

lateral

third

the trapezius,
crosses
the lateral
round
the acromion
and along the

A verticalextension
The deltoid
origin
of the

clavicle,

the

is made
is then

acromion,

laterally
cut from
and

Postoperative
second

management.

or third

for six weeks

day.
or until

needed to define
the supraspinatus.
the neurovascular
and transverse
to superficial

insertions

of the trapezius

are elevated

and the scapular

spine to 2 cm from the

of the scapula.
Careful
dissection
is
the interval
between the trapezius
and
Special attention
is needed
to preserve
bundle
of the spinal accessory
nerve

cervical
artery,
which
through
the trapezius.

courses

from

deep

are

fragment
and the humerus.
The arm
adduct
progressively
and a vigorous
programme
is started.
As strength

resisted

muscle

strengthening

the

half of the spine of the scapula

(Fig. 1).
A Gigli wire saw is used to transect
the root of the
acromion,
and then the lateral clavicle,
so as to separate
the lateral
1 cm of the clavicle
with the acromion
(Fig.

Drains

removed

on the

The soft abduction

support
is worn
union is seen between
the acromion

exercises

is then allowed
to
physical
therapy
improves,
more

are added.

RESULTS

lateral

2). The remaining

from the clavicle
vertebral
border

The acromion
and the distal clavicle
have
been
cut transversely
and
the trapezius
freed
from
the underlying
supraspinatus
muscle.
The deltoid
has been split longitudinally.

lateral
decubitus
using
a bean bag for support.
The
shoulder,
the neck, and the whole arm are prepared
and
free.
A transverse
skin incision
begins above the clavicle
over
the insertion
of
clavicle,
and continues

insertion

support.

Fig.

Fig.

new trapezius

(Fig. 4). The skin is closed

in two layers over suction
drains,
a bulky dressing
applied
and the patient
im-

Time

under

anaesthesia

averaged

3 hours

(range

2 to 5),

and the estimated

mean blood loss was 150 ml. Hospital
stay averaged
four days (range
3 to 5) and there
were no
postoperative
complications
or infections.
Two patients
required
two additional
weeks ofimmobilisation
because
bone stock.
Postoperatively,
24 patients
(89%) were pain-free,
but three with complete
brachial
plexus lesions still had
pain. Subluxation
was fully reduced
and muscle
power
ofpoor

was

The

graded

average

M4

or better

gain
THE

in

in all patients

shoulder

JOURNAL

(Figs

abduction

OF BONE

AND

5 and

was
JOINT

6).

45.4#{176}

SURGERY

TRANSFER

(p

0.001,

<

120#{176}
; the

Fishers

(p < 0.001),
with
had stable shoulders
ment

exact
in

gain

OF THE

test),

shoulder

a range

TRAPEZIUS

with

FOR

a range

flexion

FLAIL

SHOULDER

of 20#{176}
to

were

satisfied

with

Recent
The
blood
with

of pain in most. The only contra-indication

degeneration
of the shoulder.

brachial

advances

plexus

and

compatible

with

some

The
deltoid
has
transferred
trapezius.

Shoulder
arthrodesis
has been considered
the proof choice
in patients
with a flail shoulder
after
brachial
plexus
injury,
but has a high complication
rate.
cedure

Cofield
fractures,
had no

and

Briggs

(1979)

while
15%
improvement.

arthrodesis

in

reconstruction

had

1 1 brachial
plates.

reported

a 24%

aggravation
Richards
et

plexus

Shoulders

al

of pain
(1988)

patients,
were

Fig.

incidence

fused

and 25%
reported

using

72-B,

No. 4, JULY

1990

pelvic

in 30#{176}
each

tional
strong

recovery
enough

active

muscles,

acting

for high

radial

is not
to keep

abduction,

while

The treatment
be directed

limited

to the

Fig.
man
14 months
after
Figure
6 - After
operation,

muscle

some

to prevent
is also

function

to the

closed

over

the

in a similar

palsy.

manner

Even

when

as

func-

transfer

is

allow some
a full passive range.

allowing

specific

includbetter

transfer

adequate,
the trapezius
the shoulder
stable
and

of a patient

to the deltoid,

Figure
5 - Radiograph
of a 28-year-old
showing
subluxation
of the shoulder.
abduction
had improved.

VOL.

of

shoulder
girdle
Jones transfer

been

could

1983 ; Takahashi
a few years,
and

of splinting

of

Fig.

and

surgery,
will
give

Judice
takes

kind

return

Fig. 3
The acromion
process
has been fixed to the
proximal
humerus
with two lag screws.

plexus

Trapezius

the

had

transfer.
Arthrodesis
and passive movement

(Kline
and
but recovery

pain.

They

but five of the 11

neurotisation,

require

patients

subluxation

rotation.

exploration

in brachial

nerve

functional
outcomes
1983 ; Millesi
1984),
most

703

INJURY

flexion
and internal
fewer complications,

with
had

intercostal

ing

muscle
transfer
has several
advantages.
is relatively
simple
and entails
minimal
is functional
improvement
in all patients

PLEXUS

have been candidates

for trapezius
is irreversible
and gives less active
than trapezius
transfer.

the improve-

DISCUSSION

elimination
is advanced

of abduction,
results
patients
had

in function.

Trapezius
procedure
loss. There

BRACHIAL

35.2#{176} better

averaged

of 0#{176}
to 120#{176}.
All the patients

and

AFTER

with

deficits.

for instance,

a partial
brachial
plexus
injury,
subluxation
was relieved
and

a flail

shoulder

Should

abduction

must

paralysis

splinting

be

W.

704

AZIZ,

R.

M. SINGER,

T. W.

WOLFF

(Dehne
and Hall 1959) may be all that is needed.
In more
severe cases, and especially
after a brachial
plexus
injury,
trapezius
transfer
will allow the patient
to position
the
arm much
better.
Trapezius
transfer
can be used with

Hovnanian
AP. Latissimus
dorsi
transplantation
extension
at the elbow:
a preliminary
143:493-9.

other

Kline

transfers

to

achieve

maximum

use

of

the

arm.

from such procedures

as latissimus
dorsi
transfer
for elbow
flexion
(Hovnanian
1956),
elbow
flexorplasty
(Steindler
1949), and wrist fusion are important in planning
reconstructive
surgery
for patients
with
Careful

choice

brachial

plexus

Kanv

A. Trapezius

for paralysis

loss of flexion
or
Ann
Surg
1956;

of the deltoid.

J Hand

Surg

[Br] 1986; llB:8l-3.

DG,
plexus

Mayer

Judice
lesions.

Mayer

DJ.
Operative
J Neurosurg

L. Transplantation

ofthe

management
1983 ; 58:631-49.

of the trapezius

arm. J BoneJoint

L. Operative
BoneJointSurg

Millesi

injury.

transfer

for
report.

Surg

of

selected

for paralysis

ofthe

brachial
abductors

1927; 9:412-20.

reconstruction

of the paralyzed

upper

extremity.

1939; 21:377-83.

H. Brachial

plexus

injuries

: management

and

results.

C/in

P/ast

Surg 1984; 1 1 :115-20.

Our thanks
go to Maurizio
Altissimi,
MD, for his help at the beginning
ofthe
study to Grace
vonDrasek-Ascher,
AMI,
for medical
illustrations,
and to Kell Julliard
for his assistance
with writing,
research
and editing.
No benefits
in any form
have
been
received
or will be received
from a commercial
party
related
directly
or indirectly
to the subject
of
this article.

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THE

JOURNAL

for

paralysis

OF BONE

and

AND

arthrosis.

JOINT

Ada

SURGERY