adult traumatic brachial plexus injuries · the brachial plexus (c8-t1 roots or lower trunk)....

Adult Traumatic BrachialPlexus Injuries

AbstractAdult traumatic brachial plexus injuries are devastating, and theyare occurring with increasing frequency. Patient evaluationconsists of a focused assessment of upper extremity sensory andmotor function, radiologic studies, and, most important,preoperative and intraoperative electrodiagnostic studies. Thecritical concepts in surgical treatment are patient selection as wellas the timing and prioritizing of restoration of function. Surgicaltechniques include neurolysis, nerve grafting, neurotization, andfree muscle transfer. Results are variable, but increased knowledgeof nerve injury and repair, as well as advances in microsurgicaltechniques, allow not only restoration of elbow flexion andshoulder abduction but also of useful prehension of the hand insome patients.

Brachial plexus lesions frequentlylead to significant physical dis-

ability, psychological distress, andsocioeconomic hardship. These le-sions can result from a variety of eti-ologies, including birth injuries, pen-etrating injuries, falls, and motorvehicle trauma. Most are closed in-juries involving the supraclavicularregion rather than the retroclavicu-lar or infraclavicular level. The rootsand trunks are more commonly af-fected than the divisions, cords, orterminal branches. Most injuries oc-cur as a result of fracture or compres-sion or as a combination of these. Inthe supraclavicular region, tractioninjuries occur when the head andneck are violently moved away fromthe ipsilateral shoulder, often result-ing in an injury to the C5 or C6 rootsor upper trunk. Traction to the bra-chial plexus also can occur second-ary to violent arm movement; whenthe arm is abducted over the headwith significant force, traction oc-curs within the lower elements ofthe brachial plexus (C8-T1 roots or

lower trunk). Compression injuriesto the brachial plexus usually occurbetween the clavicle and the firstrib. Direct blows also may result ininjuries to the brachial plexus, espe-cially around the coracoid process ofthe scapula.

The exact number of brachialplexus injuries that occur each yearis difficult to ascertain; however,with the advent of increasingly ex-treme sporting activities and high-energy motor sports, as well as theincreasing number of survivors ofhigh-speed motor vehicle accidents,the number of brachial plexus inju-ries continues to rise throughout theworld.1-6 Most of these injuries occurin males aged 15 to 25 years.5,7,8 Basedon his experience with 1,068 patientswith brachial plexus injuries duringan 18-year span, Narakas9 developedhis rule of “seven seventies.” He re-ported that approximately 70% oftraumatic brachial plexus injuries oc-curred secondary to motor vehicleaccidents; of these, approximately70% involved motorcycles or bicy-

Alexander Y. Shin, MD,

Robert J. Spinner, MD,

Scott P. Steinmann, MD, and

Allen T. Bishop, MD

Dr. Shin is Associate Professor,Department of Orthopaedic Surgery,Division of Hand Surgery, Mayo Clinic,Rochester, MN. Dr. Spinner is AssociateProfessor, Department of Neurosurgeryand Department of OrthopaedicSurgery, Division of Hand Surgery, MayoClinic. Dr. Steinmann is AssistantProfessor, Department of OrthopaedicSurgery, Mayo Clinic. Dr. Bishop isProfessor, Department of OrthopaedicSurgery, Mayo Clinic.

None of the following authors or thedepartments with which they areaffiliated has received anything of valuefrom or owns stock in a commercialcompany or institution related directly orindirectly to the subject of this article:Dr. Shin, Dr. Spinner, Dr. Steinmann, andDr. Bishop.

Reprint requests: Dr. Shin, Mayo Clinic,E14A, 200 1st Street SW, Rochester,MN 55905.

J Am Acad Orthop Surg 2005;13:382-396

Copyright 2005 by the AmericanAcademy of Orthopaedic Surgeons.

382 Journal of the American Academy of Orthopaedic Surgeons

cles. Of the cycle riders, approxi-mately 70% had multiple injuries.Overall, 70% had supraclavicular le-sions; of those, 70% had at least oneroot avulsed. At least 70% of patientswith a root avulsion also have avul-sions of the lower roots (C7, C8, orT1). Finally, of patients with lowerroot avulsion, nearly 70% will expe-rience persistent pain.

Treatment recommendations forcomplete root avulsions have variedwidely over the past 50 years. Follow-ing World War II, the standard ap-proach was surgical reconstructionby shoulder fusion, elbow boneblock, and finger tenodesis.10 Yeomanand Seddon11 noted a tendencyamong these patients to become“one-handed” within 2 years of in-jury, resulting in few successful out-comes regardless of the treatment ap-proach. Their retrospective studyrevealed no good results from bra-

chial plexus intervention surgery.However, amputation plus shoulderfusion performed within 24 monthsof injury resulted in predominantlygood and fair outcomes. Conse-quently, in the 1960s, transhumeral(above-elbow) amputation, combinedwith shoulder fusion in slight abduc-tion and flexion, was advocated.12

However, loss of glenohumeral mo-tion caused by brachial plexus inju-ries limited the effectiveness of body-powered prostheses (eg, figure-of-8harness with farmer’s hook). Ad-vances in brachial plexus reconstruc-tion have yielded outcomes superiorto historical results. A better under-standing of the pathophysiology ofnerve injury and repair, as well as re-cent advances in microsurgical tech-niques, have allowed reliable restora-tion of elbow flexion and shoulderabduction, in addition to useful pre-hension of the hand in some cases.

