Pediatric Plastic and Reconstructive Surgery

36.2 Diagnosis
The diagnosis of polydactyly often will be evident on presenta-
tion. Investigations will di erentiate the skeletal involvement of
the polydactylous digit(s) based on both clinical examination
and standard radiographs. Radiographs will determine the
presence of an articulation of the polydactylous digit, the level
of articulation, and the presence of an additional metacarpal
(Fig. 36.6). During the clinical examination, it is important
to expose all limbs to identify additional polydactylies. Radial
and ulnar polydactylies may be isolated or part of a syndrome;
as such, a thorough examination of the child apart from
the extremities is warranted to rule out other underlying
malformations. Special attention for café au lait spots and short
stature is warranted in radial polydactyly patients due to the
association with Fanconi anemia.
36.3 Nonoperative Management
36.3.1 Radial Polydactyly
Radial polydactyly is rarely managed nonoperatively. In mild
cases of a Wassel type I deformity with a bifid distal phalanx
resulting only in a widened thumb tip and minimal nail abnor-
mality, observation may be reasonable. Otherwise, surgical in-
tervention is recommended for radial polydactyly.
36.3.2 Central Polydactyly
Surgical management is the mainstay for treatment of central
polydactyly. However, if only a small soft-tissue mass is present,
ligation may be an option. For more information, see the Liga-
tion section for ulnar polydactyly.
36.3.3 Ulnar Polydactyly
Observation
Observation is an option for both types A and B ulnar polydac-
tyly; however, the supernumerary digit can cause functional
deficits, particularly with pedunculated digits that can catch on
objects. Observation is likely most appropriate when a nubbin
is present and is asymptomatic.
Ligation
Other nonsurgical options for type B include ligation, usually
with a 4.0 silk suture or a surgical clip. Ligation has traditionally
been the most common form of treatment for pedunculated
type B digits, producing necrosis of the digit and subsequent
autoamputation. Ligation can be done in the nursery shortly
after delivery, but can be performed at a later stage ranging
from 2 to 40 weeks (average 8 weeks of age). Rayan et al
Fig. 36.3 Example of a distal type III polydactyly of the index finger.
Fig. 36.4 A clinical example of type A ulnar polydactyly.
Upper Extremity
334

recommended ligation only for digits with narrow stalks with
suture placement as close to the finger to limit nubbin forma-
tion. Additionally, Mullick et al recommend limiting this treat-
ment to stalks <2 mm with the presence of any bony or
ligamentous attachments as a contraindication to ligation. Close
observation for bleeding and infection and a discussion with
parents about the risk of potential revision procedures are also
important components of this management strategy. This tech-
nique has become controversial due to the concern of associ-
ated complications (see Complications section). A recent poll of
pediatricians and hand surgeons in the United Kingdom on
referral to a hand surgeon versus ligation in the neonatal period
demonstrated that the majority of clinicians would refer for
surgical assessment. However, proponents of ligation cite its
low cost and simplicity.
36.4 Operative Treatment
36.4.1 Radial Polydactyly
Treatment of radial polydactyly is typically surgical and can be
initiated at 6 to 9 months of age. The goals of surgery are both
functional and cosmetic. Preoperative surgical splinting has
been found to be valuable for improving angular and rotatory
deformities prior to surgical correction. There are two primary
surgical treatment options: (1) ablation with collateral ligament
reconstruction or (2) the Bilhaut–Cloquet procedure.
Ablation with collateral ligament reconstruction is preferred
for duplications with asymmetry resulting in the presence of a
larger dominant thumb and smaller hypoplastic thumb. This
most commonly includes removal of the radial (hypoplastic)
duplicate, centralization of the flexor and extensor mechanism,
collateral ligament reconstruction, and correctional osteoto-
mies for angular deviation. Removing the radial duplicate when
possible leaves the ulnar collateral ligament intact, which is of
primary importance in thumb stability and pinch (Fig. 36.7).
In a type IV thumb, partial resection of the metacarpal head
may be necessary for proper alignment of the phalanx on the
metacarpal head. Therapy following surgery usually includes
scar management and nighttime splinting for a period of 3 to 6
months. In cases where significant reconstruction of the radial
collateral ligament is required, a full-time thumb spica splint
may be worn for 2 to 3 months for additional stability. It should
be mentioned ablation alone is not recommended for radial
polydactyly treatment as it uniformly leads to joint instability.
The Bilhaut–Cloquet procedure was originally described in
1889. It involved the excision of the central portion of a type I
thumb duplication with preservation of the ulnar aspect of the
ulnar most portion and the radial aspect of the radial most por-
tion of the duplicated distal phalanges. The idea was to allow a
normal-size digit to be created from the two abnormal portions
while maintaining the collateral ligaments for stability. It was
initially used for type I and II deformities but expanded to types
Fig. 36.5 A clinical example of ulnar type B
polydactyly.
Fig. 36.6 Anteroposterior radiograph of type A ulnar polydactyly.
Polydactyly
335

III and IV. The Bilhaut–Cloquet procedure is technically di cult
requiring exact alignment of the nail, bone, and grow th plate
(Fig. 36.8). It may be recommended when the duplicated dig-
its are similar in size. In an e ort to avoid nail grooving and
growth plate problems associated with the Bilhaut–Cloquet
procedure, some surgeons recommend a modification in which
the lateral components of the radial digit are maintained for
digital width, but the entire nail is taken from the ulnar digit.
36.4.2 Central Polydactyly
Surgical care is usually initiated between 6 and 12 months of
age (Fig. 36.9). The goal is to begin surgical management
before joint angulation and contractures occur. Despite an early
start on surgical management, patients usually require multiple
operations to obtain a cosmetically pleasing and functional
hand. Because central polydactyly is so often seen in combina-
tion with syndactyly, radiographs are necessary to define the
underlying bony anatomy and ideal surgical management.
In type II polydactyly, each phalanx has its own epiphysis. As
the duplicated digit grows, it will displace the normal digit.
Simple ablation is not appropriate and collateral ligament
reconstruction is necessary. As the deformity worsens, correc-
tive osteotomies and joint arthrodesis may be necessary. Tendi-
nous attachments to both the digit to be maintained and that to
be removed should be examined at the time of surgery. The
most appropriate tendon should be retained. Accessory tendons
may need to be transferred from the accessory digit to the
retained proper digit.
36.4.3 Ulnar Polydactyly
The surgical treatment for both types A and B ulnar polydactyly
ranges from soft-tissue excision to amputation of the polydac-
tylous digit and may require augmentation of the soft tissues of
retained digit. Functional outcomes are good, with minimal re-
habilitation considerations.
Fig. 36.7 (a) Surgical reconstruction of the collateral ligament in a 14-month-old child with Wassel type IV thumb duplication. (b) The radial duplicate
is dissected free from the preserved ulnar thumb. (c) During dissection, the radial collateral ligament of the radial thumb, along with a piece of
cartilage and periosteum, is preserved. (d) This flap of tissue is then imbricated into the radial aspect of the retained thumb. Sutures can often be
passed through the bone and periosteum surrounding the base of the metacarpal. (e) The metacarpophalangeal joint is then immobilized for 3 to 4
weeks with a K-wire placed through the joint.
Fig. 36.8 Image of a 9-year-old girl treated with the Bilhaut–Cloquet
technique for Wassel type II thumb. The reconstructed thumb shows
residual nail grooving and minimal interphalangeal joint motion as
evident by lack of skin wrinkling over joint.
Upper Extremity
336

Type A
Surgical ablation of the duplicated digit is indicated to improve
hand function and aesthetics. An elliptical incision is planned
around the digit. If a soft-tissue deficit is anticipated after abla-
tion of the digit, a racquet-type incision can be made to use
ulnar border skin of the polydactylous digit for augmenting
soft-tissue coverage of the small finger. Incisions should be
designed in a midaxial position when possible, as volar
incisions have the potential to migrate and lead to flexion con-
tractures. Exploration and division of the tendinous and neuro-
vascular structures to the extra digit is critical while preserving
the function and sensation to the remaining digit. Excision may
also require soft-tissue release, tendon balancing, joint surface
alignment, corrective osteotomies, and reattachment of intrin-
sic muscles.
Type B
Surgical excision of pedunculated digits can be performed in
the operating room using either a combination of oral sedation
with topical and local anesthetic or general anesthesia after
the age of 3 months. The polydactylous digit is placed under
tension and an elliptical incision is made at the base. The vessel
and nerve are identified. The vessel is coagulated and the nerve
is dissected and transected proximally under tension to avoid
neuroma formation. The digit is then excised completely.
Absorbable suture can be used to close the wound.
36.5 Complications
36.5.1 Radial Polydactyly
The most common complications following surgery are insta-
bility or sti ness at either the interphalangeal (IP) or
Fig. 36.9 (a–d) Example of bilateral central polydactyly with corresponding anteroposterior (AP) radiographs. Surgical treatment of central polydactyly
is complicated by differential growth of shared physis and potential for physeal injury during separation of the digits. (e) AP radiograph of both hands
at the age of 7 years. (f–h) Functional and cosmetic result. Function is complicated by minimal motion at central digit proximal interphalangeal (PIP)
and distal interphalangeal (DIP) joints, which has resulted in some scissoring of the digits.
Polydactyly
337

metacarpophalangeal (MCP) joint, grow th plate injury, and
angular deformity. First webspace narrowing, nail deformities,
and pulp deficiencies may also be seen.
Goldfarb et al reviewed the results of 31 thumbs treated for
duplication. They found significantly decreased nail width
(111% of the index nail on the operative side compared to 136%
on the nonoperative side), while girth and length were similar
between the operative and nonoperative sides. Twenty-two
thumbs demonstrated IP joint angulation, with 12 thumbs hav-
ing more than 5 degrees of angulation. IP joint angulation nega-
tively correlated with visual analog scale score.
Stutz et al evaluated 43 thumbs with an average of 17 years
after initial treatment for radial polydactyly. Eight patients
underwent reoperation an average 8 years after the initial ope-
ration. Five patients underwent IP joint arthrodesis, while three
had extrinsic tendon realignments for zigzag deformities after
type IV thumb reconstruction (Fig. 36.10).
36.5.2 Central Polydactyly
Early physeal closure, limited digital range of motion, and joint
instability are frequent complications for type II central poly-
dactylies. Webspace and joint contractures are also common in
central polydactyly and synpolydactyly.
Wood reviewed the University of Iowa experience treating
central polydactyly over 50 years. Fifteen percent of all polydac-
tyly cases involved the ring (26) or long (8) fingers. Thirteen of
22 patients had bilateral hand involvement. A positive family
history of similar hand anomalies was present in 55% of
patients. Twenty of 22 patients had a complex syndactyly with
a type II polydactyly. Sixteen of 22 patients underwent 91 pro-
cedures. The most common complications included webspace
and flexion contractures. Fused, deviated, or nonfunctional dig-
its represented more severe complications ( Fig. 36.9).
In 1982, Tada et al published a series of 12 patients with
central polydactyly. In the series, all were type II and 10 of
12 hands had associated syndactyly. In Japan, maintaining a
five-digit hand is of paramount importance even if the digits are
nonfunctional. Therefore, in the majority of patients, the authors
removed the polydactylous digit at the first surgery and focused
on improving function during subsequent surgeries. Primary
complications included joint deviations and contractures as well
as rotatory deformities, believed to be secondary to intrinsic
muscle atrophy. The authors conclude that creation of a five-
digit hand usually led to poor functional results and they believe
a four-digit hand with removal of the hypoplastic ray should be
the goal of reconstruction in central polydactyly.
36.5.3 Ulnar Polydactyly
Most commonly, complications occur after ligation of an ulnar
polydactyly. These include (1) residual nubbin or incomplete
amputation that may or may not contain neuroma, (2) gangre-
nous digit that does not slough and requires a secondary proce-
dure for removal, and (3) infection. Watson and Hennrikus
reported infection in 1 of 21 patients, but a residual bump in
43%; yet these did not require surgical intervention. Mullick et
al reported on 10 cases of residual neuroma after ligation that
required a revision procedure for symptomatic relief.
Complications of surgical excision in type A ulnar polydactyly
include unsightly or painful scar, intrinsic tightness if transfer
was necessary, prominence of the metacarpal head, and insta-
bility of the MCP joint. However, these complications are less
common than those associated with ligation.
36.6 Conclusion
Radial polydactyly is a relatively rare condition. The di erent
types of thumb duplication are most commonly described by
the Wassel classification. The majority of cases are treated sur-
gically anywhere from 6 to 24 months of age depending on
thumb type and surgeon preference. The two main treatment
options are ablation of the hypoplastic duplicate thumb with
soft-tissue reconstruction and the Bilhaut–Cloquet procedure
(or modification). The most common complications are joint
sti ness or instability.
Central polydactyly is relatively rare. It is often associated
with syndactyly. Radiographic imaging is key to successful sur-
gical planning, which is the mainstay of management for cen-
tral polydactyly. The overall goal is to create a functional and
aesthetically pleasing hand.
Type A ulnar polydactyly is relatively uncommon, while type
B is relatively prevalent among African American patients. Type
A polydactyly is managed with surgical excision. Although con-
troversy exists over the most appropriate treatment option for
type B polydactyly, ligation is generally accepted in cases of
uncomplicated, narrow stalks.
36.7 Key Points
● Radial polydactyly is most commonly classified by the Wassel
classification, of which type IV is the most common.
● The two main surgical options for management of radial poly-
dactyly are ablation with collateral ligament reconstruction
are the Bilhaut–Cloquet procedure.
● Central polydactyly is usually associated with syndactyly and,
therefore, radiographs are key to surgical success.
● Ulnar polydactyly is classified as type A or B, with the latter
being more common, particularly among African American
patients.
● Management of type A ulnar polydactyly is usually surgical,
while type B is often managed surgically, with ligation an op-
tion in appropriate cases.
Fig. 36.10 Clinical image of a late zigzag deformity in a patient with
previous Wassel type IV thumb duplication. Long-term instability of
thumb metacarpophalangeal (MP) joint has resulted in subsequent
instability at interphalangeal and MP joints.
Upper Extremity
338

Suggested Readings
Goldfarb: A detailed technique article for treating radial polydactyly. The
manuscript addresses indications, contraindications, and complications;
2006
Stutz, et al: A review of 43 surgically reconstructed thumbs >10 years after
treatment. Two scoring systems, reoperation rates, as well as pinch strength
are reported; 2014
Mills, et al: A review of the outcomes and cost-e ectiveness of the use of a
surgical clip for type B ulnar polydactyly; 2014
Wood: A seminal paper on central polydactyly reviewing frequencies of each
type of polydactyly as well as surgical management and outcomes; 1971
Rayan, et al: A retrospective review of a large series of ulnar polydactylous
digits. Management and outcomes are discussed as well as an in-depth intro-
duction to ulnar polydactyly pathology and epidemiology; 2001
Abzug, et al: A recent review of the evidence supporting management of type
B ulnar polydactyly with a discussion on ligation of the polydactylous digit;
2013
Pritsch, et al: This article reviews and classifies type A ulnar polydactyly with
a thorough introduction to the pathology; 2013
Polydactyly
339

