Adult Traumatic Brachial

Plexus Injuries

Alexander Y. Shin, MD, Abstract

Robert J. Spinner, MD, Adult traumatic brachial plexus injuries are devastating, and they
Scott P. Steinmann, MD, and are occurring with increasing frequency. Patient evaluation
Allen T. Bishop, MD consists of a focused assessment of upper extremity sensory and
motor function, radiologic studies, and, most important,
preoperative and intraoperative electrodiagnostic studies. The
critical concepts in surgical treatment are patient selection as well
as the timing and prioritizing of restoration of function. Surgical
techniques include neurolysis, nerve grafting, neurotization, and
free muscle transfer. Results are variable, but increased knowledge
of nerve injury and repair, as well as advances in microsurgical
techniques, allow not only restoration of elbow flexion and
shoulder abduction but also of useful prehension of the hand in
some patients.

Dr. Shin is Associate Professor,

Department of Orthopaedic Surgery,
Division of Hand Surgery, Mayo Clinic,
Rochester, MN. Dr. Spinner is Associate
Professor, Department of Neurosurgery
and Department of Orthopaedic
Surgery, Division of Hand Surgery, Mayo
Clinic. Dr. Steinmann is Assistant
Professor, Department of Orthopaedic
Surgery, Mayo Clinic. Dr. Bishop is
Professor, Department of Orthopaedic
Surgery, Mayo Clinic.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Shin, Dr. Spinner, Dr. Steinmann, and
Dr. Bishop.
Reprint requests: Dr. Shin, Mayo Clinic,
E14A, 200 1st Street SW, Rochester,
MN 55905.
J Am Acad Orthop Surg 2005;13:382-
396
Copyright 2005 by the American
Academy of Orthopaedic Surgeons.
B rachial plexus lesions frequently
lead to significant physical dis-
ability, psychological distress, and
socioeconomic hardship. These le-
sions can result from a variety of eti-
ologies, including birth injuries, pen-
etrating injuries, falls, and motor
vehicle trauma. Most are closed in-
juries involving the supraclavicular
region rather than the retroclavicu-
lar or infraclavicular level. The roots
and trunks are more commonly af-
fected than the divisions, cords, or
terminal branches. Most injuries oc-
cur as a result of fracture or compres-
sion or as a combination of these. In
the supraclavicular region, traction
injuries occur when the head and
neck are violently moved away from
the ipsilateral shoulder, often result-
ing in an injury to the C5 or C6 roots
or upper trunk. Traction to the bra-
chial plexus also can occur second-
ary to violent arm movement; when
the arm is abducted over the head
with significant force, traction oc-
curs within the lower elements of
the brachial plexus (C8-T1 roots or
lower trunk). Compression injuries
to the brachial plexus usually occur
between the clavicle and the first
rib. Direct blows also may result in
injuries to the brachial plexus, espe-
cially around the coracoid process of
the scapula.
The exact number of brachial
plexus injuries that occur each year
is difficult to ascertain; however,
with the advent of increasingly ex-
treme sporting activities and high-
energy motor sports, as well as the
increasing number of survivors of
high-speed motor vehicle accidents,
the number of brachial plexus inju-
ries continues to rise throughout the
world.1-6 Most of these injuries occur
in males aged 15 to 25 years.5,7,8 Based
on his experience with 1,068 patients
with brachial plexus injuries during
an 18-year span, Narakas9 developed
his rule of “seven seventies.” He re-
ported that approximately 70% of
traumatic brachial plexus injuries oc-
curred secondary to motor vehicle
accidents; of these, approximately
70% involved motorcycles or bicy-

382 Journal of the American Academy of Orthopaedic Surgeons

 Alexander Y. Shin, MD, et al

Figure 1

Anatomy of the brachial plexus. A, The brachial plexus has five major segments: roots, trunks, divisions, cords, and branches.
The clavicle overlies the divisions. The roots and trunks compose the supraclavicular plexus, and the cords and branches
compose the infraclavicular plexus. B, The relationship between the axillary artery and the cords. The cords are named for their
anatomic relationship to the axillary artery: lateral, medial, and posterior. LC = lateral cord, LSS = lower subscapular nerve,
MABC = medial antebrachial cutaneous nerve, MBC = medial brachial cutaneous nerve, MC = medial cord, PC = posterior
cord, TD = thoracodorsal nerve, USS = upper subscapular nerve. (Adapted by permission of Mayo Foundation.)

