OT notes · Orthopaedics

Steindler's procedure (polio surgery)

Usual anaesthesia
General anaesthesia, with or without brachial plexus block
Position
Supine with the arm on a hand table
Setting
elective

Operative note template for Steindler flexorplasty of the elbow (proximal and anterior transfer of the flexor-pronator origin to restore elbow flexion), with a filled example for a modified Steindler in post-polio paralysis of the elbow flexors; this note covers the elbow flexorplasty, not the Steindler plantar fascia release for cavus foot.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • pronation deformity of the forearm (common)
  • elbow flexion contracture
  • elbow flexion strength stays weaker than normal
  • ulnar nerve tingling or weakness
  • injury to the median nerve or brachial vessels
  • non-union or loosening of the epicondyle fragment and screw
  • wound infection
  • long splint and months of muscle re-education
  • the operation may fail if the donor muscles are weaker than they seemed

Pre-operative details for this operation

  1. Cause of elbow flexor paralysisPost-polio residual paralysisUpper brachial plexus palsy (C5-C6 / C5-C7)Otherfor plexus injury: time since injury (more than 6 to 9 months)
  2. Muscle chartingbiceps and brachialis grade; flexor-pronator group grade (needs grade 4 to 5 for the modified technique); triceps; wrist and finger flexors and extensors
  3. Steindler effectPresentAbsentcan the patient flex the elbow with gravity eliminated using the forearm flexors (arm at right angle to body, rotated)
  4. Active supinationPresentAbsentabsence predicts pronation deformity
  5. Shoulder control and hand functionstable shoulder; hand flexors working (if finger flexors are paralysed this transfer is not done)
  6. Passive elbow rangefull passive flexion needed; existing contracture
  7. Ulnar nerve symptoms before surgery
  8. Implants available3.5 mm cortical screw set, suture anchors, osteotomes, burr

Anaesthesia and position

  1. AnaesthesiaGeneralGeneral with brachial plexus block
  2. PositionSupine, arm on hand table
  3. Tourniquetsterile / non-sterile, pressure, time; or none

Operative findings

  1. Biceps and brachialis appearancepale / fibrotic / partly contracting
  2. Flexor-pronator massbulk and colour; contracts on stimulation or not
  3. Ulnar nerveposition, branches to FCU
  4. Median nerve branches to pronator tereslevel of origin, preserved
  5. Distance advancedcm proximal to original origin

Procedure (steps)

  1. Incisioncurved, centred just behind the medial epicondyle, 8 to 10 cm up the arm and 8 to 10 cm down the forearm along pronator teres
  2. Ulnar nervefound behind the medial epicondyle, articular branch divided, FCU branches kept, mobilised about 5 cm distal to the elbow and protected
  3. Median nerve and brachial vesselsidentified at the proximal edge of pronator teres; branches to pronator (2.5 to 5 cm above elbow) kept
  4. Medial epicondylepre-drilled and tapped before osteotomy
  5. Detachment of flexor-pronator originWith 1.5 cm epicondyle bone fragment (Mayer-Green)Soft-tissue detachment close to periosteum (Steindler / Bunnell)anterior bundle of medial collateral ligament preserved
  6. Muscle mobilised from ulnauntil origin reaches 5 to 8 cm proximal with elbow flexed to 130 degrees
  7. Recipient sitebrachialis split longitudinally, anterior humerus exposed subperiosteally and roughened with burr / osteotome
  8. Fixation3.5 mm screw plus suture anchors to anterior humerusSuture to medial intermuscular septum and fascia (original Steindler)Fascia lata extension to lateral humerus (Bunnell)screw length; number of anchors; elbow angle and forearm rotation at tying
  9. Checkno kinking or tension on median / ulnar nerves; brachial pulse present

Closure, drains and dressing

  1. Woundlayers, suture material
  2. DrainNoneSuction drain
  3. Immobilisationabove-elbow cast / splint with elbow in 100 degrees or acute flexion; forearm position

Specimens and implants

  1. Implantsscrew diameter and length; suture anchors type and number; make, batch number, stickers

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Hand circulation and nerve checkradial pulse, capillary refill; median and ulnar nerve sensation and movement
  2. Elevationlimb on pillows; watch for tight cast in acute flexion
  3. Analgesiadrug, dose, frequency
  4. Immobilisationelbow held at 100 degrees until the epicondyle fragment unites, usually 6 to 8 weeks
  5. Early movementpassive flexion of elbow, wrist and fingers from day 1; active wrist and finger flexion with elbow fully flexed from week 3
  6. Extensionelbow, wrist and finger extension allowed from week 7
  7. X-raycheck screw and fragment position after surgery and for union at 6 to 8 weeks
  8. Rehabilitationmuscle re-education for several months; target full active flexion with about 30 degrees extension lag
  9. Watch for pronation contracturesplinting and stretching; FCU transfer if it persists

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. S.P., 19 years, post-polio residual paralysis of the right upper limb since age 3. Biceps grade 1, brachialis grade 1, flexor-pronator group grade 4+, triceps grade 4, hand muscles normal. Positive Steindler effect. Active supination present. Stable shoulder.

Case details

Date: 03/03/2026. Elective. OT 1.

In OT 09:00. GA induced 09:10. Incision 09:45. Splint completed 11:50.