Anatomy

The brachial plexus is formed fromfive cervical nerve roots: typically,C5, C6, C7, C8, and T1 (Fig. 1). Ad-ditionally, there may be contribu-tions to the brachial plexus from C4,ranging from small branches to largercontributions, and from T2. A plexuswith contributions from C4 is called“prefixed.” The incidence of prefixedplexuses ranges from 28% to 62%.When contributions from T2 occur,the plexus is termed “postfixed.” Theincidence of postfixed plexusesranges from 16% to 73%.13

The so-called true form of the bra-chial plexus was described by Kerr,13

who performed detailed anatomicdissections on 175 specimens. In thetrue form there are five separate sec-tions of the brachial plexus: roots,trunks, divisions, cords, and terminalbranches. Formed by the coalescence

Figure 1

Anatomy of the brachial plexus. A, The brachial plexus has five major segments: roots, trunks, divisions, cords, and branches.The clavicle overlies the divisions. The roots and trunks compose the supraclavicular plexus, and the cords and branchescompose the infraclavicular plexus. B, The relationship between the axillary artery and the cords. The cords are named for theiranatomic relationship to the axillary artery: lateral, medial, and posterior. LC = lateral cord, LSS = lower subscapular nerve,MABC = medial antebrachial cutaneous nerve, MBC = medial brachial cutaneous nerve, MC = medial cord, PC = posteriorcord, TD = thoracodorsal nerve, USS = upper subscapular nerve. (Adapted by permission of Mayo Foundation.)

Alexander Y. Shin, MD, et al

Volume 13, Number 6, October 2005 383

of the ventral and dorsal nerve root-lets, the root passes through the spi-nal foramen (Fig. 2, A). The dorsalroot ganglion holds the cell bodies ofthe sensory nerves and lies within theconfines of the spinal canal and fora-men. A preganglionic injury is one inwhich the spinal roots are avulsedfrom the spinal cord (Fig. 2, B).Preganglionic injuries can be sepa-rated into central avulsions, in whichthe nerve is avulsed directly from thespinal cord, and intradural ruptures,in which rootlets rupture proximal tothe dorsal root ganglion. An injurydistal to the dorsal root ganglion iscalled postganglionic (Fig. 2, B). Dis-tinguishing between a preganglionicand a postganglionic injury is impor-tant when considering the possibilityof spontaneous recovery and implica-tions for surgical reconstruction be-cause there is little potential recov-

ery at this time for preganglionicinjury.

The C5 and C6 roots merge toform the upper trunk, and the C8and T1 roots merge to form the low-er trunk. C7 becomes the middletrunk. The point at which C5 andC6 merge (Erb’s point) marks the lo-cation at which the suprascapularnerve emerges. Each trunk then di-vides into an anterior and a posteri-or division and passes beneath theclavicle. The posterior divisionsmerge to become the posterior cord,and the anterior divisions of the up-per and middle trunk merge to formthe lateral cord (Fig. 1, B). The ante-rior division from the lower trunkforms the medial cord. The posteri-or cord forms the axillary nerve andthe radial nerve. The lateral cordsplits into two terminal branches:the musculocutaneous nerve and

the lateral cord contribution to themedian nerve. The medial cord con-tributes to the median nerve as wellas to the ulnar nerve.

A few terminal nerve branchescome off the roots, trunks, and cords.The branches off the C5 root includea branch to the phrenic nerve, thedorsal scapular nerve (rhomboidmuscles), and the long thoracic nerve(serratus anterior muscle) (Fig. 1, A).The branches off C6 and C7 also con-tribute to the long thoracic nerve(serratus anterior muscle). Thebranches off the upper trunk includethe suprascapular nerve (supraspina-tus and infraspinatus muscles) andthe nerve to the subclavius muscle.The lateral cord gives off the lateralpectoral nerve, while the posteriorand medial cords each have threebranches. The posterior cord gives offbranches (proximal to distal) that in-

Figure 2

A, Anatomy of the brachial plexus roots and types of injury. The roots are formed by the coalescence of the ventral (motor) anddorsal (sensory) rootlets as they pass through the spinal foramen (A). The dorsal root ganglion holds the cell bodies of thesensory nerves; the cell bodies for the ventral nerves lie within the spinal cord. Three types of injury can occur: avulsion injuriespull the rootlets out of the spinal cord (B); stretch injuries attenuate the nerve (C); and ruptures result in complete discontinuityof the nerve (D). B, Intraoperative photograph of a preganglionic injury (root avulsion) as well as a postganglionic injury. TheC5 root is avulsed with its dorsal and ventral rootlets. The asterisk marks the dorsal root ganglion. The C6 root, which is inferior,demonstrates a rupture at the root level. (Panel A adapted by permission of Mayo Foundation. Panel B reproduced by permissionof Mayo Foundation.)

Adult Traumatic Brachial Plexus Injuries


clude the upper subscapular nerve,thoracodorsal nerve, and the lowersubscapular nerve. The medial cordgives off the medial pectoral nerve,the medial antebrachial cutaneousnerve, and the medial brachial cuta-neous nerve. By noting loss of func-tion to these muscles, one can gainknowledge on pinpointing the levelof brachial plexus injury.

The sympathetic ganglion for T1lies in close proximity to the T1 rootand provides sympathetic outflow tothe head and neck. Avulsion of theT1 root (a pre-ganglionic injury) re-sults in interruption of the T1 sym-pathetic ganglion, resulting in Hor-ner syndrome, which consists ofmiosis (small pupil), enophthalmos(sinking of the orbit), ptosis (liddroop), and anhydrosis (dry eyes).

Patient Evaluation

Physical ExaminationBrachial plexus injury is often

seen in patients who have sustainedpolytrauma; thus, diagnosis of thenerve injury necessarily may be de-layed until the patient is stabilizedand resuscitated. A high index ofsuspicion for a brachial plexus inju-ry should be maintained when ex-amining a patient with severe shoul-der girdle injury. On initialexamination, the patient is often ob-tunded or sedated, and careful obser-vation is needed as the patient be-comes more coherent.

A detailed examination of thebrachial plexus and its terminalbranches can be performed in a fewminutes on an awake, cooperativepatient when the examiner is experi-enced and systematic. The median,ulnar, and radial nerves are evaluat-ed by examining finger and wristmotion. Elbow flexion and extensionare examined to determine musculo-cutaneous and high radial nervefunction. Examination of shoulderabduction can determine the func-tion of the axillary nerve, a branch ofthe posterior cord. Injury to the pos-terior cord may affect both deltoid

function and the muscles innervatedby the radial nerve. Examination ofwrist extension, elbow extension,and shoulder abduction may help de-termine the condition of the posteri-or cord.