cles. Of the cycle riders, approxi- chial plexus intervention surgery.

mately 70% had multiple injuries.
Overall, 70% had supraclavicular le-
sions; of those, 70% had at least one
root avulsed. At least 70% of patients
with a root avulsion also have avul-
sions of the lower roots (C7, C8, or
T1). Finally, of patients with lower
root avulsion, nearly 70% will expe-
rience persistent pain.
Treatment recommendations for
complete root avulsions have varied
widely over the past 50 years. Follow-
ing World War II, the standard ap-
proach was surgical reconstruction
by shoulder fusion, elbow bone
block, and finger tenodesis.10 Yeoman
and Seddon11 noted a tendency
among these patients to become
“one-handed” within 2 years of in-
jury, resulting in few successful out-
comes regardless of the treatment ap-
proach. Their retrospective study
revealed no good results from bra-
However, amputation plus shoulder
fusion performed within 24 months
of injury resulted in predominantly
good and fair outcomes. Conse-
quently, in the 1960s, transhumeral
(above-elbow) amputation, combined
with shoulder fusion in slight abduc-
tion and flexion, was advocated.12
However, loss of glenohumeral mo-
tion caused by brachial plexus inju-
ries limited the effectiveness of body-
powered prostheses (eg, figure-of-8
harness with farmer’s hook). Ad-
vances in brachial plexus reconstruc-
tion have yielded outcomes superior
to historical results. A better under-
standing of the pathophysiology of
nerve injury and repair, as well as re-
cent advances in microsurgical tech-
niques, have allowed reliable restora-
tion of elbow flexion and shoulder
abduction, in addition to useful pre-
hension of the hand in some cases.
Anatomy
The brachial plexus is formed from
five cervical nerve roots: typically,
C5, C6, C7, C8, and T1 (Fig. 1). Ad-
ditionally, there may be contribu-
tions to the brachial plexus from C4,
ranging from small branches to larger
contributions, and from T2. A plexus
with contributions from C4 is called
“prefixed.” The incidence of prefixed
plexuses ranges from 28% to 62%.
When contributions from T2 occur,
the plexus is termed “postfixed.” The
incidence of postfixed plexuses
ranges from 16% to 73%.13
The so-called true form of the bra-
chial plexus was described by Kerr,13
who performed detailed anatomic
dissections on 175 specimens. In the
true form there are five separate sec-
tions of the brachial plexus: roots,
trunks, divisions, cords, and terminal
branches. Formed by the coalescence

Volume 13, Number 6, October 2005 383

Adult Traumatic Brachial Plexus Injuries

Figure 2

A, Anatomy of the brachial plexus roots and types of injury. The roots are formed by the coalescence of the ventral (motor) and
dorsal (sensory) rootlets as they pass through the spinal foramen (A). The dorsal root ganglion holds the cell bodies of the
sensory nerves; the cell bodies for the ventral nerves lie within the spinal cord. Three types of injury can occur: avulsion injuries
pull the rootlets out of the spinal cord (B); stretch injuries attenuate the nerve (C); and ruptures result in complete discontinuity
of the nerve (D). B, Intraoperative photograph of a preganglionic injury (root avulsion) as well as a postganglionic injury. The
C5 root is avulsed with its dorsal and ventral rootlets. The asterisk marks the dorsal root ganglion. The C6 root, which is inferior,
demonstrates a rupture at the root level. (Panel A adapted by permission of Mayo Foundation. Panel B reproduced by permission
of Mayo Foundation.)

