Double fascicular transfer for elbow

flexion

Cadaveric dissection

First Nerve transfer workshop,KTPH, Singapore

Practical 5

• Fascicle (FCU) - motor branch of biceps (MBrBi) • Median fascicle (FCR) transfer - motor branch of brachialis (MBrBr)

Incision

• 10cm longitudinal incision on the medial arm in the interval between biceps and triceps• The proximal incision should start 3 finger breadths below the anterior

axillary fold and extend to the junction of the upper 2/3 and lower 1/3 of the upper arm

Superficial dissection

• Open the skin (avoid damage to the cutaneous nerve branches from the medial cutaneous nerve of arm)• Incise the deep fascia• Using gentle digital dissection expose the interval between biceps and

triceps• Retract the distal biceps muscle belly to elevate biceps and identify

the motor branch entering the undersurface proximally

Deep dissection

• Loop around the MBrBi• Follow the MBrBi proximally to the take-off from the MCuN and then

use a surgical loop to lift the MCuN and trace distally for 5cm• Place a surgical loop around the MBrBr and using gentle traction on

the surgical loops undertake a limited external neurolysis of the MBrBr• Do the same to MBrBi• Internal neurolysis

Identifying the ulnar nerve

• Retract the posterior skin flap at the level of the MBrBi• Identify the medial cutaneous nerve of forearm• Mobilize this medially and then incise the medial intermuscular

septum to expose the ulnar nerve in the posterior compartment of the arm• Free the nerve through the septum and position a proximal and distal

surgical loop under the ulnar nerve

Identifying the ulnar nerve

• Mobilize the MBrBi and section proximally - reflect distally and ulnarwards• Make a longitudinal epineurotomy and expose the fascicles in the

suitable segment of the nerve and identify the FCU fascicle from the UN (lateral or central)• Place a surgical loop under this fascicle (confirm with the faculty

before dividing the fascicles • Typically 2-3 cm of ulnar nerve fascicle is needed through internal

neurolysis

Identifying the median nerve

• Expose the median nerve immediately medial to the MCuN and lying anterior to the brachial artery at the level of the MBrBr• Make a longitudinal epineurotomy and expose the fascicles in the

suitable segment of the nerve (usually anteromedial)• Carefully position a surgical loop under this fascicle • Mobilize the MBrBr and section proximally and reflect distally and

ulnarwards

• The two nerve stumps should reach without tension with the shoulder in abduction and the elbow extended

• Donor distal

• Recipient proximal

Coaptation

• The two nerve ends under the operating microscope with 2-3 well placed 9’0 nylon sutures

• (support with fibrin glue in real situations)

Youtube video

Thank you