Phẫu Thuật Tạo Hình (Tập 6): Bàn Tay Và Chi Trên – Neligan (Ấn bản 4)

SECTION V • Paralytic Disorders
35 
Free-functioning muscle transfer in the
upper extremity
Pundrique Sharma, Isaac Harvey, and Gregory H. Borschel
SYNOPSIS
■ Free-functioning muscle transfer involves the transfer of a muscle from
a distant location to replace a lost function.
■ It is a complex procedure that requires a highly motivated patient.
■ The procedure involves microvascular anastomoses and neural
coaptation.
■ Meticulous attention must be paid to proper positioning and tensioning
of the transferred muscle.
■ Postoperatively, a highly structured rehabilitation program is required
for a prolonged period, often up to 2 years.
■ In the appropriate patient, reliably good results can be achieved for
patients with otherwise devastating injuries.
Introduction
developed for situations where no simpler alternative is avail­
able. Most muscles in the body have been assessed for their
usefulness for tissue transfer, and many have been identified
as expendable and suitable for microvascular transfer. Most
of these muscles have a long pedicle of suitably large caliber.
The viability of the muscle is maintained by microvascular
anastomosis between the muscle’s artery and vein and a suit­
able artery and vein in the recipient area. Neural coaptation
of the transferred muscle’s motor nerve to a suitable nerve in
the recipient area provides the ability of the muscle to contract,
giving functionality to the transfer. This functionality is
dependent on viability of the muscle and neural regeneration
as well as correct technical placement, positioning, and reha­
bilitative programs. The common indications for free func­
tional muscle transfer include direct trauma with muscle loss,
Volkmann’s ischemic contracture, nerve injury such as bra­
chial plexus injuries, and oncologic resection.
Free muscle transfers to the upper limb have been used to
reconstruct functional deficits in finger flexion, finger exten­
sion, thumb abduction, elbow flexion and extension, and
shoulder flexion. Key planning issues include: the choice of
appropriate muscle for a given function, the choice of an
appropriate local nerve to motor the transferred muscle, and/
or creation of such a nerve via nerve grafts.
Although function may be restored, patients must be
counseled to be realistic about their expectations of outcome
from this type of surgery.
Access the Historical Perspective section online at

Basic science/disease process
The basic functional purpose of a muscle is to provide both
static tension and functional shortening. To understand its
functioning, one must understand the structure of a muscle
Key points
• This is a complex procedure for use where no simpler
alternative is available.
• Meticulous attention to microsurgical technique is required;
thrombosis leads to muscle loss.
• Attention to muscle placement and tensioning is also
critical.
• This technique is applicable to restoration of finger, thumb,
and wrist flexion and extension, elbow flexion and
extension, and shoulder flexion.
Free-functioning muscle transfer involves the microneurovas­
cular transfer of a functioning muscle from its donor site to a
recipient site in the upper limb. The aim of the procedure is
to restore functionality that has been lost as a result of trauma
or other acquired pathology such as sarcoma, or which was
never present as in the case of congenital anomalies such
as arthrogryposis.1,2 It is a complex procedure that was
  Access video content for this chapter online at expertconsult.com

800.e1
Historical perspective
Historical perspective
After multiple attempts by numerous authors, Thompson3
was able to demonstrate that non-vascularized muscular
transfer was possible. The first functioning muscle transfer
was reported in 1970 by Tamai et al.,4 who transplanted the
rectus femoris muscle in dogs. He was able to provide elec­
trophysiological and biomechanical evidence of muscular
contraction of the transferred muscle. Since this time, multiple
authors have pursued functional muscle transfers throughout
the body to replace lost function. Functional muscle transfers
have been reported in both the upper and lower limb and also
for facial reanimation. In 1973 at the Sixth People’s Hospital
in Shanghai, microsurgeons successfully transplanted the
lateral portion of pectoralis major into the forearm of a patient
with Volkmann’s ischemic contracture.5 This was the first
clinical application of free functional muscle transplantation
in the upper limb. A good range of finger motion and sub­
stantial grip force were reported. In 1976, Ikuta et al.6 per­
formed experimental work demonstrating the efficacy of free
functional muscle transfer. They were also able to demonstrate
almost normal histological condition of the transplanted
muscle. In the same year, Harii et al.7 showed that it was
possible to transfer muscle to the face for treatment of facial
paralysis.

801
Basic science/disease process
myosin that interact at a subcellular level (Fig. 35.2). When a
muscle is stimulated to contract, the actin and myosin fibers
move over one another by the flexing action of myosin
cross-bridges.9
The amount of overlap of the actin and myosin fibers
determines the number of side chains that are in contact and
therefore able to contribute to force generation. When a muscle
is overstretched there are fewer side chains in contact. When
a muscle is overcontracted the myosin chains crumple and
cannot contract further.10
This relationship leads to a length–tension relationship that
provides for maximal force generation when the muscle is at
its native physiological length (Fig. 35.3). The total force
exerted by a muscle is the sum of the passive force provided
by the elastic properties of the muscle fibers and surrounding
tissues and the active force produced by the contraction of
actin and myosin filaments.8 The relationship of length to
contractile force generation is described by a bell curve with
decreasing ability of force generation further from the physi­
ological resting state corresponding with less overlap of the
actin and myosin fibers. For this reason, determination of the
resting length of the donor muscle is critical prior to transfer,
such that this length can be reconstituted after transfer at
inset of the muscle and maximal contractile force can be
generated.10
There are many morphological types of muscle in the body.
They can be divided into two major types, strap muscles and
pennate muscles, or a combination of the two (Fig. 35.4). In a
strap muscle, the muscle fibers are arranged in parallel to the
long axis of the muscle. This is important from a functional
(Fig. 35.1). A skeletal muscle is composed of parallel muscle
cells called myofibers. Each muscle cell is composed of smaller
parallel myofibrils. These myofibrils are further subdivided
into thin and thick filaments containing actin and myosin.8
Within each muscle cell the myofibrils are arranged within
functional compartments known as sarcomeres. These sarco­
meres are made up of interdigitating fibers of actin and
Fig. 35.1  Structure of striated muscle.
Z
Z
Sarcomere
Contraction
Thick filament
(myosin)
Relaxation
Thin filament
(actin)
Fig. 35.2  Myosin cross-bridges in action. ADP,
Adenosine diphosphate; ATP, adenosine triphosphate; Pi,
inorganic phosphate.
1
2
3
4
Myosin cross-bridge attaches to the actin
myofilament.
Thin filament
ATP
hydrolysis
Thick filament
Myosin head
(high-energy
configuration)
ADP
Pi
Working stroke - the myosin head pivots
and bends as it pulls on the actin filament,
sliding it toward the M line.
ATP
ADP and Pi
(inorganic
phosphate)
released
ADP
Pi
As new ATP attaches to the myosin head,
the cross-bridge detaches.
Myosin head
(low-energy
configuration)
As ATP is split into ADP and Pi, cocking of the
myosin head occurs.
ADP
Pi
ATP

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SECTION V
CHAPTER 35 • Free-functioning muscle transfer in the upper extremity
standpoint, as the excursion of a strap muscle is directly
proportional to its length. It has been demonstrated that at
maximal contraction a strap muscle can contract up to 65% of
its resting length.8 In a pennate muscle, the muscle fibers are
arranged at an angle to a central tendon (Fig. 35.5). As a result,
the individual fibers in a pennate muscle usually do not run
the entire length of the muscle. The excursion achieved by a
pennate muscle is proportional to the length of the muscle
fibers, not the length of the entire muscle. As such, a pennate
muscle will usually yield lesser excursion than a strap
muscle.10
The pennation angle, or angle of pull of the muscle in
relation to the tendon, affects both force generation and excur­
sion. Muscles with a lesser pennation angle (a straighter angle
between the fibers and the tendon) produce a greater excur­
sion with contraction but less power than those with a greater
pennation angle.
The force generated by a muscle is proportional to its total
cross-sectional area. Whether this is due to a greater number
of muscle fibers or hypertrophy of a smaller number of fibers,
the maximal force generation has been calculated in mammals
to be approximately 4 kg/cm2.8 The cross-sectional area is
calculated perpendicular to the direction of the muscle fibers.
In a strap muscle this is perpendicular to the muscle as a
whole and perpendicular to the tendon. In a pennate muscle
this is perpendicular to the fibers and oblique to the tendon
and muscle as a whole, resulting in a greater cross-sectional
area and thus a greater potential for force generation.
The contraction of an individual muscle fiber is an all-or-
none phenomenon: when a weak contraction is required, only
a few fibers within the muscle are stimulated to contract.9
When a forceful contraction is required, a greater number of
muscle fibers are stimulated to contract. Each muscle is inner­
vated by a motor nerve. The motor nerve joins the muscle via
its motor endplates at the neuromuscular junction. A given
nerve fiber within the nerve will have a defined number of
motor endplates, each of these innervating specific fibers
within the muscle. A muscle is thus composed of functional
motor units, multiple muscle fibers innervated by the same
Fig. 35.3  The length–tension relationship.
Length
Tension
Resting length
Total tension
Active tension
Passive tension
Fig. 35.4  Strap and pennate muscles.
Strap
Pennate
Relaxed
Contracted
Fig. 35.5  In pennate muscle, the muscle fibers are arranged at an angle to a
central tendon.
Strap
Pennate
Relaxed

803
Patient selection
electrical burns and post gas gangrene and post-replant
patients.12 Each of these indications presents its own special
set of considerations.
Of particular note, in the setting of brachial plexus recon­
struction, local donor nerves to power the muscle transfer
may be limited or completely unavailable. In this case, careful
consideration must be given to the choice of donor motor
nerve. In some cases, it is necessary to perform nerve grafts
as a preliminary procedure to bring viable motor axons into
the denervated limb.13,14 A similar picture can be found in the
setting of Volkmann’s ischemic contracture; however, here the
anterior interosseous nerve of the forearm is often spared and
can be available as a motor donor nerve.15 This will be dis­
cussed further later in the chapter in the section on choice of
donor motor nerve.
Patient selection
Probably the most important decision to be made is whether
to proceed with free muscle transfer at all. This is a highly
involved surgical procedure that requires a motivated patient
who is aware of the potential of the procedure and who is
fully equipped and prepared to undertake the oftentimes
intensive pre- and postoperative rehabilitation that is required
for a successful outcome. The patient must understand that
the maximal outcome of the procedure will not be realized
inside 1–2 years.16 The importance of having a cooperative
patient cannot be overemphasized. The ideal patient is stable,
intelligent, and motivated to regain function and return to
work, with no medical comorbidities. Inappropriate candi­
dates are unfortunately common among patients with injuries
who might otherwise benefit from this procedure. Head
injuries may often accompany brachial plexus injuries in
motor vehicle and motorcycle accidents.
Multiple physical factors must be taken into account prior
to muscle transfer. The patient must have stable skeletal
structure, including functional joints. He or she must have
normal or near normal range of motion in the hand, wrist,
and elbow. There must be adequate soft-tissue cover over the
planned tendon-gliding site. If there is insufficient unscarred
soft tissue to cover the planned site, soft-tissue reconstruction
in the form of tissue expansion or local flaps may need to be
performed prior to muscle transfer. Sensation in the hand
should be normal to achieve optimal results, though this is
not an absolute requirement.12 There must be sufficient evi­
dence that there are suitable recipient artery and veins in
the arm to vascularize the transferred muscle. Preoperative
Doppler ultrasound or angiography can be very helpful in
this regard.10 Also, a suitable donor nerve must be available
Table 35.1  Principles of tendon transfer applicable to free-
functioning muscle transfer
• An elective tendon/muscle transfer should never be performed
in the presence of unhealed wounds
• Full passive joint motion must be restored before tendon/
muscle transfer
• The transfer should not pass through areas of scar tissue or
under skin grafts. Furthermore, surgical incisions should not be
placed directly over the transfer
• Whenever possible, cutaneous sensibility should be restored
before tendon/muscle transfer
• The normal function of the transferred muscle must be
expendable
• Synergism between the muscle’s original and new actions
facilitates rehabilitation (in the case of free muscle transfer this
principle could be applied to the function of the donor motor
nerve)
• The transferred muscle must have sufficient amplitude and
power to perform its new function; thus, reinnervated muscles
should be used only in exceptional circumstances
(Adapted from Anastakis D, Manktelow R. Free functioning muscle transfers. In:
Green’s Operative Hand Surgery, 5th edn. Philadelphia, PA: Elsevier, 2005.)
Fig. 35.6  Appearance of arm with Volkmann’s ischemic contracture.
nerve fiber. Depending on the muscle, this may be as few as
five muscle fibers, such as in the extraocular muscles, or as
many as several hundred, as is the case with most major
skeletal muscles. This relationship is important in relation to
reinnervation and the number of axons provided by a given
donor motor nerve. A muscle with smaller muscle units may
provide finer control but less power for a given number of
axons, and vice versa – a muscle with larger motor units
requires fewer axons for greater force generation.
Individual muscles considered for transfer have been
assessed with regard to their internal architecture, vascular
anatomy, motor innervation, and characteristics relevant to
desired function. Ideally, the transferred muscle should have
a single dominant vascular pedicle (Mathes and Nahai type
1)11 of sufficient length to allow easy anastomosis after transfer
without the need for vein grafts. The muscle should possess
a single motor nerve of sufficient length and in the correct
orientation to allow for primary coaptation of the nerve to
the donor motor nerve. The muscle and the limb into which
it is to be transferred should possess the appropriate charac­
teristics to allow the muscle to perform its desired function
(Table 35.1). These characteristics have been well described for
tendon transfers in the upper limb, but apply equally to free
functional muscle transfer.
Diagnosis/patient presentation
Free functional muscle transfer is applicable to patients who
have sustained a major loss of skeletal muscle in the upper
limb resulting in a significant functional disability. Free func­
tional muscle transfer is indicated to replace lost function
where no easier local option is available. This may be seen
following direct trauma, in the setting of Volkmann’s ischemic
contracture (Fig. 35.6), following tumor ablation such as
sarcoma resection, and in longstanding nerve injury such
as brachial plexus lesions. Other rarer indications include

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SECTION V
CHAPTER 35 • Free-functioning muscle transfer in the upper extremity
dehiscence of the muscle insertion. Muscle fibers of uniform
length make the procedure technically much easier.
Multiple muscles have been used as functional transfers in
the upper limb. For most applications in the upper limb, the
gracilis muscle comes closest to satisfying the above crite­
ria.10,12 It is a fusiform muscle with longitudinally arranged
fibers in the proximal portion. It has a single vascular pedicle
easily accessible in the upper thigh with a single motor branch
from the obturator nerve. Its functional range of motion can
be up to 12–16 cm. The donor scar from the gracilis harvest
on the inner thigh often widens but is placed in a relatively
inconspicuous location for most patients. An additional
advantage of the gracilis muscle is that the nerve is often
arranged in 2–3 motor fascicles,10,12 which stimulate discrete
portions of the muscle. As such, it is possible to use the muscle
split into two components for dual functionality with separate
motor innervations.32,33 A notable disadvantage of the gracilis
muscle is the relatively short vascular and neural pedicles.
The gracilis muscle is a long slender strap-like muscle in
the adductor compartment of the thigh (Fig. 35.7). It is the
most superficial of the adductor muscles. It is thickest in its
proximal portions and narrows to a tendon in its distal quarter.
The gracilis originates from the body and inferior ramus of
the pubis. Distally it narrows into a tendon, which passes
behind the femoral condyle and inserts on the medial aspect
of the tibia adjacent to the tibial tuberosity. McKee et al.33
studied the muscle fiber anatomy of the gracilis in fresh and
preserved cadavers. They described the muscle as fusiform
with fibers of varying length. The shorter posterior fibers were
found to insert more proximally into the gracilis tendon,
whereas the longer more anterior fibers insert more distally.
They also found that the fibers were parallel in the proximal
three-fifths, whereas distally the fibers converge on to the
tendon. The average fiber length within the gracilis muscle is
24 cm. The action of the gracilis is as a weak adductor of the
leg and weak flexor of the knee joint. It also produces slight
medial rotation of the tibia on the femur. Several authors have
reported on harvest of the gracilis, finding that it does not
result in a significant functional deficit.
The gracilis muscle may be harvested by a second team
concurrent with preparation of the arm. The two-team
approach significantly reduces operative time. For gracilis
harvest, the markings are made along a line from the posterior
aspect of the medial femoral condyle to the pubic tubercle.
This line approximates the position of the adductor longus
muscle. The gracilis muscle is found 2–4 cm posterior to
the palpable margin of the adductor longus. An incision is
planned in the upper thigh 2 cm behind the previously
marked line. The patient is draped with the entire leg exposed
and free-draped in the abducted and externally rotated
position (Fig. 35.8). This allows movement of the limb
intraoperatively.
An incision 8–10 cm long is made in the junction of the
upper and middle third of the thigh. The gracilis muscle is
identified beneath the deep fascia (Video 35.1
). For the inex­
perienced operator, it can be useful to extend the knee to aid
with identification of the gracilis muscle. The gracilis becomes
taut on knee extension; the tension of the other adductors is
unaffected. The fascia overlying the gracilis muscle is split
longitudinally. This layer is preserved for later repair to
prevent muscular herniation, a not uncommon problem if
this layer is not repaired. The muscle is dissected proximally
to power the transferred muscle. There should be adequate
antagonist function in the arm to allow the transfer to be of
use, for example in performing a transfer to replace long
finger flexor function and restore grip, there must be adequate
finger extensor function to oppose the new action of the
transferred muscle and to release the grip (Table 35.2).
Multiple muscles have been used for free transfer in the
upper limb. The gracilis muscle (see Fig. 35.6) has been the
most widely used as it fulfills many of the criteria for
the “ideal” muscle transfer.17,18 Other transfers have included
latissimus dorsi,19,20 rectus femoris,21,22 serratus anterior,23–34
gastrocnemius,26 hemisoleus,27 flexor hallucis longus,28 flexor
carpi ulnaris,29 pectoralis major,30,31 pectoralis minor,24 and
tensor fasciae latae.25 As the reconstructive community’s
comfort with microsurgical transfer has increased over the
years, more complex reconstructions have also been success­
fully attempted. Of particular note, the use of double-free
flaps for dual functional reconstruction (such as elbow flexion
and extension) has come into more common use. For example,
Doi et al.35 in 1995 described the use of a staged double free
muscle transfer in children following brachial plexus palsy.
Simultaneous transfer and neurotization of the adductor
longus and gracilis on the same vascular axis has also been
described.36,37
The principles governing the choice of muscle for free
functional transfer are similar to those that have been well
described for tendon transfer. Additionally, the muscle ideally
will have a singular dominant vascular pedicle and a single
dominant motor nerve available for transfer.
Treatment/surgical technique
Selecting the appropriate muscle for transplantation is key to
the success of the procedure. The ideal muscle to transfer will
vary depending on which function it is intended to replace.
Important considerations are the length, excursion, and power
that are required for the given deficit, e.g., finger flexors
normally have an excursion of ∼7 cm and finger extensors
∼5 cm. A transplanted muscle must be able to generate a suf­
ficient force over the appropriate range of motion to be of
functional value. The muscle must be expendable from its
donor site with minimal functional deficit from its harvest.
The muscle ideally should be easy to harvest, and should have
a singular dominant vascular pedicle for ease and reliability
of microvascular transfer. Ideally, the muscle should have a
single easily identifiable motor nerve. Additionally a strong
tendon allows for ease of inset with reduced chance of
Table 35.2  Requirements for free functional muscle transfer
• Available, undamaged motor nerve, artery, and vein at the site
of muscle transplantation
• Adequate skin coverage for the distal half of the muscle
• Supple joints and gliding tendons
• Good hand sensibility and intrinsic function
• Adequate antagonist muscle function
• Good patient motivation
• No simpler solution for the patient’s problem
(Adapted from Anastakis D, Manktelow R. Free functioning muscle transfers. In:
Green’s Operative Hand Surgery, 5th edn. Philadelphia, PA: Elsevier, 2005.)

