Elbow Function After Brachial Plexus Injury

CME

Restoration of Elbow Flexion after BrachialPlexus Injury: The Role of Nerve andMuscle TransfersKarol A. Gutowski, M.D., and Harry H. Orenstein, M.D.New York, N.Y., and Dallas, Texas

Learning Objectives: After studying this article, the participant should be able to: 1. Perform appropriate diagnosticevaluation of a brachial plexus injury. 2. Define goals of treatment in brachial plexus injuries resulting in loss of elbowflexion. 3. Identify appropriate nerves and muscles for transfer procedures to regain elbow flexion. 4. Make anappropriate selection of surgical procedures to achieve elbow flexion.

Brachial plexus trauma results in a variable loss of up-per extremity function. The restoration of this functionrequires elbow flexion of adequate strength and range ofmotion. A proper evaluation of brachial plexus lesions isa prerequisite to any reconstructive procedure, and ap-propriate guidelines are presented. One option for re-storing elbow flexion is a nerve transfer. The best resultswith this procedure are obtained in young patients treatedwithin 6 months of injury. Another option is a free orpedicled muscle transfer, which should be considered inolder patients or patients treated more than 6 monthsafter an injury. Muscle transfers may also be used to aug-ment the results of nerve transfer procedures. Choicesand clinical results of donor nerves and muscle for trans-fer are discussed, and an algorithm for treatment is pre-sented. (Plast. Reconstr. Surg. 106: 1348, 2000.)

Although uncommon, brachial plexustrauma may be devastating because of the re-sulting severe upper extremity functional im-pairment. The difficulty in treating these inju-ries is compounded by the complex andvariable anatomy of the brachial plexus, thelong time intervals required for resolution af-ter injury or improvement after surgical inter-vention, the need for a long-term patient-physician commitment, and the need for amotivated patient to proceed with the difficultrehabilitation. Goals of treatment depend onthe extent of remaining function and on thenature of the injury itself. When a flail arm ispresent, the most important function to regain

is elbow flexion. This review will cover the com-mon patterns of nonobstetric brachial plexusinjuries, offer options for nerve and muscletransfer reconstructive procedures, and pro-vide treatment recommendations for elbow re-animation on the basis of an analysis of pub-lished data.

PATIENT CHARACTERISTICS

Most brachial plexus injuries are a result ofhigh velocity, traction-type trauma, as seen inmotor vehicle collisions, especially motorcycleand motor scooter accidents. The victims areusually young men who are unskilled or juststarting manual labor careers and, therefore,the economic costs of these injuries is high.One-quarter to one-third of those with severeinjuries will regain minimal or no function. Inthe largest series of brachial plexus reconstruc-tions in North America, good or excellent re-sults were obtained in 75 percent of suprascap-ular reconstructions, 48 percent of bicepsreconstructions, 30 percent of triceps recon-structions, 35 percent of finger-flexion recon-structions, and 15 percent of finger-extensionreconstructions.1

PATTERNS OF INJURY

Figure 1 diagrams the brachial plexus, whichconsists of contributions from the C5, C6, C7,

From the Institute of Reconstructive Plastic Surgery, New York University, and the Department of Plastic and Reconstructive Surgery, Universityof Texas Southwestern. Received for publication January 7, 2000; revised April 18, 2000.

1348

C8, and T1 nerve roots, with variable contribu-tion from the C4 and T2 roots, and providesmotor and sensory innervation to the upperextremity.2 Large reviews of the patterns ofinjury show that 75 percent of the lesions aresupraclavicular at the root level, whereas theremaining 25 percent are infraclavicular. Ofthe supraclavicular lesions, 75 to 80 percentinvolve the plexus from C5 to T1, with the most

common pattern being a C5-C6 rupture and aC7-C8-T1 root avulsion from the spinal cord. Atotal of 20 to 25 percent of supraclavicularinjuries involve C5-C6 or C5-C6-C7 and 2 to 3percent involve C8-T1.3 Muscles affected byeach pattern of injury, resultant functionalloss, and reconstructive goals are listed in Ta-ble I.4 When the C5 and C6 nerve roots areinvolved, the goal is to reproduce the elbow

TABLE IPatterns of Brachial Plexus Injuries and Affected Muscles with Corresponding Functional Losses and Reconstructive Goals4

Nerve Roots Muscles Affected Functional Loss Reconstructive Goals

C5-C6 Subscapularis, subclavius, deltoid, supraspinatus,infraspinatus, biceps brachialiscoracobrachialis, andbrachioradialis (6 radial wrist extensors and cavicularpectoralis major)

Shoulder rotation, abduction andforward flexion, and elbowflexion (6 wrist extension)

Stable shoulder and elbowflexion

C5-C6-C7 Same as C5-C6 and serratus anterior, extensor carpi radialislongus and brevus, flexor carpi radialis, extensordigitorum communis, extensor pollicus longus, extensorpollicus brevus, and abductor pollicus longus