37 Macrodactyly
Carolyn M. Pike and Brian I. Labow
Sum m ary
Macrodactyly is a rare congenital overgrowth disorder of the
upper or lower limb. Although all tissue types are a ected vari-
ably, proportion and patterning are maintained within the
a ected territory, and structures appear grossly normal. The
disease process often follows a sensory nerve distribution
within the hand or foot. Recent genetic studies have identified
somatic mosaic gain-of-function mutations in the kinase
PIK3CA in patients with macrodactyly, as well as a number of
related overgrow th conditions. However, the basis for pheno-
typic variation, such as severity and tissue distribution of over-
growth, as well as rate of growth, remains to be established.
The diagnosis of macrodactyly should be reserved for patients
with a sporadic, isolated congenital digital enlargement a ect-
ing all tissue types not attributable to a syndrome or underlying
vascular anomaly. Current treatment options are limited to sur-
gery and can include staged debulking of soft tissue, epiphy-
siodesis, osteotomy, or ray amputation. Longitudinal growth is
far easier to correct than circumferential growth. The major
goals of treatment are to enable optimal hand function and to
provide an aesthetic limb. Minor complications of operative
treatment include hypertrophic scarring, decreased sensation,
and flexion contractures. As patients age, many will develop
progressive sti ness in the a ected digit, and some will show
radiological signs of a progressive osteoarthritis. In the future,
pharmacotherapy may provide an additional treatment option
for patients with digital overgrowth.
Keywords: macrodactyly, overgrowth, limb, congenital
37.1 Introduction
Macrodactyly is a rare congenital overgrowth disorder a ecting
the digits of the upper or lower extremity. The condition
accounts for 0.9% of all upper limb congenital anomalies. Mac-
rodactyly is sporadic, nonsyndromic, and often follows a sen-
sory nerve distribution within the hand or foot. Overgrowth is
usually noted at birth; however, both the extent and rate of
growth can vary widely. Macrodactyly can be classified by rate
of growth, with the term “progressive” describing rapid, dispro-
portionate enlargement relative to the rest of the limb, while
“static” refers to a slower, proportionate growth. Although all
tissue types are a ected variably, proportion and patterning are
maintained within the a ected territory, and structures appear
grossly normal. Another means of classification has been
through the predominant tissue type involved, for example, lip-
omatous macrodactyly for cases with gross excess of adipose tis-
sue out of proportion to other tissue types. In contrast, nerve-
territory-oriented macrodactyly has been used for digits with
enlarged nerves within the a ected zone of overgrowth that
clearly follow a sensory nerve territory. A biological distinction
between these two clinical entities has not been shown. To fur-
ther confound the situation, a wide array of descriptive terms
and eponyms has also been used to refer to macrodactyly. Given
the rarity of this condition, the lack of precision in nomencla-
ture, and our limited understanding of the pathophysiology of
this disorder, it is not surprising that there exists a paucity of lit-
erature on treatment options and long-term outcomes.
37.2 Diagnosis
In most cases, digital enlargement is obvious soon after birth.
Occasionally, minor degrees of enlargement may not be
detected until later in infancy, when continued enlargement
occurs (Fig. 37.1, Fig. 37.2). A variety of syndromic and non-
syndromic causes for digital enlargement exist. A thorough
physical examination to look for other findings or a local or
regional cause for the overgrowth (e.g., expansile mass, vascular
anomaly) should be carefully undertaken. The diagnosis of mac-
rodactyly should be reserved for patients with a sporadic, iso-
lated congenital digital enlargement a ecting all tissue types
not attributable to a syndrome or underlying vascular anomaly.
Radiographic imaging such as ultrasonography or plain films
can be useful to document the absence of a vascular lesion and
the presence of skeletal involvement, respectively. Magnetic
resonance imaging can also be used to plan debulking proce-
dures by documenting the extent of fatty overgrowth in the
limb that frequently contributes to additional limb or digit girth
and weight. Recent genetic studies have identified somatic
mosaic gain-of-function mutations in the kinase PIK3CA in
patients with macrodactyly. These mutations have been impli-
cated in a growing number of related overgrowth conditions as
Fig. 37.1 A 13-month-old male with severe macrodactyly and syn-
dactyly of the index and middle fingers. The overgrowth includes the
thumb and adjacent palm and follows a roughly median nerve sensory
pattern.
Upper Extremity
340

well. However, the basis for phenotypic variation, such as
severity and tissue distribution of overgrowth, as well as rate of
growth, remains to be established.
37.3 Nonoperative Treatment
Since macrodactyly typically gives rise to a poorly functioning
and aesthetically displeasing digit, treatment is rarely nonoper-
ative. If the a ected digit is mildly overgrown with adequate
function and is pain free, then observation should be recom-
mended. In some cases, therapy may help with digits that are
mildly sti , though progressive arthritic changes may still
occur.
In the future, it is possible that pharmacological inhibitors of
the PI3K-AKT pathway may halt disease progression or prevent
recurrence in postoperative patients. Small clinical trials have
been initiated with drugs such as rapamycin, but there have
been limited results published. For the most part, current treat-
ment options remain limited to surgery.
37.4 Operative Treatment
Surgical treatment for patients with macrodactyly should be
individualized. The patient’s age, digit involved, type and rate of
overgrowth, as well parental and surgeon preferences will all
be factors in determining the treatment plan. The major goals
of treatment are to enable optimal hand function and to pro-
vide an aesthetic limb. In some instances, that may mean
amputation. However, a variety of procedures have been
described that reduce the length and circumferential bulk of
the digit, while maintaining sensation and circulation within
the extremity.
An overgrown digit may be salvaged via skeletal or soft-tissue
reduction, or a combination of the two. In some instances, sev-
eral procedures may be performed over time. Longitudinal
excess is far easier to correct than circumferential excess, and
it should be noted that these digits never look or function
normally ( Fig. 37.3). Adjunct procedures such as epiphyseal
growth arrest and osteotomies can also be performed to correct
angular deformities. Debulking procedures should be limited to
one side of a digit at a time to minimize the risk of vascular
compromise and usually require a staged approach.
If the digit is characterized as progressive macrodactyly with
a grossly overgrown appearance and minimal functionality that
often interferes with the other digits, amputation may be con-
sidered. Generally, a complete ray resection or transmetacarpal
amputation is required. If the thumb must be amputated to the
level of the metacarpal, a minimally a ected index ray can be
pollicized or a microvascular toe transfer can be considered.
37.5 Complications
Minor complications of operative treatment include hypertro-
phic scarring, decreased sensation, and flexion contractures.
After repeated debulking and nerve manipulation, protective
Fig. 37.2 A 15-month-old female with mild macrodactyly affecting the
index finger. The overgrowth is predominately circumferential with
minimal length difference as compared to the contralateral side.
Fig. 37.3 (a) A 7-year-old female with ulnar-sided
macrodactyly affecting the small and ring fingers
predominantly. (b) One year following soft-tissue
debulking and closing wedge osteotomy of the
small finger. The ring finger treated at another
institution was managed with partial middle and
distal phalangectomies and distal interphalangeal
joint fusion. Although the length discrepancy has
been improved, circumferential overgrowth re-
mains marked.
Macrodactyly
341

sensation is typically the result. As patients age, many will
develop progressive sti ness in the a ected digit and some will
show radiological signs of a progressive osteoarthritis. Early
arthritis in toes transferred to the hand has also been observed.
37.6 Conclusion
The rarity of macrodactyly and the highly variable phenotypic
presentation have hindered both descriptive and comparative
studies on treatment options and long-term outcomes. In gen-
eral, treatment for macrodactyly should be viewed as palliative,
although surgical therapy can certainly benefit many patients.
Depending on clinical circumstances and patient or parent pref-
erence, debulking techniques and amputation both have a role
in managing the a ected digits. Although reconstruction will
not result in a fully normal digit and often require multiple
operations, they are well-tolerated procedures and may o er a
restoration of function and aesthetics. In the near future, phar-
macological options may exist to abrogate digital overgrow th or
prevent additional growth after surgical debulking.
37.7 Key Points
● Macrodactyly is rare and characterized by congenital distal
overgrowth of the upper or lower limb. All tissue types are
a ected to a variable degree.
● Recent studies have identified somatic mosaic mutations in
the PIK3CA gene in patients with macrodactyly.
● Current treatment options are limited to surgery and can
include staged debulking of soft tissues, epiphysiodesis,
osteotomy, or ray amputation.
● In general, treatment options are well tolerated with few
minor complications; however, patients and families should
be counseled that no treatment is entirely satisfactory.
Suggested Readings
Cerrato F, Eberlin KR, Waters P, Upton J, Taghinia A, Labow BI. Presentation
and treatment of macrodactyly in children. J Hand Surg Am. 2013; 38
(11):2112–2123
Carty MJ, Taghinia A, Upton J. Overgrowth conditions: a diagnostic and thera-
peutic conundrum. Hand Clin. 2009; 25(2):229–245
Upper Extremity
342

38 Brachial Plexus Palsies
Raymond Tse and Angelo B. Lipira
Sum m ary
Pediatric brachial plexus palsies can present at birth (1 in 1000
newborns) and from blunt trauma in older children. The extent
of involvement and severity of injury is variable. This chapter
will discuss assessment, nonsurgical treatment, and surgical
treatment of brachial plexus palsy.
The approach to surgical exploration will be detailed and a
spectrum of scenarios will be presented so that the principles
of primary nerve reconstruction (including nerve graft and
nerve transfers) can be illustrated. These include upper plexus,
pan- plexus, multiple root avulsions, isolated deficits, delayed
presentation and failed reconstruction. Technical details of
nerve grafting and nerve transfers will be described.
Secondary musculoskeletal consequences of brachial plexus
palsy will also be discussed including strategies for prevention
and options for secondary surgical reconstruction.
Keywords: brachial plexus palsy, erb palsy, glenohumeral dys-
plasia, nerve graft, nerve transfer
38.1 Introduction
The brachial plexus is a complex network of nerves that provide
sensation and motor control of the upper extremity. In addition
to the intricacies of its form and functions, growth and develop-
ment in the setting of chronic denervation add another layer of
complexity to the management of pediatric brachial plexus
palsies.
An understanding of the anatomy and presentations is
important in the evaluation of patients. An appreciation of the
natural history and outcomes is critical when deciding upon
treatment. Preservation of musculoskeletal health in the setting
of chronic denervation is needed to optimize functional results.
Given the many dimensions of pediatric brachial plexus
palsy, children are best served through a multidisciplinary team
approach at specialized centers o ering coordinated, longitudi-
nal care. Early referral allows for better clinical assessment
and may reduce the chances of sequelae that a ect long-term
outcomes.
38.2 Presentation
Neonatal brachial plexus palsy (NBPP) occurs in 1/1,000 live
births and presents immediately after delivery. Downward trac-
tion on the brachial plexus results in injuries of the upper
plexus. With further traction, the zone of injury progresses to
lower regions of the plexus, ultimately resulting in pan-plexus
palsy in its most severe expression. Presentations can generally
be grouped into four patterns: type I involves C5 and C6 deficits
(Erb/Duchenne type) with loss of shoulder abduction, shoulder
external rotation, elbow flexion, and forearm supination. The
limb assumes the Erb posture due to intact antagonist muscles.
Type II involves C5–C7/C8 deficits (extended Erb type), resulting
in the additional loss of wrist extension. The limb assumes the
“waiter’s tip” posture. Type III involves deficits from C5 to C8/
T1, resulting in an arm that is generally flaccid or paralyzed.
Type IV involves C5 to T1 as well as the sympathetic chain,
resulting in flail arm with a Horner syndrome.
Upward traction on the brachial plexus results in injuries of
the lower plexus, resulting in loss of hand and wrist function
with intact elbow and shoulder function. This presentation is
known as Klumpke’s palsy and is extremely rare in NBPP.
When a root level is a ected, the site of injury tends to be at
the trunk level in the upper plexus and more proximal in the
lower plexus. This may be related to the presence of fascial
sleeves that extend from the bony vertebrae to the extraforami-
nal nerve roots in the upper plexus. This fascia is progressively
absent at more inferior nerve root levels. As such, lesions of the
lower roots are more likely to be preganglionic spinal root avul-
sions. One exception to this pattern occurs in breech deliveries,
in which C5 and C6 lesions tend to be avulsions.
Traumatic brachial plexus palsy (TBPP) can occur in older
children, but is rare. The mechanism is usually blunt injury and
most often results from motorized vehicle accidents. Compared
to NBPP, the forces involved are rapid and high energy. Conse-
quently, the patterns of injury in TBPP are varied and more
likely involve spinal root avulsions.
Injuries associated with NBPP can include fractures of
clavicle, humerus, and rarely cervical spine. Phrenic nerve
injury can occur with severe palsies, and hypoxic brain injury
can result from asphyxia. Children with TBPP should undergo a
general trauma survey.
Several conditions may present with altered limb posture or
movement and must be di erentiated from brachial plexus
palsy. “Pseudoparalysis” can result from pain related to bony
fracture; however, once healed, normal limb function resumes.
A septic shoulder may present with loss of shoulder movement,
but fever, constitutional symptoms, and a “hot joint” will often
be present. Congenital limb di erences such as arthrogryposis
can be distinguished by skeletal hypoplasia, absent skin creases
across joints, and associated anomalies. Lesions of the central
nervous system may present with altered tone, lower extremity
findings, global cognitive impairment, and/or progressive
weakness.
38.3 Assessment
38.3.1 Initial Assessment
Initial history focuses on birth, associated injuries, limb presen-
tation, and progression of recovery. Specific limb postures
should be elicited, given many families will describe a flaccid
arm in spite of intact motor functions. For example, when hand
function is present, it can be helpful to understand if the hand
function has always been present (i.e., a Type 1 palsy) or if that
function has recovered (i.e., a Type 3 palsy with persistent
upper plexus deficits). Any history of recovery helps under-
stand the type of nerve injury that has occurred. Neuropraxia
(Sunderland 1) involves no Wallerian degeneration, and func-
tion recovers rapidly. Axonotmesis (Sunderland 2) involves
Brachial Plexus Palsies
343