805
Treatment/surgical technique
Fig. 35.7  The gracilis muscle.
Semimembranosus
Semitendinosus
Adductor magnus
Adductor longus
Gracilis
Saphenous bulb
Profunda femoris artery and vein
Saphenous vein
Major pedicle
Minor pedicle
Fig. 35.8  Patient draped for simultaneous gracilis harvest and forearm dissection.
Fig. 35.9  Marking the length of the gracilis muscle with sutures placed 5 cm
apart.
and distally. The vascular pedicle is found approximately
10–12 cm inferior to the pubis in adults and proportion­
ately the same distance in children (approximately 25% of
the length of the thigh), usually entering the muscle from
the posterior medial surface. The pedicle courses deep to the
adductor longus muscle, which can be retracted to expose the
pedicle. Muscular branches are given off to each of the adduc­
tors, which need to be divided. The origin of the pedicle is
usually from the profunda femoris artery and it can be traced
to here with relative ease in most cases. This usually yields a
pedicle length of 6–8 cm. The nerve supply to the gracilis is
from a branch of the anterior division of the obturator nerve
(L2–3). This can be located taking an oblique course in the
plane between adductor longus and magnus and entering
the posterior medial surface of the muscle 1–3 cm above the
vascular pedicle. This is traced superiorly as far as required
to obtain sufficient length for transfer. This may be as much
as 10 cm.16 It is preferable to perform the nerve coaptation as
close to the transferred muscle as possible, so a shorter nerve
is preferable. A tension-free nerve coaptation is necessary;
a single nerve coaptation is always preferable over a nerve
graft, so harvest of a longer motor nerve is performed where
required. It is necessary to mark the length of the muscle
with the leg in full abduction prior to release of either the
origin or insertion. 5-0 silk sutures placed at 5-cm intervals
will ensure that a correct muscle length–tension relationship
is re-established (Fig. 35.9).
If required, it is possible to perform intraneural dissection
to identify discrete motor fascicles within the motor nerve that
innervate separate portions of the muscle. In 90% of cases it
is possible to identify a single fascicle that innervates the
anterior 20–50% of the muscle.10,31,34 Once these functional
muscle subunits have been identified, it is possible to separate
and inset them individually to the flexor pollicis longus and
flexor digitorum profundus (FDP) tendons to recreate inde­
pendent function of finger and thumb function.17
The gracilis is usually harvested as a muscle-only transfer.
If it is to be used with a cutaneous paddle, care must be taken
in orientation of the skin paddle over the proximal two-thirds
of the muscle as the skin paddle becomes unreliable more
distally. The operating surgeon must avoid injury to the
musculocutaneous perforators, which are almost always

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SECTION V
CHAPTER 35 • Free-functioning muscle transfer in the upper extremity
branches of the ulnar nerve previously supplying the FDP. For
reconstruction of the finger and wrist extensors, branches of
the radial nerve are used. For biceps reconstruction, branches
of the musculocutaneous nerve are used; for the triceps,
branches of the proximal radial nerve are used; and finally, for
the deltoid, motor branches of the axillary nerve are selected.
Fig. 35.10  Incisions planned to avoid the gliding path of tendons.
Fig. 35.11  Transferred muscle skin grafted where insufficient coverage is available
from local tissue (graft ideally would not be required for distal portions of the
muscle).
located directly over the dominant muscular pedicle. It is
useful once the skin paddle has been incised to suture the skin
edge to the gracilis fascia to prevent shearing of the musculo­
cutaneous pedicle.
Preparation of the arm is an integral part of the procedure.
Prior to embarking on a muscle transfer the surgeon should
be satisfied that there is available a suitable vascular pedicle
with which to vascularize the transferred muscle. Assessment
of the vascularity of the limb should be performed clinically
prior to any operation. In equivocal cases, imaging of the
vascular system can be of assistance. A preoperative Doppler
ultrasound examination or angiogram can be used.17 However,
the final decision to proceed with muscle transfer should be
made intraoperatively once a suitable vascular pedicle and
donor motor nerve have been identified. The choice of motor
nerve is discussed further in the section on choice of donor
motor nerve, below.
Incisions should be planned such that they do not cross the
path of gliding tendons (Fig. 35.10). Wound closure can often
be a problem. In adding the bulk of a transferred muscle and
with intraoperative swelling, it is often not possible to close the
arm completely. In this case, skin grafts are required to cover
the remaining skin defect (Fig. 35.11). This should be planned
for with the incisions, so that any areas that require skin graft­
ing are over the more proximal portions of the transferred
muscle that undergo less excursion with contraction.
Choice of donor motor nerve
A nerve must be selected that provides motor axons for rein­
nervation of the transferred muscle. For replacement of long
finger flexor musculature, the preferred motor nerves are the
anterior interosseous nerve, branches of the median nerve that
previously supplied the flexor digitorum superficialis, or
Hints and tips
The anterior interosseous nerve may be found arising from the
median nerve 3–6 cm distal to the elbow in adults. It courses
through the pronator teres and then passes dorsally toward
the interosseous membrane, lying next to the flexor digitorum
profundus and flexor pollicis longus.
It is important to ensure that an undamaged motor nerve is
available for use. This is usually apparent by clinical
examination. When uncertainty exists, a preliminary exploration
and biopsy of the nerve ends may be used. The biopsy
specimen is sent for neurohistology to confirm the presence of
motor axons in the resected nerve end. Once the presence of
suitable motor nerve is confirmed, the surgeon may proceed
with confidence. In the absence of a suitable motor nerve in
the upper limb, e.g., in total brachial plexus avulsions, it is
possible to perform nerve grafts as a preliminary procedure to
introduce a donor source of motor axons into the upper limb.
Once a sufficient period of time has elapsed to allow ingrowth
of motor axons and there is evidence of regeneration along
the nerve, such as a Tinel’s sign at the distal end, the surgeon
may then proceed with functional muscle transfer.

807
Choice of donor motor nerve
to perform preliminary procedures to provide this. These
procedures may include tissue expansion, or local and distant
flaps such as groin or abdominal flaps. Once incisions are
planned, dissection begins usually from proximal unscarred
tissue to distal injured tissue. In dissecting the neurovascular
structures, it is important that meticulous technique is used
to avoid inadvertent damage to important structures (Fig.
35.12). The medial epicondyle is exposed in anticipation of
suturing the proximal end of the transferred muscle. The FDP
tendons are explored and checked for their gliding ability.
Fig. 35.12  The dissected forearm.
Muscle transfer to the flexor aspect of
the forearm
Muscle transfers to replace long finger flexion are the most
common indication for free muscle transfer in the upper limb.
It is commonly required following trauma resulting in direct
damage to the muscle or from ischemic necrosis following
compartment syndrome. Where the extensor compartment
remains undamaged, it may be more appropriate to perform
a tendon transfer such as extensor carpi radialis longus
(ECRL), as this is a less involved procedure with a faster
recovery. However, evidence suggests that a free gracilis
transfer is able to provide greater excursion and range of
movement compared with an ECRL transfer.10,12,31
The forearm must satisfy all the previously mentioned
requirements for transfer. If these are satisfied and suitable
vessels and nerve are available, transfer may proceed. The
gracilis has proven the most useful muscle for this location.
The known location of the neurovascular hilum in the donor
muscle is matched to the available recipients in the forearm.
The length and orientation of the muscle are planned. Inci­
sions are planned to provide good exposure of neurovascular
structures and to provide cover of the musculotendinous
junction in the distal forearm. As such, it is important that
primary skin coverage is provided for the distal half of the
muscle transfer. It is possible to harvest the gracilis muscle
with a cutaneous pedicle to provide extra skin coverage in the
forearm. In the majority of patients, this cutaneous paddle is
too thick, resulting in suboptimal cosmetic appearance. Many
patients later request revision of this skin paddle. Alterna­
tively, the muscle can be transferred as a muscle-only flap and
the proximal half can be skin-grafted. This solves the problem
of the bulky skin paddle. The skin graft in the proximal half
does not interfere with gliding and excursion of the transfer.
If it will not be possible to provide coverage of the distal
muscle and musculotendinous junction, it will be necessary
Hints and tips
Placing a small bean bag or gel roll under the ipsilateral hip
permits greater exposure. A headlight is valuable for
visualization. The incision must be carried quite proximally in
order to visualize the neurovascular bundle adequately. There
are usually two veins surrounding a single artery. A small set
of perforating vessels may be seen entering the skin at the
same level as the vascular pedicle deep to the muscle. A
malleable retractor placed deep (posterior) to the pedicle
assists in its dissection.
Once the forearm is dissected the muscle may be
transferred. The neurovascular structures are aligned and the
nerve positioned to allow nerve coaptation as close to the
muscle as possible (Fig. 35.13). While the proximal portion is
held to the medial condyle, the distal portion of the muscle is
stretched to simulate finger flexion and extension. The
neurovascular pedicle is observed during this movement to
ensure that no tension will be placed on the repair during
finger movement. Tacking sutures are then placed in the
muscle to hold it to the forearm and prevent contraction
during neurovascular repair. Microvascular repair is then
performed under the operating microscope. Once vascular
flow is re-established, the muscle is observed for bleeding
from cut ends and the re-establishment of a “pink color”. The
distal portions of the muscle will typically take some minutes
to regain their color. Any area that fails to appear adequately
revascularized can be excised. This does not present a
problem as the tendon of the gracilis extends intramuscularly
for some way and the cut ends of resected muscle fibers can
be rejoined to the intramuscular portion of the tendon without
affecting function. The neural repair is performed as a
fascicular repair using 10-0 or 11-0 suture, as the nerve to
gracilis contains approximately 60% fatty connective tissue.
This ensures proper alignment of the fascicles.
When a single muscle is to be used to provide flexion to all
of the fingers, they should be positioned such that they flex
together, giving simultaneous contact with the object being
gripped. A side-to-side tenodesis of the FDP tendons is
performed distally in this position with each finger slightly
more flexed than the previous. This provides a balanced
mass flexion effect of all the fingers together (Fig. 35.14).
Where FDP is to be included with a single muscle function, it
should be positioned such that the thumb closes slightly later
than the fingers. This results in a useful pinch grip for the
patient. Alternatively, the muscle may be separated into its
functional components to provide separate finger and
thumb flexion.

808
SECTION V
CHAPTER 35 • Free-functioning muscle transfer in the upper extremity
Fig. 35.13  Neurovascular structures aligned.
Fig. 35.14  Flexor tendons sutured to provide mass flexion effect.
Hints and tips
Most side-to-side tenodeses between adjacent distal tendons
can be readily performed with mattressed 3-0 or 4-0 polyester
sutures. A tendon weaver is not generally needed.
The muscle is inserted into the FDP tendons in such a way
as to recreate its optimal functional length and excursion. Prior
to transfer, the gracilis is placed on maximal physiological
stretch by placing the thigh in maximal abduction. Sutures are
then placed in the muscle every 5 cm. Once the muscle is
transferred, the origin is fixed to the common flexor origin from
the medial epicondyle. The wrist and fingers are then placed
in maximal extension. The gracilis is then stretched distally to
recreate the 5-cm distance between marking sutures
(Fig. 35.15). The intersection of the FDP and gracilis
muscle and tendons is then marked. The hand is then relaxed
and a tendon weave is performed under no tension at the
premarked site. This technique ensures that, once the
procedure is completed, the transfer will allow a full range of
finger and wrist extension and will allow finger flexion within
the maximal force-generating range of the muscle. The
principles of this technique are applicable to muscle transfers
in all locations.
The limb is rested with the wrist and fingers slightly flexed
so as to relieve any tension on the musculotendinous junction.
Postoperatively at the 3-week mark, a program of passive
mobilization and stretching is instituted. This helps prevent any
myoclonic contracture and promotes gliding at the
musculotendinous junction. Once the muscle regains
innervation it is very important to institute an active
mobilization program. Once a functional range of motion is
regained, a graduated weight-training program can be
instituted to improve strength. This should be pursued for at
least 1 year following regaining a useful range of motion. This
should be incorporated into the patient’s work and activities of
daily living to maintain patient interest and participation.
In the correct patient, good flexion (Fig. 35.16) can be
expected including, where planned, independent finger and
thumb flexion (Fig. 35.17).
Muscle transfer for finger extension
Muscle transfer for finger extension follows the same basic
pattern as for finger flexion, although a marginally lesser
degree of excursion is required. The gracilis muscle has also
been used most widely for this application. The choice of
motor nerve for reinnervation is crucial. The posterior interos­
seous nerve has been used most commonly. The most appro­
priate site for identification and use of the nerve is as it
emerges from supinator. At this point, it is possible to identify
the branches innervating finger, thumb, and wrist extensors.
The ideal branches to use are those to the finger extensors;
wrist extensor branches are less ideal. Identification of the
nerve at this level is particularly useful if there are remnants
of extensor motor function. In this case the nerve branches can
be individually stimulated to select the appropriate branch or
branches. The arterial anastomosis may be to any available
artery. The posterior interosseous artery has been used,
although this may be scarred or insufficient. In this case, the
radial artery has been used in an end-to-side fashion, or the
radial recurrent artery may be used. Similar attention as with
the flexor reconstruction must be paid to achieving an appro­
priate physiological length. The distal extensors are joined
together with a side-to-side tenodesis with the fingers in a

809
Complications
Fig. 35.16  (A–C) Postoperative patient demonstrating good finger flexion.
A
B
C
Fig. 35.15  Muscle in situ with recreation of original resting tension.
normal cascade. After proximal fixation of the muscle and
establishment of vascularity, the wrist and fingers are maxi­
mally flexed. The muscle is stretched to recreate the 5-cm
distance between marking sutures. The distal insertion is
marked after attachment of the muscle has been performed.
This allows fixation of the muscle at its maximal physiological
length. Postoperatively, the wrist is splinted in neutral with
the digits in the safe position. This relieves tension on the
muscle during the initial healing period. A mobilization
program similar to that used with flexor reconstructions is
initiated.
Muscle transfers for elbow flexion
(biceps reconstruction)
The loss of elbow flexion can be a devastating injury. Fortu­
nately both the biceps and brachialis can accomplish this
function in the absence of the other. Loss of both these muscles
is rare. Loss of innervation of these muscles is, however, much
more common in the setting of brachial plexus injuries. Many
authors have reported on the use of free functional muscle for
reconstruction of elbow flexion in this setting.16,18 The princi­
ples are the same as for the previously described transfers.
The acromion and bicipital aponeurosis are exposed for
attachment of the transferred muscle. End-to-side vascular
anastomosis to the brachial artery is performed and, if avail­
able, the musculocutaneous nerve is used for neural coapta­
tion. The choice of nerve in brachial plexus cases may be more
difficult and is based on preoperative examination and intra­
operative findings. In this case, donor nerves can be intercostal
nerves (ideally three nerves), motor fascicles of the ulnar or
median nerves, or occasionally the spinal accessory or thora­
codorsal nerve. Similar attention to length and tension of inset
must be paid as previously described.
Transfers have been described for elbow extension, shoul­
der flexion, and thumb opposition, in which similar principles
are applied.
Complications
Complications can be divided into early or late. As the proce­
dure is long and complicated, care must be taken during the

810
SECTION V
CHAPTER 35 • Free-functioning muscle transfer in the upper extremity
Fig. 35.17  (A–D) Postoperative patient demonstrating independent finger and thumb flexion after separation of gracilis into independent functional units.
A
B
C
D
intraoperative period to protect the patient with particular
attention to care of pressure areas and appropriate use of
thromboprophylaxis. The most feared early complication
is vascular insufficiency of the transferred muscle. After
a period of 4–5 h sufficient ischemic damage is sustained
by the muscle as to make salvage impossible. In this cir­
cumstance, a new free muscle transfer is required. Though
not a common complication, this is unfortunately more
common than detecting the vascular compromise in time
to salvage the muscle. Vascular insufficiency may be due
to thrombosis or technical problems with the anastomosis
such as kinking or external pressure. Infection is also a
risk, as the procedure is often performed through a heavily
scarred bed and involves open wounds for a prolonged
period. The routine use of pre- and intraoperative antibiot­
ics is necessary. Delayed wound healing is a not uncom­
mon complication but should not delay a rehabilitative
program.
Late complications include inadequate power and adhe­
sions. Insufficient power can be due to insufficient motor
reinnervation either from an insufficient nerve or problems
with the neural coaptation. In the setting of adhesions, a
tenolysis may be required to allow improved function. If this
is to be done, it is wise to wait for complete reinnervation of
the muscle so that an aggressive postoperative mobilization
program can be instituted. Wrist flexion contractures have
been noted as a late complication after transfers for finger
flexion. As the transferred muscle regains power, it may
overpower the extensors, resulting in a flexion deformity. This
can be overcome by early splinting programs but, even with
appropriate treatment, further serial casting or surgical pro­
cedures may be required.
Secondary procedures
Unfortunately, some patients will not regain function follow­
ing transfer. This can be due to technical problems, loss of the
muscle due to ischemia, failure to reinnervate the muscle,
tendinous adhesions, or co-contraction of antagonist muscles.
In each case, a reason must be sought individually to explain
the poor outcome. In the case of tendinous adhesions, a simple
tenolysis may be sufficient. Inadequate or excessive tension
on the muscle may result in a functioning muscle with incom­
plete or weak range of motion. In these cases, it may be
possible to reposition the musculotendinous junction, or
to perform repositioning of the muscular origin from the
common flexor origin. These are both difficult procedures and
are best addressed by attaining the correct tension at the
primary procedure. In the case of muscle loss or failure of
reinnervation, where a reason for the failure can be addressed,
it is reasonable to perform a second free-functioning transfer
with the expectation of a good functional result.
Future directions
Future developments in free muscle transfer are likely to
involve techniques to improve neural regeneration, as it is
known that the number of motor nerve units that grow across
a nerve repair site affect the functional outcome.38 Potentially
exciting new avenues to improve neural regeneration include
nerve cross-bridging,39,40 in which nerve grafts from a healthy
nerve are coapted to a regenerating nerve and the use of a 1-h
period of electrical stimulation at the time of neurorraphy.41
4. Tamai S, Komatsu S, Sakamoto A, et al. Free-muscle transplants in
dogs with microsurgical neurovascular anastomoses. Plast Reconstr
Surg. 1970;46:219–225. This paper represents the pioneering work on free
functional muscle transplantation. Rectus femoris muscles were
microvascularly transplanted and analyzed with light and electron
microscopy and electromyography. The authors demonstrated viable
muscles with normal thresholds for stimulation by 3 months
postoperatively.
7. Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation
with microneurovascular anastomoses for the treatment of facial
paralysis. Plast Reconstr Surg. 1976;57:133–143. This is the original
description of gracilis transfer as applied to facial nerve palsy, and
includes the authors’ technique and two case reports.
17. Zuker RM, Manktelow RT. Functioning free muscle transfers. Hand
Clin. 2007;23:57–72. This is an excellent review of the current status of
Access the complete reference list online at

811
Future directions
functioning muscle transfer from a highly respected unit covering both
their adult and pediatric experience.
31. Manktelow RT, Zuker RM. Muscle transplantation by fascicular
territory. Plast Reconstr Surg. 1984;73:751–755. The authors describe the
fascicular functional anatomy of the gracilis muscle and the ability to
separate the functioning muscle into its component parts. A single case
report is presented.
33. McKee NH, Fish JS, Manktelow RT, et al. Gracilis muscle
anatomy as related to function of a free functioning muscle
transplant. Clin Anat. 1990;30:87–92. This is an excellent description of
the anatomy of the gracilis muscle in relation to its use as a functional
transplant.