Same as C5-C6 and extension ofelbow wrist, fingers, and thumb(presence of winged scapula)

Stable shoulder, elbowflexion, and wristextension

C7-C8-T1 Latissimus dorsi, extensor digitorum communis, extensorpollicus longus flexor digitorum superficialis andprofundus, flexor pollicus longus, and all intrinsic handmuscles

Finger extension, finger and thumbflexion, and intrinsic handfunctions

Wrist extension and thumbpinch

C5-C6-C7-C8-T1 All above muscles All above functions Elbow flexion

FIG. 1. Anatomy of the brachial plexus.2

Vol. 106, No. 6 / RESTORING ELBOW FLEXION 1349

flexion normally provided by the biceps mus-cle, which is innervated by the musculocutane-ous nerve from the C5 and C6 roots.

CLINICAL EVALUATION

A clinical examination of the patient with abrachial plexus injury should identify the af-fected muscles and look for signs of root avul-sion and nerve regeneration. A winged scapulawith an intact spinal accessory nerve is highlysuggestive of a C5-C6-C7 avulsion, whereas thepresence of Horner’s syndrome (enophthal-mos, myosis, ptosis, and absence of facial sweat-ing on the affected side) suggests a cervical orT1 root avulsion and interruption of sympa-thetic innervation.5 A sensory-sweating dissoci-ation in an anesthetic and flail arm also sug-gests root avulsion.6 In these cases, recoverycannot be expected, and surgical exploration iswarranted. A functioning supraspinatus musclepredicts that C5 is not avulsed.7 A supraclavic-ular Tinel’s sign suggests a connection betweenthe involved nerve and the central nervoussystem and, therefore, recovery of the affectednerve may occur.5 A paralyzed diaphragm, asdetermined by inspiratory/expiratory chestx-rays or fluoroscopic studies, suggests a highplexus lesion.1

Upper extremity angiograms should be usedin patients with a history of significant vascularinjury, especially if free tissue transfer is antic-ipated. Shoulder and arm muscles should betested individually and graded using the follow-ing system.8

M0: No contractionM1: Flicker or trace of contractionM2: Active movement with gravity eliminatedM3: Active movement against gravityM4: Active movement against resistanceM5: Normal movement

Muscles must be grade M4 or M5 to be usefulfor transfer because one grade of strength islost after transfer. Muscles with uncontrolledspasticity should not be transferred. A datasheetshown in Figure 2 is useful for documentingfunctional recovery after serial examinationsand in identifying the location of lesions in thebrachial plexus.9

Further clinical studies include electrodiag-nostics, which consist of an electromyogram(which should be done at least 3 weeks afterinjury) and the determination of nerve con-duction velocities. Imaging studies traditionallyconsisted of myelography and, later, computed

tomography myelography; however, magneticresonance imaging is noninvasive and offersmultiplanar imaging without shoulder arti-fact.10 The decision of when to explore an in-jured brachial plexus depends on these clinicalfindings, with functional recovery being lookedfor during serial examinations. Figure 3 showsan algorithm proposed by Brunelli andBrunelli,6 which is based on their extensiveexperience with these injuries.

GOALS OF TREATMENT

The goals of treatment are to restore gradeM4 or M41 elbow flexion with a range ofmotion that will allow the hand to reach theface. Although many studies report obtainingM5 elbow flexion, it is unlikely that fullstrength is ever achieved. Realistically, M41strength is the best one can expect from areconstructive procedure. The resulting func-tion of elbow flexion must outweigh the defi-cits caused by transferring functional nerves ormuscles. Furthermore, there should be a rea-sonable time to recovery of useful function. Toprevent dissipation of elbow flexion strength,the shoulder must be stable. This can beachieved by a nerve transfer of the spinal ac-cessory or phrenic nerves, arthrodesis, or ten-don transfers. After adequate elbow flexion hasbeen established, procedures to allow wrist andfinger extension may follow. Occasionally, ac-tive elbow extension or wrist and finger flexioncan also be achieved.

NERVE REPAIR AND RECONSTRUCTION PROCEDURES

Extremity reanimation may be achieved bynerve repair or by nerve transfer, which is thetransfer of a nerve in continuity with the spinalcord to the end of a nerve that has lost itsspinal cord connection. This is different fromneurotization, which is the process of reinner-vating a muscle by placing a functional nervedirectly in contact with muscle tissue. Whendealing with nerve ruptures, neurorrhaphy isthe simplest method of repair. If a significantnerve gap exists or if extensive scaring andfibrosis are present, nerve grafts should beused to bridge the gap or bypass the fibroticarea. Common sources of grafts include thesural and medial cutaneous nerves and, incases of C8 and T1 avulsion, the ulnar nervemay also be used.11 Results tend to be better ingrafts placed in the upper trunk than in thelower trunk. If a significant neuroma is presentat the site of injury, neurolysis or neuroma

1350 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2000

excision and nerve grafting is indicated, de-pending on the amount of functional nervefibers.