The latissimus dorsi is innervatedby the thoracodorsal nerve, which isalso a branch of the posterior cord.This muscle can be palpated in theposterior axillary fold and can be feltto contract when a patient is askedto cough. The pectoralis major is in-nervated by the medial and lateralpectoral nerves, each a branch of themedial and lateral cords, respective-ly. The medial pectoral nerve inner-vates the sternal head of the pectora-lis major, and the lateral pectoralnerve innervates the clavicular head.The entire pectoralis major musclecan be palpated from superior to in-ferior as the patient adducts the armagainst resistance.

Located proximal to the cord lev-el, the suprascapular nerve is a ter-minal branch at the trunk level. Itcan be examined by assessing shoul-der external rotation and elevation.Often, in a chronic situation, theposterior aspect of the shoulder dem-onstrates significant atrophy in thearea of the infraspinatus muscle. Su-praspinatus muscle atrophy is hard-er to detect clinically because thetrapezius muscle covers most of thesupraspinatus muscle. Loss of shoul-der flexion, rotation, and abductionalso may be caused by a significantrotator cuff or deltoid injury. Bothaxillary nerve function and rotatorcuff integrity should be evaluatedwhen testing shoulder function.

Certain findings suggest pregan-glionic injury on clinical examina-tion. For example, the patient shouldbe examined for the presence of Hor-ner syndrome, which is suggestive ofa root avulsion at the C8-T1 level.Injury to the long thoracic nerve orthe dorsal scapular nerve suggests ahigher (more proximal) level of inju-ry because both nerves originate atthe root level. The long thoracicnerve is formed from the roots of C5-

C7 and innervates the serratus ante-rior muscle. This nerve, >20 cmlong, is vulnerable to injury as it de-scends along the chest wall. Injury tothe long thoracic nerve with result-ant dysfunction of the serratus ante-rior muscle causes significant scap-ular winging as the patient attemptsto forward elevate the arm. The dor-sal scapular nerve is derived fromC4-C5 and innervates the rhomboidmuscles, often at a foraminal level.Careful examination demonstratesatrophy of the rhomboids and para-scapular muscles when this nerve isinjured. The patient must be ob-served posteriorly to fully evaluatethe serratus anterior and rhomboidmuscles.

Neighboring cranial nerves mustbe considered during motor testing.The spinal accessory nerve that in-nervates the trapezius muscle canoccasionally be injured with theneck or shoulder trauma that affectsthe brachial plexus. Its integrity isimportant because the spinal acces-sory increasingly is used as a nervetransfer.

Careful sensory (and/or autonom-ic) examination should include var-ious nerve distributions (especiallyautonomous zones). Sensation ofroot-level dermatomes can be unre-liable because of either overlap fromother nerves or anatomic variation.

The examiner should record ac-tive and passive ranges of motion aswell as the presence or absence of re-flexes. The presence of concomitantspinal cord injury should be consid-ered by examining for lower limbstrength, sensory levels, increasedreflexes, and pathologic reflexes. Per-cussing the nerve is especially help-ful. Acutely, pain over a nerve sug-gests a rupture. Lack of percussiontenderness over the brachial plexusindicates an avulsion. An advancingTinel sign is sometimes suggestiveof a recovering lesion.

Because it is possible also to rup-ture the axillary artery at the time ofsignificant brachial plexus injury, avascular examination should be per-



formed. Vascular injuries are not in-frequent findings with infraclavicu-lar lesions or with even more severeinjuries, such as scapulothoracic dis-sociation.

Radiographic EvaluationAfter a traumatic injury to the

neck or shoulder girdle, radiograph-ic examination should include viewsof the cervical spine, shoulder (an-teroposterior and axillary views),and chest. The spine radiographsshould determine the presence ofany associated cervical fractures thatcould put the spinal cord at risk.Transverse process fractures in thecervical vertebrae may suggest rootavulsion at the same level. Clavicleor rib fractures (first or second rib)may indicate trauma to the brachialplexus. Chest radiographs may re-veal old rib fractures, which are im-portant should intercostal nerves beconsidered for nerve transfer (ribfractures often injure the associatedintercostal nerves). Additionally,phrenic nerve injury causes associat-ed paralysis of the hemidiaphragm.When vascular injury is suspected,arteriography or magnetic resonance

angiography may be indicated toconfirm the patency of a previousvascular repair or reconstruction.

Computed tomography (CT)combined with myelography hasbeen instrumental in helping to de-fine the level of nerve rootinjury.14-16 With an avulsion of a cer-vical root, the dural sheath healswith development of a pseudomen-ingocele. Immediately after injury,blood clot is often present in the areaof the nerve root avulsion and candisplace dye from the myelogram.Therefore, a CT myelogram shouldbe done 3 to 4 weeks after injury toallow time for blood clots to dissi-pate and for pseudomeningoceles tofully form. A pseudomeningocele onCT myelogram is highly suggestiveof a root avulsion (Fig. 3).

Magnetic resonance imaging(MRI) may be useful in evaluatingpatients with a suspected nerve rootavulsion,17-19 and it has some advan-tages over CT myelogram. MRI canvisualize much of the brachialplexus, whereas CT myelographydemonstrates only nerve root injury.Additionally, MRI can demonstratelarge neuromas after trauma or asso-

ciated inflammation or edema, andit can evaluate mass lesions in thepatient with spontaneous non-traumatic neuropathy affecting thebrachial plexus or its terminalbranches. Despite this, in the acutesetting, CT myelography remainsthe primary mode of radiographicevaluation for nerve root avulsion.