Wallerian degeneration and requires axon regrow th. In general,
recovery of full active range of motion within 1 month of age is
associated with no measurable long-term deficits in strength,
sensation, or limb growth. Slower recovery (i.e., Sunderland 3
and 4 injuries) is associated with greater long-term deficits.
Complete nerve disruption (Sunderland 5) results in no
recovery.
Initial examination includes an assessment of global cortical
function including age-appropriate developmental milestones,
trunk control, tone, and posturing. Neurologic examination of
lower extremities helps rule out central nervous system lesions.
Respiratory function should be assessed to screen for associated
phrenic nerve injury. The face should be assessed for Horner
syndrome (ptosis, myosis, anhydrosis) that results from disrup-
tion of the sympathetic chain. Given that the most cephalic
contribution to the sympathetic chain exits the spinal cord
along the T1 foramen, persistent Horner syndrome associated
with pan plexus palsy suggests a proximal T1 injury and possi-
bly an avulsion. Scapular stability and rhomboid function
should be assessed to determine involvement of dorsal scapular
nerve. Given the very proximal divergence of this nerve from
the brachial plexus, a deficit suggests a proximal zone of injury
that may involve a preganglionic root avulsion. Infants
with NBPP should also be assessed for torticollis, which is fre-
quently present and may be related to traction injury to neck
musculature.
Focused examination of the brachial plexus follows the
more general initial exam. Examination of infants with NBPP is
limited to observed and encouraged movements and these can
be rated according to the Active Movement Scale (AMS;
Table 38.1). Movement at each major limb articulation is
examined and recorded at each visit. Infants may or may not
“perform” on a given day and repeated examination helps in
developing a more reliable assessment.
Older cooperative children with TBPP may undergo more
detailed examination including sensation and specific muscle
group testing. Both AMS and British Medical Research Council
(MRC) scale can be used to record motor function. The Mallet
scale measures composite motions that are important for activ-
ities of daily life, and is useful for assessing outcomes and for
determining the need for secondary procedures in children
with both NBPP and TBPP (Fig. 38.1).
One of the di culties in management of nerve injuries is the
uncertainty of a single examination. The spectrum of the extent
of injury (i.e., zone of injury), severity (i.e., Sunderland class),
and the fact that variations in injury severity can exist in di er-
ent regions of a patient’s brachial plexus make the prediction of
outcome complex. In infants with NBPP, electromyogram (EMG)
has been found to be “overly optimistic.” As such, an apprecia-
tion of the severity of nerve injury relies upon repeated longitu-
dinal assessments.
Early assessment within 1 month of age or injury establishes
a baseline, and repeated monthly or bimonthly examination
helps understand the pattern of recovery. Assessment by a con-
sistent examiner helps reduce variation. Ongoing therapy and
nonsurgical treatment are critical and should be incorporated
into assessments and longitudinal care.
38.4 Nonsurgical Treatment,
Natural History, and Indications for
Nerve Surgery
38.4.1 Nonsurgical Treatment
All children with brachial plexus palsy should receive nonsurgi-
cal treatment with therapy to maintain passive range of motion,
encourage limb awareness, maintain sensory feedback, and
facilitate cortical development and functional adaptation. Dedi-
cated physical and occupational therapists, as well as rehabilita-
tion specialists with expertise in pediatric brachial plexus palsy
are central in these e orts. Nonsurgical treatment may be more
important to outcomes than surgical treatment, given that con-
tractures and limb neglect can negate any improvements from
nerve reconstruction. More detailed discussions of strategies to
avoid musculoskeletal complications follow (see section “Mus-
culoskeletal considerations and complications”).
The decision to pursue nerve reconstruction is based on the
fundamental question of whether the results with surgery will
be better than nonsurgical treatment alone. Given that nerve
reconstruction is imperfect and final outcomes are uncertain,
an understanding of natural history and surgical outcomes is
important in deciding a course of treatment.
38.4.2 Indications for Surgical Explora-
tion: Neonatal Brachial Plexus Palsy
The majority (70–90%) of infants with NBPP rapidly recover ad-
equate function that nerve exploration is not indicated.
Most agree that a flail arm (i.e., flaccid limb with no hand
function) associated with a persistent Horner syndrome beyond
1 month of age portends to a poor prognosis. The association of
Horner syndrome with no hand function suggests a proximal
injury of T1 (i.e., nerve root avulsion). There is a consensus that
in this situation, early exploration and reconstruction are war-
ranted in attempt to achieve reinnervation of hand functions.
Tassin (1983) studied a cohort of children with NBPP and
found that infants who did not recover any elbow flexion by 3
months tended to have poor long-term shoulder and elbow func-
tion. Based on that study, Gilbert recommended surgical explora-
tion for any infant who did not recover biceps by 3 months of
age. Although Gilbert’s reported outcomes are favorable, these
have not been compared to outcomes without surgery.
Table 38.1 Active movement scale
Score

Gravity

Observation
0

Gravity eliminated

No contraction
1

Gravity eliminated

Contraction, no motion
2

Gravity eliminated

≤1/2 active range of motion
3

Gravity eliminated

>1/2 active range of motion
4

Gravity eliminated

Full active range of motion
5

Against gravity

≤1/2 active range of motion
6

Against gravity

>1/2 active range of motion
7

Against gravity

Full active range of motion
Upper Extremity
344

Both Carter (2004) and Clarke (2007) have suggested that
absence of elbow flexion at 3 months may be an overly aggres-
sive indication for surgical treatment. Waters (1999) compared
the results of microsurgical reconstruction with outcomes of
nonsurgical treatment and stratified patients by the month
after which elbow flexion recovered. He found that when elbow
flexion takes greater than 5 months to recover, outcomes are
better with surgery. He recommends the absence of elbow flex-
ion within the first 6 months of life as an indication for nerve
reconstruction.
Surgical indications based on the absence of elbow flexion or
“biceps function” simplify recovery of the brachial plexus to a
single clinical finding. Whereas simplifying decision-making for
a complex condition has merit, our preferred approach consid-
ers all of the movements of the limb.
Clarke (1994) examined a cohort of patients with NBPP
treated nonsurgically and analyzed all limb active movements
at 3 months of age using the Toronto scale. Although lack of
elbow flexion was the most significant predictor of a poor out-
come, the lack of wrist, finger, thumb, and elbow extensions
were also independent predictors of poor outcome. These find-
ings led to a statistical model in which a composite AMS score
for these movements (elbow flexion, elbow extension, wrist ex-
tension, thumb extension, and finger extension) of less than
3.5/10 always predicted a poor outcome, and was thus an indi-
cation for surgical treatment. The clinical picture of this score is
that of C5–C8 or worse deficits (i.e., pan-plexus or near pan-
plexus palsy) at 3 months of age. These indications did not
account for all patients with a poor outcome. As such, an addi-
tional test at 9 months was added for those infants who had ad-
equate scores at 3 months of age. If a child was unable to pass
the “cookie test” (the composite movement of getting hand to
mouth with arm in an adducted position), they were o ered
surgical treatment. Fifteen years later, Clarke published results
of nerve reconstruction (2009) suggesting that the results of
nerve grafting were better than neurolysis (and presumably no
treatment) based on the above indications for surgery. The
Toronto protocol has evolved to include the lack of elbow flex-
ion at 6 months as another indication for surgical treatment
(Table 38.2).
Fig. 38.1 Mallet scale.
Brachial Plexus Palsies
345

38.4.3 Indications for Surgical Explora-
tion: Traumatic Brachial Plexus Palsy
Older children with TBPP need to be considered on an individ-
ual basis given that there is little data to guide generalized
treatment. The rapid, high-energy nature of TBPP results in
greater variations of presentation and a greater likelihood of
root avulsions. Older children have less capacity for nerve
regeneration and the distance for axons to reach target is
greater. In addition, development is not as rapid and cortical
plasticity may not be as great. Principles applied to adult bra-
chial plexus palsy may be adapted to the management of chil-
dren with TBPP.
The presence of a Tinel’s sign and careful clinical examination
can help localize the specific site of injury. Given that axons
grow at a rate of 1 mm per day, the measured distance from site
of injury to target muscle can be used as a guide to determine
how long an axonotmetic injury would be expected to recover.
Exploration is considered if there is no evidence of nerve recov-
ery beyond this time. As opposed to infants, serial EMG pro-
vides insights into potential recovery and should be used as an
adjunct to clinical exam.
38.4.4 Investigations Prior to Nerve
Exploration and Reconstruction
Once the decision to proceed with surgery has been made,
assessment for nerve root avulsion can help with surgical plan-
ning. Nerve root avulsions are preganglionic lesions in which
discontinuity of neurons from the spinal cord renders the root
nonfunctional and without the possibility of functional end tar-
get reinnervation. A pseudomeningocele with absent rootlets is
highly predictive of an avulsion. Computed tomography (CT)
myelogram has been the standard imaging modality; however,
this requires a lumber puncture and significant radiation expo-
sure in a young infant. We have compared newer techniques of
magnetic resonance (MR) myelography and have found them to
be equal in accuracy to CT myelogram (Tse 2014). MR myelogra-
phy does not require lumbar puncture and avoids radiation
exposure. Another advantage of MR is that bilateral shoulders
can be included in the study to assess for glenohumeral dyspla-
sia (GHD), skeletal changes that occur with chronic muscular
imbalance. We have examined scans of infant shoulders and
have found a very high incidence of skeletal changes (74%) that
can occur early and in the absence of limited passive range of
motion. If significant skeletal changes are detected, the method
of postoperative immobilization can be modified to address
these abnorm alities.
If nerve transfers are anticipated, EMG can be used to confirm
suitability of potential donor nerves for transfer, given that
some donor nerves can be a ected by the brachial plexus palsy.
For example, involvement of C7 results in partial denervation of
the triceps muscles and can a ect results of radial to axillary
nerve transfers. EMG is used to assess the status of potential
donors and to select the best one.
Ultrasound of the diaphragm is routinely performed to assess
the functional status of the phrenic nerve, which can be inter-
twined with injured nerve elements and result in limited respi-
ratory reserve.
38.5 Nerve Exploration and
Reconstruction
38.5.1 Positioning
The posterior triangle of the neck can be accessed in the supine
position by turning the head to the opposite shoulder (neck
rotation and flexion; Fig. 38.2). A midline bump supports the
kyphotic curvature of the lower cervical and upper thoracic
spine to bring the plane of the brachial plexus parallel to the
floor. The arm, shoulder, neck, and chest on the a ected side
should be exposed. Dissection is carried out with shoulder
adducted to maximize the costoclavicular space.
38.5.2 Exposure
Supraclavicular Region
A horizontal incision is designed along a skin crease parallel
to the clavicle, extending from the clavicular insertion of the ster-
nocleidomastoid to the medial insertion of the trapezius. A verti-
cal limb parallels the posterior border of the sternocleidomastoid
and extends approximately midway to the mastoid (Fig. 38.2).
Although a single horizontal incision can be used, the exposure
is more limited and relies upon soft-tissue retraction.
Table 38.2 Indications for nerve exploration and reconstruction (the
Toronto protocol)
Age

Findings
1 mo

Flail arm with Horner syndrome
3 mo

Composite AMS score for elbow flexion, elbow exten-
sion, wrist extension, finger extension, and thumb
extension of<3.5/10
6 mo

No elbow flexion
9 mo

Failed “cookie test”
Abbreviation: AMS, active movement scale.
Fig. 38.2 Brachial plexus exploration: positioning and incision.
Upper Extremity
346

The initial incision is made through platysma, and the super-
olaterally based flap is elevated in a subplatysmal plane.
The playsma is thin and di cult to visualize in infants, but can
be di erentiated from overlying subcutaneous fat and underly-
ing supraclavicular fat pad by its white smooth texture
(Fig. 38.3). The external jugular vein and the cervical plexus
of sensory nerves are deep to the platysma and can also help
define the appropriate plane of dissection. The external jugular
vein needs to be retracted or ligated and the cervical plexus
should be lysed from the network of veins intertwined with it
so that it can be later used for transfer or as graft material (it is
easier to clean the nerves before dividing distally). Each of the
cervical plexus branches is traced proximally where they con-
verge with each other and with the great auricular nerve
(which courses over the anterior surface of sternocleidomas-
toid; Fig. 38.4a). Further dissection proximal reveals the C4
root and the phrenic nerve in a region outside of the zone of
injury and severe scar ( Fig. 38.4b).
The C4 contribution to phrenic nerve is usually the most
medial branch and can be found by gentle blunt dissection over
the anterior surface of the anterior scalene. It takes a direct cau-
dal course, paralleling the fibers of anterior scalene, and is
under the prevertebral fascia. Its identity can be confirmed by
electrical stimulation.
Once the phrenic nerve has been visualized, the supraclavicu-
lar fat pad is divided along the posterior border of the sterno-
cleidomastoid and superior border of the clavicle. Bipolar
cautery is used to reduce the possibility of lymphatic leak. Trac-
tion on the fat pad should be avoided, given this layer is contin-
uous with the tissues that envelop the carotid sheath (whose
contents can become unnecessarily exposed). Care should also
be taken deep to the junction of sternocleidomastoid muscle
and clavicle to avoid inadvertent injury to the thoracic duct or
exposure of the subclavian vein. The bluish hue of the latter
can sometimes be seen within the fat if the external jugular
vein is followed too far caudal along its course. Clean incisions
and preservation of the supraclavicular fat pad facilitates later
repair, which is important in providing a protective layer for
nerve reconstruction, an ideal gliding surface for nerve excur-
sion, and a vascular environment for nerve grafts.
Deep to the fat pad, the transverse cervical artery and vein
can usually be found running parallel to the clavicle. These ves-
sels are often ligated for exposure. The omohyoid muscle is
encountered at its tendinous midportion before exposing the
brachial plexus. This muscle can be retracted or transected, and
should be mobilized adequately to allow transposition so that it
lies superficial to the supraclavicular fat pad at closure. This
avoids muscle movements directly over newly reconstructed
nerves.
Fig. 38.3 Brachial plexus exploration: (the same patient and orienta-
tion as in Fig. 38.2) subplatysmal dissection to expose external
jugular vein and cervical plexus. Note the shiny white appearance of
the undersurface of platysma.
Fig. 38.4 Brachial plexus exploration. (a) The cervical plexus has lysed from the supraclavicular fat pad (FP). The great auricular nerve (asterisk)
converges with cervical plexus branches proximally. The clavicular head of sternocleidomastoid (C-SCM) can be released for better inferior exposure if
needed. (b) The cervical plexus (ph) can be traced proximally to the C4 root where the phrenic nerve can be identified in a region outside the zone of
injury.
Brachial Plexus Palsies
347