Nerve root avulsions must be treated bynerve or muscle transfer procedures. In thesecases, it is important to anticipate the func-tional result and to keep in mind the resultingdeficit from the donor nerve or muscle. Fur-thermore, studies of nerve and muscle transferoutcomes must be critically examined becausesome positive results may be due to spontane-ous recovery by alternate neural pathways. Fig-ure 4 shows the ideal donors for nerve transfer,which should be in proximity to the brachialplexus.12

Useful donor nerves are listed in Table IIwith their corresponding number of myelin-ated axons.13 In comparison, the numbers ofmyelinated axons in the recipient nerves arelisted in Table III.13 It is clear that most axonsin a peripheral nerve will not be functionalafter a single donor nerve transfer because ofthe unfavorable ratio of donor to recipientaxons. Fortunately, a simple action, such aselbow flexion by the biceps, requires only hun-dreds of functioning axons to be useful.14 Com-plex actions, such as those of the intrinsic mus-cles, require thousands of axons, and usefulresults should not be expected after nervetransfers to these muscles. In a review of 107

FIG. 2. Worksheet to document brachial plexus lesions and progression of recovery.9


cases, Millesi15 found useful arm function wasobtained more often with neurolysis (72 per-cent), nerve grafts (70 percent), and neuror-rhaphy (67 percent) than with nerve transfers(41 percent).

Intercostal Nerve Transfer

Intercostal nerve transfer is one of the morecommon methods of reanimating the arm.Typically, the third, fourth, and fifth intercos-tal nerves are used; however, up to seven uni-lateral intercostal nerves have been used.16

When possible, the fourth intercostal nerve

should be spared in women. Candidates forthis procedure should have no history of ribfractures, thoracotomies, or chest tube place-ment in the potential donor nerve region.Electromyograms should be performed on in-tercostal nerves adjacent to previously frac-tured ribs to assure adequate function.1

The highest content of motor nerves can befound just distal to the lateral cutaneousbranch. Sensory reinnervation may beachieved by coapting the intercostal nerve sen-sory axons, which are located in the superiorportion of the nerve, with the sensory axons ofthe musculocutaneous nerve, which are lo-cated in the superior and inferior poles of thenerve. The intercostal nerve motor fibers,which run in the inferior portion of the nerve,are coapted to the motor fibers located in themiddle of the musculocutaneous nerve.17 Sev-eral large studies with a combined total of 377patients treated by intercostal nerve transferfound that 46 percent of patients achievedgrade M4 or M5 elbow flexion.17–23

Additionally, Millesi24 found intercostalnerve transfers were more likely to have a use-ful result when the spinal accessory nerve wasused to stabilize the shoulder by nerve transferto the axillary or suprascapular nerves. Naganoet al.18 discovered that results were better whenpatients were younger than 40 years old andnerve transfer was undertaken within 6 months

TABLE IIINumber of Myelinated Axons in Nerves of the

Upper Extremity13

Root/Nerve Myelinated Axons

Brachial plexus 100,000 to 160,000C5-T1 (each root) 7000 to 41,000Axillary 6500Musculocutaneous 6000Median 18,000Ulnar 16,000Radial 19,000

FIG. 3. Algorithm for decision making in the treatment ofbrachial plexus injuries.6 MRI indicates magnetic resonanceimaging.

FIG. 4. Proximity of donor nerves to brachial plexus.12

TABLE IIPotential Donor Nerves and Number of

Myelinated Axons13

Donor Nerve Myelinated Axons

Intercostal 1300Cervical plexus motors 4000Spinal accessory 1700Long thoracic 1600Phrenic 800C7 24,000Ulnar (partial) 1600


of injury. Generally, only two or three intercos-tal nerves are needed to achieve elbow flexion,and nerve grafts should be avoided. If afterappropriate follow-up elbow flexion is gradeM3 or less, a muscle transfer procedure may beused to supplement the biceps. In less than 10percent of patients, uncontrolled elbow flexionwas reported with coughing, sneezing, or yawn-ing, but none had a loss of pulmonary func-tion.25

Spinal Accessory Nerve Transfer

The spinal accessory nerve is another poten-tial donor to achieve elbow flexion. The seg-ment distal to the trapezius ramus is used topreserve sternocleidomastoid and trapeziusfunction. Advantages include its sole functionas a motor nerve and similar functional rela-tionship with the musculocutaneous nerve.However, its use does require a nerve graft and,when needed, it is best saved for shoulder sta-bilization by nerve transfer. Songcharoen etal.26 showed good results when nerve transferwas undertaken within 6 to 9 months of injuryand when patients were younger than 40 yearsold. Kawai et al.22 compared spinal accessoryand intercostal nerve transfers for elbow flex-ion and found strength was greater than M3 in44 and 42 percent of patients, respectively. In aprospective randomized trial, Waikakul et al.25

found very good or good power in 83 percentof patients who underwent spinal accessorynerve transfers using sural nerve grafts com-pared with 64 percent of those who had atransfer of three intercostal nerves withoutnerve grafts. However, the later group had ear-lier evidence of motor reinnervation, improve-ment in protective sensation, and a reductionin arm pain.