Electrodiagnostic StudiesElectrodiagnostic studies are inte-

gral to both preoperative and intra-operative decision-making. Theyhelp in confirming a diagnosis, local-izing lesions, defining the severity ofaxon loss and the completeness of alesion, eliminating other conditionsfrom the differential diagnosis, andrevealing subclinical recovery orunrecognized subclinical disorders.Electrodiagnostic studies are an im-portant adjunct to a thorough histo-ry, physical examination, and imag-ing studies, not a substitute forthem.

For closed injuries, baseline elec-tromyography (EMG) and nerve con-duction velocity (NCV) studies arebest performed 3 to 4 weeks after in-jury because wallerian degenerationwill have occurred by then. Serialelectrodiagnostic studies can bedone every few months in conjunc-tion with a repeat physical examina-tion to document and quantify ongo-ing reinnervation or denervation.

EMG tests muscles at rest andwith activity. Denervational chang-es (ie, fibrillation potentials) in dif-ferent muscles can be seen in proxi-mal muscles as early as 10 to 14 daysafter injury (and in 3 to 6 weeks inmore distal muscles). Reduced re-cruitment of motor unit potentialscan be demonstrated immediatelyafter weakness occurs from lowermotor neuron injury. The presenceof active motor units with voluntaryeffort and few fibrillations at rest of-fers a good prognosis compared withthe absence of motor units andmany fibrillations. EMG may helpdistinguish preganglionic from post-ganglionic lesions by needle exami-

Figure 3

Presence of a pseudomeningocele (asterisks) indicates greater likelihood of a nerveroot avulsion. A, Anteroposterior myelogram demonstrating multiple root avulsions(asterisks). B, Those avulsions (asterisk) are clearly seen on axial CT myelogram.The arrows on the opposite side of the avulsion demonstrate the normal dorsal andventral rootlet outline of the uninjured side. These outlines are missing on the injuredside. (Reproduced by permission of Mayo Foundation.)



nation of proximally innervatedmuscles that are innervated by rootlevel motor branches (eg, cervicalparaspinals, rhomboids, serratus an-terior).

NCV studies are performed alongwith EMG. In posttraumatic brachialplexus lesions, the amplitudes ofcompound muscle action potentials(CMAPs) are generally low. Sensorynerve action potentials (SNAPs) areimportant in localizing a lesionas preganglionic or postganglionic.SNAPs are preserved in lesions prox-imal to the dorsal root ganglia. Be-cause the sensory nerve cell body isintact and within the dorsal root gan-glion, NCV studies often demonstratethat the SNAP is normal, when clin-ically the patient is insensate in theassociated nerve sensory distribution.SNAPs are absent in a postganglionicor a combined pre- and postganglioniclesion. For example, a patient with anormal SNAP in the ulnar nerve,with an insensate ulnar nerve distri-bution, has avulsions (preganglionicinjury) of the C8-T1 roots.

There are limitations to electrodi-agnostic studies. The EMG/NCVstudy is only as good as the experi-enced physician who is performingthe study and interpreting the re-sults. EMG may demonstrate evi-dence of early recovery in muscles(eg, emergence of nascent potentials,a decreased number of fibrillationpotentials, or the appearance of or anincreased number of motor unit po-tentials); these findings may predateclinically apparent recovery byweeks to months. However, EMGrecovery does not always equatewith clinically relevant recovery ei-ther in terms of quality of regenera-tion or extent of recovery. EMG re-covery merely indicates that anunknown number of fibers havereached muscles and have estab-lished motor end plate connections.Conversely, evidence of reinnerva-tion may not be detected on EMG incomplete lesions, despite ongoing re-generation, when target end organsare more distal.

Intraoperative electrodiagnosticstudies also may play a part in bra-chial plexus surgery. A combinationof intraoperative electrodiagnostictechniques can be used to maximizethe information gathered beforemaking a surgical decision. Thesetechniques routinely include nerveaction potentials (NAPs) and soma-tosensory evoked potentials (SSEPs),as well as CMAPs. NAPs allow thesurgeon to test a nerve directlyacross a lesion to detect reinnerva-tion months before conventionalEMG techniques would demon-strate activity and to determinewhether a lesion is neurapractic(negative NAP) or axonotmetic (pos-itive NAP). The presence of a NAPacross a lesion indicates preservedaxons or significant regeneration.Primate studies have suggested thatthe presence of a NAP indicates theviability of thousands of axons rath-er than the hundreds seen with oth-er techniques.20 The presence of aNAP suggests that recovery will oc-cur after neurolysis alone withoutthe need for additional treatment(eg, neuroma resection and grafting).More than 90% of patients with apreserved NAP will gain clinicallyuseful recovery.20 NAPs indirectlycan help distinguish between pre-and postganglionic injury. A fasterconduction velocity with large am-plitude and short latency, togetherwith severe neurologic loss, indicatea preganglionic injury. A flat tracingsuggests that adequate regenerationis not occurring; this is consistentwith either a reparable postganglion-ic lesion or an irreparable combinedpre- and postganglionic lesion. Withthe latter, sectioning the nerve backto an intraforaminal level would notreveal good fascicular structure.20

Intraoperative somatosensory-evoked potentials (SSEPs) are alsoused during brachial plexus surgery.The presence of an SSEP suggestscontinuity between the peripheralnervous system and the central ner-vous system via a dorsal root. A pos-itive response is determined by the

integrity of a few hundred intactfibers. The actual state of the ventralroot is not tested directly with thistechnique. Instead, it is inferred fromthe state of the sensory nerve root-lets, even though perfect correlationbetween dorsal and ventral root avul-sions does not always exist. SSEPsare absent in postganglionic orcombined pre- and postganglioniclesions. Motor-evoked potentialsassess the integrity of the motorpathway via the ventral root. Thistechnique, which uses transcranialelectrical stimulation, has recentlybeen approved in the United States.21

CMAPs are not useful intraopera-tively in complete distal lesions be-cause of the time required for regen-eration to occur into distal muscles.However, CMAPs are useful in par-tial lesions because the size of the le-sion is proportional to the number offunctioning axons.