The upper trunk of the brachial plexus is found just deep
to the om ohyoid m uscle, and is often heavily scarred and
distorted ( Fig. 38.5). Follow ing the principle of working
from “known to unknow n,” the brachial plexus is exposed
and defined starting outside of the zone of injury to facili-
tate the m ore di cult dissection through the scarred
region.
The previously identified phrenic nerve can be followed
along its caudal course from the C4 root on the anterior surface
of the anterior scalene. As the nerve approaches the lateral bor-
der of muscle, it gives o a small branch to and receives a small
branch from the C5 root. This interconnection is usually scarred
and in most cases, a significant length of the phrenic nerve is
enveloped in scar from upper trunk neuroma (Fig. 38.5).
Exposure between sternocleidomastoid and anterior scalene
allows visualization of the distal course of phrenic nerve so that
the phrenic nerve can be lysed from the neuroma. A thin layer
of scar is left on the phrenic nerve to facilitate its safe handling.
The interconnection between the phrenic nerve and the C5 root
can be sacrificed without morbidity. With the phrenic nerve
mobilized, the C5 and C6 nerve roots can be exposed. Partial
release of the anterior scalene provides proximal exposure up
to the bony intervertebral foramina. Dissection here should
progress carefully given the rich venous plexus of the vertebral
vessels just proximal. Care should also be taken to avoid trac-
tion on the phrenic nerve as it becomes particularly vulnerable
with medial exposure.
Working from distal, the branches of the upper trunk can be
identified under the clavicle where they are usually unscarred
(Fig. 38.6). The suprascapular nerve (SSN) parallels the omo-
hyoid on its course toward the suprascapular notch and defines
the lateral border of dissection. The anterior division of upper
trunk (AD-UT) is the most medial branch and defines the
medial border of dissection. The posterior division of upper
trunk (PD-UT) is found in the middle. The three branches can
be followed to their convergence at the trifurcation of the upper
trunk, which is usually found at the level of the clavicle.
The posterior surface of neuroma can be di cult to dissect
free from the middle scalene muscle due to scarification. As the
dissection progresses proximally, the planes become clearer;
however, the C5, C6, and C7 contributions to the long thoracic
nerve become vulnerable as these branches dive through the
middle scalene muscle proximally (Fig. 38.7). Preservation of
these branches can often be achieved to avoid scapular
instability.
Fig. 38.5 Brachial plexus exploration. The omohyoid (Om) has been
divided at its tendinous portion. The supraclavicular fat pad (FP) has
been incised and elevated off of the brachial plexus. The clavicle (Cl) is
being elevated by an umbilical tape to open the retroclavicular space.
The phrenic nerve (Ph) is encased in the scar of the neuroma of upper
trunk (UT).
Fig. 38.6 Brachial plexus exploration: The phrenic nerve (Ph) has been
lysed from the neuroma of upper trunk (UT). The distal branches,
suprascapular nerve (SSN), posterior division of upper trunk (PD-UT),
and anterior division of upper trunk (AD-UT) have been exposed and
neurolysed.
Fig. 38.7 Brachial plexus exploration. Branches from proximal nerve
roots dive through the middle scalene to contribute to the long
thoracic nerve (LTN). In this example image, some of the middle
scalene muscle was inadvertently elevated with dissection on the
posterior surface of the neuroma of upper trunk (UT) due to heavy
scarification. Preservation of LTN is important to maintain scapular
stability.
Upper Extremity
348

Retroclavicular Region
Due to the curvature of the spine, each sequential lower root is
found inferior and dorsal to the root above. From the surgeon’s
perspective, each sequential lower root will seem to be deeper
in the exposure. The middle trunk is identified behind the
upper trunk (Fig. 38.8).
Further deep and slightly inferior dissection reveals the lower
trunk. Proximal dissection to and between the anterior and
middle scalenes reveals the respective proximal nerve roots.
The C8 and T1 roots can be traced proximally and can be seen
originating above and below the first cervical rib, respectively
(Fig. 38.9). Dissection too far inferior and anterior will quickly
lead to the subclavian artery. This structure can be easily mis-
taken for the lower trunk, but it is pulsatile and can be con-
firmed with Doppler if needed. The subclavian artery should be
carefully lysed from the brachial plexus. The trunks of the bra-
chial plexus normally divide into divisions at or beneath the
clavicle. The divisions are rarely scarred or injured.
Although the vertebral artery is generally not visualized, it
traverses ventral to the C7 root to enter the foramen transver-
sarium of the C6 vertebra. It can potentially be injured when
releasing anterior scalene muscle while exposing proximal
nerve roots.
Infraclavicular Region
Exposure of the supraclavicular and retroclavicular brachial
plexus is adequate for exploration of the vast majority of bra-
chial plexus injuries. If further exposure is needed, an extensile
approach may include a deltopectoral incision. The cephalic
vein is found in the interval between deltoid and pectoralis
major. Depending upon the exposure needed, the deltoid and
pectoralis major can be separated, the pectoralis major can be
split along its fibers, the clavicular head of pectoralis major can
be detached, or the entire pectoralis major can be taken down.
The coracoid process is identified and pectoralis minor can be
Fig. 38.8 Brachial plexus exploration. C7 can be found in the interval between anterior scalene (AS) and middle scalene (MS). In this case, there is a
neuroma of the middle trunk (MT) that appears as a single scarred mass that includes the upper trunk (UT).
Fig. 38.9 Brachial plexus exploration. The lower roots are further caudal and, from the surgeon’s perspective, deep in the retroclavicular exposure. In
this case example, C8 has been avulsed and a dorsal root ganglion (DRG) is found outside of the C8 intervertebral foramen. The T1 root is marked with
purple dots. The subclavian artery (SA) needs to be lysed from the brachial plexus. The lower external jugular (EJ) stump serves as a landmark for the
subclavian vein, which courses anterior to the subclavian artery.
Brachial Plexus Palsies
349

disinserted to reveal the underlying fat encompassing the neu-
rovascular structures.
At this level, the most superficial element of the brachial
plexus is the lateral cord, which gives o a lateral branch that
becomes the musculocutaneous nerve (and runs through cora-
cobrachialis) and a medial branch that contributes to the
median nerve. The medial cord is found further medially and
posterior to the axillary artery. The posterior cord and the axil-
lary and radial nerve branches are best exposed with dissection
lateral and posterior to the axillary artery. The axillary nerve
branches first toward the quadrilateral space between the sub-
scapularis and latissimus dorsi. The radial nerve crosses over
the latissimus dorsi tendinous insertion before diving into the
triangular space.
Clavicular Suspension
Retraction or elevation of the clavicle to open the costoclavicu-
lar space greatly facilitates the retroclavicular exposure. In
order to reduce reliance on manual retraction, we suspend
the clavicle with an umbilical tape that is passed around the
clavicle in a subperiosteal plane to avoid the subclavian vein
(Fig. 38.10). The umbilical tape can be suspended on a retrac-
tor system such as a pediatric Bookwalter ( Fig. 38.11). Using
this technique, we have been able to achieve satisfactory retro-
clavicular exposure without performing clavicular osteotomy.
38.5.3 Intraoperative Assessment of
Brachial Plexus
Direct inspection of the brachial plexus provides insight into
the location and extent of injury. A neuroma of the upper trunk
is frequently encountered ( Fig. 38.5), and proximal dissection
to normal-appearing nerve roots is important to define the
zone of injury and assure healthy proximal roots to graft from.
When the middle trunk is injured (Fig. 38.8), it is often
encased in the scar of the upper trunk neuroma or ruptured.
When lower roots are involved, avulsions are progressively
more common at lower root levels ( Fig. 38.9).
Complete avulsions can be confirmed by one of the
following:
● Finding a dorsal root ganglion outside of the bony foramen
(Fig. 38.9). The dorsal root ganglion can be confirmed on
frozen section histology.
● Finding an empty bony foramen devoid of nerve tissue.
● Finding a normal-appearing nerve root (i.e., no signs of distal
lesion) that is clinically nonfunctional on preoperative exam
and does not respond to electrical stimulation. In this case,
there is no neuroma formation as the injury is preganglionic.
Each nerve root is assessed by electrical stimulation. The volt-
age applied and the elicited motor response are recorded. Neu-
rolysis has previously been performed as a treatment for nerve
injury; however, studies have failed to demonstrate consistent
clinical improvements using this strategy and the results of
excision and grafting have been shown to be superior. Much of
the decision to excise a portion of the brachial plexus is made
based on preoperative clinical function, since a response to
electrical stimulation alone does not necessarily indicate clini-
cally useful motor function. The injured segment of nerve is
excised to healthy-appearing nerve using loupe magnification.
The ends of the nerve are marked and submitted to pathol-
ogy for frozen section histology. If a nerve end displays features
of a neuroma (architectural disorganization, perineural
Fig. 38.10 Clavicle suspension. Periclavicular dissection for suspension (parasagittal section). (a) The sternocleidomastoid and pectoralis muscle
originate from the cranial and caudal surfaces of the clavicle. The subclavius originates from a groove on the undersurface of the clavicle. Its fascia is
continuous with the clavipectoral fascia and the fascia of the omohyoid. (b) Supraperiosteal dissection requires dissection of the subclavius from the
groove in the clavicle, thereby providing a layer separating the suspending lace/tape from the subclavian vein. (c) Subperiosteal dissection can
facilitate dissection of the subclavius from the groove in the clavicle. Incisions can be placed to preserve the anterior periosteum.
Upper Extremity
350

microfascicles, or severe endoneurial/perineurial/epineurial fib-
rosis), the nerve can be cut further away from the zone of
injury. Proximally, the bony foramen limits the extent in which
a nerve can be trimmed. Distally, the nerve can generally be
trimmed to healthy-appearing nerve. Some perineurial fibrosis
of the distal target is accepted if there are no perineural micro-
fascicles because further trimming of the nerve results in longer
grafts that may adversely a ect reinnervation.
The combination of the histologic appearance of the proximal
nerve roots and the response to electrical stimulation is used to
determine the relative quality of proximal nerve roots for nerve
grafting.
The use of intraoperative nerve conduction studies and of
evoked potentials have been reported; however, there is dis-
agreement with regard to the use of these studies and their cor-
relation to clinical outcomes.
38.5.4 Reconstruction for Neonatal
Brachial Plexus Palsy
Depending on the clinical scenario and intraoperative findings,
specific reconstructive strategies will vary. There is general con-
sensus that reconstructive priorities should be:
● Hand function.
● Elbow flexion.
● Shoulder stability and function.
Excision and grafting are the current standard for nerve recon-
struction. Although nerve transfer as a primary strategy for
reconstruction has gained popularity in the treatment of adult
brachial plexus palsy, the role in treatment of NBPP has yet to
be fully defined. Results of reconstruction using nerve transfers
have been reported; however, these are limited to case reports
and small case series. Nerve grafts take advantage of the abun-
dant proximal regenerating axons, allow for anatomic recon-
struction, and avoid sacrifice of motor donors. Nerve transfers
reduce the distance of regenerating axon to target, allow for
greater motor-to-motor specificity, require fewer sites of coap-
tation, and can be technically easier to perform. There are no
direct comparisons of nerve transfers to nerve grafting as a sole
strategy for reconstruction of NBPP, so the relative e cacy
remains unclear (Tse 2015). It is possible that multiple nerve
transfers for Erb/type 1 palsies may have similar results to
nerve grafting; however, when more than the upper plexus
(C5–C6) is involved, nerve transfers alone will be inadequate for
maximal reinnervation. Reinnervation of as many targets as
possible provides the best outcomes and options for secondary
reconstruction. Any surgeon engaging in nerve reconstruction
for NBPP should be willing and able to perform nerve explora-
tion and graft reconstruction as well as nerve transfers.
There may be a number of reasons that the relative advantage
of nerve transfers in adults may not be the case in infants. Com-
pared to adult brachial plexus palsy, infants with NBPP greatly
di er in the mechanisms, patterns, severity, extent of injury,
and scar tissue formation. The potential for neuromuscular
recovery diminishes with age, and infants have a shorter limb
over which axons need to regrow to reach their targets. In addi-
tion, due to rapid growth and development, infants possess
much greater potential for central nervous system adaptation.
Although the role of nerve transfers as a sole strategy for pri-
mary reconstruction of Erb (Type I) brachial plexus palsy is
unclear, there are several specific situations in which nerve
transfers are preferred over nerve graft reconstruction. These
situations include the following:
● Inadequate proximal nerve roots (i.e., avulsion).
● Delayed presentation.
● Isolated deficits.
● Failed primary reconstruction.
The following clinical scenarios illustrate some principles in the
selection of strategies of nerve graft and nerve transfer for
reconstruction of NBPP.
Fig. 38.11 Clavicle suspension. Supero-lateral view of left shoulder and neck. Blue star is on patient’s face and orange circle is on patient’s shoulder.
(a) The superolateral-based supraclavicular fat pad (FP) has been turned over and both the sternocleidomastoid (SCM) and pectoralis major (PM) have
been exposed and released. Circumferential dissection around the lateral portion of the clavicle allows umbilical tape to be passed around it. (b)
Suspension apparatus. The left chest and shoulder arm are in view. A sterile stand is used for suspension of the clavicle.
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351

Neonatal Brachial Plexus Palsy Example 1:
Upper Plexus Palsy (Isolated Neuroma of
Upper Trunk)
In the case of an upper trunk neuroma (Fig. 38.5) and when
both C5 and C6 roots are available, axons are delivered to target
by cable grafts. The neuroma is excised in preparation
(Fig. 38.12). Bilateral sural nerve grafts are harvested under
direct visualization via three small transverse incisions
(Fig. 38.13). If visualization is di cult, an endoscope is used.
The first priority of reconstruction is elbow flexion, followed by
shoulder control. A surgical plan is devised based upon preope-
rative clinical function, findings on exploration, direct electrical
stimulation of the proximal nerve roots, and histologic exami-
nation of cut ends to determine the relative quality of proximal
stumps ( Fig. 38.14).
On the recipient side, the SSN innervates supraspinatus
and infraspinatus (shoulder abduction and external rotation,
respectively). The PD-UT is a major contributor to the axillary
nerve that innervates the deltoid (shoulder flexion and abduc-
tion). The AD-UT is a major contributor to the musculocutane-
ous nerve that innervates the primary flexors of the elbow.
The cranial surface of the proximal C5 stump corresponds to
the fascicular group of SSN and is generally reserved for this
purpose. The cross-sectional surface of C5 can accommodate
two additional sural nerve grafts, and these are used to inner-
vate AD-UT and PD-UT. C6 tends to be a larger root and has a
cross-sectional area that fits four sural nerve grafts. Two can be
directed to AD-UT and two can be directed to the PD-UT. One
advantage of this approach is if one of the two roots happens to
have poor axon sprouting (i.e., unrecognized proximal injury),
the crossover from roots may avoid total failure ( Fig. 38.14).
An alternate approach is to arrange the cable grafts into a
more anatomic configuration with two grafts from C5 to the
posterior division, a single graft from the cranial portion of C6
to the posterior division, and the remaining three grafts from
C6 to the anterior division. A disadvantage of this approach is a
lack of crossover between roots, meaning a higher chance of
failure if there is an unrecognized proximal injury to one of the
roots.
Nerve coaptation is performed under microscope securing
grafts with fibrin glue proximally (Fig. 38.15) and then dis-
tally (Fig. 38.16), working form deep to superficial. The fibrin
should be allowed to set before releasing retractors to avoid
adherence and potentially tethering to surrounding tissues
(Fig. 38.17).
Fig. 38.12 Nerve graft reconstruction: The neu-
roma of the upper trunk has been excised in
preparation for grafting.
Fig. 38.13 Nerve graft reconstruction. Bilateral sural nerve grafts are
harvested via three short transverse incisions. Incisions are planned
along creases at the ankle and popliteal fossa. The middle incision is
planned at the junction of muscular and tendinous gastrocnemius.
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Neonatal Brachial Plexus Palsy Example 2:
Upper Plexus Palsy (Lesions of Upper and
Middle Trunk)
The strategy in this scenario is similar to example 1 with the
addition of grafts from C7 to middle trunk (Fig. 38.18). Sural
nerve grafts are preferentially used to reinnervate the upper
trunk and restore elbow flexion via AD-UT and shoulder abduc-
tors via PD-UT and SSN. Given the redundancy of function, the
lower quality cervical plexus grafts are used for the middle trunk.
Neonatal Brachial Plexus Palsy Example 3:
Pan Plexus Palsy with Two Avulsions (C8–T1)
In the case of pan-plexus palsy, reinnervation of the hand is the
first priority ( Fig. 38.19). The intrinsic hand muscles and
extrinsic finger flexors are targeted via the T1 and C8 roots of
the lower trunk. The best-quality proximal roots and nerve
grafts are dedicated to these targets. In the case of a nerve root
avulsion in which the dorsal root ganglion is found in the supra-
clavicular space, neurolysis can be performed to separate the
dorsal root from the ventral root. In doing so, the sensory and
motor nerve components, respectively, can be isolated. The
lower trunk can then be mobilized so that a direct coaptation
between C7 and the ventral root (pure motor component) of
the T1 target can be achieved. When the ventral and dorsal
roots cannot be separated, as with C8 in this case, short grafts
are used.
Elbow flexion is the next priority and is targeted via grafts to
AD-UT. The shoulder is the third priority and is targeted via
grafts to PD-UT with an additional nerve transfer to SSN. Given
that two of three roots in this case are not available, the number
Fig. 38.14 Example case 1, surgical note (upper trunk neuroma): findings and plan for reconstruction. Neuroma is resected and cable grafts are used
to innervate suprascapular nerve (SSN), posterior division of upper trunk (PD-UT), and anterior division of upper trunk (AD).
Brachial Plexus Palsies
353