Phrenic Nerve Transfer

Despite concerns of decreased pulmonaryfunction, the phrenic nerve has been success-fully transferred. Gu and Ma27 found elbowflexion of grade M4 or M5 in 49 percent oftheir 49 patients. Although pulmonary capacitywas decreased for 1 year after surgery, thisnormalized by 2 years. No respiratory compli-cations were seen, even when intercostal nerveswere also used.

Cervical Plexus Transfer

Up to four of the motor branches from thecervical plexus may be used for nerve trans-fer.28 Nerve grafts are required, and results are

unpredictable when used alone; therefore, it isrecommended that the spinal accessory orphrenic nerve be used in combination withcervical plexus nerve transfer to achieve betterresults.12

Hypoglossal Nerve Transfer

An infrequent donor is the hypoglossalnerve. Disadvantages include the need for anerve graft and the problem of the innervatedmuscle being activated during eating.12 Nara-kas29 cautions that there are no convincingreports that the functional donor deficit is in-significant.

C7 Spinal Nerve Transfer

Because the C7 spinal nerve may be sacri-ficed without significant loss of function, it is areasonable donor for transfer.12,30 Often, thecontralateral nerve is used.

Partial Ulnar Nerve Transfer

Oberlin et al.31 recently reported using a 10percent cross-sectional area of the ulnar nervein performing a two fascicle coaptation tobranches of the musculocutaneous nerve infour patients. Three patients achieved M4 el-bow flexion, whereas the fourth patient hadM3 flexion by 9 months after surgery. Carefultesting revealed no loss in ulnar nerve motor orsensory function.

MUSCLE TRANSFER PROCEDURES

The local and distant muscles that may betransferred and used to provide elbow flexioninclude the following: flexor-pronator mass,pectoralis major, pectoralis minor, latissimusdorsi, triceps, and sternocleidomastoid and thegracilis, rectus femoris, and latissimus dorsi asfree muscle transfers. This may be done aloneor in combination with a nerve transfer proce-dure. Unlike nerve transfers, in which the orig-inal elbow flexor, the biceps muscle, is reacti-vated, muscle transfer procedures alter thebiomechanics of elbow flexion. Therefore, atleast M4 strength and the creation of at least 90to 100 degrees of elbow flexion are needed toprovide useful function.

Steindler Flexorplasty

A commonly used muscle transfer procedurefor elbow reanimation is the flexorplasty, asoriginally described by Steindler.32 The proce-dure involves transfer of the flexor pronatormass (pronator teres, flexor carpi radialis,


flexor carpi ulnaris, palmaris longus, andflexor digitorum superficialis) from its inser-tion on the medial epicondyle to a point 4 to 6cm more proximal on the humerus. An elec-tromyogram study is recommended first toevaluate flexor digitorum superficialis andflexor carpi radialis muscle function. The flex-orplasty may be technically easier if it is donebefore shoulder fusion (when this is needed).Generally, 1 to 2 kg of lift is achieved. Thisprocedure is better at increasing elbowstrength from M2 to M3 or M4 than from M0or M1 to M3.

Brunelli et al.33 modified Steindler’s proce-dure by not including the flexor digitorumsuperficialis in an effort to avoid hand prona-tion and finger flexion during active elbowflexion. With this modification, 81 percent of32 patients were able to lift 2 kg or more, and56 percent had greater than 120 degrees ofelbow flexion. A dramatic increase in the over-all results of the flexorplasty can be achieved byperforming additional tendon transfers forwrist and finger extension.34

Pectoralis Major Transfer

The sternocostal portion of the pectoralismajor muscle may be transferred and insertedto the biceps tendon by way of a fascia latainterposition graft. A stable shoulder is a pre-requisite to prevent dissipation of power. Thisprocedure may have better functional resultsthan a flexorplasty, but the ability to hold ob-jects against the body may be lost. In Brooksand Seddon’s35 report, all patients achieved atleast 90 degrees of flexion and M3 or M4strength.

Pectoralis Minor Transfer

There are few reports on the use of thepectoralis minor for elbow reanimation. It issuggested for C5-C6 palsy and provides M3strength without donor functional loss. Thistransfer has been used to supplement a flexor-plasty when initial elbow flexion is less thanM2.36

Latissimus Dorsi Transfer

The powerful latissimus dorsi muscle canprovide more lift strength than a flexorplasty,but cortical retraining may be more difficult.Because of its C5-C6-C7 innervation, musclestrength must be assessed before transfer. Mo-neim and Omer37 could achieve only 65 to 115degrees of flexion in their patients, whereas

Hirayama et al.38 had 2 of 6 patients who couldraise their hands to their mouths. Berger andBrenner39 found the maximal strength in el-bow flexion for unipolar and bipolar latissimusdorsi transfers was 10 to 15 kg and 5 to 8 kg,respectively.