811.e1
References
References
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with functioning free muscle transfer in arthrogryposis: a report of
two cases. J Bone Joint Surg Am. 2011;93:e105.
3. Thompson N. Autogenous free grafts of skeletal muscle. A
preliminary experimental and clinical study. Plast Reconstr Surg.
1971;48:11–27.
4. Tamai S, Komatsu S, Sakamoto A, et al. Free-muscle transplants in
dogs with microsurgical neurovascular anastomoses. Plast Reconstr
Surg. 1970;46:219–225. This paper represents the pioneering work on free
functional muscle transplantation. Rectus femoris muscles were
microvascularly transplanted and analyzed with light and electron
microscopy and electromyography. The authors demonstrated viable
muscles with normal thresholds for stimulation by 3 months
postoperatively.
5. Sixth People’s Hospital, Microvascular Service, Shanghai. Free
muscle transplantation by microsurgical neurovascular
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6. Ikuta Y, Kubo T, Tsuge K. Free muscle transplantation by
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Plast Reconstr Surg. 1976;58:407–411.
7. Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation
with microneurovascular anastomoses for the treatment of facial
paralysis. Plast Reconstr Surg. 1976;57:133–143. This is the original
description of gracilis transfer as applied to facial nerve palsy, and
includes the authors’ technique and two case reports.
8. Carlson FD, Wilkie DR. Muscle Physiology. Englewood Cliffs, NJ:
Prentice-Hall; 1974.
9. Barrett KE, Barman SM, Boitano S, et al. Brooks Ganong’s Review of
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with the double free muscle technique following complete avulsion
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Surg Am. 2000;82:652–666.
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15. Zuker RM. Volkmann’s ischemic contracture. Clin Plast Surg.
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Clin. 2007;23:57–72. This is an excellent review of the current status of
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their adult and pediatric experience.
18. Barrie KA, Steinmann SP, Shin AY, et al. Gracilis free muscle
transfer for restoration of function after complete brachial plexus
avulsion. Neurosurg Focus. 2004;16:E8.
19. Tobin GR, Shusterman M, Peterson GH, et al. The intra-muscular
neurovascular anatomy of the latissimus dorsi muscle: the basis for
splitting the flap. Plast Reconstr Surg. 1981;67:637–641.
20. Favero KJ, Wood MB, Meland NB. Transfer of innervated latissimus
dorsi free musculocutaneous flap for the restoration of finger
flexion. J Hand Surg Am. 1993;18:535–540.
21. Yang D, Morris S, Tang M, et al. A modified longitudinally
split segmental rectus femoris muscle flap transfer for facial
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muscle related to functioning muscle transfer. Plast Reconstr Surg.
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muscle flap transplantation (lateral half of soleus fibula and skin
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29. Lim A, Kumar V, Sebastin S, et al. Split flexor carpi ulnaris transfer:
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30. Manktelow RT, McKee NH, Vettese T. An anatomical study of the
pectoralis major muscle as related to functioning free muscle
transplantation. Plast Reconstr Surg. 1980;65:610.
31. Manktelow RT, Zuker RM. Muscle transplantation by fascicular
territory. Plast Reconstr Surg. 1984;73:751–755. The authors describe the
fascicular functional anatomy of the gracilis muscle and the ability to
separate the functioning muscle into its component parts. A single case
report is presented.
32. Harii K. Muscle transplantation by fascicular territory (discussion).
Plast Reconstr Surg. 1984;73:756.
33. McKee NH, Fish JS, Manktelow RT, et al. Gracilis muscle anatomy
as related to function of a free functioning muscle transplant. Clin
Anat. 1990;30:87–92. This is an excellent description of the anatomy of
the gracilis muscle in relation to its use as a functional transplant.
34. Lifchez SD, Sanger JR, Godat DM, et al. The serratus anterior
subslip: anatomy and implications for facial and hand reanimation.
Plast Reconstr Surg. 2004;114:1068.
35. Doi K, Sakai K, Kuwata N, et al. Double free-muscle transfer to
restore prehension following complete brachial plexus avulsion.
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36. Chuang DC, Strauch RJ, Wei FC. Technical considerations in
two-stage functioning free muscle transplantation reconstruction of
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1994;15:338–343.
37. Sananpanich K, Tu YK, Pookhang S, et al. Anatomic variance in
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SECTION V • Paralytic Disorders
36 
Brachial plexus injuries: Adult and pediatric
David Chwei-Chin Chuang
SYNOPSIS
■ Complexity of brachial plexus injury (BPI): BPI is characterized by
many complex problems and remains a dilemma to many
reconstructive microsurgeons. These complexities include: (1) diverse
injury patterns; (2) disrupted anatomy; (3) unpredictable nerve
degeneration and regeneration; (4) difficult physical examination and
diagnosis; (5) challenging nerve surgery; (6) long rehabilitation;
(7) different palliative surgeries for sequelae deformity; (8) no
consensus of outcome evaluation; and (9) difficult pain management.
Many reconstructive microsurgeons show great interest but are greatly
frustrated by this field.
■ BPI can occur in adults and children. Although the anatomy is the
same, there are many differences. Therefore, these two different
entities will be discussed separately.
Introduction
Adult brachial plexus injury
Introduction
Clinical tips
There are significant differences between adult brachial plexus
injury and obstetric brachial plexus palsy (or neonatal brachial
plexus palsy). The diagnosis and treatment of these different
entities should be considered separately.
BPI can occur in adults and children. Although the anatomy
is the same, there are many differences, including mechanism
of injury, type and degree of injury, preoperative evaluation
and diagnosis, surgical options, postoperative management
and rehabilitation, palliative surgery for sequelae deformities,
outcomes evaluation and pain management (Table 36.1).
Over 1900 adult and 500 pediatric brachial plexus palsy
patients have been treated by the author since 1985. The fol­
lowing text will deal with the author’s experience regarding
adult and pediatric BPI.
Clinical tips
For adult brachial plexus injury, there is debate between early
(within 1 month) and delayed early (within 3–5 months after
injury) nerve exploration. The latter is becoming more popular.
Clinical evaluation is the most essential step for preoperative
and postoperative judgment. Imaging studies can help the
diagnosis, especially for level I (root) injury. Predicting the level
of the lesion can help avoid unnecessarily long incision and
dissection.
Adult brachial plexus injury (BPI) is characterized by many
complex problems, and remains a dilemma to many recon­
structive microsurgeons. These complexities include: (1)
complexity of anatomy; (2) level of BPI; (3) diverse injury
patterns; (3) unpredictable nerve degeneration and regen­
eration; (4) difficult physical examination and diagnosis;
(5) challenging nerve surgery; (6) long rehabilitation and
follow-up; (7) different palliative surgeries for sequelae defor­
mity; (8) no consensus of outcome evaluation; and (9) difficult
pain management. Many reconstructive microsurgeons show
great interest but are greatly frustrated by this field.
Anatomy
Gross anatomy
The brachial plexus is a large plexus, which has the most
complex structures in the peripheral nerve system. It is located
superficially between two highly mobile structures, the neck
and arm, causing its susceptibility to sustain injury, especially
traction injury.
  Access video content for this chapter online at expertconsult.com

Table 36.1  Differences between adult and pediatric brachial plexus injury
Adult brachial plexus injury
Obstetric brachial plexus palsy
Popular terminology
BPI
Two types:
(1) infantile OBPP (I-OBPP; also called neonatal brachial
plexus palsy, NBPP) and (2) child OBPP with deformity
Etiology (mechanism)
Trauma, more closed injuries than open
Majority caused by traction injury, mostly by
motorcycle accident
All are closed and traction injuries following delivery
Demography
All ages
All are infants and children
Incidence
Increasing
Reducing (improvement in obstetric care)
Physical examination
Complex
Simple
Horner’s syndrome
Reliable and persistent
Not reliable, not persistent
Spontaneous recovery
Less
Many
Classification of Injury
Four levels of injury:
Level I: inside the bone
Level II: inside the muscle
Level III: pre- and retroclavicular
Level IV: infraclavicular
All are level I–III injuries, very rare in level IV
Five types of injury:
Type 1: upper plexus palsy (Erb’s palsy)
Type 2: extended Erb’s palsy
Type 3: entire plexus without Horner’s syndrome
Type 4: entire plexus with Horner’s syndrome
Type 5: lower plexus palsy, Klumpke palsy
Intraoperative findings
Patterns
More in root injury (level I)
Upper plexus tend to be rupture injury; lower plexus
tends to be avulsion injury
In operated cases, type 3 or 4 more common; in
non-operated cases, type I or 2 more common
Dissection 3 months after
injury
Difficult, more hazardous to dissect and expose
the lower plexus
Highly possible to expose the whole spinal nerves
Vessel injury
Segmental occlusion of the subclavian artery in
level I, and axillary artery in level IV are
common
Rarely associated with vascular damage
Degree of nerve injury
In rupture injury, the gap is always more than
5 cm
The gap is short (2–4 cm); high incidence of aberrant
reinnervation with co-contraction following nerve repair
or spontaneous regeneration
Platysma muscle
Varies in thickness
Very thin or scarce
Surgical techniques
Priority
Elbow flexion, shoulder abduction and rotation,
hand sensation and finger flexion, then elbow
and finger extension
Hand and shoulder function, elbow flexion
Nerve reconstruction
Nerve transfers more than nerve grafts
Nerve grafts more than nerve transfers
Phrenic nerve transfer
A strong neurotizer, often utilized
Rarely applied, risk for severe respiratory distress
Distal nerve transfers
Often
Less required
Contralateral C7 transfer
Often applied in total root avulsion
Rare
Postoperative
Postoperative immobilization
3 weeks
4 weeks
Rehabilitation
Good and cooperative
Poor cooperation
Prognosis
Recovery after repair
More expected, e.g., nerve grafts in level II
rupture injury, time to achieve elbow flexion
> M3, usually takes 1 year
Slow and unpredictable, e.g., nerve grafts in rupture
injury, time to achieve elbow flexion usually takes 2
years
Intercostal nerve transfer
Fair result
Better result
C8 and T1 root injury
Recovery, all or none
Usually incomplete, (some T1 function is spared)
Intrinsic recovery following
repair
Never
May happen
Backup (second) procedure
to improve results
Less frequent (less than 10%)
More often (> 50%)
Pain management
Big issue
Little problem

814
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
The brachial plexus is formed by the anterior primary rami
of the lower cervical (C5–8) and the first thoracic (T1) spinal
nerves, which give motor innervation to muscles of the shoul­
der, including all anterior and posterior chest muscles related
to glenohumeral joint movement, muscles of the entire upper
limb, and sensory innervation of the entire upper limb except
the skin on some part of the medial aspect of the upper arm
(T2 zone). Not infrequently, the C4 and T2 spinal nerve also
contribute nerve fibers to it. Whenever the C4 contribution is
large and the T1 contribution is small, the brachial plexus is
called the “prefixed brachial plexus”. When the C5 contribu­
tion is small and T2 contribution is large, it is termed the
“postfixed brachial plexus”. Clinically, the prefixed type is
more common than the postfixed. But postfixed plexus in
adult BPI has been rarely seen, probably because the injuries
are either so extensive that further dissection of C8–T1 is
hazardous and unnecessary, or the injuries are diagnosed not
to involve C8–T1, so that further identification is also unnec­
essary. Each spinal nerve is formed by the joining of the
ventral root (motor fibers) and the dorsal root (sensory fibers).
Each root is formed by a number of rootlets, which exit from
each spinal cord. These separate rootlets can be defined on
magnetic resonance imaging (MRI) with three or four bands
in the upper cervical roots (C5–7) and two bands of rootlets
in the lower roots (C8–T1). The dorsal roots carry sensory
information to the central nervous system, while the ventral
roots convey motor fibers to the muscles. The cell bodies
(neurons) of the motor fibers are located in the anterior horn
of the spinal cord, while the cell bodies of the sensory fibers
reside in the dorsal root ganglion located within the interver­
tebral foramen, immediately outside the dura mater of the
spinal cord. The ventral and dorsal roots carry with them an
extension of the arachnoid and dura, which forms the root
sleeve, where the root sleeve attaches to the ventral root and
ganglion to form the sheath of the spinal nerve so that the
cerebrospinal fluid space does not extend beyond the inter­
vertebral foramen.
The dorsal and ventral roots unite a few millimeters distal
from the ganglion to form a spinal nerve, a mixed nerve,
which goes through the interscalene space between the scalene
anterior and middle muscles. Nerves arising from the anterior
primary ramus include branch to scalene muscles (C5–8),
branch to longus colli muscle (C5–8), the long thoracic nerve
(C5–7), a portion of phrenic nerve (C5), and a portion of the
dorsal scapular nerve (C5).
Just out of the scalene muscles, the five postganglionic
spinal nerves make a first union to form the three trunks:
upper (formed by C5 and C6), middle (C7 itself), and lower
trunk (formed by C8 and T1 spinal nerves). Two branches are
given off from the upper trunk: the nerve to the subclavius
muscle and the suprascapular nerve. Each trunk divides into
anterior and posterior divisions just proximal to or directly
under the clavicle, i.e., retroclavicular. Lateral pectoral nerve
is formed from anterior divisions of the upper and middle
trunk to innervate the clavicular part of pectoralis major
muscle; medial pectoral nerve is formed from the anterior
division of the lower trunk to innervate the sternal part of the
pectoralis major muscle.
Infraclavicularly, the nerves exchange fibers and form the
second union, just distal to the clavicle, and are termed
“cords”. The lateral cord is formed by the fusion of the two
anterior divisions of the upper and middle trunks, containing
fibers derives from the C5 through C7. The posterior cord is
a joining of all three posterior divisions, containing fibers
derived from the C5 through C8. The medial cord is simply
continuation of the anterior division of the lower trunk, con­
taining fibers from the C8 and T1. Subclavian artery becomes
axillary artery at lateral border of the first rib. Names for cord
relationship are based on the axillary artery. Lateral and
medial cords pass anterior, and the posterior cord passes
posterior to the axillary artery. The cords run anterior to the
subscapularis muscle, just distally behind the pectoralis minor
muscle. Each cord has two or more terminal branches to the
periphery. The medial and lateral cords, giving one or two
terminal branches, join in a Y-shape to form the median nerve.
Other main terminal branches of the cords contain the mus­
culocutaneous nerve from the lateral cord, the ulnar nerve
from the medial cord, the axillary and radial nerve from the
posterior cord.
Numerous anatomical variations of the brachial plexus do
exist1–3 and should be always kept in mind. For example,
the musculocutaneous nerve may sometimes arise from the
median nerve and not from the lateral cord. In some rare cases
of C5–6 root avulsion, the musculocutaneous nerve is still
found to be functional because part of the musculocutaneous
nerve derives from the median nerve with its origins from C7.
Microanatomy
The microanatomy or internal topography of the brachial
plexus has been extensively studied and described.2,3 The
monofascicular pattern is usually found in regions of: (1) the
spinal nerves; (2) anterior and posterior divisions of the upper
trunk; and (3) the origin of the suprascapular and musculo­
cutaneous nerve. Marked changes in fascicular topography
occur every 10 mm. It is especially true at the level of the
upper trunk where interfascicular crossovers are so extensive
that direct repair or repair with short nerve grafts will fre­
quently lead to co-contractions due to aberrant regeneration
of a group of muscles. This aberrant regeneration is mainly
found in obstetric brachial plexus palsy (OBPP) patients but
rarely in adult BPI. In addition, plexus connective tissue is
more abundant than neural tissue. All these factors are reasons
why the results of brachial plexus nerve surgery are so unpre­
dictable. Knowledge of the internal topography of the plexus
can be helpful in connecting corresponding nerve fibers with
bridging nerve grafts. However, localization within the spinal
nerve to define specific axonal groups to supply specific
muscles or specific branches is difficult and not practical.
Level of brachial plexus injury
Various classifications of the level of BPI have been
proposed1, 4–12 (Table 36.2), e.g., two levels as supraclavicular
and infraclavicular4; three levels as supra-, retro-, and infra­
clavicular,5,6 four levels as preganglionic root, postganglionic
root, trunk and division, cord and terminal branches.7–8 These
numerous classifications have made the understanding of the
anatomy of the brachial plexus complex and confusing. The
most confusing aspect is the so-called postganglionic root
(Fig. 36.1). In fact, after the dorsal root ganglion, both ventral
and dorsal roots continue for only a few millimeters (< 5 mm)
in distance and unite to become a mixed nerve where it is no
longer a root. Sunderland13 has stated that “the term nerve

815
Adult brachial plexus injury
Table 36.2  Classifications for level of brachial plexus injury
Authors
Levels
Area of injury
Leffert1
2 levels
Supraclavicular injury (supraganglionic, infraganglionic, and sub- or retroclavicular) and
infraclavicular injury
Krakauer and Wood4
2 levels
Supraclavicular (roots, trunks and divisions), infraclavicular (cords and branches)
Terzis et al.5
3 levels
Root, supraclavicular postganglionic, infraclavicular
Ferrante6
3 levels
Supra-, retro-, and infraclavicular
Millesi7
4 levels
Supraganglionic root, infraganglionic root, trunk, and cord
Alnot8
4 levels
Preganglionic root, postganglionic root, supra- and retroclavicular, and infraclavicular
Chuang9
4 levels
Preganglionic root, postganglionic spinal nerve, pre- and retroclavicular, and infraclavicular
Narakas10
5 levels
Supraganglionic root, infraganglionic spinal nerve, infraganglionic trunk, retroclavicular and terminal
branches
Mackinnon and Dellon11
6 levels
Root avulsion (preganglionic and postganglionic), trunk injury, lateral cord, posterior cord, medial
cord, terminal cord branches injury
Boome12
8 levels
C5–6; C5–6–7; C5–6–7 posterior divisions; C5; C6; lateral and medial cords; posterior cord
Fig. 36.1  (A) The illustration shows that the postganglionic root is part “a”;
postganglionic spinal nerve is part “b” from the anatomical point of view; (B) an
avulsion C7 (distal stump) during dissection.
A
Dura
a
b
Dura
B
root should be reserved for the paired anterior and posterior
nerve roots in the spinal canal,” and that “the part of the
plexus extending from the union of nerve roots to the forma­
tion of the trunks of the plexus should be referred to as a
spinal nerve.” The author agrees with this statement. There­
fore, the components of the brachial plexus are roots, spinal
nerves, trunks, divisions, cords, and terminal branches.
To avoid anatomical confusion, we have described brachial
plexus lesions with “numbers”, levels I–IV, instead of word
descriptions14 (Fig. 36.2), e.g., two levels 4, three levels 5, 6;
four levels 7–9; five levels 10; six levels 11 and even eight
levels 12. A total of 819 cases of adult BPI were included
(1986–2003) in this new classification and the incidence at
different levels was determined:
Fig. 36.2  Anatomy and numbered level of brachial plexus injury (see text).
Level IV
Level IV Infraclavicular injury (cords and terminal branches injury)
Level III
Level III Pre- and retroclavicular injury (trunks and divisions injury)
Level II Postganglionic spinal nerve injury
Level II
Level I Preganglionic root injury
Level I