of axons for potential reinnervation is reduced. The spinal
accessory nerve (SAN) is a close match in size and axons to SSN
and is thus used as a donor for transfer.
The remaining functions of the brachial plexus are the last
priority, and the lower quality cervical plexus graft is typically
used to target the middle trunk.
Neonatal Brachial Plexus Palsy Example 4:
Pan Plexus Palsy with Three Avulsions
(C7–T1)
Meaningful function can still be achieved in spite of three avul-
sions (Fig. 38.20). Hand function is the first priority, and three
grafts are dedicated to the lower trunk. Two grafts are used to
Fig. 38.15 Nerve graft reconstruction. View through microscope of cable graft coaptations to proximal C5 nerve root at the intervertebral foramen.
The C6 graft inset can be seen at bottom right of each frame.
Fig. 38.16 Nerve graft reconstruction. Coaptation of nerve grafts to distal target nerve stumps.
Upper Extremity
354

target AD-UT and PD-UT for elbow flexion and shoulder con-
trol. Additional axons are recruited with a SAN–SSN transfer.
The remaining cervical plexus graft is used for the lowest prior-
ity target, the middle trunk.
Neonatal Brachial Plexus Palsy Example 5:
Pan Plexus Palsy with Four Avulsions (C6–T1)
When four of five roots are avulsed, an additional source of
axons is needed to restore meaningful motor function
(Fig. 38.21). In this case, both C8 and T1 roots are isolated and
two grafts are dedicated to each for reinnervation of the hand.
SAN–SSN transfer and grafts to PD-UT address the shoulder.
Additional axons for innervation can be obtained from the
third, fourth, and fifth intercostals (see section “Intercostal to
Musculocutaneous Nerve Transfer”), which are transferred
directly to the musculocutaneous nerve with a coaptation in
the axilla.
Neonatal Brachial Plexus Palsy Example 6:
Upper Palsy with Delayed Presentation or C5
and C6 Avulsions
In the case of breech presentation, there may be an upper palsy
with C5 and C6 avulsions and no proximal nerve roots available
for grafting. In the case of delayed presentation, moving the site
of nerve repair closer to the distal target allows for earlier
reinnervation.
Multiple nerve transfers are indicated in these cases (see sec-
tion “Technical Notes for Nerve Transfers”). In addition to SAN-
SSN, one of the three motor branches of radial nerve to triceps
can be transferred to the axillary nerve (Tri-Ax). Reinnervation
of elbow flexion can be achieved via a bifascicular transfer (M/
U-Bi/Br), in which a redundant fascicle of ulnar (FCU) nerve is
transferred to the brachialis branch of musculocutaneous nerve,
and a redundant fascicle of median nerve (flexor digitorum
superficialis [FDS] or flexor carpi radialis [FCR]) is transferred to
the biceps branch. We prefer this double fascicular transfer in
these situations, in which a greater number of motor axons are
transferred for elbow flexion restoration than with the tradi-
tional single ulnar to musculocutaneous transfer originally
described by Oberlin.
Neonatal Brachial Plexus Palsy Example 7:
Upper Plexus Palsy with Isolated Deficits
Isolated deficits following brachial plexus palsy are unusual. In
the case of poor elbow flexion with excellent shoulder abduc-
tion, the decision can be made to proceed with nerve graft
reconstruction of the upper trunk with the goals of improving
elbow flexion but with the accepted risk of downgrading
shoulder abduction.
The alternative is to perform specific nerve transfer(s) to
address the isolated deficit(s). The example illustrated in
Fig. 38.22 was a 9-month-old who failed the Cookie test but
who had excellent shoulder abduction. Elbow flexion was poor
(less than 90 degrees against gravity with no progression over 6
months) and there was no shoulder external rotation. Preope-
rative myelogram was suggestive of an avulsion of C6. On
exploration, C5 and the upper trunk had grossly recognizable
architecture following neurolysis, but the C6 root was severely
scarred up to the level of the upper trunk. An intact C5 contri-
bution to upper trunk with an avulsion of C6 explained the
clinical presentation. Given the excellent shoulder abduction
and a lesion that may not be improved by excision and grafting,
isolated nerve transfers were performed including SAN-SSN
and M/U-Bi/Br.
Neonatal Brachial Plexus Palsy Example 8:
Pan Plexus Palsy with Failed Reconstruction
of Elbow Flexion
These situations are rare, and there is no consensus on the indi-
cations for secondary reconstruction. Clarke reported that
recovery following NBPP plateaus at 2 to 3 years. Given this
long time span and the competing threat of permanent motor
endplate atrophy, it is di cult to determine when and if to
intervene. In the case of nerve graft reconstruction for pan-
Fig. 38.17 Nerve graft reconstruction. Multiple
cable grafts secured using fibrin glue according
to surgical plan ( Fig. 38.14).
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355

plexus plexus palsy (as in NBPP example 4), if there is inad-
equate elbow flexion but adequate hand and shoulder function
1 year after surgery, it may be reasonable to o er secondary
reconstruction. Intercostal (third, fourth, and fifth) to musculo-
cutaneous nerve transfer is one option (see "Intercostal to Mus-
culocutaneous Nerve Transfer"). In the author’s experience of
two cases, recovery of meaningful elbow flexion occurred 3 to 6
months after secondary reconstruction. It is possible that this
recovery could still have occurred with primary reconstruction
alone, and parents must be informed that recovery without fur-
ther surgery is possible. If secondary reconstruction is deferred
and no meaningful elbow flexion is recovered, innervated free
muscle transfer or other secondary musculoskeletal procedures
remain options.
38.5.5 Reconstruction for Traumatic
Brachial Plexus Palsy
Principles of TBPP reconstruction are similar to NBPP, but avul-
sions are more common and the distance from regenerating
axon to target is greater. Similar to adults, older children have
less regenerative capacity than infants. Nerve grafts may be
used for reconstruction of proximal targets (i.e., shoulder) to
take advantage of the abundant regenerating axons, but nerve
transfers may be required for more distal targets (i.e., elbow) to
bring regenerating axons closer to target. As has been reported
in the treatment of adult brachial plexus palsy, the combination
of nerve grafts and transfers likely maximizes potential
outcomes.
Fig. 38.18 Example case 2, surgical note (upper trunk neuroma, middle trunk rupture): findings and plan for reconstruction that include nerve grafts
to posterior division of upper trunk (PD-UT) and anterior division of upper trunk (AD). The suprascapular nerve (SSN) was innerved by the spinal
accessory nerve (SAN).
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38.5.6 Technical Notes for Nerve
Grafting
Fibrin sealant is used as a “nerve glue” to ensure accurate end-
to-end coaptation and optimize nerve recovery. Sutures have
been found to produce granulomas that can impair nerve recov-
ery. Sutures repair is also not possible if a proximal nerve root
is trimmed to or within the bony intervertebral foramen
(Fig. 38.15). Grafts should be tailored in the position that
requires the greatest nerve length (i.e., shoulder adducted and
head turned to contralateral side) and with some redundancy
to avoid any tension and to allow nerve gliding with movement.
An organizational strategy helps with the management of mul-
tiple cables.
Each sural nerve is individually repaired under the micro-
scope starting on the proximal side, working from the deepest
root/region to the most superficial ( Fig. 38.15 and
Fig. 38.16). Although the internal neural topography of the
brachial plexus is not well described, cables are organized on
the proximal roots that mimic their course to distal targets.
Dilator forceps can be used to manipulate epineurium and
ensure accurate coaptation. The two components of fibrin
sealant (i.e., fibrin and activator) can be delivered via separate
syringes to avoid the delivering catheter from getting clogged
when multiple applications are performed. Fibrin glue is only
applied to the sites of coaptation so that the rest of the nerve
graft can glide across tissues in the case of any movement.
Heat from the operating microscope can easily result in des-
iccation of nerve grafts, and significant soft-tissue burns have
been reported in infants. Room lights are dimmed so the micro-
scope light source can be lowered in intensity. The wound and
nerve grafts should be irrigated frequently.
Fig. 38.19 Example case 3, surgical note (pan plexus palsy with two avulsions): findings and plan for reconstruction. On clinical examination, the hand
was flail with no apparent function. On exploration, C8 was found to have progressively greater scarification that extended proximal to the vertebral
foramen and T1 had a normal appearance with no response to electrical stimulation. The findings for both C8 and T1 were consistent with avulsion of
rootlets from spinal cord. The C8 contribution to lower trunk was innervated via nerve grafts. The T1 contribution to lower trunk was repaired directly
to the C7 stump.
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357

38.5.7 Technical Notes for Nerve
Transfers
Donor nerve selection should be determined preoperatively by
clinical exam and with EMG when needed (i.e., the donor may
be partially innervated or have incomplete reinnervation). Int-
raoperative testing with an electrical stimulator is helpful in
confirming adequate motor response of the donor nerve. The
use of smaller voltages (0.1–0.5 mV) avoids overstimulation and
electrical spread. Intermittent stimulation prevents tetanic con-
traction, which can result in fatigue. Donor nerves should have
a strong response to stimulation, but caution must be employed
to avoid sacrificing critical functions. Stimulation of nerves,
branches, or fascicles being preserved is important to confirm
that the critical function is left intact.
Nerve repair is best performed with redundancy in length,
allowing for motion without consequent tension on the site of
coaptation. To ensure length, the donor should be transected
distally, while the recipient should be transected proximally.
Neurolysis provides additional length.
Spinal Accessory to Suprascapular Nerve
Transfer
When performed from the anterior approach, the SAN can be
found between the supraclavicular fat pad and the trapezius
muscle in the lower one-third of the neck. The nerve can be fol-
lowed to the lower scapula, transected distally, and then passed
through an opening in the supraclavicular fat pad to the SSN.
This may be performed during primary nerve exploration and
grafting. It is critical to leave one to two branches of SAN to
upper trapezius intact to avoid significant scapulothoracic mor-
bidity and scapula instability.
The posterior approach o ers the advantage of SSN decom-
pression, but requires prone positioning. The trapezius is split
at the level of the scapular spine and the SAN is identified
approximately 40% of the distance from midline to acromion
(Fig. 38.23a, b, c). The SAN should be followed as far distal as
possible to ensure length. The SSN is found along the anterior
border of the supraspinatus, approximately halfway between
the superior angle of scapula and acromion (Fig. 38.23a). Pal-
pation of the coracoid anteriorly helps orient the surgeon to the
Fig. 38.20 Example case 4, surgical note (pan plexus palsy with three avulsions): findings and plan for reconstruction.
Upper Extremity
358

vicinity of the scapular notch. Retraction of the scapula poster-
oinferiorly helps with the deep exposure. The origin of the
omohyoid muscle can often be visualized and the adjacent
notch palpated. The suprascapular artery can be seen coursing
over the suprascapular ligament. Once this ligament is divided
(Fig. 38.23e), the nerve can be visualized and followed as
proximal as possible to allow laxity for direct coaptation
(Fig. 38.23f).
Sacrifice of lower trapezius function bears little morbidity;
however, the lower trapezius is sometimes used as a donor
muscle for tendon transfer in the case of persistent deficits in
external rotation. When additional axons are needed for recon-
struction, and if latissimus dorsi function is intact or to be rein-
nervated, sacrifice of the lower trapezius to potentially achieve
external rotation is a reasonable strategy.
Triceps to Axillary Nerve Transfer
Preoperative EMG to examine the pattern and strength of vol-
untary innervation for each head ensures that an adequate
donor is available and is helpful in the selection of an appropri-
ate branch for transfer.
Fig. 38.21 Example case 5, surgical note (pan plexus palsy with four avulsions): findings and plan for reconstruction. Given the limited number of
proximal roots to graft from, three intercostal nerves were used as a distal transfer to innervate musculocutaneous nerve, thereby targeting the elbow
flexors.
Brachial Plexus Palsies
359

The posterior approach provides ideal visualization to both
donor and recipient branches. An incision is designed along the
posterior midline of the arm extending to the posterior border
of deltoid (Fig. 38.24a). The interval between triceps and del-
toid leads to the quadrangular space ( Fig. 38.24b, c). The sen-
sory branch of the axillary nerve can then be traced to the
posterior, anterior, and teres major branches (Fig. 38.24d).
Depending upon the circumstances, the main trunk of the axil-
lary nerve, or one of the posterior or anterior branches, can be
selected as the target. Proximal dissection provides length for
coaptation. The triangular space can be found on the inferior
border of teres major, containing the branches to the three
heads of triceps ( Fig. 38.24d). The branch to medial head is
found overlying the radial nerve and is often larger with longer
Fig. 38.22 Example case 7, surgical note (upper plexus palsy with isolated deficits): findings and plan for reconstruction. Given satisfactory shoulder
abduction, specific deficits of shoulder external rotation and elbow flexion, and an apparent avulsion of the C6 root, the brachial plexus was left intact
and distal nerve transfers were used for reconstruction. Spinal accessory nerve (SAN) was transferred to suprascapular nerve (SSN) and the flexor
digitorum superficialis (FDS) fascicle of median nerve was transferred to brachialis branch of the musculocutaneous nerve.
Upper Extremity
360