Triceps Transfer

Good strength is obtained from a tricepsmuscle transfer, but active elbow extension islost and a flexion contracture may occur. Hoanget al.’s40 experience with 7 patients showed theachievement of 90 to 140 degrees of flexion,and 5 patients could bring their hands to theirmouths. Alnot36 suggests this transfer for C5-C6palsy when elbow flexion is M0.

Sternocleidomastoid Transfer

Although excellent results were reportedwith the sternocleidomastoid muscle transfer,it is no longer used because of the resultantneck deformity and the need for grotesquefacial and neck manipulations to achieve flex-ion.4

Free Muscle Transfer

In cases of delayed nerve reconstruction withtarget muscle atrophy and motor endplate de-generation, a free gracilis, rectus femoris, orcontralateral latissimus dorsi muscle transfer isuseful. Other indications include injury to theflexor muscle mass, lack of local donor mus-cles, and as a salvage procedure in completebrachial plexus avulsions or in failures of nervetransfer. Chuang et al.41 achieved M4 strengthin 25 of 31 patients who had two or threeintercostal nerve transfers to a free gracilismuscle transfer; however, this strength was notachieved in four patients who had spinal acces-sory nerve transfers with nerve grafts to the freegracilis muscle. Akasaka et al.’s42 experiencewith free rectus femoris transfer innervated bytwo intercostal nerves yielded four patientswith M4 and four patients with M3 strength outof 11 patients. Berger and Brenner39 also usedfree unipolar and bipolar latissimus dorsi trans-fers and achieved 2 to 4 kg and 1 to 2 kg ofstrength in elbow flexion, respectively.

Comparisons of Muscle Transfer Procedures

Marshall et al.43 reported 19 of their 23 pa-tients had good or fair results with a flexor-plasty, and their best elbow flexion was 130degrees. All six patients with latissimus dorsiand all five with triceps transfer had good or


fair results, with the best flexion being 130 and120 degrees, respectively. Only 6 of the 11patients who had pectoralis major transfershad good or fair results; their best flexion was120 degrees. Although all patients with latis-simus dorsi and triceps transfers achievedgreater than 90 degrees of elbow flexion, only74 percent of those who had flexorplasties and55 percent of those with pectoralis major trans-fers reached this goal. A lack of shoulder sta-bilization was cited as the cause of poor resultsin these muscle transfers.

Chuang et al.44 found about half of theirpatients who had a flexorplasty or latissimusdorsi or free gracilis transfer could achievegreater than M3 strength, whereas all flexor-plasty patients who underwent the procedureafter previous unsatisfactory nerve or muscletransfers achieved this goal.

In a large series, Berger and Brenner39 dem-onstrated that the latissimus dorsi transfer pro-vided the strongest force of lift; this was fol-lowed by the triceps transfer and then theflexorplasty. Eggers et al.45 also found the latis-simus dorsi transfer was stronger than the flex-orplasty, but both yielded at least M4 strength.The flexorplasty, however, had a lesser degreeof elbow flexion. When the flexorplasty wascompared with a pectoralis major transfer,Beaton et al.46 found no statistical difference infunction, strength, range of motion, or activi-ties of daily living in their patients.

COMBINED TREATMENT: NERVE AND

MUSCLE TRANSFERS

Various combinations of nerve and muscletransfers have been proposed. Berger et al.47

suggest an initial nerve transfer procedure sup-plemented at least 1 year later by a tricepstransfer or flexorplasty to achieve elbow flex-ion. Doi et al.48 used latissimus dorsi transfersfor elbow flexion together with nerve transfersfor wrist and finger extension. Alnot36 reportedgood results by adding muscle transfers tonerve graft and neurolysis procedures, eitherconcurrently or as a secondary procedure.

TREATMENT RECOMMENDATIONS

On the basis of the expected outcomes ofthe many nerve and muscle transfer proce-dures, the following recommendations are of-fered to help guide treatment and achieve use-ful elbow flexion. In cases of C5-C6 rupture orsevere traction injury (Fig. 5), the nerve root isintact and so treatment should be directed at

the nerve lesion. Primary neurorrhaphy is per-formed when possible, and nerve grafts arereserved for extensive scaring and fibrosis.Neuromas may be treated by neurolysis or neu-roma excision followed by nerve grafting.

If minimal or no improvement occurs afteran appropriate waiting period, a muscle trans-fer is indicated. If elbow flexion is less than M2,a triceps transfer is preferred or, alternatively, aflexorplasty combined with a pectoralis minortransfer. If elbow flexion is M2 or greater, aflexorplasty alone should provide adequatestrength. Other options include a pectoralismajor or latissimus dorsi transfer or a free mus-cle transfer if the previous muscles are notavailable or do not have at least M4 strength.