Concepts of SurgicalManagement

The three most important conceptsin the surgical management of bra-chial plexus injuries are patient se-lection, the exact timing of surgery,and the prioritization of restorationof function in the upper arm.

Surgery should be performed inthe absence of clinical or electricalevidence of recovery or when spon-taneous recovery is impossible. De-spite the improvements in electro-diagnostic studies and imaging,selecting when and on whom to op-erate remains one of the most diffi-cult decisions in peripheral nervesurgery. During the observation peri-od, physical therapy should be per-formed to prevent contractures andto strengthen functioning muscles.

Timing of surgery or interventiondepends on the mechanism of injuryas well as the type of injury. Imme-diate exploration and primary repairof the injured portion of the brachi-al plexus is indicated in sharp openinjuries. This facilitates end-to-endrepair of the injured nerves. When



the open injury is secondary to ablunt object with avulsion of thenerve, the ends of the laceratednerve should be tagged and a delayedrepair performed 3 to 4 weeks later.By 3 to 4 weeks, the injured nerveends will have demarcated, enablingbetter access to the zone of nerve in-jury. Low-velocity gunshot woundsshould be observed because most ofthese injuries are neurapraxic; how-ever, high-velocity gunshot woundsare associated with significant soft-tissue damage and usually mandatesurgical exploration.

For stretch injuries, the exact tim-ing of surgery is more controversial.The timing is determined somewhatby the mechanism and type of injury,physical examination and imagingfindings, and surgeon preference. Op-erating early may not allow sufficient

time for spontaneous reinnervation,but waiting too long before operatingmay unnecessarily lead to failure ofthe motor end plate and thus failureof reinnervation. Early explorationand reconstruction (between 3 and 6weeks) is indicated when there is ahigh suspicion of root avulsion. Rou-tine exploration is performed 3 to 6months after injury in patients whohave not demonstrated adequate rein-nervation. Results from delayed (6 to12 months) or late (>12 months) sur-gery are poorer because the time forthe nerve to regenerate to the targetmuscles is greater than the survivaltime of the motor end plate after de-enervation.

Most surgeons consider elbowflexion the highest priority when re-storing function to the flail extrem-ity. Next in priority are shoulder ab-

duction and stability, hand sensibility,wrist extension and finger flexion,wrist flexion and finger extension,and intrinsic function of the hand.

Surgery

Brachial plexus surgery can be dividedinto primary and secondary recon-struction. Primary reconstruction isthe initial surgical management andmay include nerve surgery/recon-struction (eg, direct repair, neuroly-sis, nerve grafting, nerve transfers)and/or soft-tissue procedures (eg, freefunctioning muscle transfer). Second-ary reconstruction may be necessaryto improve function, either to aug-ment partial recovery or to obtainfunction when none has beenachieved. This may include soft-tissue reconstruction (eg, tendon/muscle transfer, free muscle transfer)and bony procedures (eg, arthrodesis,osteotomy), but typically not nervesurgery. Often a combination of thesetechniques can be used, necessitatinga broad surgical armamentarium.

Primary ReconstructionDirect repair of nerve ends can be

done after sharp injuries (eg, lacera-tions), but it cannot be applied tostretch injuries. External neurolysisis a necessary prerequisite for intra-operative electrical studies. Neurol-ysis alone may be performed whenthe nerve is in continuity and a NAPis obtained.22

Intraplexal Nerve GraftingNerve grafting can be performed

with ruptures or postganglionic neu-romas that do not conduct a NAPacross the lesion. In such cases, thenerve root—because of its connec-tion to the spinal cord—has main-tained viable motor axons that canbe grafted to specific targets. Interpo-sitional grafts (typically using cablegrafts of sural or other cutaneousnerves) are coapted between nervestumps without undue tension. Forexample, C5 is targeted for shoulderabduction (suprascapular nerve, axil-

Figure 4

Intraplexal nerve grafting with donor nerves can be performed in the setting ofpostganglionic injury with viable nerve root stumps available. With postganglionicinjuries on C5, C6, and C7, nerve grafts can be used to target shoulder abduction(C5 to the suprascapular nerve [A] and posterior division of the upper trunk [B]),elbow flexion (C6 to the anterior division of the upper trunk [C]), and wrist extensionand elbow extension (C7 to the posterior division of the middle trunk, targetingradial nerve function [D]). SSN = suprascapular nerve. (Adapted by permission ofMayo Foundation.)



lary nerve), C6 for elbow flexion(musculocutaneous nerve), and C7for elbow extension and wrist exten-sion (radial nerve)22 (Fig. 4).

Nerve Transfer (Neurotization)Nerve transfer can be performed

for preganglionic injury or to acceler-ate recovery by reducing the time forreinnervation by decreasing the dis-tance between the site of nerve re-pair and the end organ. A function-ing nerve of lesser importance istransferred to the more importantdenervated distal nerve. Ideally,nerve transfers should be performedwithin 6 months of injury; however,even after the preferred 6-monthtime frame, nerve transfers may bemore suitable than grafting becausenerve transfers have faster recoverythan grafting.