of the ventral and dorsal nerve root-
lets, the root passes through the spi-
nal foramen (Fig. 2, A). The dorsal
root ganglion holds the cell bodies of
the sensory nerves and lies within the
confines of the spinal canal and fora-
men. A preganglionic injury is one in
which the spinal roots are avulsed
from the spinal cord (Fig. 2, B).
Preganglionic injuries can be sepa-
rated into central avulsions, in which
the nerve is avulsed directly from the
spinal cord, and intradural ruptures,
in which rootlets rupture proximal to
the dorsal root ganglion. An injury
distal to the dorsal root ganglion is
called postganglionic (Fig. 2, B). Dis-
tinguishing between a preganglionic
and a postganglionic injury is impor-
tant when considering the possibility
of spontaneous recovery and implica-
tions for surgical reconstruction be-
cause there is little potential recov-
ery at this time for preganglionic
injury.
The C5 and C6 roots merge to
form the upper trunk, and the C8
and T1 roots merge to form the low-
er trunk. C7 becomes the middle
trunk. The point at which C5 and
C6 merge (Erb’s point) marks the lo-
cation at which the suprascapular
nerve emerges. Each trunk then di-
vides into an anterior and a posteri-
or division and passes beneath the
clavicle. The posterior divisions
merge to become the posterior cord,
and the anterior divisions of the up-
per and middle trunk merge to form
the lateral cord (Fig. 1, B). The ante-
rior division from the lower trunk
forms the medial cord. The posteri-
or cord forms the axillary nerve and
the radial nerve. The lateral cord
splits into two terminal branches:
the musculocutaneous nerve and
the lateral cord contribution to the
median nerve. The medial cord con-
tributes to the median nerve as well
as to the ulnar nerve.
A few terminal nerve branches
come off the roots, trunks, and cords.
The branches off the C5 root include
a branch to the phrenic nerve, the
dorsal scapular nerve (rhomboid
muscles), and the long thoracic nerve
(serratus anterior muscle) (Fig. 1, A).
The branches off C6 and C7 also con-
tribute to the long thoracic nerve
(serratus anterior muscle). The
branches off the upper trunk include
the suprascapular nerve (supraspina-
tus and infraspinatus muscles) and
the nerve to the subclavius muscle.
The lateral cord gives off the lateral
pectoral nerve, while the posterior
and medial cords each have three
branches. The posterior cord gives off
branches (proximal to distal) that in-

