Factors Impacting the Success of Free Functioning Gracilis Muscle Transfer for Elbow Flexion in Brachial Plexus Reconstruction.

BACKGROUND: Free functioning muscle transfer is a reconstructive option to restore elbow flexion in brachial plexus injuries. The authors determined the impact of body mass index, age, and location of distal tendon attachment on elbow flexion strength after free functioning muscle transfer in traumatic brachial plexus injury patients. METHODS: A retrospective review of patients who underwent free functioning muscle transfer for elbow flexion as part of their brachial plexus injury reconstruction with a minimum 2-year follow-up were evaluated. Outcomes assessed included elbow flexion strength (British Medical Research Council grade) and change in Disabilities of the Arm, Shoulder and Hand questionnaire and visual analogue scale pain scores. RESULTS: One hundred six patients met inclusion criteria. The average age was 32 years, and the average body mass index was 27.1 kg/m2; 56.5 percent of patients achieved M3 or greater muscle grade using the authors' strict modification of the British Medical Research Council scale. Disabilities of the Arm, Shoulder and Hand questionnaire scores improved from 45.7 to 38.8 (p < 0.05). Visual analogue scale pain scores decreased, but this trend did not obtain significance. Age and body mass index both had a significant negative impact on final free functioning muscle transfer grade (p < 0.05). Use of a distal tendon insertion led to improved muscle grade outcomes, with targeting of wrist extension being superior to finger flexion (p < 0.05). Simultaneous musculocutaneous nerve grafting did not significantly alter final elbow flexion strength. CONCLUSIONS: Increasing age and body mass index both imparted a deleterious effect on free functioning muscle transfer muscle grade. Distal muscle targets had better strength outcomes than when the biceps tendon was used. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Distal Nerve Transfers to the Triceps Brachii Muscle: Surgical Technique and Clinical Outcomes.

PURPOSE: To report the clinical outcomes and describe the surgical technique of triceps muscle reinnervation using 2 different distal nerve transfers: the flexor carpi ulnaris (FCU) fascicle of the ulnar nerve and the posterior branch of the axillary nerve (PBAN) to the triceps nerve branch. METHODS: A retrospective review of patients undergoing FCU fascicle of ulnar nerve or PBAN to triceps nerve branch transfer was performed. Outcome measures included preoperative and postoperative modified British Medical Research Council (MRC) score, EMG results, and complications. RESULTS: Between September 2003 and April 2017, 6 patients were identified. Four patients with a traumatic upper trunk and posterior cord palsy underwent ulnar nerve fascicle to triceps nerve transfer. Two patients with a recovering upper trunk following a pan-brachial plexus palsy underwent PBAN to triceps nerve branch transfer. The median age was 30.0 years (range, 18-68 years). Surgery was performed at a median of 6.9 months (range, 5.0-8.9 months) postinjury, with a median follow-up of 18.4 months (range, 7.6-176.3) months. Before surgery, 4 patients exhibited grade M0 and 2 patients exhibited grade M1 triceps strength. Four patients had M5 donor muscle strength and 2 had grade M4. Postoperatively, 4 patients regained MRC grade M4 triceps muscle strength, 1 regained M3, and 1 regained M2. There was no noticeable donor muscle weakness. CONCLUSIONS: Nerve fascicles to the FCU and PBAN are viable options for obtaining meaningful triceps muscle recovery in a select group of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Factors associated with failed ulnar nerve fascicle to biceps motor branch transfer: a case control study.

We sought to identify predictors of failed ulnar nerve fascicle (to flexor carpi ulnaris) to biceps motor branch transfer. A retrospective review of adult brachial plexus patients treated with flexor carpi ulnaris to biceps transfer with a minimum 1-year follow-up was performed. Failure, defined as modified British Medical Research Council grade <3 elbow flexion was compared with randomly selected controls (M ≥ 4-). Ninety-one patients, of which 80% regained >M3 flexion met criteria. Eighteen failures and 18 controls, with similar follow-up (20 vs 23 months) were evaluated. Preoperative flexor carpi ulnaris weakness (M < 5) was significantly more common in failures (78% vs 33%). The rate of flexor carpi ulnaris recovery after operation was significantly higher in controls (86% vs 7%). Increased failure risk can be expected with impaired preoperative flexor carpi ulnaris function. The challenge is how to identify which patients will regain near normal flexor carpi ulnaris strength as excellent outcomes can be obtained. Level of evidence: III.