Several donor nerves are sourcesfor neurotization. Some of the morecommon include the spinal accesso-ry nerve (cranial nerve XI), intercos-tal nerves (motor and sensory), andmedial pectoral nerve. More recent-

ly, using a fascicle of a functioningulnar nerve (Oberlin transfer) or themedian nerve in patients with intactC8 and T1 nerves has allowed rapidand powerful return of elbow flex-ion, with 94% of patients achievingM4 strength.23 The phrenic nerve24

and the contralateral C7 (or hemi-contralateral C7)25 nerve also havebeen used to expand the pool of ex-traplexal donors and to improve out-comes. The deep cervical plexus andhypoglossal nerve (cranial nerve XII)have been used, but poor motor re-covery has been reported.26

The average number of myelinat-ed axons in these donor nerves var-ies. The spinal accessory nerve hasapproximately 1,700 axons; thephrenic nerve, 800 axons; a single in-tercostal motor nerve, 1,300 axons;and the contralateral C7 nerve,23,780 axons.26 The goal is to maxi-mize the number of myelinated ax-ons per target function and mini-mize donor site morbidity. Severalseries have reported an acceptablemorbidity with transfer of the con-

tralateral C7 and phrenic nerves, butlong-term studies are not avail-able.25,27

Neurotization for shoulder abduc-tion can be easily obtained by nervetransfer of either the spinal accesso-ry nerve or the phrenic nerve to thesuprascapular nerve.24,26,28 The bene-fit of these two transfers is that noadditional interposition nerve graftsare needed, and a direct coaptation ofthe nerves is possible (Fig. 5). Whenadditional nerve sources are avail-able, neurotization of the axillarynerve (nerve grafting from C5) is rec-ommended to provide further shoul-der stability and abduction.

Neurotization for elbow flexioncan be performed using either inter-costal nerves (Fig. 6) directly or thespinal accessory nerve with an inter-positional graft29 directly targetingthe biceps motor branch (rather thanthe entire musculocutaneous nerve).Separating the biceps motor branchfrom the lateral antebrachial cutane-ous nerve in a retrograde manner al-lows the maximum number of mo-

Figure 5

Neurotization for shoulder abduction with the spinal accessory nerve29 (A) or the phrenic nerve24 (B) can be performed in thesupraclavicular exposure. (Adapted by permission of Mayo Foundation.)



tor axons to be transferred directly tothe biceps muscle. This also helpsgain length for the transfer, thuseliminating the need for interposi-tional grafts in the case of intercos-tal nerves and shortening the lengthof the graft for the accessory nerve.Some have advocated using thephrenic nerve with an interposition-al graft to the musculocutaneousnerve.24

In the event of an upper trunkavulsion injury, two popular optionsexist for restoring elbow flexion.The medial pectoral nerve may betransferred to the musculocutane-ous nerve or the biceps branch.26 Al-ternatively, a fascicle from the ulnarnerve (Oberlin transfer) can be trans-ferred to the motor branch of the bi-ceps with excellent results (94% ofpatients achieved M4 strength)23

(Fig. 7). Before separating the fasci-cles from the ulnar nerve, they aretested with a nerve stimulator. Fas-cicles that stimulate the intrinsicmuscles of the hand are avoided;those that stimulate wrist flexion(flexor carpi ulnaris) are chosen.

This technique is an excellent alter-native to the intercostal neurotiza-tions or spinal accessory nerve withan interpositional graft.

The contralateral C7 or a hemi-contralateral C7 nerve can be usedvia a vascularized ulnar nerve graft(in the case of a complete plexusavulsion injury) or via sural nervegrafts to bring a large number of mo-tor axons to the injured side.25,27

When used with the vascularized ul-nar nerve graft, the contralateral orhemicontralateral C7 nerve can beused to innervate the median nerve,with the goal of obtaining useful fin-ger flexion (29% of patients achievedM3 or M4 finger flexion) and protec-tive sensation in the median nervedistribution (81% of patients)27 (Fig.8).

Outcomes of Nerve TransfersNeurotization for elbow flexion

and shoulder stability has beenshown to be an effective means of re-storing muscle function.28 In a criti-cal meta-analysis of the English-language literature, Merrell et al28

Figure 7

A, When the ulnar nerve is normal (ie, upper trunk injury sparing C8 and T1), a fascicle can be transferred to the motor branchof the biceps to obtain elbow flexion. Top left: Transection (dashed line) of the motor branch to the biceps muscle. Top center:Fascicle(s) obtained from normal ulnar nerve (dashed line). Top right: Fascicle(s) transferred to the motor branch of themusculocutaneous nerve. B, Intraoperative photograph demonstrating the fascicle from the ulnar nerve transferred to the motorbranch of the biceps. MC n = musculocutaneous nerve, Transferred fascicle = portion of ulnar nerve, Ulnar n = ulnar nerve.(Part A adapted by permission of Mayo Foundation. Part B reproduced by permission of Mayo Foundation.)

Figure 6

Neurotization for elbow flexion withintercostal nerves. The motor branchesfrom the intercostal nerves can beeasily harvested and neurotized to themotor branch of the musculocutaneousnerve to the biceps. (Adapted bypermission of Mayo Foundation.)



evaluated the results of 1,088 nervetransfers in 27 studies to determinethe outcome of nerve transfers of theshoulder and elbow.

For restoration of elbow flexion, 26studies with a total of 965 nervetransfers were evaluated. Overall,71% of transfers to the musculocuta-neous nerve achieved ≥M3 (antigrav-ity) flexion on the Medical ResearchCouncil grading scale, and 37%achieved ≥M4 (against gravity, notnormal) flexion. The two most com-mon donor nerves were the intercos-tal (54%) and spinal accessory (39%).Overall, the intercostal achieved ≥M3in 72% of patients. When an interpo-

sition nerve graft was used, only 47%achieved ≥M3 strength. When the spi-nal accessory nerve was transferred tothe musculocutaneous nerve, 77% ofpatients had restoration of elbow flex-ion ≥M3 and 29% had restoration offunction ≥M4. Use of the Oberlintransfer (two fascicles of the ulnarnerve transferred to the musculocu-taneous nerve) resulted in 97% ≥M3flexion and 94% ≥M4 flexion.28

For restoration of shoulder abduc-tion, 8 studies with a total of 123transfers were evaluated. Overall,73% of patients achieved ≥M3 shoul-der abduction, and 26% achieved≥M4 abduction. The spinal accessory

nerve was used in 41% of transfersand the intercostal nerves in 26%.The spinal accessory nerve per-formed significantly (P < 0.001) bet-ter than the intercostals in achieving≥M3 abduction (98% and 56%, re-spectively). However, even with goodresults, shoulder abduction reachedonly 45°.