384 Journal of the American Academy of Orthopaedic Surgeons


clude the upper subscapular nerve,
thoracodorsal nerve, and the lower
subscapular nerve. The medial cord
gives off the medial pectoral nerve,
the medial antebrachial cutaneous
nerve, and the medial brachial cuta-
neous nerve. By noting loss of func-
tion to these muscles, one can gain
knowledge on pinpointing the level
of brachial plexus injury.
The sympathetic ganglion for T1
lies in close proximity to the T1 root
and provides sympathetic outflow to
the head and neck. Avulsion of the
T1 root (a pre-ganglionic injury) re-
sults in interruption of the T1 sym-
pathetic ganglion, resulting in Hor-
ner syndrome, which consists of
miosis (small pupil), enophthalmos
(sinking of the orbit), ptosis (lid
droop), and anhydrosis (dry eyes).
Patient Evaluation
Physical Examination
Brachial plexus injury is often
seen in patients who have sustained
polytrauma; thus, diagnosis of the
nerve injury necessarily may be de-
layed until the patient is stabilized
and resuscitated. A high index of
suspicion for a brachial plexus inju-
ry should be maintained when ex-
amining a patient with severe shoul-
der girdle injury. On initial
examination, the patient is often ob-
tunded or sedated, and careful obser-
vation is needed as the patient be-
comes more coherent.
A detailed examination of the
brachial plexus and its terminal
branches can be performed in a few
minutes on an awake, cooperative
patient when the examiner is experi-
enced and systematic. The median,
ulnar, and radial nerves are evaluat-
ed by examining finger and wrist
motion. Elbow flexion and extension
are examined to determine musculo-
cutaneous and high radial nerve
function. Examination of shoulder
abduction can determine the func-
tion of the axillary nerve, a branch of
the posterior cord. Injury to the pos-
terior cord may affect both deltoid
Volume 13, Number 6, October 2005
function and the muscles innervated
by the radial nerve. Examination of
wrist extension, elbow extension,
and shoulder abduction may help de-
termine the condition of the posteri-
or cord.
The latissimus dorsi is innervated
by the thoracodorsal nerve, which is
also a branch of the posterior cord.
This muscle can be palpated in the
posterior axillary fold and can be felt
to contract when a patient is asked
to cough. The pectoralis major is in-
nervated by the medial and lateral
pectoral nerves, each a branch of the
medial and lateral cords, respective-
ly. The medial pectoral nerve inner-
vates the sternal head of the pectora-
lis major, and the lateral pectoral
nerve innervates the clavicular head.
The entire pectoralis major muscle
can be palpated from superior to in-
ferior as the patient adducts the arm
against resistance.
Located proximal to the cord lev-
el, the suprascapular nerve is a ter-
minal branch at the trunk level. It
can be examined by assessing shoul-
der external rotation and elevation.
Often, in a chronic situation, the
posterior aspect of the shoulder dem-
onstrates significant atrophy in the
area of the infraspinatus muscle. Su-
praspinatus muscle atrophy is hard-
er to detect clinically because the
trapezius muscle covers most of the
supraspinatus muscle. Loss of shoul-
der flexion, rotation, and abduction
also may be caused by a significant
rotator cuff or deltoid injury. Both
axillary nerve function and rotator
cuff integrity should be evaluated
when testing shoulder function.
Certain findings suggest pregan-
glionic injury on clinical examina-
tion. For example, the patient should
be examined for the presence of Hor-
ner syndrome, which is suggestive of
a root avulsion at the C8-T1 level.
Injury to the long thoracic nerve or
the dorsal scapular nerve suggests a
higher (more proximal) level of inju-
ry because both nerves originate at
the root level. The long thoracic
nerve is formed from the roots of C5-
Alexander Y. Shin, MD, et al
C7 and innervates the serratus ante-
rior muscle. This nerve, >20 cm
long, is vulnerable to injury as it de-
scends along the chest wall. Injury to
the long thoracic nerve with result-
ant dysfunction of the serratus ante-
rior muscle causes significant scap-
ular winging as the patient attempts
to forward elevate the arm. The dor-
sal scapular nerve is derived from
C4-C5 and innervates the rhomboid
muscles, often at a foraminal level.
Careful examination demonstrates
atrophy of the rhomboids and para-
scapular muscles when this nerve is
injured. The patient must be ob-
served posteriorly to fully evaluate
the serratus anterior and rhomboid
muscles.
Neighboring cranial nerves must
be considered during motor testing.
The spinal accessory nerve that in-
nervates the trapezius muscle can
occasionally be injured with the
neck or shoulder trauma that affects
the brachial plexus. Its integrity is
important because the spinal acces-
sory increasingly is used as a nerve
transfer.
Careful sensory (and/or autonom-
ic) examination should include var-
ious nerve distributions (especially
autonomous zones). Sensation of
root-level dermatomes can be unre-
liable because of either overlap from
other nerves or anatomic variation.
The examiner should record ac-
tive and passive ranges of motion as
well as the presence or absence of re-
flexes. The presence of concomitant
spinal cord injury should be consid-
ered by examining for lower limb
strength, sensory levels, increased
reflexes, and pathologic reflexes. Per-
cussing the nerve is especially help-
ful. Acutely, pain over a nerve sug-
gests a rupture. Lack of percussion
tenderness over the brachial plexus
indicates an avulsion. An advancing
Tinel sign is sometimes suggestive
of a recovering lesion.
Because it is possible also to rup-
ture the axillary artery at the time of
significant brachial plexus injury, a
vascular examination should be per-
385
Adult Traumatic Brachial Plexus Injuries

Figure 3 ciated inflammation or edema, and

it can evaluate mass lesions in the
patient with spontaneous non-
traumatic neuropathy affecting the
brachial plexus or its terminal
branches. Despite this, in the acute
setting, CT myelography remains
the primary mode of radiographic
evaluation for nerve root avulsion.