Outcomes of shoulder abduction after nerve surgery in patients over 50 years following traumatic brachial plexus injury.

PURPOSE: There is controversy regarding the effectiveness of brachial plexus reconstruction in older patients, as outcomes are thought to be poor. The aim of this study is to determine the outcomes of shoulder abduction obtained after nerve reconstruction in patients over the age of 50 years and factors related to success. METHODS: Forty patients over the age of 50 years underwent nerve surgery to improve shoulder function after a traumatic brachial plexus injury. Patients were evaluated pre- and postoperatively for shoulder abduction strength and range of motion (ROM); Disability of the Arm, Shoulder and Hand (DASH) scores; pain; age bracket; gender; body mass index (BMI); delay from injury to operation; concomitant trauma; severity of trauma; and type of reconstruction. RESULTS: The average age was 58.2 years (range 50-77 years) with an average follow-up of 18.8 months. The average modified British Medical Research Council (BMRC) shoulder abduction grade improved significantly from 0.23 to 2.03 (p < 0.005). Fourteen patients achieved functional shoulder abduction of ≥ M3 postoperatively. There was no correlation between age or age range stratification and BMRC grade or those obtaining useful shoulder abduction ≥ M3. Active shoulder abduction improved significantly from 18.25° to 40.64°, with no difference on the basis of age or age stratification. There were improved modified BMRC grades with nerve transfers versus nerve grafts. Less patients achieved ≥ M3 function if surgery was delayed > 6 months. The mean DASH score decreased from 45.3 to 40.7 postoperatively, and the average pain score decreased from 3.7 to 3.0. Patients with a higher postoperative BMRC grade for shoulder abduction had improved postoperative DASH scores and VAS for pain (p = 0.011 and 0.005, respectively). CONCLUSION: Brachial plexus nerve reconstruction for shoulder abduction in patients over the age of 50 years can yield useful BMRC scores and ROM, and age should not be used to exclude nerve reconstruction in these patients.

Outcomes of Elbow Flexion Reconstruction in Patients Older than 50 with Traumatic Brachial Plexus Injury.

BACKGROUND: There is controversy regarding the effectiveness of brachial plexus reconstruction for elbow function in older patients, as reported outcomes are generally poor. The purpose of this study was to evaluate elbow function outcomes in patients older than 50. METHODS: Fifty-eight patients older than 50 years underwent nerve grafting, transfers, or free functioning muscle transfer to improve elbow function after traumatic brachial plexus injury. Patients were evaluated preoperatively and postoperatively for elbow flexion strength and range of motion; Disabilities of the Arm, Shoulder and Hand scores; pain; concomitant trauma; severity of trauma; and type of reconstruction. RESULTS: The average age of the patients was 57.8 years, and the average follow-up was 24.0 months. The average modified British Medical Research Council elbow flexion grade improved significantly from 0.26 to 2.63. Thirty-three patients (60 percent) achieved functional flexion greater than or equal to M3 postoperatively, compared to zero patients preoperatively. There was no correlation between age and modified British Medical Research Council grade. Active elbow range of motion improved significantly postoperatively, with no effect of age on flexion motion. More patients achieved greater than or equal to M3 flexion with nerve transfers (69 percent) compared to free functioning muscle transfer (43 percent). Patients had worse outcomes with high-energy injuries. The mean Disabilities of the Arm, Shoulder and Hand score decreased from 51.5 to 49.6 postoperatively, and the average pain score decreased from 5.0 to 4.3. CONCLUSION: Brachial plexus reconstruction for elbow function in patients older than 50 can yield useful flexion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Spinal accessory nerve to triceps muscle transfer using long autologous nerve grafts for recovery of elbow extension in traumatic brachial plexus injuries.

Despite continuous improvement and expansion of reconstructive options for traumatic brachial plexus injury, options to reinnervate the triceps muscle remain somewhat sparse. This study describes a novel option, using a spinal accessory nerve transfer to the long head of the triceps muscle with an intervening autologous nerve graft. The resulting quality of elbow extension and factors that influence outcome are discussed.