816
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
■ Level I injury: inside the (vertebral) bone; this is a
preganglionic root injury including spinal cord, rootlet,
and root injury; 70% of BPI patients are unfortunately
injured at this level.
■ Level II injury: inside the (scalene) muscle;
this is a postganglionic spinal nerve injury, located
at the interscalene space proximal to the
suprascapular nerve; pure level II injuries account for
around 8%.
■ Level III injury: pre- and retroclavicular; this includes
trunks and divisions; pure level III injuries account for
about 5%.
■ Level IV injury: infraclavicular; including cords and
terminal branches injury proximal to the axillary fossa;
the second largest population of BPI patients, at about
17%.
There are some relationships among the levels of injury:
1. An extended-level injury on the same nerve is
frequently observed: for instance, C7 injury from the
root level down to the interscalene space (level I and II
injury).
2. A combined-level injury on different nerves is common:
for instance, C5 and C6 spinal nerve rupture injury
(level II) accompanied with C7–T1 root avulsion (level
I).
3. A skip-level injury is rare: for instance, a longitudinal
skip-level injury in which C5 and C7 are injured
(avulsion or rupture) but C6 is intact; a horizontal
skip-level injury in which level I and level III are
injured, but level II is grossly intact.
4. Level IV injuries are usually isolated, and rarely show
upward extension.
The term “supraclavicular BPI” will cover a large zone of
injury, including level I, II, or III lesions.
Preoperative differential diagnosis of supra- (level I–III)
and infraclavicular (level IV) injury is important to avoid
large incisions, unnecessary dissection and tissue damage,
prolonged operative time, increased postoperative morbidity
and resulting scars. With help of imaging studies and preop­
erative clinical evaluation, it is not difficult to diagnose a level
I lesion. However, when the injuries are incomplete, differen­
tial diagnosis becomes difficult15 (Table 36.3).
Patterns of brachial plexus injury
There are two types of characteristic lesions seen in BPI: avul­
sion and rupture. Both are traction injuries but with different
characteristics. Avulsion refers to the nerve being torn from
its attachment (proximal avulsion occurs at the spinal cord,
distal avulsion at the muscle or bone edge). Rupture is a nerve
injury involving a traction force on an incompletely divided
nerve, causing a complete division with irregular proximal
and distal ends. In avulsion injury, only one disrupted end
with a coiled spring-like appearance can be seen in the opera­
tive field in the acute stage (Figs. 36.3A & 36.4A), or a fusiform
pattern (glioma) in the chronic stage (see Figs. 36.3B & 36.4B).
If a surgeon attempts to locate the other avulsed end, a second
operative wound is usually required. However, in rupture
injury the two nerve ends can be visualized in the same opera­
tive wound in the acute stage (see Fig. 36.3C), or within a big
neuroma noted in the chronic stage.
Table 36.3  Differentiation diagnosis (DD) between supra- and infraclavicular BPI with incomplete paralysis of shoulder and elbow
Condition
Supraclavicular BPI
Infraclavicular BPI
Differential diagnosis
Isolated axillary nerve injury
Impossible
Yes
No need to DD
Isolated musculocutaneous nerve injury
Impossible
Yes
No need to DD
Shoulder dislocation
Yes
No need to DD
Infraclavicular Tinel’s sign (+)
+ (due to nerve regeneration)
+
Need to DD
Muscle strength examination
(A)
When supraspinatus (M0), serratus anterior
(M0)
Yes
Impossible
No need to DD
(B)
When supraspinatus (M > 3), serratus anterior
(M > 3)
Impossible
Yes
No need to DD
(C)
When supraspinatus (M < 2), serratus anterior
(M < 2)
?
?
Need to DD
(C-1) When C-PM (M > 3), teres major (M > 3), LD
(M > 3)
Impossible
Yes
No need to DD
(C-2) When C-PM (M < 2), teres major (M > 3), LD
(M > 3)
High possible level III
(C-3) When C-PM(M < 2), TM (M < 2), LD (M < 2)
High possible level II–III
Condition
Scapular fracture
Potential lesion
Imaging studies
Important for level I
Not important
EMG, NCV
Important
Important
C-PM, Clavicular part of pectoralis major muscle; EMG, electromyography; LD, latissimus dorsi; NCV, nerve conduction velocity.

817
Adult brachial plexus injury
Fig. 36.3  The drawing shows the mechanism of avulsion injury (A,B) vs. rupture injury (C).
A
B
C
Division
Traction
Traction
Coiled spring-like structure (acute stage)
Fusiform pattern neuroma (chronic stage)
Avulsion injury
Rupture injury
Fig. 36.4  (A) Coiled spring-like structure with irregularity of stumps of C5 and C6 avulsion (acute stage); (B) fusiform pattern neuroma (or glioma) of the distal C7 stump
(chronic stage) during dissection.
A
B
Root avulsion is very common in BPI due to its weak sup­
porting structures consisting of dura and dentate ligaments.
A novel approach to performing spinal cord implantation
with or without nerve graft16,17 showed unsatisfactory clinical
results. This implies that in avulsion injury only one end
(distal end) is available, while the other end (proximal) is
absent or unsuitable for repair. “Root injury” is an obscure
term that may mean avulsion from the cord (true avulsion) or
rupture or stretch at rootlets or roots. Root avulsion in BPI is
usually accompanied by dural tearing and a cerebrospinal
fluid leak with cyst formation, called pseudomeningocele.
However, in some cases, the root can be avulsed at its origin
with an intact dura cone (called “avulsion in situ”). The nerve
root may remain inside the spinal canal or at the dural orifice,
giving a grossly normal appearance or loosening with curva­
ture of the spinal nerve at the time of surgical intervention
despite established paralysis. Most often, however, the entire
avulsed root, including ventral and dorsal roots, and ganglia,
retracts and migrates downward to the interscalene or precla­
vicular region (see Fig. 36.2B).
Pathophysiology and degree of nerve injury
Timing of nerve exploration is dependent upon the degree of
nerve injury. The degree of peripheral nerve injury can be
classified into neuropraxia, axonotmesis, and neurotmesis
(Seddon classification18) or grade 1–5 injury (Sunderland clas­
sification19). Seddon’s axonotmesis or Sunderland’s second-
degree injury starts to have Wallerian degeneration at proximal
and distal stumps. Seddon’s neurotmesis or Sunderland’s
third- to fifth-degree injury has the potential for aberrant
reinnervation after nerve regeneration. In Sunderland’s
fourth- or fifth-degree injuries, only nerve repair can succeed
in restoring continuity, but in first-, second-, or third-degree

818
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
motor neuron lesion below the level of lesion, and contra­
lateral abnormal sensation to pain and temperature, which
may not be at the same level) is also noted in the level I
injury.24
Preoperative evaluation and diagnosis
Most adult BPIs are closed injuries. Accurate assessment of
the extent and severity of the injury in closed BPI is difficult.
Clinical evaluation is still essential and is the most important
step in establishing the diagnosis of site and degree of injury,
and determining the treatment and prognosis. A brachial
plexus chart (left and right formats, Fig. 36.5A,B) outlining the
possible injury should be completed before definitive brachial
plexus surgery. This chart is filled at the initial examination,
and usually performed at 2 months after injury. The chart is
also useful for follow-up evaluations, allowing comparison of
clinical pictures.
Motor examination
Muscle-by-muscle examination should be completed in a
distal-to-proximal fashion and recorded using the British
Medical Research Council (MRC) scale (M0–5).25 We have
modified the motor evaluation system, adding more detailed
differentiation: M5, strength against four-finger (examiner)
resistance; M4, against one finger, resistance for longer than
30 s; and M3, against gravity (Table 36.4). M4 is recognized as
useful muscle strength. The action of each muscle should be
examined separately in relation to the movement of a single
joint. Although there is no single muscle innervated by a
single spinal nerve, some muscle palsy can give specific
information related to the level of the injury. For instance:
1. Diaphragm palsy implies C4 and very proximal C5
(level I) injury.
2. The levator scapulae muscle lies anterior to the
trapezius muscle in the neck, and can be more easily
detected than the rhomboid muscles, which are covered
by the trapezius muscle. Both levator scapulae and
rhomboid muscles are innervated by the same nerve
(dorsal scapular nerve, or C4 and C5). Preservation of
its function in upper plexus or total plexus injury may
imply C5 is a rupture injury (level II) with an available
proximal stump.
3. Serratus anterior muscle: The long thoracic nerve has
two portions: the upper portion originating from C5 and
C6, and the lower portion from C7. The upper portion is
responsible for scapular protraction, and the lower
portion is important for scapular stabilization.26 Positive
anterior traction of the scapula (shoulder protraction
test) shows that at least C5 is ruptured after branching
to the long thoracic nerve, so the proximal C5 is
available for transfer. Scapular winging is observed only
when the lower portion is denervated, but isolated C7
root avulsion is rarely seen in adult BPI. In pure C5–6
level I injury, the lower part of the muscle is still
functional. The result of spinal accessory nerve transfer
to the suprascapular nerve is much superior in the
reconstruction of total root avulsion.
4. Clavicular and sternal portions of the pectoralis major
muscle: The major pectoral muscle can be separated into
two parts: clavicular and sternal parts. The clavicular
injuries, spontaneous recovery, complete and incomplete,
may occur.
Timing of brachial plexus exploration
There are five times for brachial plexus exploration and repair:
■ Immediate repair or repair within days
■ Early repair within a month
■ Delayed early repair within 3–5 months
■ Late repair at more than 6 months
■ Chronic repair at more than 1 year.
There is rarely an argument against immediate exploration
after penetrating injury by sharp objects for direct nerve
repair. Some surgeons also advocate exploration of the BPI as
early as possible20,21 for adult closed BPI for its advantages,
including easy diagnosis of root avulsion and avoidance of
difficult dissection through scarring. However, such early
exploration is not recommended by most brachial plexus
surgeons.7–9,22 In cases of closed BPI, the degree and extent of
injury are difficult to judge soon after injury and are often
underestimated. The benefits of waiting usually outweigh the
advantages of early surgery.14
Clinical evaluation
Etiology of adult brachial plexus injury
BPI may be caused by trauma (open or closed type), com­
pression, tumor, infection, inflammation, toxins, and other
etiologies.
Patient history
Patient history should include mechanism of injury, level of
consciousness at the time of trauma, associated injury (such
as head injury, fracture, open wound, chest injury, vascular
injury), kinds of previous surgical intervention (such as chest
intubation, cervical spine surgery), and characteristics of pain.
This information helps to determine the degree and extent of
injury and the need for surgical intervention. Mechanism
of injury (e.g., upward or downward traction and with or
without rotation) is not easily detected due to the patient’s
loss of consciousness or amnesia for the accident. A history of
shoulder dislocation or glenoid fracture may have a high
incidence of level IV injury, whereas a history of cervical spine
injury or fracture may cause a level I root injury. Artery
rupture and repair imply the site of nerve injury. For instance,
arm traction by rolling machine or conveyor belt often causes
an open wound in the axilla, extensive ecchymosis around the
shoulder and chest (due to rupture of axillary vessels), and
level IV BPI. Segmental thrombosis of the subclavian artery is
usually associated with C8–T1 root injury. History of rib
fracture and chest intubation may preclude intercostal nerve
transfer because of a higher failure rate.23 Extreme causalgia
with or without a phantom limb is often seen in cases of root
avulsion in lower-root (C8–T1) avulsion as they contain the
richest sympathetic fibers. The pain character, like electric
shooting pains, continues for a short duration (seconds), fol­
lowed by spontaneous relief and recurrence. Extreme causal­
gia is also a major factor for poor outcome due to poor
rehabilitation. Sometimes a partial Brown–Sequard syndrome
(hemitransection of the spinal cord with ipsilateral upper

Right Brachial Plexus
Date exam
Date of injury
Name
Address:
Present illness
Past history
Date operation
EMG
Chart #
X-Ray and
MRI
Horner's syndrome
Vascular lesion
Mobility of diaphragm
Birth date
PAIN
Intolerable
Disturbance
Acceptable
None
Tinel
C3
C4
C5
T2
T1
C6
C7
C8
C3
C4
C5
T2
T1
C6
C7
C8
FLEX DIG SUBL
OPP
POL
ABD
V
POST
INTEROSS
ANT
INTEROSS
APB
FLEX
POL
LONG
FL
POL
BR
FL
POL
BR
FLEX
II
DIG
III
PROF
IV

V
TRAPEZ
Rhomb
Levator scap
Post
Lat
BICEPS
PRON
III
IV
V
II
FCR
PL
ECR
ECU
APL EPB
EPL
FCU
LATISSIMUS DORSI
PECTORALIS MAJOR
CAVICULAR STERNAL
BRACHIALIS
TRICEPS
EXT DIG
COM+
PROPRII
SUPINATOR
TERES MAJ
BRACHIO-
RADIALIS
SUPRA
SPIN
INFRA
SPIN
ant
DELT
SERRATUS ANT
C5
C6
C7
C8
T1
M0
M1
M2
M3
M4
M5
S0
S1
S2
S2+
S3
S3+
S4
A
Fig. 36.5  Special charts for evaluation of brachial plexus injured patient, (A) for the right and (B) for the left upper limb.
Table 36.4  British Medical Research Council (MRC) scale and Chuang modification
British MRC scale
Motor scale
Sensory scale
M0: No contraction
M1: Flicker (trace of contraction)
M2: Active movement with gravity eliminated
M3: Active movement against gravity
M4: Active movement against gravity and resistance
M5: Normal (full) power
S0: No sensation
S1: Pain sensation
S2: Pain and some touch sensation
S3: Pain and touch with no overreaction
S3+: Some two-point discrimination
S4: Normal sensation
Chuang modification
Motor scale
Sensory scale
M4: Active movement against examiner’s one-finger resistance ≥30 s
S2+: Pain and touch with overreaction
M5: Active movement against examiner’s four-finger resistance
Continued

820
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
constant touch, and vibration. However, performing complete
sensory tests in BPI is both unnecessary and illogical because
we are examining the dermatomal distribution from spinal
nerves, not the cutaneous distribution. Pinprick test from
areas of normal to abnormal sensation to map out the area
of sensory disturbance is sufficient for most brachial plexus-
injured patients. Sensory grading is based on the British MRC
scale (S0–4),25 modified by adding a grade for sensory over­
reaction (S2+) (see Table 36.4). Such sensory evaluations can
give some clues about the level and degree of BPI.
The Hoffman–Tinel’s sign is an important clinical sign
to determine the location of a neuroma or to track the
part is innervated by upper and middle trunks or its
divisions (lateral pectoral nerve), while the sternal part
is innervated by the lower trunk (medial pectoral
nerve). An incomplete and complete paralysis of the
clavicular part of the pectoralis major muscle may imply
at least level III or more proximal lesion.15
Sensory examination
Sensory evaluation should include sensory tests and elicitation
of a Tinel’s sign. Sensibility tests include pain and temperature
appreciation, static and moving two-point discrimination,
Left Brachial Plexus
Date exam
Date of injury
Name
Address:
Present illness
Past history
Date operation
EMG
Chart #
X-Ray and
MRI
Horner's syndrome
Vascular lesion
Mobility of diaphragm
Birth date
PAIN
Intolerable
Disturbance
Acceptable
None
Tinel
C3
C4
C5
T2
T1
C6
C7
C8
C3
C4
C5
T2
T1
C6
C7
C8
FLEX DIG SUBL
OPP
POL
ABD
V
POST
INTEROSS
ANT
INTEROSS
APB
FLEX
POL
LONG
FL
POL
BR
FL
POL
BR
FLEX
II
DIG
III
PROF
IV

V
TRAPEZ
Rhomb
Levator scap
Post
Lat
BICEPS
PRON
III
IV
V
II
FCR
PL
ECR
ECU
APL EPB
EPL
FCU
LATISSIMUS DORSI
PECTORALIS MAJOR
CAVICULAR STERNAL
BRACHIALIS
TRICEPS
EXT DIG
COM+
PROPRII
SUPINATOR
TERES MAJ
BRACHIO-
RADIALIS
SUPRA
SPIN
INFRA
SPIN
ant
DELT
SERRATUS ANT
C5
C6
C7
C8
T1
M0
M1
M2
M3
M4
M5
S0
S1
S2
S2+
S3
S3+
S4
B
Fig. 36.5, cont’d

821
Adult brachial plexus injury
regeneration of the injured nerves. Palpation or percussion at
the neck, at the supraclavicular Erb’s point (clavicular inser­
tion of the sternocleidomastoid muscle), at the infraclavicular
coracoid process of the scapula, or at the route of different
nerves along their course may induce an electric current
sensation (like pins and needles) running down to the shoul­
der or the hand (positive Tinel’s sign). If the Tinel’s sign
remains at a fixed point, which means retardation of its pro­
gression, surgical exploration is warranted. If the Tinel’s sign
advances from supraclavicular to infraclavicular and distally
to the arm or forearm at successive examinations, observation
is recommended, as this may indicate a Sunderland third-
degree lesion. A weak or absent Tinel’s sign in the neck region
usually indicates total root avulsion.
Horner’s syndrome (miosis, ptosis, enophthalmos, and
anhidrosis) is a sign of sympathetic nervous system distur­
bance. It indirectly implies avulsion of the T1 and C8 roots
because the sympathetic fibers from the T1–2 sympathetic
ganglia are quite close to the preganglionic fibers of T1 and
C8. This syndrome may regress with time. It is a more reliable
sign in adult BPI, but less accurate in obstetric traction injury.
Plain X-ray and imaging studies
Clinical tips
• Direct multiplanar imaging capabilities and superior
soft-tissue contrast have turned MRI into the primary
imaging tool for BPI evaluation.
• The MRI protocol for brachial plexus includes MRI
myelogram (two-dimensional), FIESTA (three-dimensional),
Cor (coronal) T1, Cor STIR, Sag (sagittal) T1, Sag STIR, Ax
(Axial) T1 and Ax STIR, and DWI (diffusion-weighted
imaging) techniques for determination of the BPI level.
Plain X-rays of the chest and cervical spine are required. The
chest X-ray should include inspiration and expiration views
to exclude diaphragmatic palsy. Cervical spine X-rays are
evaluated for any fracture of the transverse process, spinous
process, or vertebrae body.
Cervical myelography and computed tomography (CT)
myelography can provide valuable information related to the
level I injury of the brachial plexus.27,28 However, in recent
years these studies have been gradually replaced by non-
invasive MRI.29,30 The most useful MRI technique for the
evaluation of a possible level I lesion is the three-dimensional
(3D) fast imaging employing steady-state acquisition (FIESTA).
These 3D source data are reconstructed along the planes of
ventral and dorsal rootlets using a curve planar reformat
technique to demonstrate the respective rootlets in a better
perspective. Other MR techniques help in the imaging of the
whole brachial plexus, notably of level II (Fig. 36.6A–F).
Electrodiagnostic studies
(Sunderland 1 injury) and axon loss lesions (Sunderland
2–5 lesions).
• Before Wallerian degeneration occurs, the distal
stump remains capable of conduction of action
potentials (within 2 weeks); the EDX during this period
is useless.
• Most adult BPI are due to axon loss without accompanying
focal demyelination; however, less frequently, concomitant
demyelination is present (especially in shoulder dislocation
reduced within 2 h).
• EDX essentially includes three components: sensory nerve
conduction velocity (SNCV), motor nerve conduction
velocity (MNCV), and needle electromyography (EMG).
• The amplitude of compound muscle action potentials
(CMAP) (in MNCV) is the most useful component for
quantifying the amount of axon loss. The amplitude in
SNCV and fibrillation in EMG tend to overestimate, and the
amplitude of MNCV (CMAP) tends to underestimate the
severity of axon loss.
Electrodiagnostic studies, mainly consisting of nerve conduc­
tion studies (NCS) and needle EMG, are used to localize the
lesion and to assess its severity. For the NCS, only amplitudes
of the sensory nerve action potentials (SNAP) and CMAP are
of value. Both SNAP and CMAP amplitudes provide a good
indication of the degree of axon loss, or in contrast, the number
of survival axons capable of conducting impulses.31,32 Sensory
NCSs assess the function of the postganglionic portion of the
sensory pathway. Therefore, abnormally low SNAP ampli­
tudes indicate a ganglionic or postganglionic lesion. Con­
versely, the SNAP amplitude remains normal in a complete
paralysis of limb implies pure level I lesion (root avulsion). A
combination of unelicitable CMAPs with abnormal low or
absent SNAP amplitudes suggests a combined preganglionic
and postganglionic lesion. To assess the major elements of the
brachial plexus, NCSs of multiple nerves are usually required.
These include sensory NCS of the median, ulnar, radial,
musculocutaneous, and axillary nerves, as well as motor NCS
of the median, ulnar, radial, musculocutaneous, and axillary
nerves. The presence of fibrillation potentials on needle EMG
may suggest that the lesion is at least axonotmesis. The reduc­
tion of amplitude of compound muscle action potentials
during motor NCS is more reliable than the presence of fibril­
lation potentials to indicate axonal loss rather than a neura­
praxia lesion.
Needle EMG can detect a minimal amount of motor axon
loss. For a comprehensive evaluation of the brachial plexus,
adequate EMG sampling of muscles is critical. In addition to
muscles innervated by major terminal nerves, examination of
those supplied from or proximal to the brachial plexus can
help to localize the lesion. These include the rhomboid major,
serratus anterior, pectoralis major (both the clavicular and
sternocostal parts), latissimus dorsi, teres major, and cervical
paraspinous muscles. Needle EMG can also reveal evidence
of early reinnervation and chronicity of the lesion. Presence
of denervation potentials (i.e., fibrillation potentials and posi­
tive sharp waves) is the most sensitive indicator of motor axon
loss. However, they require about 3 weeks to develop after
axon injury.27
Clinical tips
• Electrodiagnostic studies (EDX) are useful for differential
diagnosis between demyelinating conduction block

