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Double Oberlin Nerve Transfer to Restore Elbow Flexion

February 10, 2018

Contributors: Alice Chu, MD, FAAOS; Amos Dai, BS; Dylan Lowe, MD; Michael J Moses, MD; Themistocles Stavros Protopsaltis, MD, FAAOS; Themistocles Stavros Protopsaltis, MD, FAAOS

Purpose: Oberlin nerve transfer is a technique in which the ulnar nerve is transferred to the biceps brachii muscle to restore elbow flexion. This technique typically is used in patients with an upper plexus injury in which C5 to C7 nerve damage exists, such as a traumatic brachial plexus avulsion injury. Limited studies are available on the double Oberlin transfer, in which motor fascicles from the ulnar and median nerves reinnervate the biceps brachii and brachialis muscles to restore elbow flexion. A paucity of literature is available on these transfers and their outcomes. This video discusses the indications and technique for a double Oberlin transfer for the management of a brachial plexus C5-C6 avulsion injury and the role of the procedure in restoring elbow flexion. Methods: This video discusses the case presentation of a 25-year-old man who presented to our institution after a motor vehicle accident in which his car hit a tree and rolled over. Since the accident, he has experienced considerable left upper extremity weakness. On physical examination, the patient was noted to have 0/5 deltoid, supraspinatus, and infraspinatus biceps strength on the left, with decreased sensation to light touch over the lateral brachium, radial forearm and hand, and dorsal forearm and middle finger. Reflexes were absent at the biceps and brachioradialis on the left and were diminished at the triceps. MRI and CT myelography revealed pseudomeningoceles from C2-3 through C7-T1, with root avulsions of C5 and C6 and partial root avulsions of C7 and C8. Electromyography findings were consistent with root avulsions, with complete involvement of C5 and C6 and partial involvement of C7. The video reviews the patient's history and physical examination, provides an analysis of his MRI findings, and discusses indications for surgery. The video then demonstrates the technique for the double Oberlin transfer, including neurolysis of the median and ulnar nerves, intraoperative nerve stimulation, and neurorrhaphy. Results: Postoperative clinical examination findings are reviewed at various follow-up times. The patient regained a considerable amount of elbow flexion, with 4+/5 elbow flexion noted on the left at his most recent physical examination. At 12 months postoperatively, the patient was able to perform active flexion up to 140° with strength against 10 lbs of resistance. Conclusion: Double Oberlin transfers are uncommonly performed, and a paucity of information is available in the literature on the indications for, techniques for, and postoperative outcomes of double Oberlin transfer. This video demonstrates how a double Oberlin transfer can be performed safely, affording considerable restoration of elbow flexion.