Free Functioning Gracilis Muscle Transfer With and Without Simultaneous Intercostal Nerve Transfer to Musculocutaneous Nerve for Restoration of Elbow Flexion After Traumatic Adult Brachial Pan-Plexus Injury.

PURPOSE: After complete 5-level root avulsion brachial plexus injury, the free-functioning muscle transfer (FFMT) and the intercostal nerve (ICN) to musculocutaneous nerve (MCN) transfer are 2 potential reconstructive options for restoration of elbow flexion. The aim of this study was to determine if the combination of the gracilis FFMT and the ICN to MCN transfer provides stronger elbow flexion compared with the gracilis FFMT alone. METHODS: Sixty-five patients who underwent the gracilis FFMT only (32 patients) or the gracilis FFMT in addition to the ICN to MCN transfer (33 patients) for elbow flexion after a pan-plexus injury were included. The 2 groups were compared with respect to postoperative elbow flexion strength according to the modified British Medical Research Council grading system as well as preoperative and postoperative Disability of the Arm, Shoulder, and Hand scores. Two subgroup analyses were performed for the British Medical Research Council elbow flexion strength grade: FFMT neurotization (spinal accessory nerve vs ICN) and the attachment of the distal gracilis tendon (biceps tendon vs flexor digitorum profundus/flexor pollicis longus tendon). RESULTS: The proportion of patients reaching the M3/M4 elbow flexion muscle grade were similar in both groups (FFMT vs FFMT + ICN to MCN transfer). Statistically significant improvement in postoperative Disability of the Arm, Shoulder, and Hand score was found in the FFMT + ICN to MCN transfer group but not in the FFMT group. There was a significant difference between gracilis to biceps (M3/M4 = 52.6%) and gracilis to FDP/flexor pollicis longus (M3/M4 = 85.2%) tendon attachment. CONCLUSIONS: The use of the ICN to MCN transfer associated with the FFMT does not improve the elbow flexion modified British Medical Research Council grade, although better postoperative Disability of the Arm, Shoulder, and Hand scores were found in this group. The more distal attachment of the gracilis FFMT tendon may play an important role in elbow flexion strength. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Evaluation of infraspinatus reinnervation and function following spinal accessory nerve to suprascapular nerve transfer in adult traumatic brachial plexus injuries.

PURPOSE: Our objective was to determine the prevalence and quality of restored external rotation (ER) in adult brachial plexus injury (BPI) patients who underwent spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, and to identify patient and injury factors that may influence results. METHODS: Fifty-one adult traumatic BPI patients who underwent SAN to SSN transfer between 2000 and 2013, all treated less than 1 year after injury with >1 year follow-up. The primary outcome measured was shoulder ER. The outcomes we utilized included "clinically useful ER" (motion ≥ -35° with ≥MRC 2 strength), modified British Medical Research Council (MRC) grading, and electromyographic (EMG) reinnervation. RESULTS: EMG evidence of re-innervation was found in 85% of patients. Surgery resulted in improved ER in 41% (21/51) of shoulders at an average of 28 months follow-up. Of these, only 31% (17/51) had clinically useful ER. The average ER active range of motion was 12° from full internal rotation (Range: -60° to 90°) and MRC grade 2.2 (2-4). The only predictor of ER improvement was an isolated upper trunk (C5-C6) injury. Improved ER was clinically evident in 76%, 37% and 26% of upper trunk (UT), C5-C6-C7 and panplexus injuries, respectively (P < 0.03). CONCLUSIONS: Although 85% had EMG signs of recovery, the SAN to SSN transfer failed to provide useful recovery of ER through reinnervation of the infraspinatus muscle in injuries involving more levels than a C5-C6 root/upper trunk pattern. In patients with greater than C5-6 level injuries alternatives to SAN to SSN transfer should be considered to restore shoulder ER. © 2016 Wiley Periodicals, Inc. Microsurgery 37:365-370, 2017.

Free Functioning Gracilis Muscle Transfer versus Intercostal Nerve Transfer to Musculocutaneous Nerve for Restoration of Elbow Flexion after Traumatic Adult Brachial Pan-Plexus Injury.