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CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
A
B
C
D
Fig. 36.6  The patient with right C5-T1 total root avulsion: (A) coronary view of MR(magnetic resonance) FIESTA (fast imaging emplying stead-state acquisition) neurogram,
(B) oblique view of FIESTA neurogram, and (C) MR myelogram all show right C5-T1 avulsion cysts; The other patient with left C7 root avulsion: (D) using MRI curve planar
reformat techniques, (E) axial view, and (F) Short-Tau Inversion Recovery (STIR) neurogram show the C7 avulsed cyst, and all other spinal nerves are still in continuity in
Level II and III.
Percutaneous somatosensory evoked potentials (SEPs)
provide far less information than comprehensive NCSs and
needle EMG studies in most patients with BPI. Thus SEPs are
not routinely performed. Intraoperative SEPs may be useful
to determine the continuity of individual segments of the
brachial plexus and roots.
Vascular injury
Absence or weakness of pulsation of the radial artery at the
wrist indicates a possible vascular injury of the axillary or
subclavian artery. It may further indicate the extent and sever­
ity of the trauma. Subclavian artery occlusion may indicate a

823
Adult brachial plexus injury
Clinical tips
• There are different incision lines for different purposes
(Fig. 36.7).
• There are many important landmarks and key points for
brachial plexus exploration for supraclavicular and
infraclavicular brachial plexus exploration with safety and
efficiency (Fig. 36.8).
• Surgical methods depend on the level of BPI. (Table 36.5).
• Debate between proximal nerve transfers and distal nerve
transfers for incomplete BPI exists. The former is a
traditional strategy; the latter is a new strategy and is
becoming more popular (Table 36.6).
• Debate of reconstruction strategy between primary nerve
reconstruction (multiple nerve transfers) and functioning
muscle transplantation for total root avulsion of BPI exists.
The former is proximal-to-distal, the latter is distal-to-
proximal in reconstruction priority (Table 36.7).
• Postoperative management and follow-up should be longer:
at least 2 years for upper plexus, and 4 years for lower
plexus reconstruction.
• Induction exercise is an essential rehabilitation when any
type of nerve transfer is utilized, including functioning free
muscle transplantation.
Fig. 36.6, cont’d
level I injury, while axillary artery occlusion may be associ­
ated with a level IV lesion. Vascular injury should be taken
into account when considering the use of a vascularized ulnar
nerve grafts for reconstruction because the ulnar artery is
transferred with the ulnar nerve.
Surgical treatment and techniques
Fig. 36.7  Multiple incision lines for different purposes: 1, for supraclavicular
brachial plexus exploration; 2, for infraclavicular brachial plexus exploration; 3, for
Oberlin or Mackinnon method of nerve transfer; 4, for intercostals nerve dissection;
5, for contralateral C7 dissection; 6, for hypoglossal nerve dissection; and extended
1 incision for spinal accessory nerve dissection.
Different incision lines for different approaches
Different incision lines for brachial plexus surgery are deter­
mined by preoperative diagnosis of level of BPI and manage­
ment strategy (see Fig. 36.7). For the supraclavicular approach,
a linear incision from the midpoint between the mastoid
process of the temporal bone and the jugular notch, going
along the posterior border of the sternocleidomastoid muscle,
and curving laterally parallel to and above the clavicle (a
C-curved incision) is a popular incision (see Fig. 36.7, mark
1). For the infraclavicular approach, the incision is just along
E
F

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CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
Table 36.5  Reconstructive strategies for different level of root avulsion
Condition
Nerve reconstruction
Late reconstruction
Five-root (C5–T1) level 1 injury
Ph → distal C5 for shoulder elevation
IC → musculocutaneous nerve for elbow flexion contralateral
C7 → median nerve for hand
Wrist and thumb fusion, FFMT
for EDC and elbow (XI)
Four-root injury (C5 level 2, C6–T1
level 1)
C5 → median nerve for hand
IC → musculocutaneous nerve for elbow flexion
Ph → distal C5 for shoulder elevation
Wrist and thumb fusion, FFMT
for EDC and elbow (XI)
Three-root injury
1. C5, C6 level 2, C7–T1 level 1
C5 → SS + PD of UT for shoulder
C6 → C8 or median nerve for hand
IC → musculocutaneous nerve for elbow flexion
Variable
2. C5–7 level 1, C8–T1 intact
Ph + XI → distal C5 for shoulder elevation
Part ulnar → biceps br
Part median → brachialis br for elbow
Variable
Two-root injury
1. C5–6 level 1, C7–T1 intact
Ph + XI → distal C5 for shoulder elevation
Part ulnar → biceps br
Part median → brachialis br for elbow
Variable
2. C6–7 level 1, C5 level 2, C8–T1 intact
Ph + XI → distal C5 for shoulder elevation
C5 → AD of UT for elbow
Variable
3. C8–T1 level 1, C5–7 level 2 injury
C5 nerve grafts for shoulder
C6 → median nerve for hand
C7 nerve grafts to C7
Variable
4. C8–T1 level 1 injury, others intact
No nerve reconstruction
ECRL → EDC for finger extension
FCR → FDP for finger flexion
Br for opponensplasty
Thumb IP fusion
Single-root injury
1. C5 level 1 injury
Ph + XI + CMB → distal C5
2. C6 level 1, usually C5 level 2 injury
C5 → C6 or AD of UT for elbow
Ph + XI + CMB → distal C5
3. C7 level 1, C5–6 level 2 injury
C5, C6 nerve grafts itself
Ph, Phrenic nerve; IC, intercostal; XI, spinal accessory nerve; CMB, cervical motor branches; FFMT, functioning free muscle transplantation; EDC, extensor digitorum
communis; SS, suprascapular nerve; PD, AD, UT, posterior division, anterior division of the upper trunk; br, branch; ECRL, extensor carpi radialis longus; FCR, flexor carpi
radialis; FDP, flexor digitorum profundus; IP, interphalangeal joint.
Table 36.6  Proximal nerve transfer versus distal nerve transfer in adult BPI
Proximal nerve transfer
Distal nerve transfer
Philosophy
Traditional and physiological
New strategy
Donor nerve
Supraclavicular, far from the target muscle
The nearby nerve close to the target muscle
Advantages
For diagnostic and treatment
Proximal nerve(s), powerful
Nerve cut stump often unhealthy, fewer functional deficits
A treatment procedure, but not diagnostic
Direct repair; no need of nerve graft
No scars, easy dissection, shorter operation time
Nerve cut stump healthy
Short rehabilitation, faster recovery
Disadvantages
More scars, difficult dissection
Nerve cut stump unpredictable, often unhealthy
All need nerve grafts, moreover long nerve grafts (>8 cm)
Longer operation time
Longer rehabilitation period
Nerve cut, risk of causing deficits
Risk of iatrogenic injury
May need multiple incisions
Indication
All kinds of avulsion/rupture injury of brachial plexus injury
Not global BPI
Intrinsic palsy of the hand

825
Adult brachial plexus injury
Table 36.7  Comparison of multiple nerve transfers vs. functioning muscle transplantation for total root avulsion of BPI
Multiple nerve transfers first
FFMT first
Authors prefer
Chuang40
Doi39
Philosophy
Traditional strategy
New strategy
Proximal-to-distal in reconstruction priority
Distal-to-proximal in reconstruction priority
Shoulder, elbow first, then finger sensation
and flexion, then finger extension
Finger extension and flexion, then elbow
flexion; then shoulder
Reconstructive strategy
Multiple nerve transfers are essential
Two FFMTs are essential
FFMT is an adjuvant procedure to backup
the results
Nerve transfers are adjuvant
Brachial plexus exploration
Yes
Maybe not
Nerve reconstruction:
For shoulder
Yes (by NT)
May or may not be needed
For elbow
Yes (by NT)
Need FFMT
For finger
Yes (by NT)
Need FFMT
Stage requirement for full reconstruction
Can be one stage
Always multiple stages
Rehabilitation period
At least 4 years
2 years
Patient selection
Should be a highly motivated and
intelligent patient
Can be a less intelligent and impatient patient
Predict outcomes:
Shoulder elevation
Better (≥60°)
Shoulder fusion (10–30°)
Elbow flexion
Usually better (M4)
M3–4
Finger flexion
M2–4
M2–4
Finger extension (EDC)
M0
M2–3
NT, Nerve transfer; FFMT, functioning free muscle transplantation; EDC, extensor digitorum communis.
the deltopectoral groove and extends upward to meet the
supraclavicular incision, or downward to the medial sulcus
of the biceps (see Fig. 36.7, mark 2). Other additional incisions
may be required: extended neck incision for accessing the
spinal accessory nerve (upward extending incision of the
mark 1 incision); chest semicircular incision for the intercostal
nerve (see Fig. 36.7, mark 4); inframental incision for the
hypoglossal nerve (see Fig. 36.7, mark 6); medial arm incision
for the biceps nerve and brachialis nerves (see Fig. 36.7, mark
3); and a contralateral neck C-curved incision for contralateral
C7 spinal nerve dissection and transfer (see Fig. 36.7, mark 5).
The different incision lines are used to avoid: a large incision
wound, unnecessary dissection, prolonged operative time,
increased postoperative morbidity (pain and numbness), and
long ugly scars.
Landmarks and key points for
supraclavicular dissection
1. A platysma musculocutaneous flap is elevated with the
C-curved incision.
2. Dissection beneath the sternocleidomastoid muscle to
the internal jugular vein is made but should never go
beyond the internal jugular vein, the most medial
landmark of the brachial plexus exploration. In addition,
the suprascapular sensory nerves are the uppermost
landmark, and one should never go above them.
3. The omohyoid muscle just behind the
sternocleidomastoid muscle is identified and spared if
Fig. 36.8  Chuang angle, and “white line” between clavicular and sternal part of
pectoralis major muscle (see text). C-PM, Cervical part of pectoralis major; S-PM,
sternal part of pectoralis major.

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CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
possible as it is an important landmark for possible
secondary exploration.
4. Below the omohyoid muscle, there is an abundance of
adipofascial tissue containing rich lymphatic ducts,
lymph nodes, and the transverse cervical vessels. A
similar C-shaped incision along the internal jugular vein
medially and subclavian vein inferiorly is made and a
superiorly based adipofascial flap is elevated. All the
lymph tissues, including the ducts coming from the
deep plane of the internal jugular vein, should be
coagulated or ligated before division to avoid
postoperative lymph leakage. The phrenic nerve and
anterior scalene muscle are identified following
adipofascial flap elevation.
5. The transverse cervical artery and vein in the inferior
plane of the adipofascial tissue are preserved if possible
as they are potentially required as the recipient vessels
for a vascularized ulnar nerve graft. Sometimes the
transverse cervical artery is abnormally beneath the
brachial plexus. The subclavian artery just beneath
the scalene anterior muscle is carefully protected.
6. The fibrotic scalene anterior muscle can be segmentally
or totally excised depending on the necessity to
expose the more proximal spinal nerve in level II
injury for intraoperative diagnosis and nerve
manipulation.
7. The vertebra C5 has a more prominent anterior tubercle
of the transverse process than vertebra C6 or C4. While
detaching the scalene anterior muscle and fascia, the
nerve comes out above the tubercle is C5, and below is
C6 spinal nerve.
8. Other anatomic landmarks are also helpful for
localization:
a. The nerve beneath the transverse cervical artery is
usually C5 or the upper trunk.
b. The nerve beneath the subclavian artery is C8 or the
lower trunk.
c. The first branch from the upper trunk is the
suprascapular nerve, exiting from the plexus and
traveling backward. The division beside the
suprascapular nerve is the posterior division of the
upper trunk, which travels in a posterior plane, while
the anterior division of the upper trunk travels in an
anterior plane.
d. The spinal accessory (XI) nerve can be found through
two ways: (1) dissection between the adipofascial
tissue and platysma skin flap down to the trapezius
muscle where the XI nerve lies in front of the
trapezius muscle; or (2) extending the incision
upward across the supraclavicular (sensory) nerves to
locate the great auricular nerve, when the XI nerve
will be seen within about one finger-breadth above
the great auricular nerve, and beneath the
sternocleidomastoid muscle. This can be confirmed
by a nerve stimulator.
Landmarks and key points for
infraclavicular dissection
1. Chuang’s angle (Fig. 36.8A) is an angle shaped
by the main branch of the cephalic vein on one side and
the clavicle on the other side. Some of the deltoid and
the clavicular part of pectoralis major muscle
attachments can be detached to increase the angle
zone. Under the clavicle is the subclavius muscle, and
under the subclavius muscle is a space where the
posterior cord, lateral cord, and suprascapular
nerve can be seen. From this, the suprascapular and
infrascapular fossa can be connected through this
avascular plane which can be created by a finger
dissection without fracturing the clavicle. The clavicle
and the subclavius muscle are lifted together by a rolled
gauze.
2. The “white line” (see Fig. 36.8B) is an intermuscular
septal line between the clavicular and sternal parts of
pectoralis major muscle. Opening the line, the
underlying pectoralis minor muscle and infraclavicular
brachial plexus can be visualized. Some anatomical
landmarks are also helpful for anatomical localization
infraclavicularly. The first cord encountered beneath the
proximal pectoralis minor muscle is the lateral cord.
Y-shaped limbs from lateral and medial cords will
become the median nerve. The axillary artery (the artery
beyond the first rib is axillary artery) can be easily
found between the Y-shaped limbs. The posterior cord
lying posterior to the subclavian artery has two terminal
branches: the larger one is the radial nerve, and the
smaller one is the axillary nerve.
3. In the upper arm, the musculocutaneous nerve can
usually be found between the biceps and
coracobrachialis muscles. The musculocutaneous nerve
will penetrate the proximal coracobrachialis muscle.
Sometimes it has anatomical variation and comes from
the median nerve.
4. The axillary nerve in the axilla can be found at the
humeral neck, above the tendinous portion of the teres
major, accompanied by the lateral circumflex humeral
artery.
Surgical techniques
Surgical methods include neurolysis, nerve grafts, nerve
transfers and functioning free muscle, depending on preop­
erative diagnosis of level of injury and intraoperative findings.
The following pages detail our experience with BPI treatment
in terms of the level of injury (see Table 36.5).
Level I injury
The incidence of level I lesions is unfortunately very high,
about 70%. Most are avulsion injuries. Nerves may be avulsed
from the spinal cord (true avulsion), or ruptured at the pre­
ganglionic roots and rootlets. Partial Brown–Séquard syn­
drome is an example of true avulsion.22 One to all five roots
may be avulsed. Root avulsion injuries lack central connection
and are considered irreparable. Nerve transfer, pedicled or
functioning free muscle transplantation (FFMT) provide the
only possibilities for functional restoration.
Nerve transfer (Video 36.3
)
Nerve transfer is a surgical option which intentionally divides
a physiologically active nerve (with low donor morbidity)