Further research is still needed inthe field of outcomes analysis of bra-chial plexus injuries. Unfortunately,it is not known which treatment pro-duces the best outcomes for C5 andC6 ruptures or severe neuromas. Tobe determined, for example, iswhether it is best to graft from C5

Figure 8

Contralateral C7 (or a hemicontralateral C7 [A and B]) nerve transfer via a vascularized ulnar nerve graft (in cases of completeC5-T1 avulsions) can be used to bring a large number of motor axons into the injured side. The hemicontralateral C7 transfer canbe used effectively with a vascularized ulnar nerve graft to reinnervate the median nerve for finger flexion and sensation. (A) Theportion of the C7 (contralateral) that primarily innervates pectoral function is isolated, and half of the nerve is isolated (B). Theipsilateral distal ulnar nerve is coapted with the hemicontralateral portion of C7 (C). The proximal ulnar nerve (*) is divided(dashed line). The injured side median nerve (D) is identified and divided (dashed line). The proximal ulnar nerve is transferred tothe distal median nerve stump of the injured side (E). (Adapted by permission of Mayo Foundation.)



and C6, or whether nerve transfersshould be performed closer to the endorgan.

Free Functioning MuscleTransfer

Advances in microsurgical tech-niques have led to innovations in sur-gical reconstruction of the upper ex-tremity following brachial plexusinjury. Free functioning muscletransfer is the transplantation of amuscle and its neurovascular pedicleto a new location to assume a newfunction. The muscle is powered byneurotizing the motor nerve by a do-

nor motor nerve; circulation is re-stored to the transferred muscle viamicrosurgical anastomosis of the do-nor and recipient vessels. Within sev-eral months, the transferred musclebegins to become reinnervated by thedonor nerve; it eventually begins tocontract and then gains independentfunction.

Free functioning muscle transferswere first done either in patients whopresented late (>12 months after in-jury) or as a salvage procedure inthose who had failed earlier nervereconstruction.30-32 Based on the suc-cess with free muscle transfer in

these late situations, it has been in-corporated into a strategy for early re-construction in patients for whomother donors of tendon transfers areunavailable.

Most commonly, free muscletransfer is used to provide reliable el-bow flexion.5,33-37 A variety of freefunctioning muscles can be trans-ferred, including the latissimus dorsi(thoracodorsal nerve), the rectus fem-oris (femoral nerve), and the gracilis(anterior division of the obturatornerve). The gracilis has become oneof the most commonly used musclesin brachial plexus reconstruction be-cause of its proximally based neu-rovascular pedicle (which allows ear-lier reinnervation) and its long tendonlength (which reaches into the fore-arm for hand reanimation). The gra-cilis can be used for restoring bicepsfunction,38,39 wrist extension, or fin-ger flexion, or as a double muscletransfer in the two-stage Doi proce-dure.5,6,40

For elbow flexion, it is desirable toplace the major vascular pedicle ofthe gracilis in proximity to the tho-racoacromial trunk in the infraclavic-ular fossa. The proximal gracilis ten-don is passed beneath the clavicleand secured to its superior border. Itis then tunneled subcutaneously tothe antecubital fossa in preparationfor securing it to the biceps tendon.The obturator nerve branch to thegracilis may be repaired to the spinalaccessory nerve or to the two inter-costal motor nerves, either of whichshould be harvested at as great alength as possible to allow directnerve repair distal to the clavicle.Distally, the gracilis tendon is woveninto the biceps tendon (Fig. 9).

Doi et al5 recently described usinga double free functioning gracilismuscle transfer, which has providedhope of achieving prehension to pa-tients with complete brachial plexuslesions. The goals of this two-stageoperation are to restore both elbowflexion and extension as well as wristextension and finger flexion. In stageI, the brachial plexus is explored and

Figure 9

Free gracilis muscle transfer for elbow flexion. The proximal end of the gracilis issecured to the clavicle (A). The vascular inflow and outflow is via thethoracoacromial trunk, and the muscle is powered by the spinal accessory orintercostal motor nerves (inset). Distally, the gracilis tendon is woven into the bicepstendon (B). (Adapted by permission of Mayo Foundation.)



a free functioning gracilis muscle isharvested and neurotized by the spi-nal accessory nerve (Fig. 10). The gra-cilis is proximally attached to theclavicle and routed distally under thebrachioradialis to the radial wristdigit extensors. The gracilis vesselsare anastamosed to the thoracoacro-mial artery and venae comitantes orother available venous outflow.

Stage II is performed approxi-mately 6 to 8 weeks after stage I (Fig.11). The second gracilis muscle andthe motor and sensory intercostalnerves from the third to sixth inter-costal spaces are harvested. The gra-cilis is attached proximally to the sec-ond rib, routed subcutaneously alongthe medial side of the arm, and at-tached to the flexor tendons. It is thenneurotized with two of the motor in-tercostal nerves, while the sensory in-tercostals are neurotized to the me-dian nerve to provide hand sensation.The gracilis is vascularized by thethoracodorsal vessels. The remainingtwo motor intercostal nerves are neu-rotized to the radial nerve innervat-ing the triceps.

At our institution, we haveslightly modified the double free mus-cle transfer as originally described byDoi and colleagues.5,6,34,35,37,39-42 Weprefer to secure the stage I gracilismuscle to wrist extensors rather thanto finger extensors, believing that thishelps promote finger flexion througha tenodesis effect. To create a more ef-fective pulley with diminished bow-stringing of the tendon, we route thegracilis tendon posterior to the bicepstendon and underneath the brachio-radialis muscle. A more effective pul-ley should improve muscle excursionand strengthen wrist extension.

