Steindler flexorplasty to restore elbow flexion before shoulder abduction in cases of upper trunk brachial plexus injury

Objectives: Restoration of elbow flexion remains a key priority in upper trunk brachial plexus injury (BPI). Shoulder stability is traditionally considered essential before addressing elbow function. This study evaluated whether Steindler flexorplasty (SF) can provide meaningful elbow flexion even in the absence of shoulder abduction. Methods: Motor power (M) was assessed using the Medical Research Council (MRC) muscle strength grading scale. Eleven patients with upper trunk BPI presenting more than 12 months after injury or with failed nerve transfers (<M2 at 12 months) were included. Patients with wrist extension <M3 and finger or wrist flexion <M4 were excluded. Preoperative elbow function was assessed using the Mayo Elbow Performance Index (MEPI). SF was performed using osteotomy of the medial epicondyle and its fixation to the anterior humeral shaft with a 3.5 mm stainless steel screw. Immobilization was maintained for 6 weeks, followed by structured rehabilitation. MEPI scores were recorded at 3-month intervals until stabilization. Results: The study included nine males and two females, with a mean age of 39.5 years. The average time to final MEPI scoring was 8.45 months. Postoperative MEPI scores improved significantly ( p < 0.008). No significant difference was observed between patients with stable and unstable shoulders ( p < 0.17). Conclusion: SF yields significant functional improvement in elbow flexion, even without shoulder abduction. In delayed upper trunk BPI, restoration of elbow flexion may be prioritized over shoulder reconstruction to enhance daily functional use of the limb.