827
Adult brachial plexus injury
and transfers it to a distal, more important but irreparable
paralyzed nerve. The procedure is best done within a golden
time period – within 5 months of the injury,9,33 in order to
reactivate the paralyzed muscle(s) effectively (aiming for M4).
Nerve transfer can be broadly classified into four categories:
(1) extraplexus; (2) intraplexus; (3) close-target nerve transfer
(or distal nerve transfer); and (4) end-to-side neurorrhaphy
nerve transfer.
Extraplexus nerve transfer
Extraplexus nerve transfer involves the transfer of a brachial
plexus neighboring nerve (from either the ipsilateral or
contralateral neck) to the avulsed brachial plexus for neuroti­
zation of a paralyzed nerve. The commonly used donor nerves
are mostly aimed at motor reinnervation.33 These donor nerves
include the phrenic (Ph) nerve, spinal accessory (XI) nerve
(accessed by an anterior neck approach), deep motor branches
of the cervical plexus (cervical motor branches, CMB), hypo­
glossal nerve (XII), and the contralateral C7 (CC7) spinal
nerve. Extraplexus sensory nerve transfer such as supracla­
vicular sensory nerve to median nerve transfer is sometimes
used to provide sensation to the paralyzed hand.
Intraplexus nerve transfer
Intraplexus nerve transfer is applicable in cases of non-global
root avulsion, in which at least one of the spinal nerves is
not ruptured and is still available for transfer – not to its
original pathway, but to other more important nerves. For
example, in a case of C5 rupture and C6 root avulsion, the
C5 fibers are intentionally transferred to C6 (or the anterior
division of the upper trunk) for elbow flexion, and the distal
C5 (combining the posterior division of the upper trunk and
suprascapular nerve) is then reinnervated by the phrenic
and/or spinal accessory nerve (extraplexus) nerve transfer
(Fig. 36.9). This strategy acknowledges that elbow flexion
has priority over shoulder reconstruction. Intraplexus nerve
transfer is individualized depending upon the intraoperative
findings, the surgeon’s philosophy, and the patient’s condi­
tion and requirements. Extraplexus and intraplexus nerve
transfers are both considered as proximal nerve neurotization
(see Fig. 36.9).
Closed-target nerve transfer (or distal nerve transfer)
Closed-target nerve transfer is a procedure that provides a
direct coaptation at a more distal site, closer to the neuromus­
cular junction, thus achieving faster recovery of motor out­
comes. Closed-target nerve transfer is defined as a procedure
outside the supra- and infraclavicular fossa. Examples include
spinal accessory (XI) nerve transfer to the suprascapular nerve
via a posterior approach; partial ulnar nerve transfer to the
biceps nerve; partial median nerve transfer to the brachialis
nerve; long head of triceps branch transfer to the anterior
division of axillary nerve (Fig. 36.10); intercostal nerve transfer
to the biceps nerve or the musculocutaneous nerve, or the
nerve of the long head of triceps; anterior interosseus nerve
transfer to the radial or posterior interosseus nerve; and
branch of the anterior interosseus nerve transfer to the deep
motor branch of the ulnar nerve in the forearm. Closed-target
nerve transfer is considered as distal nerve transfer.34 Selecting
proximal or distal nerve transfer as a reconstructive strategy
is now a subject of much debate (see Table 36.6).
Fig. 36.9  A case of left brachial plexus injury with drop shoulder and elbow.
Exploration proved C5 rupture and C6 root avulsion. This patient received C5 nerve
grafted (5 cm ×4) to C6 (intraplexus nerve transfer), and phrenic nerve plus spinal
accessory nerve both transfer to the distal C5 (extraplexus nerve transfer).
(A,B) Results after 3 years’ rehabilitation showed good shoulder and good
elbow recovery.
A
B
A cohort of 188 patients with different methods of muscu­
locutaneous nerve neurotization for acute brachial plexus
injuries were selected based on inclusive criteria in the
author’s series.35 Musculocutaneous nerve neurotization from
C5, medial cord, C8, contralateral C7, spinal accessory nerve,
or phrenic nerve to obtain elbow flexion were all included
into the group of proximal nerve transfer. Musculocutaneous
neurotization from partial ulnar nerve and/or partial median
nerve was classified into distal nerve transfer. Intercostal
nerve transfer to the musculocutaneous nerve was categorized
into a separate group. Results showed there were no signifi­
cant differences in the success rate of recovery of elbow flexion
(M > 3) between the use of proximal vs. distal nerve transfer
(P = 0.424). Even though the speed of recovery was faster in

828
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CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
injury) and neurolysis is maybe the only procedure without
further cutting the nerve. Other donor nerves such as phrenic
nerve, spinal accessory nerve, hypoglossal nerve, cervical
motor branches can also be found without additional inci­
sions. However, in proximal nerve graft/transfer, dense scars
with difficult dissection will be encountered. Sometimes one
needs to trim out the part of C5 transverse process to access
the ruptured stump. Oozing and bleeding will occur very
often and requires careful diathermy. Long operation time
can be expected. The health of proximal ruptured stump is
sometimes unpredictable, even accessed microscopically.
Interposition of nerve grafts is always required, which can
jeopardize functional recovery and longer rehabilitation time
is necessary. Proximal nerve graft/transfer can be applied
in either complete or incomplete avulsion brachial plexus
injuries.
End-to-side neurorrhaphy nerve transfer
End-to-side neurorrhaphy (terminolateral neurorrhaphy) is a
technique to transfer the distal end of a paralyzed and irrepa­
rable nerve to the side of an intact nerve with an epineurotomy
window for both motor and sensory reconstruction.36 The
author has never used this technique for BPI.
the distal group, 19 months vs. 23.9 months, the difference
was also not significant. The only statistically significant dif­
ference was the speed of recovery between the use of partial
ulnar nerve ± median nerve fascicle and the use of intercostals
nerves (P = 0.046). However, a selective number of patients
had grip strength deficits resulted from distal nerve transfers
for many years.
From the author’s point of view, the new strategy of distal
nerve transfer can provide an exciting alternative of the
traditional proximal nerve graft and/or transfer. However,
distal nerve transfer should not be applied in situations where
proximal nerve graft/transfer is more indicated. Proximal
nerve graft/transfer (extraplexus and intraplexus nerve
transfer) is still the main reconstructive procedure based on
the principle of “No diagnosis, no treatment” (Fig. 36.11).
Proximal nerve graft/transfer is usually performed during
brachial plexus exploration. It is quite common to find out
the proximal ruptured spinal nerve for reconstruction, which
is especially true for C5, even with a preoperative diagnosis
of total root avulsion. In proximal nerve graft/transfer, if the
transferred nerve comes from its original spinal nerve, it is
usually more powerful with a huge number of axons. Proximal
nerve graft/transfer can avoid iatrogenic injury where the
lesion is still in continuity (more are Sunderland third-degree
Fig. 36.10  A 17-year-old young male had right brachial plexus injury with C5 and C6 two-root avulsion. He
received multiple nerve transfers: spinal accessory nerve transfer to the suprascapular nerve (extraplexus
nerve transfer), and triceps branch (to long head of triceps) transfer to the anterior division of the axillary
nerve, ulnar nerve fascicle to the biceps branch and median nerve fascicle to the brachialis branch (distal
nerve transfer). (A–C) Results after 2 12 years showed good shoulder and elbow recovery with good shape
of supraspinatus, infraspinatus, deltoid, and elbow flexor muscles.
A
B
C

829
Adult brachial plexus injury
an average of 160° shoulder abduction was achieved follow­
ing triple nerve transfers, but 85° following double nerve
transfers and 65° following single nerve transfer.37
Elbow
In level I injury, reconstruction for elbow flexion is always the
first priority in adult BPI (in OBPP, reconstruction for hand
function is the first priority). Reported donor nerves for elbow
flexion include intercostal nerve, XI nerve with a nerve graft,
Ph nerve with or without nerve graft, partial ulnar nerve,
partial median nerve, pectoral nerve, thoracodorsal nerve,
and CC7. The recipient nerve is the musculocutaneous
nerve (mixed nerve), biceps nerve, or brachialis nerve. Elbow
extension is usually a lower priority for reconstruction. Ph
nerve transfer to the distal C5 or to the posterior division of
the upper trunk, or to the radial nerve with a nerve graft, can
Reconstructive strategies
Shoulder
Reconstruction for shoulder abduction in a level I lesion should
take priority over shoulder adduction. If the supraspinatus,
infraspinatus, and deltoid muscles are innervated simultane­
ously, results are predictably better. The Ph and XI are the
main donor nerves for shoulder abduction. The XII nerve,
CMB, part of C5 or C6, long thoracic nerve, branch to the long
head of triceps, medial pectoral nerve, intercostal nerves, and
CC7 have also been reported as the donor nerve for shoulder
abduction. The recipient nerves for shoulder abduction in
order of priority are the distal C5, suprascapular nerve, dorsal
division of the upper trunk, then axillary nerve.33 A study
of a series of patients operated on between 2000 and 2003
demonstrated that triple nerve transfers produced the best
and most consistently reliable results for shoulder elevation:
Fig. 36.11  A case of right brachial plexus injury with drop shoulder and elbow for 5 months. (A) A healed
scar over right neck was seen at the first clinic visit. Intraoperative findings 1 month later showed dense
scars around C4, C5 and C6. Only external neurolysis with decompression was performed. (B,C) Results
after 1-year rehabilitation showed good recovery. This case proved the principle of “No diagnosis, no
treatment.”
A
B
C

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Fig. 36.12  (A,B) Example of results of one-stage surgery for C5 rupture, C6–T1 four-root avulsion 5 years after (1) phrenic nerve transfer to the posterior division of the
upper trunk and spinal accessory transfer to the distal suprascapular nerve for shoulder elevation; (2) three intercostal nerves (T3–5) transfer to the musculocutaneous nerve
for elbow flexion; and (3) proximal C5 transfer to the median nerve using vascularized ulnar nerve graft for finger flexion and sensation.
A
B
often yield elbow extension, usually in the third year of
rehabilitation. Some authors describe transferring two or
three intercostal nerves to the branch of the long head of
triceps to achieve elbow extension.38
Finger
In global C5–T1 injury (or total limb palsy) reconstructive
priority for finger function depends on the procedure used:
nerve transfer or FFMT.39 Traditionally, reconstruction for
finger flexion is preferable to finger extension which can
sometimes be helped by a dynamic extension splint. In cases
of C5 rupture with C6–T1 four-root avulsion, transfer of C5 to
the median nerve (Fig. 36.12), or in cases of total root (C5–T1)
avulsion, transfer of the CC7 to the median nerve (Fig. 36.13)
can be performed to achieve finger and wrist flexion as well as
finger sensation. Each procedure requires a vascularized ulnar
nerve graft.
In total root avulsion, multiple nerve transfers first vs.
FFMT reconstruction first is a subject of much debate (see
Table 36.7). In the acute stage of BPI, using multiple nerve
transfers to treat the total root avulsion, which is proposed by
the author,40 aiming to achieve a one-stage full reconstruction
for shoulder, elbow, and hand functions, is a traditional
strategy of proximal-to-distal reconstruction (Fig. 36.14). In
these cases, FFMT is used as a secondary adjuvant reconstruc­
tion to enhance results at a later stage. Using FFMT to achieve
hand function (finger extension and flexion) in the acute stage
is a new strategy of distal-to-proximal reconstruction, pro­
posed by Doi et al.,38,39 and is an alternative approach: A long
FFMT (usually gracilis muscle) from the clavicle down to the
extensor digitorum communis, innervated by the XI nerve, is
performed in the first stage, followed by a second long FFMT
from the second rib to the flexor digitorum profundus, inner­
vated by intercostal nerves in the second stage. In these cases,
nerve reconstruction such as C5 transfer, contralateral C7
transfer, or intercostal transfer is an adjunctive procedure for
shoulder function. The biggest remaining deficit in Doi’s
method is that the reconstructed patients had no or poor hand
sensation. Comparison between multiple nerve transfers vs.
FFMT to treat total root avulsion of BPI in the acute stage is
illustrated in Table 36.7.
Pedicled muscle transfer (Video 36.2
)
Pedicled muscle transfer is indicated in non-global BPI such
as C5–6 root avulsion with intact C7–T1. Local latissimus
dorsi muscle transfer for elbow flexion or finger flexion,
or even for shoulder abduction; local pectoralis major muscle
transfer or local pectoralis minor transfer for elbow flexion;
part deltoid transfer for elbow extension; and forearm
muscle transfer for intrinsic palsy are examples of pedicled
muscle transfer. Using a reinnervated muscle transfer as a
pedicled muscle transfer is also an issue of debate. Preopera­
tive muscle strength examination is very important. Before
a reinnervated muscle can be used, it should be at least M4
muscle strength. Otherwise many of these transfers are useless
and wasted. For example, using a local latissimus dorsi
muscle transfer for elbow flexion in C5 and C6 (±C7) avulsion
injury usually results in M3, but not M4 muscle strength,
compared with latissimus dorsi transfer for the traumatic loss
of biceps and brachialis, which always results in M4 muscle
strength. The reason for this difference in outcome is the state
of the thoracodorsal nerve, which originates from C6–8. In the
former example, the thoracodorsal nerve is actually an injured

831
Adult brachial plexus injury
Fig. 36.13  Example of results of one-stage
surgery for total root avulsion 5 years after
(1) left contralateral C7 transfer to the
median nerve using a vascularized ulnar
nerve graft for finger flexion and sensation;
(2) three intercostal nerves (T3–5) transfer
to the musculocutaneous nerve for elbow
flexion; and (3) phrenic nerve transfer to the
suprascapular nerve for shoulder elevation.
(A) Shows 90° shoulder elevation; (B) M4
elbow flexion; and (C,D) M3 finger flexion.
B
C
A
D
Fig. 36.14  A 17-year-old girl had left brachial plexus injury with total root avulsion. She received multiple nerve transfers simultaneously with right contralateral C7 transfer
to the median nerve for finger flexion and sensation, three intercostal nerves (T3–5) transfer to the musculocutaneous nerve for elbow flexion, and spinal accessory nerve
transfer to the suprascapular nerve and phrenic nerve transfer to the posterior division of the upper trunk for shoulder. (A,B) Results 5 years after showed good shoulder,
good elbow, and acceptable hand function and sensation.
A
B

832
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
Level IV injury
Level IV BPI involves the cords and their terminal branches.
The incidence is high (17%), second after level I injury. Level
IV injury is commonly limited to this zone only and rarely has
proximal level involvement. Level IV injuries are mostly
encountered with nerve ruptures and rarely with nerve avul­
sion. Any nerve avulsion here is distal avulsion at the bone
margin (suprascapular nerve avulsion at the scapular notch,
or axillary nerve at the humeral neck, or radial nerve at the
spinal canal inlet), or at the muscle attachment (such as the
musculocutaneous nerve from the biceps surface). In closed
level IV injury, the nerve damage is variable, ranging from
simple isolated nerve injuries (axillary, musculocutaneous, or
radial nerve) to lesions of all cords or all terminal branches.
Level IV injury has particular characteristics with specific
challenges in surgical dissection and repair due to dense scar­
ring. Nerve grafts are more frequently used with less aberrant
reinnervation and better prognosis. There is a high incidence
of vascular injury, rupture or segmental occlusion of the
subclavian or axillary artery – about 30%. For ease of dissec­
tion, detachment of the insertion of the pectoralis major
muscle by Z-lengthening incision is often required. For pen­
etrating injuries, vascular and nerve repairs are usually per­
formed simultaneously.
The golden time for primary direct repair of a divided
nerve without nerve grafts in penetrating injury is within 2
weeks. Traction injuries in level IV are usually associated with
fracture of the proximal humerus or the glenoid scapula. The
nerve segments have been extensively damaged. Long nerve
grafts are usually required to bridge the nerve gap, commonly
more than 8 cm in length. Sometimes a C-loop vascularized
ulnar nerve graft is harvested from the paralyzed forearm
and utilized for median and radial nerve reconstruction. The
results are usually good. In nerve avulsion from the muscle,
nerve grafting of the proximal nerve stump and direct implan­
tation into the muscle (nerve-to-muscle neurotization) yield
fair results (around M3). As described previously, FFMT is
another option of reconstruction for such cases.
Postoperative management and rehabilitation
Immediate postoperative splinting for 3 weeks is required
after nerve grafts or nerve transfer. Thereafter, retraining and
rehabilitation should start, including physiotherapy (to avoid
joint stiffness), muscle stimulation (to delay muscle atrophy),
brain cognition, biofeedback, and occupational therapy.
Patients should be followed periodically by the surgeon
(every 3–4 months) and the physical therapist (twice a month).
Patients are encouraged to have electric muscle stimulation at
home (twice a day). In cases of intercostal nerve transfer,
passive shoulder elevation remains restricted to less than 90°
for 6 months. Regular follow-up in the rehabilitation center
and outpatient clinic is tremendously important, and should
be explained to patients before and emphasized again after
surgery.
Induction or motivation exercise is an important muscle
exercise for patients with nerve transfer and/or functioning
free muscle. The original function of the donor nerve must be
practiced to induce movement in the target muscles newly
innervated by the transfer. For example, patients who have
undergone intercostal nerve transfer must increase their
nerve, but in the latter example of traumatic muscle loss,
the thoracodorsal nerve is an uninjured one. Local pedicled
muscle transfer, although an alternative restorative option, is
often not reliable due to the presence of a partial nerve injury.
Functioning free muscle transplantation (FFMT)
FFMT is the transfer of a muscle utilizing microvascular
anastomoses for revascularization and microneural coapta­
tion to the recipient motor nerve for reinnervation. The use of
FFMT in brachial plexus reconstruction is one example of the
application of nerve transfer (including extraplexus, intra­
plexus, and closed-target nerve transfer).39,41 It has been shown
to be effective and has become increasingly popular. The
gracilis myocutaneous FFMT is the most common and best
choice of donor muscle in brachial plexus reconstruction. The
commonly used donor nerves include the XI, the intercostal,
the Ph nerve, the CC7 nerve, part of the ulnar nerve, part of
the median nerve, or more proximally from the infra- or
supraclavicular nerve, which requires nerve elongation (with
a nerve graft in the first stage) and then FFMT in a two-stage
procedure. The results from FFMT are more satisfactory than
those achieved with a local muscle transfer. It is especially
useful for elbow and hand function restoration in global
plexopathy. Indications for FFMT in BPI include acute or
chronic root avulsion, root injury with failed nerve transfer
(muscle strength less than M3), or BPI with associated Volk­
mann’s contracture of the forearm.
Level II injury
Level II injury is defined as an injury distal to the dorsal root
ganglion (or outside the intervertebral foramen) but between
the scalene muscles and proximal to the suprascapular nerve.
If the suprascapular nerve is intact, the lesion will be in
level III–IV and not in level II. The incidence of a pure level
II injury is approximately 8%. Disruption of the spinal nerve
with neuroma formation and dense scar tissue involving
the scalene muscles (especially the middle scalene muscle)
are the main findings in this type of injury. Nerve rupture
may occur at one or multiple spinal nerves. The clinical dif­
ferential diagnosis between preganglionic root (level I) and
postganglionic spinal nerve (level II) injury is of great impor­
tance with regard to the surgical approach and prognosis.
Reconstruction for this level of injury includes neurolysis,
nerve repair, nerve grafts, and nerve transfer if associated
with level I lesion in other spinal nerves, and palliative
reconstruction.
Level III injury
Level III injury involves the trunks and divisions. In the
author’s series, only 5% of patients were injured purely in this
zone. Nerve rupture with neuroma formation and dense scars
were the most common findings. Bypass nerve grafting is
required to re-establish the connection between the supra-
and infraclavicular brachial plexus. A clavicle osteotomy is
often required for wound exposure, especially for injuries
involving the lower trunk, to allow grafting or direct neuroly­
sis. Multiple nerve grafts are required and need to be harvested
from different locations. A C-loop vascularized ulnar nerve
graft is sometimes helpful to reduce the amount of nerve
grafts, especially in cases of extensive injury.