BACKGROUND: After complete five-level root brachial plexus injury, free functional muscle transfer and intercostal nerve transfer to the musculocutaneous nerve are two potential reconstructive options for elbow flexion. The aim of this study was to determine the outcomes of free functional muscle transfer versus intercostal nerve-to-musculocutaneous nerve transfers with respect to strength. METHODS: Sixty-two patients who underwent free functional muscle transfer reconstruction or intercostal nerve-to-musculocutaneous nerve transfer for elbow flexion following a pan-plexus injury were included. The two groups were compared with respect to postoperative elbow flexion strength according to the British Medical Research Council grading system; preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand questionnaire scores. RESULTS: In the free functional muscle transfer group, 67.7 percent of patients achieved M3 or M4 elbow flexion. In the intercostal nerve-to-musculocutaneous nerve transfer group, 41.9 percent of patients achieved M3 or M4 elbow flexion. The difference was statistically significant (p < 0.05). Changes in Disabilities of the Arm, Shoulder, and Hand questionnaire scores were not statistically significant. Average time from injury to surgery was significantly different (p < 0.01) in both groups. The number of intercostal nerves used for the musculocutaneous nerve transfer did not correlate with better elbow flexion grade. CONCLUSIONS: Based on this study, gracilis free functional muscle transfer reconstruction achieves better elbow flexion strength than intercostal nerve-to-musculocutaneous nerve transfer for elbow flexion after pan-plexus injury. The role of gracilis free functional muscle transfer should be carefully considered in acute reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Comparison of Outcomes of Triceps Motor Branch-to-Axillary Nerve Transfer or Sural Nerve Interpositional Grafting for Isolated Axillary Nerve Injury.

BACKGROUND: Deltoid paralysis following isolated axillary nerve injury can be managed with triceps motor branch transfer or interpositional grafting. No consensus exists on the treatment that results in superior deltoid function. The purpose of this study was to review the authors' experience with axillary nerve injury management and compare functional outcomes following these two treatment options. METHODS: Twenty-nine adult isolated axillary nerve injury patients that had either interpositional nerve grafting or triceps motor branch transfer with greater than 1 year of follow-up between 2002 and 2013 were reviewed for demographic and clinical factors and functional outcomes of deltoid reinnervation, including clinical examination (shoulder abduction and forward flexion graded by the Medical Research Council system) and electromyographic recovery. Disabilities of the Arm, Shoulder, and Hand scale grades were also compared. RESULTS: Twenty-one patients had a triceps motor transfer and eight had interpositional nerve grafting. At a mean follow-up of 22 months, Medical Research Council scores were greater in the grafting group compared with the nerve transfer group (4.3 versus 3.0), and more graft patients achieved useful deltoid function (Medical Research Council score ≥3) recovery (100 percent versus 62 percent); however, both groups had similar improvement in self-reported disability: change in Disabilities of the Arm, Shoulder, and Hand score of 11 following nerve transfer versus 15 following nerve graft. CONCLUSIONS: Although the question of nerve transfer versus grafting for restoration of axillary nerve function is controversial, this study demonstrates that grafting can result in good objective functional outcomes, particularly during an earlier time course after injury. This question requires further investigation in a larger, prospective patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The role of elective amputation in patients with traumatic brachial plexus injury.

BACKGROUND AND AIM: Despite undergoing complex brachial plexus, surgical reconstructions, and rehabilitation, some patients request an elective amputation. This study evaluates the role of elective amputation after brachial plexus injury. METHODS: A retrospective chart review was performed for all the 2140 patients with brachial plexus injuries treated with elective amputation between 1999 and 2012 at a single institution. Analysis was conducted on the potential predisposing factors for amputation, amputation level, and postamputation complications. Patients were evaluated using pre- and postamputation Disabilities of the Shoulder, Arm, and hand scores in addition to visual analog pain scores. RESULTS: The following three conditions were observed in all nine patients who requested an elective amputation: (1) Pan-plexus injury; (2) non-recovery (mid-humeral amputation) or elbow flexion recovery only (forearm amputation) 1 year after all other surgical options were performed; and (3) at least one chronic complication (chronic infection, nonunion fractures, full-thickness burns, chronic neck pain with arm weight, etc.). Pain improvement was found in five patients. Subjective patient assessments and visual analog pain scores before and after amputation did not show a statistically significant improvement in Disabilities of the Shoulder, Arm, and Hand Scores. However, four patients reported that their shoulder pain felt "better" than it did before the amputation, and two patients indicated they were completely cured of chronic pain after surgery. CONCLUSIONS: Elective amputation after brachial plexus injury should be considered as an option in the above circumstances. When the informed and educated decision is made, patients can have satisfactory outcomes regarding amputation.