Surgeon: Dr C. (Consultant, Orthopaedics). Assistant: Dr A. (3rd-year resident), did the exposure of the ulnar nerve and closure. Second assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: post-polio paralysis of right elbow flexors with strong flexor-pronator group. Cannot lift the hand to the mouth.

Full passive elbow range 0 to 140 degrees. No ulnar nerve symptoms.

Consent: general, procedure-specific and anaesthesia consent in Hindi. Explained pronation deformity, flexion contracture, weak flexion compared with normal, ulnar nerve tingling, screw loosening, 6 to 8 weeks splint and months of exercises.

WHO checklist sign in and time out done. Right side marked. Inj cefazolin 2 g IV at 09:25 (implant to be used).

Anaesthesia and position

General anaesthesia. Supine, right arm on hand table. Parts painted with povidone-iodine and draped, whole limb free.

Findings

Biceps and brachialis pale and thin. Flexor-pronator mass bulky and red.

Ulnar nerve in its groove, FCU branches seen. Median nerve branches to pronator teres arising about 4 cm above the elbow.

Procedure

Curved incision centred just behind the medial epicondyle, 9 cm up the arm and 9 cm down the forearm along pronator teres.

Ulnar nerve found behind the epicondyle, articular branch divided, FCU branches kept, nerve mobilised 5 cm distal to the elbow.

Median nerve and brachial artery identified at the proximal edge of pronator teres; branches to pronator preserved.

Medial epicondyle pre-drilled and tapped for a 3.5 mm screw. Common flexor-pronator origin detached with a 1.5 cm fragment of epicondyle using an osteotome. Anterior bundle of the medial collateral ligament preserved.

Muscle mass freed from the ulna until the fragment reached 6 cm proximal to its original site with the elbow flexed to 130 degrees.

Median nerve and brachial artery mobilised and retracted medially. Brachialis split longitudinally, anterior humeral cortex exposed and roughened with a burr.

Fragment fixed to the anterior humerus with one 3.5 mm cortical screw, 40 mm. Two suture anchors placed in the humerus beside the screw and tied to the flexor-pronator origin with the elbow at 130 degrees and forearm supinated.

Ulnar and median nerves checked: no kinking or tension. Radial pulse present. Haemostasis secured.

Closure

Wound closed in layers. Above-elbow plaster slab with elbow at 100 degrees of flexion.

Specimens and implants

3.5 mm cortical screw x 1 (40 mm). Suture anchors x 2. Make, lot numbers and stickers pasted in the implant record. No specimen.

End of procedure

Blood loss about 150 ml. No transfusion. Mop, needle and instrument count correct.

No intra-operative complications.

Shifted to ward, stable. Pulse 82/min, BP 118/76 mmHg. Fingers pink, median and ulnar sensation intact after recovery.

Post-op orders

Radial pulse, capillary refill, and median and ulnar nerve check hourly for 6 hours, then 4-hourly.

Arm elevated on pillows. Keep the elbow slab at 100 degrees.

Analgesia as per anaesthesia chart.

Check X-ray right elbow AP and lateral.

Physiotherapy from POD 1: passive flexion of elbow, wrist and fingers. Active wrist and finger flexion with elbow fully flexed from week 3. No extension until week 7.

Review at 2 weeks for wound; X-ray at 6 to 8 weeks for union of the fragment.

Signature

Dr A., JR-3, Orthopaedics, for Dr C. Reg. no. ________. 03/03/2026, 12:10.

Must document for this operation

  • Pre-operative muscle grades, the Steindler effect and active supination. These predict the result and the risk of pronation deformity, and justify the choice of transfer.
  • Which technique: original Steindler, Bunnell, or Mayer-Green with bony transfer. The fixation point and method change the pronation tendency and the post-op plan.
  • Distance the origin was advanced and the fixation point on the humerus. A later surgeon treating a contracture or failure needs to know where the transfer was placed.
  • Ulnar and median nerves and their branches seen and protected. Ulnar nerve symptoms are a known complication, and the note shows the nerves were handled with care.
  • Implant details with stickers. Needed for traceability and if the screw has to be removed.
  • Elbow angle and forearm rotation at fixation and in the splint. Wrong position risks pull-out of the transfer or a fixed contracture.

Common mistakes in these notes

  • Writing 'Steindler done' without saying whether it is the elbow flexorplasty or a foot procedure.
  • Not recording the grade of the flexor-pronator muscles before surgery.
  • Leaving out the screw size and suture anchors.
  • Not writing the immobilisation angle and the week-by-week exercise plan.
  • Not documenting ulnar nerve function after surgery.

Indian practice and paperwork

  • Record the batch and serial number of the screw and suture anchors in the case sheet; NABH also asks for it in the implant logbook and the discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. (NABH 5th ed. (2020), PRE.4(c))

Sources

  • Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS, eds. Green's Operative Hand Surgery. 7th ed. Elsevier; 2017, Ch 34, Traumatic brachial plexus injury: modified Steindler procedure (flexor-pronator transfer), pp. 1194-1196.
  • Azar FM, Sawyer JR, et al., eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 36, Paralytic disorders (poliomyelitis): elbow, muscle and tendon transfers to restore elbow flexion, flexorplasty (Steindler; Bunnell modification, eTechnique 36.25), pp. 1278.e33.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV within 60 min before incision; recommended when internal fixation devices are implanted. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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