833
Pediatric brachial plexus injury (obstetric brachial plexus palsy)
Key points
• OBPP has significant differences from adult BPI, including
mechanism of injury, classification of injury, clinical
evaluation, intraoperative findings, reconstructive strategy,
postoperative rehabilitation and follow-up, result
assessments, and pain character. It therefore presents as a
separate entity (see Table 36.1).
• OBPP has two distinct phases: (1) infant OBPP (I-OBPP);
and (2) sequelae OBPP (S-OBPP). Both have significant
differences in management and prognosis, and will be
discussed separately.
• I-OBPP includes risk factors, clinical presentation,
preoperative evaluation, timing of nerve surgery, surgical
exploration of the brachial plexus, reconstructive strategies
for nerve surgery, postoperative management, and
outcomes assessment.
• S-OBPP includes aberrant reinnervation, shoulder
reconstruction, elbow reconstruction, and forearm and hand
reconstruction.
deep-breathing rate to induce movement in their target
muscles. An induction exercise is commenced when move­
ment of the innervated muscles is palpable (M1). The action is
comparable to an internal electric stimulator. Various nerve
transfers have different induction exercises.33 Realizing the
importance of these exercises is crucial. This explains why
good results are commonly achieved by psychologically strong
and ambitious patients who cooperate well in terms of their
rehabilitation program, while poor results are often obtained
by uncooperative patients. Permanent external orthosis to
extend the interphalangeal joints of the fingers is always
required for intrinsic palsy of the hand to improve the final
result of surgical reconstruction and long rehabilitation
programs.
Palliative reconstruction for sequelae
deformities (Video 36.1 )
Palliative reconstruction procedures include local muscle or
tendon transfer, FFMT, tenodesis, and arthrodesis, or alterna­
tively the use of orthotics and prosthetics. Palliative recon­
struction can be considered when the injury involves C8 and
T1 level (Klumpke’s palsy in adults), or when deformities
persist after maximum recovery either with or without nerve
reconstruction.
Outcome evaluation (Videos 36.4, 36.5, 36.7 )
Although the British MRC scale provides the possibility of
homogeneity and consensus in motor evaluation, a consider­
able degree of heterogeneity exists in the evaluation of func­
tional recovery of the shoulder, elbow, and digits. In the
author’s opinion, establishing an international consensus on
motor evaluation of different movements is vital and impera­
tive for the advancement of our understanding and mutual
comparison. The British MRC scheme is used for individual
muscle evaluation in plexus injuries, or for evaluation of the
transferred muscle in FFMT. Both are evaluated by target joint
movement.
Conclusion
Closed traction injuries of the brachial plexus are devastating
injuries. For someone who has nothing, a little is a lot. Patients,
especially those with total root avulsion, should be encouraged
to recognize their disabilities and make use of the regained but
not completely recovered limb. This may be shoulder elevation
of 60°, M4 elbow flexion strength, and M2–3 strength of finger
flexion following reconstruction. In a failed reconstruction, or
if the patient perceives the injured limb as a useless dead
weight, amputation may be considered as a last option.
Future directions
■ Endoscopic-assisted and/or robot-assisted surgery for
brachial plexus reconstruction.
■ Unifying the level of brachial plexus injuries from level
I–IV.
■ Unifying outcomes evaluation in a simple,
straightforward manner.
■ Increasing the accuracy of MRI studies for diagnosis and
evaluation.
Pediatric brachial plexus injury
(obstetric brachial plexus palsy)
Clinical tips
• OBPP is an obstetric trauma; risk factors include
overweight babies (> 4000 g) in cephalic presentation,
underweight babies (< 2500 g) in breech presentation, or
fetal distress (such as septicemia) with loss of protective
muscular tone during Caesarean section.
• Infant OBPP focuses on nerve surgery, timing of surgery,
and results from nerve surgery.
• Sequelae OBPP focuses on palliative reconstruction for
shoulder, elbow, and hand deformities.
Introduction
There are different but similar terms being used to describe
pediatric brachial plexus injury in the literature, such as
obstetric (or obstetrical) brachial plexus palsy (OBPP),42 neo­
natal brachial plexus palsy (NBPP),43 or brachial plexus birth
palsy (BPBP).44 In this chapter, pediatric brachial plexus injury
is termed OBPP for obstetric brachial plexus palsy.
OBPP almost always results from traumatic delivery,
although some other possible causes have been mentioned.45
Overweight babies (> 4000 g) in cephalic presentation, under­
weight babies (< 2500 g) in breech presentation, and fetal
distress (such as septicemia) with loss of protective muscular
tone during Caesarean section are all susceptible to brachial
plexus injury following delivery. It is caused by traction force
during delivery, which widens the angle between neck and
shoulder and induces the plexus nerves damage. The term
“palsy”, not “injury” as in adult BPI, has been used to describe
pediatric BPI from a very early point in the literature, in 1872,
by Duchenne.45

834
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
There are many differences between OBPP and adult BPI
(see Table 36.1). The incidence of stretch (neurapraxia or
axonotmesis) and incomplete rupture are more common in
OBPP than in adult BPI in which complete rupture or avulsion
is often seen. Often there is paresis (incomplete paralysis)
rather than flaccid paralysis (complete paralysis) in OBPP.
Even when there is complete rupture, the gaps are short and
spontaneous regeneration is still possible; while in adult
brachial plexus injury the gaps are long and the scars are
dense which make spontaneous regeneration impossible. In
OBPP, most are Erb’s palsy (upper plexus injury), and the
lesion is always supraclavicular. Mixed complex neuroma of
the upper and middle trunk is frequently seen, and motor
recovery with misdirection (or aberrant reinnervation) often
occurs in OBPP, particularly in the muscles innervated by the
upper and middle trunks. Aberrant reinnervation causes
abnormal co-contraction of multiple muscles, especially in the
shoulder and elbow. Aberrant reinnervation diminishes func­
tion significantly, even in those patients considered to have
had complete spontaneous recovery. This is why consequent
deformities develop in OBPP and many require reconstruc­
tion. In adult BPI, the location of injury varies. Aberrant
reinnervation occurs only in cases of penetrating injury of the
upper trunk where trunk to trunk repair is performed directly
or indirectly with short nerve grafts. Recovery after nerve
reconstruction is generally slow in OBPP. Improvement con­
tinues for at least 3 years. Poor cooperation and rehabilitation
may be a factor. The most improved period after nerve recon­
struction is at 3 years of age. This is why second reconstruction
is always performed after the age of 4 years. Regarding sensa­
tion recovery, it usually greatly exceeds that of muscle and
sympathetic function. Central plasticity may be a factor. OBPP
patients always show remarkable absence of neuropathic
pain.
For the purpose of treatment, OBPP can be subdivided into
two distinct phases: (1) I-OBPP, and (2) S-OBPP (or late OBPP
with deformity).46 These patients may present at any time and
have a wide variation in clinical presentation. All stages have
different management and prognosis. I-OBPP refers to the
infant’s brachial plexus that has been paralyzed following
delivery. Some require early nerve surgery and some do not.
Reconstruction is focused on primary nerve surgery, in which
timing of intervention and results of nerve surgery are a
concern. S-OBPP refers to the sequelae deformities resulting
from I-OBPP with or without previous nerve surgery. Many
S-OBPP patients request surgical correction for the shoulder,
elbow, forearm, and hand.47–49 Reconstruction in sequelae
OBPP is focused on palliative surgeries on bone or joint,
tendon or muscle, and no longer on nerve surgery of the
brachial plexus.
Infant obstetric brachial plexus palsy
Although the evolution of microsurgical nerve repair has
significantly allowed surgeons to perform early intervention
for I-OBPP, many rehabilitation therapists50–51 and even some
surgeons52–53 continue to argue against early nerve surgery.
Arguments against early surgery include high rates of spon­
taneous recovery (70–92% in the literature), high risks of
surgery and postoperative care at an early age, and lack of
significant functional improvement. Nevertheless, following
developments in operative magnification (loupe and
microscope), refinements in nerve grafting and nerve transfer,
understanding of the brachial plexus anatomy, and patho­
physiology of nerve degeneration and regeneration, more
microsurgeons54–58 have begun to choose early nerve surgery
as the treatment of choice for I-OBPP. This group found that
the rate of spontaneous recovery was actually low (7–50%),
and early nerve surgery may potentially decrease or eliminate
the late sequelae. The results from the author’s series58 prove
that early nerve surgery, when indicated, is still the treatment
of choice for I-OBPP patients. In addition, the reconstructions
performed in the late group were found to be difficult,
and required complex procedures to achieve reasonable
results.47–49
Risk factors for I-OBPP during cephalic delivery include
high birth body weight (> 4000 g), shoulder dystocia, cepha­
lopelvic disproportion, forceps or vacuum suction delivery, or
poor technique of delivery. I-OBPP may also occur during
difficult breech presentation or in fetal distress (such as sep­
ticemia) during Caesarean section. Associated injuries with
birth palsy can be seen, including fracture (ipsilateral or
contralateral clavicle, humerus, femur, or ribs), respiratory
insufficiency (asphyxia) due to diaphragm palsy, ecchymosis
(neck, chest, face, or upper back), and wry neck (torticollis).
Although the cause of I-OBPP is still a subject to debate (some
believe it can be of intrauterine origin), the author believes
that it is caused by obstetric trauma and not due to intrauter­
ine compression neuropathy. All of the author’s intraoperative
findings in I-OBPP have been similar to adult brachial plexus
traction injury (avulsion, rupture with neuroma and mixed
with muscles), not like pictures of compression neuropathy
that presents with pseudoneuroma and are rarely mixed with
muscle fibers.
Clinical presentation
Determining the relationship between I-OBPP and S-OBPP
and predicting the progressive changes in I-OBPP with age is
a great challenge.46 Different surgeons have different opinions
about the clinical presentation of I-OBPP. In general, there are
five types of clinical presentation in I-OBPP: type 1 (or Erb’s)
palsy, which involves deficits of C5 and C6, resulting in a
posture of shoulder abduction or internal rotation, elbow
extension, and forearm pronation (Fig. 36.15A,B); type 2 (or
extended Erb’s) palsy, which extends further deficits to C7 or
C8, resulting in a posture of type 1 with wrist flexion (waiter
tip deformity); type 3 and 4 palsies involving the entire plexus
(global palsy), resulting in a flail arm without or with a
Horner’s syndrome, respectively; and type 5 (or Klumpke)
palsy, which involves an isolated lower plexus, resulting in
only a paralyzed hand (Fig. 36.16A,B). In unoperated cases,
type 1 or 2 is much more common than type 3 or 4. But in
operated cases, it is reversed: global palsy is more common
than Erb’s. Type 5 palsy is rarely seen, only in about 1%. In
about 1% of I-OBPP cases, the injury is bilateral but predomi­
nantly on one side, and it is frequently seen in breech delivery
or Caesarean section with fetal distress.
Clinical examination
Newborns are difficult to examine thoroughly. A precise
muscle or sensory examination of an infant is impossible. The
evaluation chart used for adult BPI (see Fig. 36.5) is not

835
Pediatric brachial plexus injury (obstetric brachial plexus palsy)
Fig. 36.15  (A) A 2-month-old infant showed improving shoulder abduction of his
right upper limb; (B) A 3-month-old infant showed improving elbow flexion of her
right upper limb. Both were type 1 OBPP with no need for primary nerve surgery.
A
B
practical. Evaluation should include parents’ observation at
home, especially during bathing or dressing, and the exam­
iner’s observation in clinic. The infant is placed in the lateral
decubitus position with the normal side down. The examiner
then tickles the baby (tickling test, Fig. 36.17A), or covers the
infant’s face with a towel (towel test, see Fig. 36.17B) and uses
this to evaluate dynamic movements of the infant’s shoulder,
elbow, and hand. An M2 (movement with weight eliminated)
muscle strength score in a newborn infant is sufficient to
predict a good result when the infant grows. In I-OBPP, there
is no need to see M4 or M5 muscle strength as in adult BPI.
Horner’s syndrome with signs of ptosis or miosis may disap­
pear with time, indicating that the T1 has a stretch but not an
avulsion injury, or that T1 has a good connection with T2
(postfixed brachial plexus). An ipsilateral clavicle fracture is
Fig. 36.16  (A,B) A 4-year-old girl shows isolated type 5 (Klumpke) palsy of her
right upper limb.
A
B
usually a good prognostic sign due to traction force diver­
gence. However, a contralateral clavicle fracture is usually a
bad prognostic sign as this indicates a high energy traction
force. Ideally the infant should be followed up after birth and
then at 1-month intervals until the decision to operate or not
is made.
Neurophysiologic studies are not performed routinely.
EMG in I-OBPP is usually positive and too optimistic, and
may not be accurate enough to predict useful function. Even
intraoperative EMG can be misleading. Improving techniques
of MRI are now useful to evaluate level I and II lesions as in
adult BPI, and are becoming the author’s routine investiga­
tion for preoperative imaging (Fig. 36.18A–D). CT myelogram
can also be useful.
Timing of surgery
Gilbert59 recommends surgical intervention for infants without
evidence of elbow flexion by 3 months. Terzis and Papakon­
stantinou60 emphasize that the presence of total palsy with
Horner’s syndrome warrants earlier surgical intervention at

836
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
biceps function and little or no hand function is an indication
for early exploration within 3 months. However, in the pres­
ence of wrist extension and finger flexion, an additional 3
months of observation is recommended. If by 6 months of age
there continues to be no improvement in elbow flexion, then
exploration is indicated. If poor shoulder or elbow function
persists by 1 year of age, surgery is indicated too. However,
poor hand function at this late age is not an indication for
exploration as it is too late. The observation of M2 wrist exten­
sion or interphalangeal extension on clinical examination may
imply that C7 may be injured (more often with avulsion), but
C8 and T1 are intact, warranting an additional 3-month period
of observation until the child reaches 6 months.
Preoperative preparation
Treating an OBPP patient is treating the whole family. A
thorough explanation of the risks and benefits of surgery to
the patient’s family is very important, including preoperative
diagnosis, surgical risks, postoperative care and rehabilita­
tion, long-term follow-up, possible outcomes, and possible
subsequent operations. After intubation, central venous pres­
sure and arterial lines with long catheters should be secured
in the femoral vessels. Those two vessel lines are crucial
during the operation and for the first 3 days of postoperative
care.
Surgical technique
Incision lines, dissection, and brachial plexus exploration are
all similar to adult BPI, except:
1. The platysma in infants is very thin and sparse,
resulting in an incision directly superficial to the surface
of the sternocleidomastoid muscle.
2. The phrenic nerve should be isolated and well
protected. Care should be taken during the operation to
avoid excessive traction as this may prolong the
extubation time due to transient palsy of the diaphragm.
3. All spinal nerves, C5–T1, should be identified and
examined.
4. The scalenus anterior muscle is usually segmentally
excised, permitting exposure of the level II spinal nerves
and release of compression of the subclavian artery.
5. Lesion-in-continuity of the upper and middle trunks is
commonly seen, requiring microneurolysis to evaluate
the severity of scarring and judge the degree of nerve
injury. If the scar is dense and the axis of the nerve
(proximal and distal segments) are badly distorted,
resection of the neuroma and nerve grafts are
required.
6. When the lesions are more distal involving the divisions
(level III injury), the incision is then extended to the
deltopectoral groove, exposing Chuang’s angle (see Fig.
36.8). The supra- and infraclavicular fossa are connected
by opening the space under the subclavius muscle. The
clavicle can be elevated easily without clavicle
osteotomy.
7. Nerve grafts are commonly harvested from the both
sural and saphenous nerves. If necessary, medial
cutaneous nerve of the arm, superficial radial nerve, and
lateral antebrachii cutaneous nerve from the injured
limb are other sources.
Fig. 36.17  (A) The tickling test; and (B) the towel test to examine the I-OBPP.
A
B
2 months of age. Clarke and Curtis61 advocate that failure to
perform a “cookie test”, to place a cookie in the mouth by 9
months of age is an indication for exploration. Our results58
indicate that shoulder and elbow recovery were not different
when surgery was performed at 2 months or at 11 months of
age. Even patients who received primary nerve surgery
beyond 1 year of age also showed significant improvement in
shoulder and elbow function, but no improvement at all in
hand function. In addition, our previous results showed
similar improvement of shoulder function in late palliative
reconstructions for late OBPP patients compared to those who
underwent primary early nerve surgery for I-OBPP.47 However,
recovery of hand function with secondary reconstructive
methods was far inferior to those who had early nerve surgery
for hand function.49 The ideal opportunity for improving
hand function is by performing nerve surgery early. Our
results demonstrate that Gilbert’s “rule of 3 months” overes­
timates the poor results of shoulder and elbow function.
However, Clarke and Curtis’s “rule of 9 months” underesti­
mates the poor results of forearm and hand function. The
presence of poor shoulder and elbow function in I-OBPP is
not an urgent indication for surgery. However, hand palsy is
an urgent condition, indicating early surgical intervention.
Therefore, our recommended timing of surgery falls between
that of Gilbert and Clarke. A global palsy with absence of

837
Pediatric brachial plexus injury (obstetric brachial plexus palsy)
about 5% (6/118). Preoperative MRI can be very helpful as a
diagnostic tool to see level I or II injury.
Pure rupture injury
Except six patients who had rupture of all three trunks, the
majority of patients (41/47, 87%) had rupture injury involving
the upper and/or middle trunk. The reconstructive proce­
dures consisted of microneurolysis and nerve grafts. Recon­
structive strategies in these pure rupture injury groups varied
Reconstructive strategies
Two groups of spinal nerve injury are classified based on
intraoperative findings: (1) pure rupture injury (40%, 47/118);
and (2) rupture injury associated with root avulsion (60%,
71/118) (Table 36.8). C5 and C6 tend to be ruptured, but C8–T1
tend to be avulsed (Table 36.9). If C8 is avulsed alone, T1 tends
to be avulsed too, but partially. Once C8–T1 two root avulsion
occurs, a ruptured C7 tends to have more proximal avulsion
injury too. In global palsy, incidence of three-trunk rupture is
Fig. 36.18  A 3-month-old with I-OBPP: (A) T2 MRI, coronal view to locate the level of cervical spine; (B) MRI 3D, coronal view, T2 normal on right side; MRI 3D FIESTA
and CPR techniques (C) ventral roots and (D) dorsal root showing left C7–C8–T1 root avulsion.
A
B
C
D

838
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
based on intraoperative findings and judgment. The majority
of patients received C5 nerve grafting to the suprascapular
nerve and posterior division of the upper trunk for shoulder,
and C6 nerve grafting to the anterior division of the upper
trunk for elbow function instead of proximal upper trunk
nerve grafting to the distal upper trunk (Table 36.10). Four to
six cable nerve grafts (2–3 cm in length) are usually required
for coaptation. A ruptured C7 has a high incidence of accom­
panying avulsion. The proximal stump of C7 was therefore
routinely repaired to the distal stump of C7 via nerve grafts.
There were few patients who received longer nerve grafting
(4–6 cm in length) from supraclavicular spinal nerves to the
infraclavicular selected target nerves (posterior and lateral
cord). Table 36.10 shows our reconstructive strategies for pure
rupture injury.
Rupture injury associated with root avulsion
A total of 72 patients (60%) were included in this series. Once
avulsion occurs, it tends to involve at least two roots (75%).
This type of reconstruction depends on the number of root
avulsions, and the remaining proximal neural resources. In
global palsy, restoration of hand function becomes the first
priority, followed by elbow flexion and then shoulder func­
tion (Table 36.11). In I-OBPP, C5 is usually ruptured, not
avulsed (see Table 36.9). The proximal C5 stump can be a
source for selective neurotization to the C8 or lower trunk
Table 36.8  Intraoperative findings of obstetric brachial plexus
palsy (1992–2004, Chang Gung Memorial Hospital)
Findings
Number of patients
(percent of total)
Ruptured injury alone
47 (40%)
Rupture of UT
17
Rupture of UT and MT
24
Rupture of UT, MT, and LT
6
Rupture and avulsion injury
72 (60%)
One-root avulsion
18
Two-root avulsion
28
Three-root avulsion
17
Four-root avulsion
9
Total
119
UT, Upper trunk; MT, middle trunk; LT, lower trunk.
Table 36.9  Incidence of type of injury on different spinal nerves
(1992–2004, Chang Gung Memorial Hospital)
Rupture
Avulsion
C5
117
12
C6
95
42
C7
49
79
C8
9
71
T1
8
39
Table 36.10  Reconstructive strategies for isolated rupture injury
Trunk rupture
Nerve reconstructive strategy
Upper trunk
C5-ng-SS and PD
C6-ng-AD
Upper and middle
C5-ng-SS and PD
C6-ng-AD
C7-ng-C7
Upper and middle and lower
C5-ng-SS and PD
C6-ng-AD
C7-ng-C7
LT-ng-LT
UT, Upper trunk; ng, nerve graft; SS, suprascapular nerve; PD, posterior division;
AD, anterior division of the upper trunk; LT, lower trunk.
(intraplexus neurotization). The frequency of nerve transfers
increases if associated root avulsion increases, including
intercostal nerve transfer for elbow or finger flexion, XI nerve
transfer for the shoulder, or intraplexus transfer from C5 or
C6 to the C8 or median nerve for hand function in three- or
four-root avulsion. Intercostal nerve transfer, either to the
musculocutaneous nerve for elbow, or to the median nerve
for hand function, is an effective procedure in infant patients
(much better than in adults). Few patients need contralateral
C7 transfer,40 branch of ulnar nerve transfer (Oberlin method62)
or combined branch of median nerve transfer (Mackinnon
method63). Table 36.11 shows our reconstructive strategies for
rupture injury associated with root avulsion.
In this series of patients, 10 cases of I-OBPP were operated
on late, at 1 year of age or older (range, 1 year to 2 years 6
months). Most of these patients showed poor spontaneous
recovery of shoulder and/or elbow function prior to surgery.
Primary nerve surgery for these late operative cases showed
encouraging results in shoulder and elbow function recovery,
but few gained recovery of hand function.
Postoperative management
A rigid premade neck splint is placed on every patient imme­
diately postoperatively (Fig. 36.19). Total operative time is
on average 8 h, with a range of 6–10 h. Postoperatively the
patient is transferred to the intensive care unit after extuba­
tion. The patient is cared for in the head-up position to avoid
dyspnea due to any temporary palsy of the diaphragm. The
patient is kept in the intensive care unit for 3–5 days, and then
transferred to the general ward for an additional 2 days. Total
hospitalization is approximately 1 week.
The neck splint is kept in place for 4 weeks. Follow-up at
regular intervals (the first month postoperatively and then
every 4 months afterwards) is performed for a minimum of 4
years. Home electrical muscle stimulation (twice daily for
15–20 min each time) is started 4 weeks after surgery and
performed for approximately 1 year or until muscle function
reaches M2 level.
There are two important exercises for prevention of shoul­
der adduction contracture: pull-up bar exercise (stretching
exercise), and swimming (dynamic exercise), where both
upper limbs are exercised simultaneously.