Triceps motor branch transfer for isolated traumatic pediatric axillary nerve injuries.

OBJECT: Transfer of the triceps motor branch has been used for treatment of isolated axillary nerve palsy in the adult population. However, there are no published data on the effectiveness of this procedure in the pediatric population with traumatic injuries. The authors reviewed demographics and outcomes in their series of pediatric patients who underwent this procedure. METHODS: Six patients ranging in age from 10 to 17 years underwent triceps motor branch transfer for the treatment of isolated axillary nerve injuries between 4 and 8 months after the inciting injury. Deltoid muscle strength was evaluated using the modified British Medical Research Council (MRC) grading system. Shoulder abduction at last follow-up was measured. RESULTS: The mean duration of follow-up was 38 months. The average postoperative MRC grading of deltoid muscle strength was 3.6 ± 1.3. The median MRC grade was 4. One patient who did not achieve an MRC grade of 3 suffered multiple injuries from high-velocity trauma. Unlike in the adult population, age, body mass index of the patient, and delay from injury to surgery were not significant factors affecting the outcome of the procedure. CONCLUSIONS: In the pediatric population with traumatic injuries, isolated axillary nerve injury treated with triceps motor branch transfer can result in good outcomes.

Prevalence of rotator cuff tears in adults with traumatic brachial plexus injuries.

BACKGROUND: Restoration of shoulder function is a primary goal when treating patients with traumatic brachial plexus injury. A concomitant rotator cuff tear may alter the treatment approach and prognosis for these individuals. The purpose of this study was to define the prevalence of rotator cuff tears in patients with traumatic brachial plexus injuries. METHODS: This is a retrospective review of 280 adult patients with traumatic brachial plexus injury treated at a single institution over a twelve-year period. An upper-extremity magnetic resonance imaging (MRI) scan was acquired for all patients as part of the initial evaluation for posttraumatic brachial plexus injury. The radiographic and clinical data on these patients were reviewed to document partial or full-thickness rotator cuff tears, mechanism and location of the brachial plexus injury, and age. RESULTS: Twenty-three patients (8.2%) had a full-thickness rotator cuff tear: one patient had tears involving three tendons, eight patients had tears involving two tendons, twelve patients had a single-tendon tear, one patient had a single-tendon tear in each shoulder, and one patient had a single-tendon tear in one shoulder and a two-tendon tear in the other. Twenty-one tears involved the supraspinatus, eight involved the infraspinatus, and seven involved the subscapularis. Thirteen patients underwent surgical repair of the rotator cuff. The average age of the patients in this cohort was 33.4 years, and older age was associated with an increased risk of full-thickness rotator cuff tears (odds ratio [OR], 1.06 per year). Patients with infraclavicular brachial plexus injury had a significantly higher rate of full-thickness rotator cuff tears. CONCLUSIONS: Concomitant rotator cuff tears are present in approximately one in ten patients with traumatic brachial plexus injury. These injuries may contribute to shoulder dysfunction; therefore, evaluation of the rotator cuff with imaging studies is appropriate when formulating treatment strategies. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Free functioning gracilis transfer for traumatic brachial plexus injuries in children.