In cases of C5-C6 avulsion (Fig. 6), a nervetransfer may be attempted. The intercostalnerve should be considered first and then theipsilateral and contralateral C7 nerve root orthe ulnar nerve in a partial fashion. The spinalaccessory and phrenic nerves should be re-

FIG. 5. Guidelines for selecting treatment for C5-C6 bra-chial plexus ruptures or severe traction injuries to achieveelbow flexion.

FIG. 6. Guidelines for selecting treatment for brachialplexus avulsions to achieve elbow flexion. *If needed, thesenerves should be saved to stabilize the shoulder.


served for shoulder stabilization, if needed. Ifat least M4 strength is not achieved, a flexor-plasty or triceps transfer (if C7 is not involved)may be added; a free muscle transfer may bedone if local muscles are unavailable. Nervetransfer may also be attempted if no musclesare available for transfer. However, if morethan 6 months have passed since the time ofinjury, if the patient is older than 30 to 40years, or if significant biceps muscle atrophy ispresent, elbow flexion is best achieved by pro-ceeding directly to a muscle transfer proce-dure, because nerve transfer procedures areunlikely to provide useful function. If localmuscles for transfer have less than M4strength, a free muscle transfer is necessary.

TREATMENT HORIZONS

Nerve root avulsions were originally thoughtto be irreparable injuries because reimplantingthe avulsed root in the spinal cord was notconsidered possible. After much research,Carlstedt et al.49 challenged this notion. In asingle patient, the C6 and C7 nerve roots werereimplanted in the spinal cord and, at 3 yearsfollow-up, voluntary deltoid, biceps, and tri-ceps activity was achieved. Although only onecase has been reported, a new option for thetreatment of avulsions may soon be possible.

Other novel avenues in improved treatmentfor brachial plexus lesions have focused onsensory and cortical re-education, technical im-provements in nerve repair, and the elimina-tion of neuromas. Nerve growth factors mayalso provide better results for these difficultinjuries.

Karol A. Gutowski, M.D.Institute of Reconstructive Plastic SurgeryNew York University Medical Center550 First AvenueNew York, N.Y. [email protected]

ACKNOWLEDGMENTS

The authors thank Mihye Choi, M.D., and Michael R.Hausman, M.D., for their review of and insightful input intothe manuscript.

REFERENCES

1. Terzis, J. K., Vekris, M. D., and Soucacos, P. N. Out-comes of brachial plexus reconstruction in 204 pa-tients with devastating paralysis. Plast. Reconstr. Surg.104: 1221, 1999.

2. Matloub, H. S., and Yousif, N. J. Peripheral nerve anat-omy and innervation pattern. Hand Clin. 8: 201, 1992.

3. Alnot, J. Traumatic brachial plexus lesions in the adult.Hand Clin. 11: 623, 1995.

4. Leffert, R. D. Brachial Plexus. In D. P. Green, R. N.Hotchkiss, and W. C. Pederson (Eds.), Operative HandSurgery, Vol. 2, 4th Ed. Philadelphia: Churchill Liv-ingstone, 1999.

5. Leffert, R. D. Clinical diagnosis, testing, and electro-myographic study in brachial plexus traction injuries.Clin. Orthop. 237: 24, 1988.

6. Brunelli, G., and Brunelli, G. Preoperative assessmentof the adult plexus patient. Microsurgery 16: 17, 1995.

7. Sedel, L. The management of supraclavicular lesions.Clin. Plast. Surg. 11: 121, 1984.

8. Medical Research Council. Aids to the Investigation ofPeripheral Nerve Injuries. In War Memorandum No. 7,2nd Ed. London: His Majesty’s Stationery Office,1943.

9. Leffert, R. D. Rehabilitation of the Patient with an In-jury to the Brachial Plexus. In J. M. Hunter, E. J.Mackin, and A. D. Callahan (Eds.), Rehabilitation of theHand: Surgery and Therapy, Vol. 1, 4th Ed. St. Louis:Mosby, 1995.

10. Panasci, D. J., Holliday, R. A., and Shpizner, B. Ad-vanced imaging techniques of the brachial plexus.Hand Clin. 11: 545, 1995.

11. Terzis, J. K., and Breidenbach, W. The Anatomy of FreeVascularized Nerve Grafts. In J. K. Terzis (Ed.), Mi-croreconstruction of Nerve Injuries. Philadelphia: Saun-ders, 1987.

12. Chuang, D. C. Neurotization procedures for brachialplexus injuries. Hand Clin. 11: 633, 1995.

13. Narakas, A. O. Thoughts on neurotization or nervetransfers in irreparable nerve lesions. Clin. Plast. Surg.11: 153, 1984.