Fig. 38.23 Spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer. (a) Surface landmarks. The course of SAN is 40% of the distance
between midline of the back and acromion (AC). The course of SSN is midway between superior angle of scapula and AC. The scapular spine and
anterior edge of scapula define the borders of the supraspinatus muscle. (b) Exposure of trapezius. (c) Trapezius is split transversely between muscular
fibers. (d) The trapezius (Tr) is also released along its bony insertion into the scapular spine. Supraspinatus muscle is exposed (SS). (e) Caudal traction
on the scapular spine rotates the anterior edge of superior scapula into view. The suprascapular notch is difficult to visualize, but the origin of
omohyoid (Om) helps define the medial edge of the notch. The SSN is visualized following release of the suprascapular ligament (Lig) and can be
traced proximally (i.e., away from SS) up to the upper trunk to attain greater length for transfer. (f) The proximal stump of SSN is flipped posteriorly.
The SAN is traced to the lower scapula before transection and flipping the stump anteriorly.
Brachial Plexus Palsies
361

length that allows for redundancy. However, the ultimate donor
branch selection is based on preoperative EMG and intraopera-
tive examination using electrical stimulation (Fig. 38.24e).
Fascicular Transfer for Elbow Flexion: Oberlin
Type (M/U-Bi/Br)
Depending on the circumstances, either one or two fascicles
can be transferred to either biceps or brachialis or both,
respectively.
A medial arm incision is placed over the medial intermuscu-
lar septum. The deep muscular fascia anterior to the septum is
incised so that the interval between biceps and brachialis can
be opened ( Fig. 38.25a). The musculocutaneous nerve can be
seen passing through the coracobrachialis before dividing into
its branches ( Fig. 38.25b). The biceps branch is most proximal
and travels lateral. The brachialis branch is next and travels
medial (often obscured by a crossing vessel from brachial artery
to biceps). The lateral antebrachial cutaneous (LABC) nerve con-
tinues and travels into the antecubital fossa. The three branches
are lysed as far proximal as possible.
The medial antebrachial cutaneous (MABC) nerve is superfi-
cial and can be mistaken for a major motor nerve. The median
nerve is found almost immediately medial to the musculocuta-
neous nerve, and the ulnar nerve is found further medially and
deep to the brachial artery. Small segments of both the ulnar
and the median nerve epineurium are opened to for internal
neurolysis to expose appropriate donors ( Fig. 38.25b). Mack-
innon has described the relevant topographical fascicular anat-
omy that allows appropriate fascicles to be isolated without
dissection of the rest of the nerve ( Fig. 38.25c). For the
median nerve, FDS and FCR fascicles are found on the medial
superficial surface of the nerve (the pronator fascicle is on the
superficial central region, sensory fascicles are found on the lat-
eral side, and the anterior interosseous nerve (AIN) fascicles are
on the deep side of the nerve). For the ulnar nerve, the FCU
branch is found on the lateral superficial aspect of the nerve. It
is critical to avoid sacrifice of any flexor digitorum profundus
(FDP) or intrinsic function. Appropriate planning ensures
redundant nerve length for transfer ( Fig. 38.25d).
Electrical stimulation should be used to confirm that the fas-
cicle being sacrificed has redundancy of function in the fascicles
being left behind. Loss of hand function in a compromised limb is
a risk and can be devastating. The e ects of median and/or ulnar
fascicle sacrifice on hand growth seem to be insignificant in the
short term; however, long-term studies are not yet available.
Intercostal to Musculocutaneous Nerve
Transfer
The intercostal nerves contain both motor and sensory compo-
nents. When used as donors for elbow flexion, three levels are
generally needed to provide adequate axons. The line of the
anticipated inframammary fold is drawn and an incision is
designed along a short segment of this ( Fig. 38.26a). The lat-
eral border of the pectoralis major is identified and elevation
exposes the chest wall (Fig. 38.26b). Fibers of pectoralis
minor and serratus anterior must be split to expose the anterior
surface of the third, fourth, and fifth ribs. The anterior perios-
teum is incised and dissected from the lower border and
Fig. 38.24 Triceps branch of radial nerve (Tr) to axillary nerve (Ax) transfer. (a) Surface landmarks. The interval between deltoid (Del) and the heads of
triceps (Tri) can be palpated. The anticipated location of teres major (TM) is marked. (b) The interval is opened. (c) The radial nerve (Rad) exits the
triangular space inferior to teres major, whereas the axillary nerve (Ax) exits the quadrangular space superior to teres major. The sensory branch of
axillary nerve can also be followed toward to the quadrangular space. (d) Branches of radial and axillary nerve are identified. The axillary branches can
be followed proximally to the nerve trunk. (e) The donor triceps branch is followed distally to allow the nerve to swing superiorly. The axillary nerve is
dissected proximally to swing the stump inferiorly.
Upper Extremity
362

posterior surface of the rib, thereby allowing downward retrac-
tion of the intercostal muscle and neurovascular structures
away from bone (Fig. 38.26c). Incision through periosteum
and gentle dissection through intercostal fibers reveal the inter-
costal nerve. There is often only a thin layer of tissue overlying
pleura. The nerve can be followed medially to the costochondral
junction before motor function diminishes, and then mobilized
posteriorly, which involves sacrificing the lateral cutaneous
branch for su cient length. A tunnel through the serratus ante-
rior muscle provides a direct course toward the axilla.
The musculocutaneous nerve is identified in the upper
medial arm and followed proximally under the pectoralis major
to its origin from the lateral cord in order to provide length
(Fig. 38.26d). The coracobrachialis often must be sacrificed to
allow direct coaptation to donor nerves in the axilla.
Sacrifice of intercostal nerves in the setting of ipsilateral
phrenic nerve palsy can result in respiratory compromise in an
infant. Preoperative ultrasound can help evaluate diaphragm
function. Denervation of the intercostals likely results in some
long-term chest wall asymmetry that families should be made
aware of. Although unlikely, breast development and sensation
may also be a ected.
Other Nerve Transfers
Other nerve transfers are less common but may be useful in
specific circumstances.
The medial pectoral nerve (MPN) may be used as a donor to
the axillary or musculocutaneous nerves. Maximal access is
gained via an infraclavicular brachial plexus approach. Pectoralis
major is retracted or released, and pectoralis minor is released
from the coracoid to expose the MPN as it branches from the
medial cord. The many branches of MPN can be followed into
muscle to attain nerve length. The musculocutaneous nerve is
the most lateral branch of the brachial plexus distal to the
coracoid and can be seen travelling through coracobrachialis. The
axillary nerve can be found deep to the musculocutaneous nerve.
The use of contralateral C7 (cC7) has significant risks, but
may be the only option in the extremely unlikely case of C5–T1
avulsions. Transient donor deficits and persistent synchronous
contralateral movements (i.e., donor limb movements when
attempting to move the reconstructed limb) are common, and
reported results have been variable.
Isolated lower plexus (Klumpke) palsy is extremely rare in
infants. In this case, upper plexus donors may be used for lower
plexus reinnervation, and brachialis to AIN transfer may be a
reasonable option if reconstruction is undertaken.
38.6 Postoperative Care Following
Primary Nerve Reconstruction
Infants are immobilized for 3 to 5 weeks. If the shoulder is supple
and there is no significant glenoid dysplasia on preoperative MRI,
they are secured in a cu -and-collar sling (Fig. 38.27a) for 3
weeks, followed by an additional 2 weeks of leaving the arm within
the shirt (i.e., arm is not brought through the sleeve) to avoid sig-
nificant arm motion. If the shoulder is sti and there is significant
GHD, the internal rotators are temporarily denervated with botuli-
num toxin A and the shoulder is stretched into external rotation
using a shoulder spica cast for the full 5 weeks (Fig. 38.27b). In
all cases, range of motion stretching is resumed after 5 weeks.
38.7 Outcomes of Nerve
Reconstruction
An in-depth appreciation of outcomes is important for treating
providers to manage patients. A comprehensive review of the
literature is beyond the scope of this chapter.
Fig. 38.25 Fascicular transfer for elbow flexion (M/U-Bi/Br). (a) Incision along medial arm and through muscular fascia to expose the space between
biceps and brachialis. (b) The branching pattern of musculocutaneous nerve is consistent. The biceps branch (Bi) is lateral, the brachialis branch (Br) is
medial, and the lateral antebrachial cutaneous (LABC) nerve continues its central course. A vascular branch of brachial artery to biceps crosses the
divergence of brachialis branch from the LABC. Medial antebrachial cutaneous nerve (MABC) is found superficial to the brachial neurovascular bundle.
Short segments of median (M) and ulnar (U) nerve are exposed for transfer. (Continued)
Brachial Plexus Palsies
363

Fig. 38.25 (Continued) (c) Internal topography of median and ulnar nerves. (d) Transfer of median fascicle to biceps branch and ulnar fascicle to
brachialis branch.
Upper Extremity
364

The results of reconstruction using nerve grafts for NBPP
have been reported by Lin, Waters, and others (see Lin 2009,
Waters 1999, Ashley 2007). The results of reconstruction using
nerve transfers for NBPP have been reported by Ladak and
Littlwe (see Ladak 2013, Little 2014).
When following the Toronto protocol in the treatment of
NBPP, reasonable expectations are for 90% of patients to have
improvements, 5 to 10% of patients with no improvements
beyond baseline, and 1 to 5% of patients with functional losses
related to a complication or failed reinnervation.
Results of reconstruction for TBPP are extremely limited and
inferences may be extrapolated from literature on adult trau-
matic brachial plexus palsies.
Improvements following reconstruction tend to plateau at 2
to 3 years after surgery.
38.8 Secondary Reconstruction
Secondary musculoskeletal reconstruction is generally consid-
ered following maximal nerve recovery.
38.8.1 Shoulder
Persistent deficits of external rotation are common in children
with brachial plexus palsies, regardless of whether they under-
went primary reconstruction or had spontaneous recovery of
function. There are several reasons for this. The infraspinatus is
the main external rotator of the shoulder, and is innervated by
the SSN, which arises from the most cranial fascicular bundle of
C5 and the upper trunk. With downward traction, the SSN is
susceptible to the greatest forces resulting in injury. Meanwhile,
the numerous internal rotators of the shoulder (pectoralis
major, subscapularis, teres major, and latissimus dorsi) are
innervated by branches originating lower in the plexus and
thus their function is often spared. The imbalance of shoulder
rotators in the setting of a rapidly growing child is thought to
be responsible for progressive contracture and skeletal changes
of the shoulder known as GHD.
GHD is characterized by glenoid morphology that progresses
from retroversion to loss of the posterior glenoid lip and even-
tually to a pseudoglenoid. Along with this progression, the
humeral head subluxates posteriorly and can take on a flat-
tened morphology (Fig. 38.28).
Lack of external rotation has significant functional conse-
quences, such as hand to mouth, hand to head, and above
shoulder activities. Strategies to address these shoulder deficits
can be grouped into those that rebalance the glenohumeral
joint and those that salvage function by altering the position of
limb range of motion in space.
Reconstruction (Shoulder Release and Tendon
Transfer)
Release of shoulder internal rotation contracture can involve
capsulotomy, tendon lengthening, ligament release, and osteot-
omy. There is no consensus on the best method and degree of
release to produce the best outcomes, but overly aggressive
release can result in scar, morbidity, and loss of internal rota-
tion with significant impacts on overall limb function. In order
to avoid excessive release, we start with an open coracohumeral
ligament release ( Fig. 38.29a). An anterior shoulder incision
provides access to the deltopectoral interval through which the
coracoid can be accessed ( Fig. 38.29b). The ligament has fibers
that run from medial to lateral, originating from the cora-
coid. The coracohum eral ligam ent can be di erentiated from
the coracoacromial ligam ent, which has vertical superior
course, and the coracobrachialis muscle origin, which has an
oblique inferolateral course. Release of the ligam ent provides
space for the hum eral head to translate anteriorly with
external rotation ( Fig. 38.29c, d), typically allowing an
additional 30 degrees of external rotation beyond neutral. If
the pectoralis major is tight, the tendinous bony insertion is
exposed and a fractional lengthening is performed. With
progressive stretch, an additional 30 degrees of external
rotation can be gained.
In order to rebalance the rotator cu , the latissimus dorsi
(and sometimes teres major) are transferred to function as
external rotators. An incision along the axillary crease provides
exposure. The conjoint tendon of latissimus dorsi and teres
major is followed to its bony insertion and released
(Fig. 38.29e). Care should be taken to avoid injury to the axil-
lary and radial nerves that course posteriorly along the cepha-
lad and caudal margins of the conjoined tendon, toward the
quadrangular and triangular spaces, respectively. The donor
muscle is mobilized so that it can insert into the greater tuber-
osity of the humerus (Fig. 38.29f). Splitting the interval
between triceps and deltoid exposes the new site of insertion.
If dissecting too distal, the sensory branch of axillary nerve and
associated blood vessels may be encountered. The axillary
nerve is in the vicinity and should be preserved.
The shoulder is immobilized in external rotation using a
shoulder spica cast for 4 weeks. Therapy and stretching are ini-
tiated at 4 weeks, and strengthening is initiated at 8 weeks after
surgery. Glenohumeral remodeling and better clinical results
have been demonstrated with shoulder release and tendon
transfer when children undergo surgery at 2 to 4 years of age.
Glenoid osteotomy to correct glenoid version has been
described as an adjunct and may allow for improved motion in
Fig. 38.25 (Continued) (e) Transfer of median fascicle to biceps branch
and ulnar fascicle to brachialis branch.
Brachial Plexus Palsies
365

Fig. 38.26 Intercostal to musculocutaneous nerve transfer (ICN-MSC). (a) Anticipated inframammary fold and planned incisions. (b) Retraction of
pectoralis major and exposure of chest wall. Periosteum on the anterior surface of the rib has been incised and elevated off the lower border and
posterior surface of the bone. (c) Sutures along periosteal edge allow downward traction to bring intercostal neurovascular structures out from the
undersurface of the ribs. Incision through periosteum allows direct exposure of nerve. (d) Medial upper arm incision allows exposure of
musculocutaneous nerve (MSC) as it courses through the coracobrachialis muscle (CB). (e) The nerve is followed up to lateral cord E.
Musculocutaneous nerve has been passed through axilla and intercostal nerves have been tunneled through serratus anterior to allow direct
coaptation.
Upper Extremity
366

older children with less potential for glenohumeral remodeling;
however, long-term outcomes and risks remain unknown.
Salvage (Humerus Osteotomy)
In the case of severe GHD that is unlikely to remodel, or if fur-
ther glenohumeral reconstruction is unlikely to provide func-
tional improvement, humeral rotation osteotomy may be an
option to reposition the available active shoulder rotation into
a more functional position in space. The available range of
motion should be assessed and the planned shift in rotation
should be measured and agreed upon with the patient before
surgery. The humeral shaft is cut and rotation to the new posi-
tion is stabilized with rigid fixation ( Fig. 38.30).
38.8.2 Elbow
Failure to recover elbow flexion following nerve reconstruction
is rare. In the case of inadequate or failed recovery, several
options to augment or produce elbow flexion have been
Fig. 38.28 (a) Progressive glenoid dysplasia:
concave-flat, convex, biconcave. (b) Measure-
ment of glenoid version and posterior sublux-
ation according to the percentage of humeral
head anterior to axis of scapula.
Fig. 38.27 Postoperative immobilization. (a) Cuff and collar sling. (b) Shoulder spica cast. External rotation reduces the humeral head anteriorly into
the glenoid fossa.
Brachial Plexus Palsies
367