PURPOSE: To report our technique and experience with use of free functioning muscle transfer (FFMT) in reconstruction of traumatic brachial plexus injuries (BPIs) in children as well as its complications and outcomes. METHODS: Twelve patients with complete BPI underwent FFMT for reconstruction between 2000 and 2012. Eight had single-stage gracilis transfer for restoration of elbow flexion, and 4 children had double free gracilis muscle transfer for restoration of elbow flexion and prehension. Mean duration of follow-up was 27 months (range, 14-55 mo). RESULTS: Eleven out of 12 patients achieved at least M3 elbow flexion, with 8 patients achieving M4 or greater elbow flexion. Eight of 12 patients had nerve transfers to the musculocutaneous nerve. Mean active elbow arc of motion was 79° (range, 30°-130°). Two patients aged 8 and 11 years with open growth plates developed elbow joint contractures, which limited range of motion, but they recovered M4 and M5 elbow flexion strength. CONCLUSIONS: FFMTs can result in good outcomes following reconstruction for traumatic BPI. The use of FFMT should be carefully considered in children prior to skeletal maturity because of the risk of the development of an elbow flexion contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reconstruction of pediatric brachial plexus injuries with nerve grafts and nerve transfers.

PURPOSE: To review the demographics and injury patterns in consecutive pediatric patients with traumatic brachial plexus injury presenting to a single center over a 16-year period and to review the outcomes of nerve grafting and nerve transfers for reconstruction of shoulder abduction and elbow flexion in these patients. METHODS: Forty-five pediatric patients presented for treatment of traumatic Brachial plexus injury from 1996 to 2012. Subgroup analysis of patients who had nerve grafting or nerve transfers for restoration of shoulder abduction and elbow flexion was carried out to compare outcomes of Medical Research Council (MRC) motor grading. RESULTS: The mean age of patients was 13.8 years (range, 3-17 y). Panplexal injuries (62%) and upper plexus injuries (16%) were particularly common. There was a very high proportion of preganglionic injuries (91%). Six of the 10 of patients who underwent intraplexal nerve grafting only for restoration of shoulder abduction achieved grade 3 or better power compared with 42% (5/12) of patients who had nerve transfers. When contralateral C7 was used as a donor for nerve transfer in restoration of shoulder abduction, 1 of the 5 patients achieved grade 3 or better shoulder abduction. All 4 patients who had nerve grafts for restoration of elbow flexion achieved grade 3 or better power, compared with 11 of 12 patients who had nerve transfers. There was no statistical difference in outcome (MRC grade 3 or 4) between patients who had nerve grafts and those who had nerve transfers. CONCLUSIONS: This study shows that nerve grafts can result in similar outcomes (MRC grading) to nerve transfers for restoration of shoulder abduction and elbow flexion in traumatic pediatric BPI. The findings of this study do not support the use of contralateral C7 as a donor for nerve transfer in reconstruction of shoulder abduction in this age group. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Iatrogenic nerve injuries during shoulder surgery.

INTRODUCTION: The current literature indicates that neurologic injuries during shoulder surgery occur infrequently and result in little if any morbidity. The purpose of this study was to review one institution's experience treating patients with iatrogenic nerve injuries after shoulder surgery. METHODS: A retrospective review of the records of patients evaluated in a brachial plexus specialty clinic from 2000 to 2010 identified twenty-six patients with iatrogenic nerve injury secondary to shoulder surgery. The records were reviewed to determine the operative procedure, time to presentation, findings on physical examination, treatment, and outcome. RESULTS: The average age was forty-three years (range, seventeen to seventy-two years), and the average delay prior to referral was 5.4 months (range, one to fifteen months). Seven nerve injuries resulted from open procedures done to treat instability; nine, from arthroscopic surgery; four, from total shoulder arthroplasty; and six, from a combined open and arthroscopic operation. The injury occurred at the level of the brachial plexus in thirteen patients and at a terminal nerve branch in thirteen. Fifteen patients (58%) did not recover nerve function after observation and required surgical management. A structural nerve injury (laceration or suture entrapment) occurred in nine patients (35%), including eight of the thirteen who presented with a terminal nerve branch injury and one of the thirteen who presented with an injury at the level of the brachial plexus. CONCLUSIONS: Nerve injuries occurring during shoulder surgery can produce severe morbidity and may require surgical management. Injuries at the level of a peripheral nerve are more likely to be surgically treatable than injuries of the brachial plexus. A high index of suspicion and early referral and evaluation should be considered when evaluating patients with iatrogenic neurologic deficits after shoulder surgery.