14. Narakas, A. Surgical treatment of traction injuries ofthe brachial plexus. Clin. Orthop. 133: 71, 1978.

15. Millesi, H. Brachial plexus injuries: Management andresults. Clin. Plast. Surg. 11: 115, 1984.

16. Dolenc, V. V. Intercostal neurotization of the periph-eral nerves in avulsion plexus injuries. Clin. Plast. Surg.11: 143, 1984.

17. Chuang, D. C., Yeh, M. C., and Wei, F. C. Intercostalnerve transfer of the musculocutaneous nerve inavulsed brachial plexus injuries: Evaluation of 66 pa-tients. J. Hand Surg. (Am.) 17: 822, 1992.

18. Nagano, A., Tsuyama, N., Ochiai, N., et al. Direct nervecrossing with the intercostal nerve to treat avulsioninjuries of the brachial plexus. J. Hand Surg. (Am.) 14:980, 1989.

19. Ruch, D. S., Friedman, A., and Nunley, J. A. The res-toration of elbow flexion with intercostal nerve trans-fers. Clin. Orthop. 314: 95, 1995.

20. Malessy, M. J. A., and Thomeer, R. T. W. M. Evaluationof intercostal to musculocutaneous nerve transfer inreconstructive brachial plexus surgery. J. Neurosurg.88: 266, 1998.

21. Minami, M., and Ishii, S. Satisfactory elbow flexion incomplete (preganglionic) brachial plexus injuries:Produced by suture of third and fourth intercostalnerves to musculocutaneous nerve. J. Hand Surg.(Am.) 12: 1114, 1987.

22. Kawai, H., Kawabata, H., Masada, K., et al. Nerve repairsfor traumatic brachial plexus palsy with root avulsion.Clin. Orthop. 237: 75, 1988.

23. Takahashi, T. Studies on conversion of motor functionin intercostal nerves crossing for complete brachialplexus injuries of root avulsion type. J. Jpn. Orthop.Assoc. 57: 1799, 1983.


24. Millesi, H. Brachial plexus injuries. Clin. Orthop. 237:36, 1988.

25. Waikakul, S., Wongtragul, S., and Vanadurongwan, V.Restoration of elbow flexion in brachial plexus avul-sion injury: Comparing spinal accessory nerve transferwith intercostal nerve transfer. J. Hand Surg. (Am.) 24:571, 1999.

26. Songcharoen, P., Mahaisavariya, B., and Chotigavanich,C. Spinal accessory neurotization for restoration ofelbow flexion in avulsion injuries of the brachialplexus. J. Hand Surg. (Am.) 21: 387, 1996.

27. Gu, Y., and Ma, M. Use of the phrenic nerve for brachialplexus reconstruction. Clin. Orthop. 323: 119, 1996.

28. Brunelli, G., and Monini, L. Neurotization of avulsedroots of brachial plexus by means of anterior nerves ofcervical plexus. Clin. Plast. Surg. 11: 149, 1984.

29. Narakas, A. O. Axon Disorders in Brachial Plexus In-jury. In Scientific Program of the 11th Symposium of theInternational Society of Reconstructive Microsurgery, Vi-enna, Austria, 1993.

30. Gu, Y. D., Zhang, G. M., Chen, D. S., et al. Cervical nerveroot transfer from contralateral normal side for treat-ment of brachial plexus root avulsion. Chin. Med. J.104: 208, 1991.

31. Oberlin, C., Beal, D., Leechavengvongs, S., et al. Nervetransfer to biceps muscle using a part of ulnar nervefor C5–C6 avulsion of the brachial plexus: Anatomicalstudy and report of four cases. J. Hand Surg. (Am.) 19:232, 1994.

32. Steindler, A. A muscle plasty for the relief of flail elbowin infantile paralysis. Interstate Med. J. 25: 235, 1918.

33. Brunelli, G. A., Vigasio, A., and Brunelli, G. R. ModifiedSteindler procedure for elbow flexion restoration.J. Hand Surg. (Am.) 20: 743, 1995.

34. Liu, T., Yang, R. S., and Sun, J. S. Long-term results ofthe Steindler flexorplasty. Clin. Orthop. 296: 104, 1993.

35. Brooks, D. M., and Seddon, H. J. Pectoral transplanta-tion for paralysis of the flexors of the elbow: A newtechnique. J. Bone Joint Surg. (Br.) 41: 36, 1959.

36. Alnot, J. Y. Elbow flexion palsy after traumatic lesions ofthe brachial plexus in adults. Hand Clin. 5: 15, 1989.

37. Moneim, M. S., and Omer, G. E. Latissimus dorsi mus-cle transfer for restoration of elbow flexion after bra-

chial plexus disruption. J. Hand Surg. (Am.) 11: 135,1986.

38. Hirayama, T., Takemitsu, Y., Atsuta, Y., et al. Restora-tion of elbow flexion by complete latissimus dorsimuscle transposition. J. Hand Surg. (Br.) 12: 194, 1987.

