SURGICAL MANAGEMENT OF BRACHIAL PLEXUS INJURIES
Surgical options
1)
neurolysis
2)
restoration of neural input
3)
Replacing non-functional muscles
4)
Treatment of secondary deformities
a. Bony stabilization
i. Arthodesis
ii. Osteotomies
b. Tendon transfers
Approach
 Incision – posterior border of SCM, then 1 finger below clavicle and then along
the deltopectoral groove
 Subplastymal flaps
 External jugular vein ligated
 omohyoid muscle and the transverse cervical vessels are identified and retracted
or divided
 Open clavicular osteotomies have the tendency to create malunions and, more
often, nonunions and therefore, they should be avoided.
 if difficult to identify all roots, dissect the infraclavicular portion by detaching
Pectoralis Minor and as much of Pectoralis Major as necessary
 phrenic nerve is identified in its usual anatomic position in the anterior border of
the anterior scalene muscle, and it is traced superiorly to its C4 and C5 origins.
Identification
 Intraoperative somatosensory evoked potentials are used by some centers.
 Biopsies can be obtained for:
1. carbonic anhydrase histochemistry or cholinesterase staining.
o carbonic anhydrase can differentiate between motor and sensory
fascicles of peripheral nerves.
o Motor nerves stain more densely for Acetylcholinesterase
o prolonged incubation time (more than 24 hours) needed to visualize
the acetylcholinesterase in motor fibers makes this staining technique
nonpractical because it means that the patient is subjected to two
operative procedures within a 2-day period.
2. frozen biopsies of a root can determine the presence of dorsal root ganglion
cells, which indicate a nonreparable lesion.
 Intraoperative nerve action potentials can also assist in distinguishing ruptured
from avulsed roots and are used by many authors.
Nerve Reconstruction
Timing
 3-6 months
Methods
 Establish root avulsion vs rupture
1. in avulsion, intraplexus donor will not be available
2. direct spinal cord implantation has been reported in 1 child using sural
nerve graft and fibrin glue containing acidic FGF.
 Mangement of neuroma in continuity
o Intraoperative nerve stimulation useful
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
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o In most cases where there is significant clinical weakness, resection of
neuroma to healthy axons is indicated with intercalated nerve grafting
Microneurolysis performed if there is significant fibrosis
o longitudinal epineurotomies
o Bulging of the entrapped fascicles strongly indicates that microneurolysis
is effective.
Nerve grafts often required
o Autograft Donors
1. Sural nerve – 35cm each leg
2. Medial cutaneous nerve of forearm
3. Ulnar nerve if avulsion of C8, T1
 Need to strip off dorsal sensory branch to reduce thickness
of the nerve for better viability
4. Great auricular nerve
o Best recovery with musculocutaneous nerve, suprascapular nerve
 75% of free nerve grafts for elbow reinnervation expected to have
M3 function and above; strength and function of the best of
these grafts are better than anything that can be produced by
tendon transfer
o Intermediate with radial nerve and poor with ulnar nerve
o Vascularised donors
 Free vascularised ulnar nerve most commonly used
 Not shown to be better than grafts
Nerve source
o Priorites
 Shoulder external rotation
 Infraspinatus – suprascapular nerve
 Teres minor – axillary nerve
 Shoulder abduction
 middle part of deltoid – suprascapular nerve
 supraspinatus – axillary nerve
 Elbow flexion
 Biceps - musculocutaneous
 Brachialis – musculocutaneous
o Intraplexus motor donors, such as the proximal stumps of ruptured
roots, yield, in general, better results because they carry a higher number
of axons.
 If C5/6 avulsed, sacrifice C7 for C5/6 and use extraplexal donor
for C7 targets
o Extraplexus donors (nerve transfer)
 If C5/6/7 avulsed – extraplexal donors include such as intercostal
nerves, accessory nerve, and the contralateral C7 root.
 Suprascapular
 Distal spinal accessory
 Intercostal
 Medial Pectoral nerve
 partial hypoglossal
 Musculocutaneous
 Intercostal – usually need 3 branches (1300 axons each
branch vs 6000 in MCN)
 Distal part of Spinal accessory nerve
 Medial Pectoral nerve
 1-2 fascicles of ulnar nerve (Oberlin transfer) – advantage
of anastamosing to the distal motor branches of biceps and
or brachioradialis. Cant use if C8,T1 damaged
 Distal spinal accessory – downgrades distal trapezius
 Axillary
 Intercostal
 Nerve to long head of triceps (Erbs palsy)
 Median/Radial nerve
 Contralateral C7
o Results
 reinnervation of the suprascapular nerve (92%) demonstrates
significantly better outcomes for >=M3 shoulder abduction
than the axillary nerve
 % of supraspinatus muscle function recovery greater than M3 with:
 accessory nerve – 84%
o often require nerve graft
 ipsilateral intercostal nerves – 52%
o usually 3rd to 5th nerve, try to spare 4th in women
o highest content of motor nerves just distal to
lateral cutaneous branch
o Studies have demonstrated that intercostal nerves
lose up to 10% of motor axons with each 10 cm of
distal progression from the midaxillary line to the
sternum
o ensure that patient has not had previous rib
fractures, chest tubes
 cervical plexus motor donors – 45%
o up to 4 rami available