Posterior branch of the axillary nerve transfer to the lateral triceps branch for restoration of elbow extension: case report.

We report a nerve transfer to the triceps using the posterior branch of the axillary nerve to restore elbow extension in an 18-year-old woman with a C7-T1 injury. Elbow extension strength improved from M0 to M4, whereas deltoid strength was minimally affected. Her Disabilities of the Arm, Shoulder and Hand score improved 14 points. This method may be considered for restoring triceps function in lower pattern brachial plexus injury.

Wrist, first carpometacarpal joint, and thumb interphalangeal joint arthrodesis in patients with brachial plexus injuries.

PURPOSE: Wrist arthrodesis, first carpometacarpal joint arthrodesis, and thumb interphalangeal joint arthrodesis can be used in conjunction with other reconstructive measures to improve function and grasp in patients with complete brachial plexus injuries. This study evaluates wrist arthrodesis, first carpometacarpal joint arthrodesis, and thumb interphalangeal joint arthrodesis as measured by fusion rate, complications, and clinical outcomes. METHODS: A retrospective chart review was performed for 24 skeletally mature patients with brachial plexus injuries treated with wrist arthrodesis by a dorsal plating technique, first carpometacarpal joint arthrodesis by staples, and thumb interphalangeal joint arthrodesis by a tension band wiring technique. Nineteen patients were subjectively evaluated using prearthrodesis and postarthrodesis Disabilities of the Shoulder, Arm, and Hand scores, visual analog pain scores, and a visual analog scale assessing appearance, function, hygiene, ease of daily care, pain, and overall satisfaction. RESULTS: There was 100% union rate with 1 postarthrodesis complication. One patient required wrist fusion plate removal because of painful hardware. Subjective patient assessments showed a statistically significant (P < .001) improvement in Disabilities of the Shoulder, Arm, and Hand scores (from 51 to 28) and pain scores (from 5.3 to 3.2) before and after arthrodeses. The visual analog questionnaire results revealed improvements in appearance, function, daily cares, hygiene, pain, and satisfaction. CONCLUSIONS: Wrist arthrodesis, first carpometacarpal joint arthrodesis, and thumb interphalangeal joint arthrodesis had high union rates with minimal complications. Patients benefited from the improved function of their upper extremities and were satisfied with the surgery. The use of wrist, first carpometacarpal joint, and thumb interphalangeal joint arthrodeses in combination should be considered one of the reconstructive possibilities for patients with complete or nearly complete brachial plexus injuries.

Factors affecting outcome of triceps motor branch transfer for isolated axillary nerve injury.

PURPOSE: Triceps motor branch transfer has been used in upper brachial plexus injury and is potentially effective for isolated axillary nerve injury in lieu of sural nerve grafting. We evaluated the functional outcome of this procedure and determined factors that influenced the outcome. METHODS: A retrospective chart review was performed of 21 patients (mean age, 38 y; range, 16-79 y) who underwent triceps motor branch transfer for the treatment of isolated axillary nerve injury. Deltoid muscle strength was evaluated using the modified British Medical Research Council grading at the last follow-up (mean, 21 mo; range, 12-41 mo). The following variables were analyzed to determine whether they affected the outcome of the nerve transfer: the age and sex of the patient, delay from injury to surgery, body mass index (BMI), severity of trauma, and presence of rotator cuff lesions. The Spearman correlation coefficient and multiple linear regression were performed for statistical analysis. RESULTS: The average Medical Research Council grade of deltoid muscle strength was 3.5 ± 1.1. Deltoid muscle strength correlated with the age of the patient, delay from injury to surgery, and BMI of the patient. Five patients failed to achieve more than M3 grade. Among them, 4 patients were older than 50 years and 1 was treated 14 months after injury. In the multiple linear regression model, the delay from injury to surgery, age of the patient, and BMI of the patient were the important factors, in that order, that affected the outcome of this procedure. CONCLUSIONS: Isolated axillary nerve injury can be treated successfully with triceps motor branch transfer. However, outstanding outcomes are not universal, with one fourth failing to achieve M3 strength. The outcome of this procedure is affected by the delay from injury to surgery and the age and BMI of the patient.