Fig. 38.29 Shoulder release and tendon transfer. (a) Exposure of coracohumeral ligament via anterior incision. Dissection through deltopectoral
interval exposes coracoid. Dissection lateral to coracoid reveals ligament. (b) Shoulder release and tendon transfer. Coracohumeral ligament blocks
external rotation. (c) Shoulder release and tendon transfer. The humeral head protrudes with external rotation following coracohumeral ligament
release. Additional release can be attained by fractional lengthening of pectoralis major through the same incision. (d) Shoulder release and tendon
transfer. A separate axillary incision provides exposure to the conjoined tendon of latissimus dorsi and teres major. The tendon is released from
humerus taking a small cuff of periosteum. (e) Shoulder release and tendon transfer. (f) The tendon is passed through the interval between triceps and
deltoid to insert into the greater tubercle.
Upper Extremity
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described. An individualized plan should be devised. If elbow
flexion is weak and the forearm flexor pronator group is strong,
the flexor pronator group origin can be translocated proximally
so that this muscle group augments elbow flexion (Steindler
transfer). Bipolar transfer of the latissimus dorsi or pectoralis
major to reconstruct elbow flexion has been described; how-
ever, these motors may not be fully expendable in an already
compromised limb.
Free muscle transfer is an option that adds an additional
motor to the limb, without sacrificing any limb function. A free
gracilis muscle can be transferred and innervated with intercos-
tal or other donor nerves. The distal tendon of the gracilis can
be harvested, allowing the tendon to be woven into the native
biceps insertion ( Fig. 38.31). Because the gracilis is longer
than the native elbow flexors, it must be tensioned appropri-
ately by shortening the proximal origin or by fixing the origin
superior to the level of the coracoid (i.e., wrapping around lat-
eral clavicle).
38.9 Musculoskeletal Considera-
tions and Complications
Management of skeletal changes resulting from chronic
denervation in a growing child has traditionally been post-
poned until the child is older than 2 years. However, poste-
rior shoulder subluxation and dislocation have been observed
in infants. A recent review of MRI performed prior to nerve
reconstruction revealed an extremely high incidence of signif-
icant GHD (74%) in spite of nonsurgical treatments and ther-
apy. These skeletal changes can be seen as early as 3 months
of age. Loss of passive range of motion in external rotation is
a significant clinical finding. A high axillary crease or addi-
tional upper limb skin creases should be noted ( Fig. 38.32)
as these can result from limb foreshortening with posterior
subluxation.
Fig. 38.30 Humerus rotation osteotomy. (a) The medial arm exposure is seen from above the patient’s head. K-wires are used to measure appropriate
rotation following transverse osteotomy. (b) Humerus rotation osteotomy. Plate fixation following osteotomy and rotation. A longitudinal slot was
made using a burr for orientation. Note displacement following rotation. K-wires for orientation have been removed.
Fig. 38.31 Free gracilis transfer for elbow flexion. (a) Planned incisions for intercostal nerve harvest and flap inset, including monitoring skin paddle.
(b) Intercostal nerve harvest. (c) Gracilis muscle harvested with obturator nerve for re-innervation and long distal tendon to weave into biceps tendon.
Brachial Plexus Palsies
369

Given the impact of shoulder dysplasia on ultimate functional
outcomes, our center now performs routine shoulder ultra-
sounds at 3 and 6 months of age in all infants with persistent
motor deficits. An alpha angle greater than 30 degrees is con-
sidered abnormal (Fig. 38.33). If there is no loss of passive
range of motion, we use botulinum toxin A to weaken the inter-
nal rotators, which allows families to continue shoulder stretch-
ing. When there is an associated loss of passive range of
motion, suspected dislocation, or dysplasia of the posterior lip
of the glenoid, chemodenervation is combined with shoulder
spica casting in external rotation for 6 weeks. External shoulder
rotation reduces the humeral head in the glenoid fossa, thereby
encouraging glenoid remodeling around a centrically reduced
humeral head ( Fig. 38.34).
There have been recent reports that early infant shoulder
repositioning may help avoid shoulder subluxation and
encourage motor recovery. We have adopted the SupER splint
described by Verchere et al, in situations where families can
return for frequent follow-up. The splint positions the fore-
arm into supination and the shoulder into external rotation.
Other centers are also accumulating experience with this
strategy.
Fig. 38.32 Arm and axillary creases. An additional upper arm crease
and a deep axillary crease that extends superiorly on the baby’s right
are due to bony foreshortening from glenohumeral subluxation.
Fig. 38.33 Shoulder ultrasound with severe sub-
luxation. Lack of ossification makes the infant
shoulder difficult to assess on X-ray. Ultrasound
allows visualization of the humeral head and its
relationship to the glenoid. In this view, the
posterior border of scapula can be seen. A line
from the posterior labrum that is tangent to the
humeral head forms an angle as it intersects with
the posterior border of scapula. This angle should
be 30 degrees or less.
Fig. 38.34 Changes with chemodenervation and casting. Pretreatment on the left. Posttreatment on the right with relocation of glenohumeral joint
and posterior labrum.
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38.10 Key Points
● The complexity of pediatric brachial plexus palsy and the ben-
efits of multidisciplinary care warrant treatment in special-
ized centers that can provide the breadth of team care.
● Given the musculoskeletal and neurodevelopmental conse-
quences of chronic denervation, nonsurgical treatment is crit-
ical in the outcome of pediatric brachial plexus palsy,
regardless of whether nerve and/or musculoskeletal recon-
struction is undertaken.
● Longitudinal assessment to understand the trajectory of
pediatric brachial plexus palsy is necessary in deciding upon
nerve reconstruction.
● The role of nerve transfers as the primary strategy in recon-
struction of NBPP is unclear. Nerve transfers alone are inad-
equate for reconstruction of palsies more severe than Erb
palsy (type 1 palsy) and nerve grafts should be used in those
situations.
● Nerve transfers are useful in the case of inadequate proximal
axons (i.e., avulsions), isolated deficits, late presentation, and
failed primary reconstruction.
Suggested Readings
Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The natu-
ral history of obstetrical brachial plexus palsy. Plast Reconstr Surg. 1994; 93
(4):675–680, discussion 681
Lin JC, Schwentker-Colizza A, Curtis CG, Clarke HM. Final results of grafting
versus neurolysis in obstetrical brachial plexus palsy. Plast Reconstr Surg.
2009; 123(3):939–948
Waters PM. Comparison of the natural history, the outcome of microsurgical
repair, and the outcome of operative reconstruction in brachial plexus birth
palsy. J Bone Joint Surg Am. 1999; 81(5):649–659
Mackinnon S.
Ladak A, Morhart M, O’Grady K, et al. Distal nerve transfers are e ective in
treating patients with upper trunk obstetrical brachial plexus injuries: an
early experience. Plast Reconstr Surg. 2013; 132(6):985e–992e
Little KJ, Zlotolow DA, Soldado F, Cornwall R, Kozin SH. Early functional recov-
ery of elbow flexion and supination following median and/or ulnar nerve fas-
cicle transfer in upper neonatal brachial plexus palsy. J Bone Joint Surg Am.
2014; 96(3):215–221
Tse R, Kozin SH, Malessy MJ, Clarke HM. International Federation of Societies
for Surgery of the Hand Committee report: the role of nerve transfers in the
treatment of neonatal brachial plexus palsy. J Hand Surg Am. 2015; 40
(6):1246–1259
Moukoko D, Ezaki M, Wilkes D, Carter P. Posterior shoulder dislocation in
infants with neonatal brachial plexus palsy. J Bone Joint Surg Am. 2004; 86-A
(4):787–793
Ezaki M, Malungpaishrope K, Harrison RJ, et al. Onabotulinum toxinA injec-
tion as an adjunct in the treatment of posterior shoulder subluxation in neo-
natal brachial plexus palsy. J Bone Joint Surg Am. 2010; 92(12):2171–2177
Brachial Plexus Palsies
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39 Pediatric Hand Trauma
Amir H. Taghinia
Sum m ary
Hand trauma in children typically results from sports and play.
Compared to adults, children experience less sti ness and bet-
ter nerve regeneration. Immobilization is often important fol-
lowing operative intervention to ensure the most favorable
outcome.
Keywords: pediatric, trauma, hand, fracture, tendon, nerve
39.1 Introduction
The surgeon’s approach to hand trauma in children should be
di erent from hand trauma in adults. The mechanism of injury,
anatomy, healing, and psychosocial concerns of a child require
special attention. As opposed to adults, injuries in children vary
substantially by age. Young children usually present with “inju-
ries of curiosity”—such as those inflicted by handling broken
glass or inserting a finger in the spokes of a spinning bicycle
wheel. Older children and adolescents sustain hand injuries
from sports and play. Luckily, large industrial hand injuries are
rarely seen in children.
Children are usually free of significant medical comorbidities,
and thus heal better and faster. Sti ness is unusual, so it is eas-
ier for the surgeon to balance healing with commencement of
activities. Children regenerate nerves better and rarely develop
painful neuromata or pain syndromes. However, in children the
important hand structures are small and there is little margin
for technical error. Diagnosis can be di cult in a young child or
uncooperative adolescent. The surgeon has to respect growth
and change over time. In more severe injuries, the surgeon may
need to spend significant time counseling the parents and deal-
ing with psychosocial issues. Lastly, there are a number of
unusual injury variants in children that if misdiagnosed or mis-
treated can lead to substantial morbidity.
Adequate immobilization is crucial for treating children with
hand injuries. Pain usually subsides several days after injury
and children are likely to resume their usual activities if they
are not held back. Inadequate immobilization is usually the
main culprit in malunions, dehisced wounds, and tendon rup-
tures. Because sti ness is rarely a problem, there is very little
downside to adequate immobilization.
39.2 Diagnosis
Observation, physical examination, and plain radiography are
the main diagnostic tools. In an uncooperative, anxious, or
hysterical child, observation is sometimes the most important
factor. The importance of distal examination cannot be overem-
phasized. Exploring a child’s hand or forearm in the emergency
department to ascertain for presence of injury is di cult and
dangerous. A more gentle approach to examination, such as by
recruiting the help of a child life specialist or touch pad game to
distract the child, is usually much more e ective than brute
force. The most di cult injuries to diagnose are flexor tendon
and digital nerve injuries in infants and young toddlers, even 5
to 7 days postinjury. Repairing an old flexor tendon injury in a
child is very di cult, so exploration is warranted if there is any
suspicion.
Plain radiographs usually detect most fractures and disloca-
tions, with the notable exception of acute nondisplaced sca-
phoid fractures. Ultrasound is instrumental in detecting
vascular injury, or more commonly, foreign bodies—especially
wood. Computed tomography or magnetic resonance imaging
is rarely needed.
39.3 Fractures
In the skeletally immature patient, the ligaments are stronger
than bones. Accordingly, it is rare to see ligamentous injury and
more common to see fractures. Fractures occur in weak areas of
the metaphysis, physis (growth plate), and epiphysis, and result
in predictable injury patterns, outlined in the Salter–Harris
classification. The most common hand fracture is a proximal
phalangeal fracture with a Salter–Harris type II configuration,
usually caused by a deviating force (Fig. 39.1).
Most pediatric hand fractures are nondisplaced or minimally
displaced and only require immobilization for 2 to 3 weeks, fol-
lowed by slow return to norm al activity. Most displaced frac-
tures can be reduced in the emergency room (ER) or the
operating room under local block, sedation, or general anesthe-
sia. Unstable fractures are usually treated with closed reduction
and percutaneous pinning. An open approach is rarely needed.
Fracture remodeling in children can and does occur
(Fig. 39.2). The closer a fracture is to the physis and the
younger the patient, the higher is the remodeling potential of
the fracture. However, caution should be exercised in treating
all fractures with the hopes that they will remodel. Severely
displaced fractures will not completely remodel, nor will those
far away from the physis (e.g., displaced phalangeal condylar
neck fractures). As a general rule, deviation of a finger in the
plane of motion is tolerated, whereas deviation perpendicular
to the plane of motion is not.
Several pediatric fracture variants can be tricky to diagnose
or treat; these are outlined below.
39.3.1 Ulnar Collateral Ligament Injury
Variant
This injury is analogous to an adult ulnar collateral ligament
injury except that the epiphysis breaks, resulting in a Salter–
Harris type III injury ( Fig. 39.3). It occurs from a radially
directed force in adolescents near skeletal maturity. The liga-
ment is attached to the small bone fragment. An open approach
is required through a dorsal incision. The adductor aponeurosis
is incised and a dorsal arthrotomy exposes the joint. The bone
is reduced with careful re-approximation of the articular sur-
face. One or two 0.035-in wires can be used to fixate the bone.
The bone fragment is small, so it is best to get the fixation as
good as possible before inserting the pins. A thumb spica cast is
Upper Extremity
372

applied for 4 weeks. The pins are then removed, gentle therapy
commences, and the thumb is protected in a splint for another
2 to 3 weeks.
39.3.2 Phalangeal Condylar Neck
Fractures
Condylar neck fractures in children are the result of hyperex-
tension injuries. They occur in the proximal or middle pha-
langes. The condyle is attached to the distal bone via collateral
ligaments and the volar plate. The bone usually fractures trans-
versely, but the ligaments remain attached. The condylar piece
will then displace and angulate dorsally. If allowed to heal in this
configuration, the retrocondylar recess is ablated and prevents
full flexion of the joint. Closed reduction, pinning, and cast
immobilization are advocated. If the fracture appears well
reduced initially, it should be immobilized (with a cast) and
watched closely with serial radiographs as it can displace. It is not
uncommon for these children to present several weeks postinjury
with an impending malunion. Waters presented an e ective tech-
nique of percutaneous osteoclasis (using a pin) and reduction.
This technique avoids an open approach that can compromise
the tenuous blood supply of the distal condylar segment.
39.3.3 Seymour Fracture
This injury is a distal phalangeal juxtaphyseal injury that results
from a sudden flexion force applied to an extended distal pha-
lanx (Fig. 39.4). It is analogous to an adult mallet injury
except the injury occurs at the grow th plate. The extensor
attaches to the dorsal epiphysis, but the attachment of the
flexor tendon is broader—onto the epiphysis as well as the dis-
tal fracture fragment. Accordingly, there is a flexion moment on
the distal fragment. A severe injury will displace the distal
fragment dorsally lacerating the nail bed—usually at the depth
of the recess where the germinal matrix meets the eponychial
fold. The bone/nail bed complex then displaces the nail fold and
herniates dorsally, thereafter sitting on top of the nail fold
(Fig. 39.5). This is an open fracture and has to be recognized
as such. There is much misrepresentation in the literature
and standardized exams about the nature of this injury. It is the
nail fold, not the nail bed, that gets trapped in the fracture
and disallows easy reduction. In the case that is demonstrated
(Fig. 39.5), one can see the entire nail plate—it is totally
adherent to the nail bed and there is no excess nail bed trapped
in the fracture. Treatment requires reduction of the fracture
(usually with relaxing incisions in the nail fold) and pin fixation.
The fracture heals quickly. This injury is misdiagnosed often,
and thus treatment can be delayed, resulting in chronic nonun-
ion and significant nail abnormalities.
39.4 Joint Injuries
Sprains of the proximal interphalangeal joint and metacarpo-
phalangeal joint are common, especially in young athletes.
These usually occur with a small chip fracture. A short period of
immobilization is usually necessary to allow the swelling and
pain to subside. Most patients can start range of motion exer-
cises within 2 weeks and then return to normal activities
within a month.
Joint dislocations in infants and toddlers are extremely rare.
Irreducible trigger thumbs are commonly misdiagnosed as dis-
locations in the toddlers. Dislocations are more common in
older children and adults. The most common joint is the finger
proximal interphalangeal joint. Reduction in children is similar
to that in adults.
Thumb metacarpophalangeal joint dislocation occurs com-
monly in older children. It is usually the result of a fall in the 6
Fig. 39.1 Examples of displaced Salter–Harris
type II fractures of the proximal phalanges (a) in
the thumb and (b) in the small finger. The small
finger proximal phalangeal fracture is best
reduced by flexing the metacarpophalangeal
(MP) joint to 90 degrees, placing a pen in the
fourth webspace, and applying radially directed
digital pressure on the distal aspect of the
proximal phalanx. MP joint flexion tightens the
collateral ligaments and prevents motion at the
MP joint. The pen acts as a fulcrum upon which
the proximal phalanx rotates.
Pediatric Hand Trauma
373