39. Berger, A., and Brenner, P. Secondary surgery follow-ing brachial plexus injuries. Microsurgery 16: 43, 1995.

40. Hoang, P. H., Mills, C., and Burke, F. D. Triceps tobiceps transfer for established brachial plexus palsy.J. Bone Joint Surg. (Br.) 71: 268, 1989.

41. Chuang, D. C., Carver, N., and Wei, F. Results of func-tioning free muscle transplantation for elbow flexion.J. Hand Surg. (Am.) 21: 1071, 1996.

42. Akasaka, Y., Hara, T., and Takahashi, M. Free muscletransplantation combined with intercostal nerve cross-ing for reconstruction of elbow flexion and wrist ex-tension in brachial plexus injuries. Microsurgery 12:346, 1991.

43. Marshall, R. W., Williams, D. H., Birch, R., et al. Oper-ations to restore elbow flexion after brachial plexusinjuries. J. Bone Joint Surg. (Br.) 70: 577, 1988.

44. Chuang, D. C., Epstein, M. D., Yeh, M. C., et al. Func-tional restoration of elbow flexion in brachial plexusinjuries: Results in 167 patients (excluding obstetricbrachial plexus injuries). J. Hand Surg. (Am.) 18: 285,1993.

45. Eggers, I. M., Mennen, U., and Matime, A. M. Elbowflexorplasty: A comparison between latissimus dorsitransfer and Steindler flexorplasty. J. Hand Surg. (Br.)17: 522, 1992.

46. Beaton, D. E., Dumont, A., Mackay, M. B., et al. Stein-dler and pectoralis major flexorplasty: A comparativeanalysis. J. Hand Surg. (Am.) 20: 747, 1995.

47. Berger, A., Schaller, E., and Mailander, P. Brachialplexus injuries: An integrated treatment concept.Ann. Plast. Surg. 26: 70, 1991.

48. Doi, K., Sakai, K., Kuwata, N., et al. Reconstruction offinger and elbow function after complete avulsion ofthe brachial plexus. J. Hand Surg. (Am.) 16: 796, 1991.

49. Carlstedt, T., Grane, P., Hallin, R. G., et al. Return offunction after spinal cord implantation of avulsed spi-nal nerve roots. Lancet 346: 1323, 1995.

Self-Assessment Examination follows onpage 1358.


Self-Assessment Examination

Restoration of Elbow Flexion after Brachial Plexus Injury: The Role of Nerveand Muscle Transfersby Karol A. Gutowski, M.D., and Harry H. Orenstein, M.D.

1. ALL OF THE FOLLOWING STATEMENTS ARE TRUE EXCEPT:A) Elbow flexion is primarily a function of the C5 and C6 nerve rootsB) Horner’s syndrome suggests a nerve root avulsionC) Lower brachial plexus root (C8-T1) injuries are more common in adult trauma than are upper brachial plexus root injuries (C5-C6-C7)D) A nondescending Tinel’s sign suggests the need for surgical exploration of the brachial plexus

2. CURRENT RECOMMENDATIONS FOR DIAGNOSTIC EVALUATION OF NONPENETRATING BRACHIALPLEXUS INJURIES INCLUDE ALL OF THE FOLLOWING EXCEPT:A) Serial examinations of upper extremity motor functionB) Contrast-enhanced tomographyC) Magnetic resonance imagingD) Electrodiagnostic studies (electromyogram)E) Elicitation of Tinel’s sign

3. POTENTIAL DONORS FOR NERVE TRANSFER PROCEDURES TO PROVIDE ELBOW FLEXION IN BRACHIALPLEXUS INJURIES INCLUDE ALL OF THE FOLLOWING EXCEPT:A) Intercostal nerveB) Spinal accessory nerveC) Musculocutaneous nerveD) Contralateral C7 nerveE) Partial ulnar nerve

4. COMMON DONORS FOR MUSCLE TRANSFER PROCEDURES TO PROVIDE ELBOW FLEXION IN BRACHIALPLEXUS INJURIES INCLUDE ALL OF THE FOLLOWING EXCEPT:A) Latissimus dorsiB) Gracilis as a free tissue transferC) Flexor-pronator mass of the forearmD) SternocleidomastoidE) Pectoralis major

5. FACTORS ASSOCIATED WITH POOR OUTCOME AFTER PROCEDURES TO TREAT BRACHIAL PLEXUSINJURIES INCLUDE ALL OF THE FOLLOWING EXCEPT:A) Nerve transfer procedures in patients older than 40 yearsB) Transfer of muscles that are grade M3 in strengthC) Nerve transfer procedures preformed more than 12 months after injuryD) Use of muscle transfers after initial nerve transfer proceduresE) Avoiding shoulder stabilization procedures

To complete the examination for CME credit, turn to page 1449 for instructions and the response form.

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Elbow Function After Brachial Plexus Injury