Using a double free muscle trans-fer, Doi et al5 restored excellent togood elbow flexion in 96% of pa-tients (25/26). At our institution,eight patients have been followed forat least 1 year after the stage II trans-fer. Transfer for combined elbowflexion and wrist extension loweredthe overall results for elbow flexionstrength compared with elbow flex-

ion alone. Seventy-nine percent ofthe free functioning muscle transfersfor elbow flexion alone (single trans-fer) and 63% of similarly innervatedmuscles transferred for combinedmotion (stage I Doi procedure)achieved ≥M4 elbow flexionstrength (P > 0.05). This is not sur-prising in that the muscles must usesome of their strength and excursionto extend the wrist or digits and in-variably lose some effect because ofbowstringing at the elbow.43

Grasp function in the double freemuscle procedure relies on recovery

of some triceps function to stabilizethe elbow during contraction of thegracilis muscle. Grasp function alsorelies on adequate muscle strengthand the absence of significant adhe-sions. In the series of Doi et al,5 65%(17 patients) achieved >30° of totalactive motion of the fingers with thesecond muscle transfer. Such func-tion allows only rudimentary graspin many patients, but grasp functionis difficult to achieve with othermethods. Previous efforts at restor-ing prehension in the setting of abrachial plexus injury have been un-

Figure 10

Stage I Doi free gracilis muscle transfer.5 A free functioning gracilis is harvestedand neurotized by the spinal accessory nerve and anastamosed to thethoracoacromial trunk. The gracilis is attached proximally to the clavicle (A) androuted distally under the brachioradialis and flexor carpi ulnaris pulley (B), thenwoven into the wrist extensors (C). (Adapted by permission of Mayo Foundation.)



successful because of the long dis-tance between nerve repair and mo-tor end plates and the resultantprolonged reinnervation time.Therefore, these results must stillbe regarded as an advance in theseotherwise irreparable avulsion inju-ries. The only alternative currently

offering the possibility of hand func-tion in root avulsion injuries is com-bining the contralateral C7 nervewith a vascularized ulnar nerve con-duit.27

Postoperative Follow-upAfter any surgical intervention of

the brachial plexus, it is imperativethat the patient and his or her fami-ly understand that the recovery ofnerve function is a slow and arduousprocess. The newly reapproximatednerve graft or nerve transfer grows atrate of 1 mm a day or 1 inch permonth. For long transfers, such as a

Figure 11

Stage II Doi free gracilis muscle transfer.5 A, Vascularity is supplied via the thoracodorsal artery and vein. The gracilis muscle isattached proximally to the second rib. B, The gracilis is neurotized with two of the intercostal motor nerves (1), while the sensoryintercostal nerves are neurotized to the median nerve for hand sensation (2). The remaining two motor intercostals are usedto neurotize the triceps (3). Lat = lateral cord, M = motor intercostal nerve, Med = medial cord, Post = posterior cord, S =sensory intercostal nerve. C, Intraoperative photograph. Motor and sensory intercostal nerves are harvested from beneath thethird to sixth ribs. (Parts A and B adapted by permission of Mayo Foundation. Part C reproduced by permission of MayoFoundation.)



hemicontralateral C7 nerve graft,clinical results may not be seen for 2to 3 years. The shorter the distanceto the target muscle, the more rapidthe time to reinnervation.

It is essential that the patient,while waiting for reinnervation, beenrolled in physical therapy to keepthe joints of the upper extremity sup-ple and to prevent joint contractures.This can be done with custom-madeplastic resting splints as well as adaily range-of-motion protocol forthe shoulder, elbow, wrist, and digits.The efficacy of electrical stimulationin preserving muscle (motor) endplates remains controversial. How-ever, its use is psychologically bene-ficial to patients who like to see mus-cles contract during the longrecovery period. Dedicated follow-upat 3- to 4-month intervals for a min-imum of 2 to 3 years (preferably 5years) is recommended to assess forfull recovery.

Secondary ReconstructionSecondary reconstruction should

be considered when there has beenno further recovery of motor functionor when function can be further im-proved or refined with a relativelyminor surgical intervention. Second-ary reconstructive options includetendon transfer,9 free functioningmuscle transfer,5,36 shoulder arthro-desis,10 and wrist and hand arthro-desis.10

Tendon transfer is commonly de-layed until maximal motor recoveryhas occurred. Such transfers repre-sent a spectrum of procedures thatprovide a gratifying result to a pa-tient who has made a partial recov-ery and who would benefit from ad-ditional function. Free functioningmuscle transfer can be performed assecondary reconstructive surgery toimprove the strength of a weaklyreinnervated biceps or triceps mus-cle or of finger flexors (provided thatthe joints are supple).

Finally, arthrodesis may be usefulfor secondary reconstructive surgeryof the shoulder, wrist, and hand.

Shoulder fusion can be performed asa salvage procedure for the persis-tently painful subluxating shouldershould the nerve surgery fail to re-sult in shoulder stability. Shoulderfusion as a primary reconstructivetechnique is less frequently done be-cause recent studies have shownthat patients prefer voluntary shoul-der abduction when it can beachieved through nerve reconstruc-tion.44 Other bony procedures, suchas humeral rotational osteotomy,thumb axis arthrodesis, bone-blockopponensplasty, or finger joint ar-throdesis, can improve function.

Summary

Injuries to the adult brachial plexusare often intimidating to the ortho-paedic surgeon who may be manag-ing concomitant injuries. The injurycan be devastating to the patient andis often difficult for the patient andfamily to comprehend. A thoroughunderstanding of the anatomy, clin-ical evaluation, radiographic andelectrodiagnostic studies, treatmentoptions, and proper timing of surgi-cal intervention will enable thetreating surgeon to offer optimalcare. Surgical options include neu-rolysis, nerve grafting, neurotiza-tion, and free muscle transfers.These treatment options offer pa-tients with brachial plexus injuriesthe ability to obtain elbow flexion,limited shoulder abduction withshoulder stability, and hope for lim-ited but potentially useful handfunction.

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adult traumatic brachial plexus injuries · the brachial plexus (c8-t1 roots or lower trunk)....

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