839
Pediatric brachial plexus injury (obstetric brachial plexus palsy)
Table 36.11  Nerve reconstructive strategy for rupture injury associated with root avulsion
Root avulsion
Nerve reconstructive strategy
For shoulder
For elbow
For hand
One
C5
XI-SS
C6-ng- (major) AD and (minor) PD
C7
C5-ng-SS and PD
C6-ng- AD
C5, C6 (minor)-C7
C8
C5-ng-SS and PD
T3–5 ICN-MCN
C6-ng-C8 (C7-ng-C7)
T1
C5-ng-SS and PD
C6-ng-AD
C7-ng-C7; C8-ng-C8
Two
C5 and C6
XI-SS
T3–5ICN-MCN
C8-ng-C8
C6 and C7
XI-SS
C5-ng-C6
C6-ng-C8
C7 and C8
XI-SS
T3–5ICN-MCN
C6-ng-C8 (or median)
C8 and T1(8)
XI-SS
T3–5ICN-MCN
(C7-ng-C7)
Three
C5–7
XI-SS
T3–5ICN-MCN
C6–8
XI-SS
T3–5ICN-MCN
C5-ng-median
C7, C8, and T1
C6-ng-SS and PD
T3–5ICN-MCN
C5-ng-median
Four
C6–T1
C5-ng-SS and PD
T3–4 ICN- MCN
T5–7ICN-median
C5-ng-SS and PD
T3–5ICN-MCN
CC7T-ng-C8
XI, Spinal accessory nerve; ng, nerve graft; SS, suprascapular nerve; ICN, intercostal nerve; MCN, musculocutaneous nerve; PD, posterior division; AD, anterior division
of the upper trunk.
Outcome assessment
There is a lack of consensus with regard to the optimal method
of assessing results. This is partly due to the complexity of the
lesions (i.e., aberrant reinnervation), complexity of the repair
(i.e., different surgical strategies), complexity of limb involve­
ment (shoulder, elbow, forearm and hand), and finally the
young age of the patients, which makes cooperation difficult.
The reported methods of functional assessment include MRC
muscle grading system, Gilbert and Tassin muscle grading
system, Clark and Curtis active movement scale, Narakas’
grading system, and others.42–45 All patients should be fol­
lowed for a minimum of 4 years. The results are categorized
as “good”, “fair”, or “poor” based on the degree of shoulder
abduction, external rotation, elbow flexion and extension, and
finger flexion (Table 36.12).
Results
Our overall results in C5 nerve grafting, especially to the
suprascapular nerve and posterior division of the upper trunk
for shoulder, and C6 nerve grafting to the anterior division of
the upper trunk for elbow function were consistently good
(Fig. 36.20A–D): shoulder abduction averaged 132° (90–180°),
shoulder external rotation averaged 67° (50–90°) and elbow
flexion was mostly M3. More than half of the patients (71/118,
60%) had rupture injury associated with at least one nerve
root avulsion. Seventy-five percent had at least two-root avul­
sion. Intraplexus nerve transfer from C5, or C6 to the C8 or to
the median nerve resulted in improvement of hand function.
Extraplexus nerve transfer by intercostal nerve transfer to the
musculocutaneous nerve or median nerve, and spinal acces­
sory nerve transfer to the suprascapular nerve have proved
useful for restoring shoulder abduction, elbow and finger
flexion (Fig. 36.21A–E).
The sequelae of obstetric brachial
plexus palsy
Aberrant regeneration (due to misdirection of regenerated
axons), muscular imbalance, and growth are the three main
causes of shoulder and elbow deformity in I-OBPP with or
without nerve surgery. Flaccid paralysis of the shoulder and
Table 36.12  Postoperative functional assessment of obstetric brachial plexus palsy
Good
Fair
Poor
Shoulder
Shoulder abduction
>120°
90–120°
<90°
Shoulder external rotation
>90°
60–90°
<60°
(Hand to occiput movement)
(Occipital line)
(Ear line)
(Preface or prechest)
Elbow
Hand to mouth movement
Easy (M = 3)
Difficult (M = 2)
Impossible (M < 2)
Elbow extension
Easy (M = 3)
Difficult (M = 2)
Impossible (M < 2)
Finger
Finger flexion
Easy (M = 3)
Difficult (M = 2)
Impossible (M < 2)

840
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
Fig. 36.19  (A,B) Postoperative neck splint.
A
B
2. Co-contraction between elbow flexors (biceps and
brachialis) and elbow extensors (triceps) can also
develop. In the mild type, patients are unable to
perform elbow flexion normally, such as pulling up
trousers, hand-to-flank or hand-to-spine movement. In
the severe type, patients cannot even perform hand-to-
mouth movement. Flexion contracture of the elbow
eventually develops.
3. Co-contraction between elbow flexors (mainly
brachialis) and shoulder abductors (mainly deltoid) is a
third possible occurrence. When asked to perform
hand-to-mouth movement, the shoulder will be
involuntarily elevated, similar to blowing a trumpet
(trumpet sign). With this deformity, if the arm-to-body
angle is less than 40°, mild cross-innervation is present;
if the angle is more than 80°, severe cross-innervation is
predicted.
4. Co-contraction among shoulder abductors, elbow
flexors, and forearm flexors is the last possibility. When
asked to perform shoulder elevation, the elbow and
fingers flex involuntarily.
A special chart for S-OBPP examination (Table 36.13) should
be completed before planning the reconstructive strategy
for the sequelae deformities of shoulder, elbow, and hand.
For motor recovery with aberrant reinnervation, release of
contractured muscles and augmentation of paretic muscles
form the basis of surgical intervention.46,47
Shoulder deformity reconstruction
Before 1968, palliative reconstruction for S-OBPP with
shoulder deformity was focused on the anatomical defor­
mity (subluxation or posterior dislocation of the shoulder).
Osteotomy of the humerus, or release of the contracted
internal rotator muscles (concept of muscle fibrosis due to
delivery trauma), such as the subscapularis, pectoralis major,
or long head of biceps64–66 was preferred, but the results were
disappointing. These techniques improved only the patient’s
cosmetic appearance but not the function. Some authors
performed local muscle transfer such as trapezius and
levator scapulae muscle transfers to restore some shoulder
abduction56 using the concept of dynamic reconstruction for
muscular imbalance. However, the concept of aberrant rein­
nervation has now been well accepted by the author as the
main cause of shoulder deformity in S-OBPP.47 All reconstruc­
tive methods should be aimed at minimizing the influence of
aberrant reinnervation. If perioperative physical examination
demonstrates the existence of muscle recovery by aberrant
regeneration, the author’s studies demonstrate the follow­
ing procedures are good for shoulder abduction: (1) release
of antagonistic muscles (pectoralis major and teres major
muscles); (2) augmentation of paretic muscles (transferring
teres major to the infraspinatus muscle, re-routing both ends
of the clavicular part of the pectoralis major muscle later­
ally). In addition, latissimus dorsi transfer to the teres minor
insertion (or lateral humerus) is good for shoulder external
rotation. The ideal age for the reconstruction is between 4
and 10 years. The average shoulder abduction following the
muscle transposition was 151° (i.e., average gain 77°), and that
of external rotation was 72 °(average gain 48°). Comparing
with the S-OBPP patients who had no surgery and with early
elbow is rare, but flaccid paralysis is commonly seen in the
hand due to root avulsion of C7–T1 without aberrant regen­
eration. Aberrant reinnervation more frequently occurs in the
shoulder and elbow and less in the hand. Therefore contrac­
tures (or hypertrophy) of the teres major, pectoralis major,
brachialis and biceps muscles are frequently seen and cause
the deformity of the shoulder and elbow. In addition, growth
is another factor in shoulder and elbow deformities, often
found in the form of concomitant skeletal deformity.
There are four main types of co-contractions resulting from
aberrant reinnervation causing different types of deformities
of the shoulder and elbow:
1. Co-contraction can occur between shoulder abductors
(supraspinatus, infraspinatus and deltoid) and
adductors (mainly, teres major and pectoralis major).
This will result in limitation of shoulder elevation.
Shoulder adduction contracture (or internal rotation)
will develop when growing.

841
Pediatric brachial plexus injury (obstetric brachial plexus palsy)
achieving elbow flexion. However, this results in loss of elbow
extension, a significant functional problem for a growing child
and one that is especially frustrating when shoulder elevation
has been restored after shoulder correction. In addition, the
loss of muscular imbalance at the elbow frequently leads to
progressive flexion contracture (40°, range 30–70°) and/or
dislocation at the elbow. Restoration of elbow extension fol­
lowing triceps-to-biceps transfer has been disappointing,
whether performed by regional muscle transfer (such as latis­
simus dorsi transfer), or by free muscle transplantation.
Because of these drawbacks, we have discontinued the use of
the triceps-to-biceps transfer. For motor recovery with aber­
rant reinnervation between elbow flexors and extensors,
reconstruction of elbow extension should precede that of
elbow flexion. This is achieved either by biceps-to-triceps
transfer with preservation of an intact brachialis muscle, or by
nerve surgery for the infant OBPP, the results of our recon­
structive strategy for the shoulder appear to be significantly
improved.47
Elbow deformity reconstruction
The common deformities of the elbow in S-OBPP include: (1)
aberrant reinnervation between elbow flexors and extensors,
which causes weak elbow extension and weak elbow flexion;
(2) aberrant reinnervation between shoulder abductors and
elbow flexors, resulting in a severe “trumpet sign” with angle
greater than 80° between the medial arm and trunk on hand-
to-mouth movement; and (3) no motor recovery with muscle
paralysis or paresis of biceps and brachialis muscles.48 Tradi­
tionally, elbow flexion has always been top priority and
triceps-to-biceps transfer is a commonly used method for
Fig. 36.20  Example of rupture of upper and middle trunks. A 3-month-old infant had right brachial plexus injury (A), receiving
nerve grafts from C5 to the suprascapular nerve and posterior division of the upper trunk for the shoulder, C6 to the anterior division
of the upper trunk for the elbow, and C7 to C7 due to rupture injury of the upper and middle trunks without C8–T1 avulsion. Six
years later she showed good shoulder abduction (B), good shoulder external rotation (C), and M4 elbow flexion (D) following
one-stage early nerve surgery. There is no aberrant reinnervation between shoulder and elbow.
A
B
C
D

842
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
aberrant regeneration, simultaneous reconstruction of the
shoulder and elbow can be safely performed.
Forearm and hand deformity reconstruction
S-OBPP in the forearm and hand includes weakness or absence
of wrist or metacarpophalangeal or interphalangeal joint exten­
sion; weakness or absence of finger flexion; forearm supination
or less commonly pronation contracture; ulnar deviation of
the wrist; dislocation of the radius or ulna; thumb instability;
or sensory disturbance of the hand.49 Palliative reconstruction
of these forearm and hand manifestations is more difficult
than for the shoulder or elbow because of the lack of powerful
regional muscles for transfer. The phenomenon of aberrant
reinnervation is less significant. Continuous physical therapy
with a rehabilitation program to optimize the residual muscle
strength in the forearm and hand is vital for later management.
Surgical treatment is highly individualized. The optimal age
for forearm and hand reconstruction is therefore usually later
(school age, 6–13 years old) than for shoulder and elbow
reconstruction (preschool years, 4–6 years old).
brachialis-to-triceps transfer with preservation of an intact
biceps when elbow shows flexion contracture.48 Half of our
patients can achieve acceptable elbow flexion and extension
in a single-stage procedure. The other half require a second
stage procedure, either by FFMT or by Steindler flexorplasty.
Existence of brachioradialis muscle power is a determining
factor. A powerful brachioradialis can decrease the need for
the second procedure.
In patients with a paralyzed biceps due to C5–7 root avul­
sion, Steindler flexorplasty or FFMT67 is the option for restora­
tion of elbow function. When shoulder–elbow co-contraction
is a major issue, the anterior half of the deltoid is transferred
to the distal biceps tendon with a fascial lata graft for biceps
augmentation to decrease the “trumpet angle”. However,
patients with intrinsic deformities of the elbow joint (i.e.,
dislocation of the radial and/or ulnar head) are not good
candidates for the above-mentioned regional elbow muscle
transfer. Altered joint anatomy and abnormal joint biome­
chanics may create instability of the elbow joint, which con­
tributes to untoward results in these patients. In patients with
deformities of shoulder and elbow due to motor recovery by
E
B
C
D
Fig. 36.21  Example of C5 rupture and C6–T1 root avulsion (A). A 3-month-old
infant had right brachial plexus injury, receiving primary nerve surgery with nerve
grafts from C5 to the surascapular nerve and posterior division of the upper trunk,
nerve transfers from T3–4 two intercostal nerves to the musculocutaneous nerve for
elbow, and T5–8 four to the median nerve. Seven years later he showed:
(B) acceptable shoulder elevation, (C) M4 elbow flexion, and (D,E) M3 finger
flexion.
A

Table 36.13  Special chart for S-OBPP examination

844
SECTION V
CHAPTER 36 • Brachial plexus injuries: Adult and pediatric
patients without elbow flexion but good hand function. Better
results can be achieved when numerous short nerve grafts are
used for rupture injuries. Cases associated with multiple root
avulsions benefit from intraplexus nerve transfer for hand
function and extraplexus nerve transfer for shoulder and/or
elbow function. This approach affords patients a one-stage
functional reconstruction of the upper limb. In S-OBPP, sec­
ondary reconstruction for shoulder and elbow deformities can
achieve acceptable function. For forearm and hand, surgical
treatment and result are highly individualized, and multiple
procedures are often required.
Future directions
■ A change in the reconstruction priority may become
evident. Since the use of FFMT for biceps replacement is
much easier and more effective than for triceps
replacement41,67 in the later reconstruction, the
reconstruction priority for I-OBPP may be changed.
Restoration of hand function should become the first
priority, followed by shoulder function and then elbow
flexion. This is different from adult BPI in which elbow
flexion is always the first priority for restoration.
■ The classification of I-OBPP will need consensus.
■ Endoscopic or robot-assisted diagnosis of I-OBPP injury
at very early stage may triage treatment.
■ Early nerve surgery on more selective patients may be
recommended.
Multiple procedures for forearm and hand function are
often performed. Sometimes they are done simultaneously
with reconstructive procedures to improve shoulder and/or
elbow function. Traditional tendon transfer techniques do
not provide satisfactory reconstruction for these deformities.
Many of the author’s patients required more complex tech­
niques such as FFMT67,68 to augment traditional techniques of
tendon and/or bone management.
For wrist and metacarpophalangeal extension, powerful
wrist or finger flexors and/or pronator teres can be useful
donor muscles for flexor-to-extensor transfers. Sometimes
two wrist flexors, flexor carpi radialis and palmaris longus,
are woven together, becoming a more powerful unit, and are
transferred to the extensor digitorum communis to achieve
both wrist and finger extension. For forearm supination con­
tracture, re-routing the biceps muscle, as described by Zan­
colli,69 is effective for mild cases. For weakness or absence of
finger flexion, wrist extensors are usually too weak to be
transferred. FFMT for flexor digitorum profundus replace­
ment using intercostal nerves as the donor nerve is required.
Sensory disturbance of the forearm and hand in late obstetric
brachial plexus palsy seems a minor problem and further
sensory reconstruction is unnecessary.
Conclusions
In I-OBPP, early primary nerve surgery provides therapeutic
advantages. Surgery within 3 months is strongly indicated in
patients with total palsy, but only relatively indicated for
2. Slingluff CL, Terzis JK, Edgerton MT. The quantitative
microanatomy of the brachial plexus in man. Reconstructive
relevance. In: Terzis JK, ed. Microreconstruction of Nerve Injuries.
Philadelphia, PA: WB Saunders; 1987:285. This is an important article
because quantitative microanatomy of the brachial plexus is described.
Many questions related to brachial plexus anatomy are answered.
6. Ferrante MA. Electrodiagnostic assessment of the brachial plexus.
Neurol Clin. 2012;30:551–580. This article presents important and useful
concepts of electrodiagnosis for BPI.
8. Alnot JY. Traumatic paralysis of the brachial plexus: preoperative
problems and therapeutic indications. In: Terzis JK, ed.
Microreconstruction of Nerve Injuries. Philadelphia, PA: WB Saunders;
1987:331. The author describes brachial plexus injury in detail, including
anatomy, diagnosis, and treatment. For a young surgeon who is interested
in brachial plexus treatment, this is an excellent article to read and
understand.
9. Chuang DCC. Adult brachial plexus injuries. In: Mathes SJ, Hentz
VR, eds. Plastic Surgery. Philadelphia, PA: Saunders Elsevier;
2006:515. The author describes brachial plexus injury in great detail
including anatomy, diagnosis, treatment, and conclusion. There are
multiple useful surgical tips. For a beginner who is interested in brachial
plexus treatment, this is a good article to read in order to gain confidence.
14. Chuang DCC. Adult brachial plexus reconstruction with the level of
injury: review and personal experience. Plast Reconstr Surg.
2009;124(suppl):e359–e369. This article presents a simple classification
system in terms of numbered levels. This easy system may become a
universal classification of brachial plexus injury.
Access the complete reference list online at

844.e1
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844.e2
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