o unpredictable results
 phrenic nerve – 40%
o pulmonary capacity decreases 1 year after surgery
but returns to normal at 2 years
 contralateral C7 – 51% (require long nerve grafts)
 ulnar nerve – 10% cross sectional area
Oberlin transfer for elbow flexion
Replacing Non Functional Muscles
Timing
 Based on either time elapsed since surgery or the direct knowledge of the state of
the nerves
 Persistence of the deformity leads to flattening of the humeral head and glenoid
over time. Humeral head subluxation and glenohumeral dislocation may also be
observed. These alterations in normal joint anatomy may limit potential motion
gains from surgery. Therefore, corrective procedures are best undertaken before
permanent bony deformity at 3 to 4 years of age in obstetrical brachial plexus
palsy.
Principles
1. Joint mobility
2. Adequate soft tissue cover
3. Absence of oedema
4. Donor muscle must be of adequate strength and amplitude of excursion
5. Patient cooperation and motivation
Shoulder reconstruction
Trapezius transfer for shoulder abduction
o transfer of the clavicular and acromial insertion of the trapezius with or
without fascia lata to the deltoid insertion on the humerus to enhance
abduction and reverse subluxation.
L’Episcopo procedure for external rotation
o Transpose latissumus dorsi and teres major posterolaterally to rotator cuff to
improve external rotation
o Two incisions, approximately 4 cm in length, are outlined in the anterior and
posterior axillary folds, respectively. Through the anterior incision, the
insertion of the pectoralis major is identified and Z-lengthened.
o insertions of the latissimus dorsi and teres major tendons are tagged with 0
nonabsorbable braided polyester (Ethibond) suture and released. Passive
external rotation is then assessed. Additional anterior structures
(subscapularis, capsule) may be released if necessary to achieve 60° of passive
external rotation
o posterior portion of the deltoid is then retracted. With the brachium held in
external rotation, the tendons are transferred and sutured as high as possible
on the insertion of the rotator cuff in the region of the greater tuberosity.
o Does not add abduction, and trapezius transfer should be added if this isn’t
present preoperatively.
Pectoralis transfer for shoulder flexion
o transfer of the sternocostal part of the pectoralis major to the anterior deltoid
for anterior flexion
Glenohumeral Arthrodesis
o As a salvage procedure
o need serratus anterior and trapezius intact to have some control of
scapulothoracic complex
o if not, better to leave it flail
Restoration of elbow flexion
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Must have a passive range of greater than 90 degrees.
Best results with Lat Dorsi>Triceps>Pec Major=flexorplasty
Steindler flexorplasty
 Devised by Arthur Steindler 1918
 EMG to ensure FDS/FCR function
 The flexor-pronator muscles (PT, FCR, FDS, PL, FCU) arising from the medial
epicondyle are transposed to a more proximal point (4-6cm) on the humerus
 Original description was insertion to the medial intermuscular septum
 Modified by Green to bony fixation to the anterior aspect of humerus
 Attachment to bone is stronger
 More lateral attachment prevents pronation during flexion
 Need normal or near normal power prior to transfer
 dramatic increase in the overall
 results of the flexorplasty can be achieved by performing additional tendon transfers
for wrist and finger extension.
Pectoralis muscle transfer
 Devised by Clark 1945
 Uses sternocostal portion
 The shoulder must be strong or fused to prevent dissipation of muscle power.
 Inserted into the biceps tendon
 Use rectus sheath attached to it for suturing
 Not recommended in women
 may have better functional results than a flexorplasty, but the ability to hold objects
against the body may be lost (thoracohumeral grasp)
 Pectoralis minor also described - has been used to supplement a flexorplasty when
initial elbow flexion is less than M2.
Latissimus transfer
 Can be used for restoration of elbow flexion and extension
 First proposed by Schottstaedt, Larsen, and Bost in1955
 Often not available because innervation C5 C6 C7 same as those being augmented

Triceps transfer
 Controversial as some consider loss of active elbow extension is disabling
 3 serious negative factors
1. precludes working with the arm in front of the body or at the horizontal position
or using the arm as a stabilizer
2. smooth action of flexion is aided by the presence of an active agonist
3. possibility of a flexion contracture secondary to an unopposed action
Sternocleidomastoid transfer
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
no longer used because of the resultant neck deformity and the need for grotesque
facial and neck manipulations to achieve flexion.
Disadvantages
1. unsightly web in the neck
2. occasionally unsightly manipulations of the neck to activate the muscle
Free Muscle Transfer
 For restoration of elbow flexion and reanimation of the hand
 Terzis leaves banked nerves from ipsilateral motor donors, such as the eleventh
cranial nerve, or intercostal nerves or cross-chest nerve grafts from the contralateral
anterior or posterior divisions of the C7 root.

Elbow Flexion
o Lat Dorsi / rectus femoris / gracilis

Finger Flexion
o Gracilis