to 10 age group. Reducing these injuries can be tricky, so seda-
tion and a wrist block are necessary adjuncts. The reduction
maneuver is more about finesse than force. The surgeon places
the dominant thumb pad on the dorsal base of the proximal
phalanx and stabilizes the metacarpal on the palmar side with
the dominant fingers. The other hand acts as an assistant as a
gentle pushing motion of the thumb and simultaneous pulling
motion of the fingers roll the head of the proximal phalanx onto
the metacarpal head. A few attempts may be needed. One
should not distract the thumb distally as this prevents reduc-
tion, instead of helping it.
39.5 Tendon Injuries
Flexor tendon injuries can be di cult to diagnose in toddlers. If
there is any doubt, early exploration is recommended as
Fig. 39.2 Displaced proximal phalangeal fracture. No intervention was undertaken on this (a) acute fracture. (b) After 1 month, there is mild
remodeling. (c) After 3 months, the remodeling continues to improve the alignment and appearance. (d) and (e) demonstrate excellent function and
range of motion at 3 months post injury.
Upper Extremity
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delayed repair can be quite di cult. The technical execution of
repairing a flexor tendon is challenging as the structures are
small and maneuvering around the pulleys and avoiding bulky
repairs is di cult. Primary repair is advocated for acute inju-
ries. A four-core repair with epitendinous suture is usually suf-
ficient ( Fig. 39.6).
The choice of postoperative rehabilitation protocol should be
based on the compliance of the patient. Because joint sti ness
is rare, the surgeon can err toward longer immobilization to
protect the repair. Older teenagers can usually comply with
adult flexor tendon rehabilitation protocols. Younger teens and
children should be immobilized in a cast for 3 to 4 weeks. After
that, a modified, more aggressive flexor tendon protocol can
begin. A similar approach is taken for most extensor tendon
injuries of the fingers and the hand.
Most authors recommend against staged flexor tendon
reconstruction in children, mainly due to compliance issues.
However, staged reconstruction is possible and can be success-
ful in the right patient—careful patient selection is critical.
39.6 Nerve Injuries
Functional return after nerve injuries in children is much better
than in adults. There are several explanations for this di er-
ence. The distances to regenerate are smaller in children, so
nerves can reach their distal targets more quickly. Axonal
Fig. 39.3 Thumb metacarpophalangeal joint ul-
nar collateral ligament variant injury in adoles-
cents. Instead of avulsing the ligament,
adolescents sustain (a) Salter–Harris type III
fractures where the ligament remains attached to
the epiphyseal fragment. (b) This injury should be
treated via an open approach and direct visual-
ization and reduction of the fracture. (c,d) Three
months postoperatively, this patient demon-
strates excellent function.
Pediatric Hand Trauma
375

sprouting in children is more robust. And finally, children have
better cortical plasticity, so the brain adapts to rewiring mis-
matches more easily (Fig. 39.7).
39.7 Fingertip Injuries
Fingertip injuries are very common in younger children. The
most common mechanism of injury is a crush injury, usually
caused by a door. The degree of injury is variable and depends
on the force. It can range from simple subungual hematoma
to an open fracture with nail bed laceration to amputation
( Fig. 39.8). As the nail gets crushed at the level of the sterile
matrix, its proximal end gets lifted o with a small bit of
eponychium. The nail bed develops a laceration with or with-
out a tuft fracture. Repair involves reconstructing the nail bed
and placing the old nail or a piece of petroleum gauze as a
Fig. 39.4 Seymour fracture. The radiographs in (a) and (b) demonstrate a juxtaphyseal fracture which herniates above the nail fold. The nail fold
prevents reduction. Lateral incisions in the nail fold (made perpendicular to the nail fold) are usually required to reduce the fracture and a pin secures it
(c). Postoperative result in the same patient 2 months postoperatively (d–f) demonstrates normal active range of motion.
Fig. 39.5 Acute Seymour fracture. The clinical
views in (a) and (b) are typical of a displaced
fracture. The bone distal to the growth plate
remains attached to the entire nail plate and nail
bed. The nail bed remains completely intact, with
the entire attached nail plate. The area of injury/
laceration is at the depth of the recess where the
nail bed meets the nail fold. Once reduced, this
area cannot actually be repaired as it lies in a
recess. The author’s experience is that the nail
plate does not need to be removed, nor does the
nail bed require repair. Reduction (usually by the
help of relaxing incisions in the nail fold) and pin
fixation are all that is needed.
Upper Extremity
376

stent under the nail fold. The tuft fractures rarely need
intervention.
In more severe injuries, the distal skin and nail bed can be
amputated. The common teaching is to replace the amputated
tip as a composite graft and that it usually takes well in small
children. We studied this in our institution in a large series of
patients and found that only 40% took fully. Nevertheless, most
patients healed with minor deformity and no functional conse-
quence without the need for any additional procedures. At best,
the graft takes and heals well; at worst, it provides a biological
dressing that will ultimately slough as the skin grows under it.
39.8 Amputations
An amputation injury in a child is uniformly devastating for
parents. The loss creates feelings of guilt, sorrow, and remorse
that overwhelm most parents. Most will “do anything” includ-
ing giving up their own limbs for their child to be whole again.
The surgeon treating these patients often spends more time
counseling the parents and children than providing direct
clinical care, especially in more proximal injuries where recon-
struction or replantation is not possible. In the case where
replantation is not possible or not successful, the surgeon
should consider revision amputation a reconstructive proce-
dure, not a failure.
In treating patients with amputations, the primary goal is to
maximize functional length. If there is extra bone, then soft-tis-
sue coverage in the form of local or free tissue transfer should
be considered. One should preserve growth plates and joints if
possible. About 80% of the grow th of the radius is owed to the
distal radial growth plate, as compared to 20% for the proximal
radial physis. In children, metaphyseal or diaphyseal amputa-
tion stumps can overgrow irregularly, creating heterotopic ossi-
fication and sharp spicules that perforate the skin and are
painful. Preserving the entire bony length is thus important to
avoid subsequent complications related to growth.
Fig. 39.6 Zone II flexor tendon repair in a 12-
year-old female. (a) The flexor digitorum pro-
fundus tendon alone was lacerated. (b) A four-
core repair followed by epitendinous suture is
performed. (c,d) Postoperative result 3 months
later demonstrates normal active range of
motion.
Pediatric Hand Trauma
377

Fig. 39.7 Median nerve injury in a 14-year-old female. (a) This patient sustained a glass injury to the dominant antecubital fossa, resulting in laceration
of the brachial artery, median nerve, and brachialis muscle. (b) These structures were repaired on the day of injury. (c,d)Three months postoperatively,
she had regained elbow and digital flexion, though she had not recovered motor function of the anterior interosseous nerve. (e) She was unable to flex
the index finger distal interphalangeal and the thumb interphalangeal joints. (f) Several months later, the acute interstitial nephritis recovered fully as
did intrinsic muscles of the thumb.
Upper Extremity
378

39.9 Replantation
Children rarely develop sti ness or chronic nerve-related pain
issues. The concept of speeding “return to work” does not apply,
and children have healthy vessels and robust nerve regenera-
tion. Accordingly, the pediatric hand surgeon can be more
aggressive in attempting replantation. The author’s experience
is that digital replantations are—on the whole—much easier in
children than in adults. Dissecting the tissues and finding the
important structures is easier and faster. The vessels can
undergo significant stretch without causing undue tension.
Subsequent recovery is smoother—as rarely does one see bony
nonunion, soft-tissue atrophy, pain syndromes, or other com-
plications of adult replantation. The main challenge is technical
Fig. 39.8 Crush injury with fingertip amputation.
(a,b) This 16-year-old female sustained a crush
injury with exposed distal phalanx. (c,d) A thenar
flap was used to cover the bone and avoid
shortening. (e,f) The flap was divided 2 weeks
later and allowed to heal spontaneously without
any inset. Three months later, the patient had a
well-contoured stump with normal range of
motion of the proximal interphalangeal joint.
Pediatric Hand Trauma
379

execution of repairing the vessels, especially small dorsal veins,
which must be done with an operating microscope and ultra-
fine instruments (Fig. 39.9).
39.10 Conclusion
Treatment of traumatic hand injuries in children can be a
gratifying endeavor. Children heal well and exhibit better
recovery from most injuries to the hand. Functional outcome
is far superior to similar injuries in adults. However, the tech-
nical repair of these injuries can be challenging, as the struc-
tures are small.
Suggested Readings
Berlin NL, Tuggle CT, Thomson JG, Au A. Digit replantation in children: a
nationwide analysis of outcomes and trends of 455 pediatric patients. Hand
(NY). 2014; 9(2):244–252
Barr JS, Chu MW, Thanik V, Sharma S. Pediatric thenar flaps: a modified
design, case series and review of the literature. J Pediatr Surg. 2014; 49
(9):1433–1438
Cornwall R. Finger metacarpal fractures and dislocations in children. Hand
Clin. 2006; 22(1):1–10
Eberlin KR, Busa K, Bae DS, Waters PM, Labow BI, Taghinia AH. Composite
grafting for pediatric fingertip injuries. Hand (NY). 2015; 10(1):28–33
Havenhill TG, Birnie R. Pediatric flexor tendon injuries. Hand Clin. 2005; 21
(2):253–256
Waters PM, Taylor BA, Kuo AY. Percutaneous reduction of incipient malunion
of phalangeal neck fractures in children. J Hand Surg Am. 2004; 29(4):707–711
Fig. 39.9 Replantation. (a) This 3-year-old male sustained a complete amputation of the dominant index finger at the distal interphalangeal (DIP)
joint. (b) The cartilage of the middle phalangeal condyle was missing and (c) the radial digital nerve was avulsed. The digit was replanted; one digital
artery and two digital veins were repaired. The finger survived. (d-f)One year postoperatively, the patient has very little motion at the DIP joint. Four
years postoperatively, the patient has normal sensation with no cold intolerance or pain symptoms, but the DIP remains stiff.
Upper Extremity
380

VI
Part VI
Integument
40 Vascular Anomalies

382
41 Burns

394
42 Melanocytic Nevi

403
43 Pediatric Skin Lesions

411

40 Vascular Anomalies
Arin K. Greene
Sum m ary
Vascular anomalies are common lesions that a ect the pediatric
population. The most common tumors include infantile heman-
gioma, congenital hemangioma, kaposiform hemangio-
endothelioma, and pyogenic granuloma. The most frequent
malformations are capillary malformation, venous malforma-
tion, lymphatic malformation, and arteriovenous malformation.
Management is based on the type of lesion and may include
laser, sclerotherapy, embolization, resection, or pharmacother-
apy (topical, intralesional, systemic).
Keywords: vascular, anomaly, tumor, hemangioma, malformation
40.1 Introduction
Vascular anomalies are disorders that a ect capillaries, arteries,
veins, or lymphatics. Because these lesions usually involve the
skin, the initial consultation often is with a plastic surgeon. Vas-
cular anomalies are common, a ecting 5.5% of the population.
Lesions are classified biologically, based on their clinical behav-
ior and cellular characteristics (Table 40.1). The field is con-
fusing because lesions look similar, and imprecise terminology
is used ( Table 40.2).
There are two broad types of vascular anomalies: tumors and
malformations. Tumors demonstrate endothelial proliferation
and a ect approximately 5% of the population. There are four
major lesions: (1) infantile hemangioma (IH), (2) congenital
hemangioma (CH), (3) kaposiform hemangioendothelioma
(KHE), and (4) pyogenic granuloma (PG; Fig. 40.1). Vascular
malformations are errors in vascular development and have
minimal endothelial turnover; they a ect approximately 0.5%
of the population. There are four major types based on the
anomalous vessel(s): (1) capillary malformation (CM), (2) lym-
phatic malformation (LM), (3) venous malformation (VM), (4)
arteriovenous malformation (AVM; Fig. 40.2). Recently, the
causative mutation for many vascular anomalies has been iden-
tified ( Fig. 40.3).
40.2 Diagnosis
More than 90% of vascular anomalies can be diagnosed by his-
tory and physical examination (Table 40.3). Approximately 9%
of lesions require imaging for diagnosis, and less than 1% of vas-
cular anomalies need histopathology to identify the lesion.
Generally, the first-line imaging modality to confirm the type of
vascular anomaly is ultrasound because it does not require se-
dation and is easy to perform. Magnetic resonance imaging
(MRI) is used for lymphatic, venous, and AVMs to confirm their
diagnosis and determine the extent of disease. Biopsy is
reserved for a vascular anomaly that cannot be diagnosed
despite imaging.
40.2.1 Infantile Hemangioma
IH is the most common tumor of infancy, a ecting 4 to 5% of
infants. IH is more frequent in premature children and in
Table 40.1 Classification of vascular anomalies
Tumors

Malformations
Slow flow

Fast flow

Overgrowth syndromes
Infantile hemangioma

Capillary malformation

Arteriovenous malformation

CLOVES
Congenital hemangioma

Venous malformation

Klippel–Trénaunay
Kaposiform hemangioendothelioma Lymphatic malformation

Parkes Weber
Pyogenic granuloma

Sturge–Weber
Abbreviation: CLOVES, Congenital Lipomatosis Overgrowth, Vascular malformations, Epidermal nevi, and Scoliosis.
Table 40.2 Incorrect terminology commonly used to describe vascular anomalies
Tumors

Malformations
Biological name

Incorrect term

Biologic name

Incorrect term
Infantile hemangioma

“Strawberry hemangioma”
“Capillary hemangioma”
“Cavernous hemangioma”
Capillary malformation

“Port-wine stain”
“Capillary hemangioma”
Congenital hemangioma

“Infantile hemangioma”

Lymphatic malformation

“Cystic hygroma”
“Lymphangioma”
Kaposiform hemangioendothelioma “Capillary hemangioma”

Venous malformation

“Cavernous hemangioma”
Pyogenic granuloma

“Hemangioma”

Arteriovenous malformation

“Arteriovenous hemangioma”
Integument
382