Electrodiagnostic Studies
Electrodiagnostic studies are inte-
gral to both preoperative and intra-
operative decision-making. They
help in confirming a diagnosis, local-
izing lesions, defining the severity of
axon loss and the completeness of a
Presence of a pseudomeningocele (asterisks) indicates greater likelihood of a nerve lesion, eliminating other conditions
root avulsion. A, Anteroposterior myelogram demonstrating multiple root avulsions from the differential diagnosis, and
(asterisks). B, Those avulsions (asterisk) are clearly seen on axial CT myelogram. revealing subclinical recovery or
The arrows on the opposite side of the avulsion demonstrate the normal dorsal and
unrecognized subclinical disorders.
ventral rootlet outline of the uninjured side. These outlines are missing on the injured
Electrodiagnostic studies are an im-
side. (Reproduced by permission of Mayo Foundation.)
portant adjunct to a thorough histo-
ry, physical examination, and imag-
formed. Vascular injuries are not in- angiography may be indicated to ing studies, not a substitute for
frequent findings with infraclavicu- confirm the patency of a previous them.
lar lesions or with even more severe vascular repair or reconstruction. For closed injuries, baseline elec-
injuries, such as scapulothoracic dis- Computed tomography (CT) tromyography (EMG) and nerve con-
sociation. combined with myelography has duction velocity (NCV) studies are
been instrumental in helping to de- best performed 3 to 4 weeks after in-
Radiographic Evaluation fine the level of nerve root jury because wallerian degeneration
After a traumatic injury to the injury.14-16 With an avulsion of a cer- will have occurred by then. Serial
neck or shoulder girdle, radiograph- vical root, the dural sheath heals electrodiagnostic studies can be
ic examination should include views with development of a pseudomen- done every few months in conjunc-
of the cervical spine, shoulder (an- ingocele. Immediately after injury, tion with a repeat physical examina-
teroposterior and axillary views), blood clot is often present in the area tion to document and quantify ongo-
and chest. The spine radiographs of the nerve root avulsion and can ing reinnervation or denervation.
should determine the presence of displace dye from the myelogram. EMG tests muscles at rest and
any associated cervical fractures that Therefore, a CT myelogram should with activity. Denervational chang-
could put the spinal cord at risk. be done 3 to 4 weeks after injury to es (ie, fibrillation potentials) in dif-
Transverse process fractures in the allow time for blood clots to dissi- ferent muscles can be seen in proxi-
cervical vertebrae may suggest root pate and for pseudomeningoceles to mal muscles as early as 10 to 14 days
avulsion at the same level. Clavicle fully form. A pseudomeningocele on after injury (and in 3 to 6 weeks in
or rib fractures (first or second rib) CT myelogram is highly suggestive more distal muscles). Reduced re-
may indicate trauma to the brachial of a root avulsion (Fig. 3). cruitment of motor unit potentials
plexus. Chest radiographs may re- Magnetic resonance imaging can be demonstrated immediately
veal old rib fractures, which are im- (MRI) may be useful in evaluating after weakness occurs from lower
portant should intercostal nerves be patients with a suspected nerve root motor neuron injury. The presence
considered for nerve transfer (rib avulsion,17-19 and it has some advan- of active motor units with voluntary
fractures often injure the associated tages over CT myelogram. MRI can effort and few fibrillations at rest of-
intercostal nerves). Additionally, visualize much of the brachial fers a good prognosis compared with
phrenic nerve injury causes associat- plexus, whereas CT myelography the absence of motor units and
ed paralysis of the hemidiaphragm. demonstrates only nerve root injury. many fibrillations. EMG may help
When vascular injury is suspected, Additionally, MRI can demonstrate distinguish preganglionic from post-
arteriography or magnetic resonance large neuromas after trauma or asso- ganglionic lesions by needle exami-

386 Journal of the American Academy of Orthopaedic Surgeons


nation of proximally innervated
muscles that are innervated by root
level motor branches (eg, cervical
paraspinals, rhomboids, serratus an-
terior).
NCV studies are performed along
with EMG. In posttraumatic brachial
plexus lesions, the amplitudes of
compound muscle action potentials
(CMAPs) are generally low. Sensory
nerve action potentials (SNAPs) are
important in localizing a lesion
as preganglionic or postganglionic.
SNAPs are preserved in lesions prox-
imal to the dorsal root ganglia. Be-
cause the sensory nerve cell body is
intact and within the dorsal root gan-
glion, NCV studies often demonstrate
that the SNAP is normal, when clin-
ically the patient is insensate in the
associated nerve sensory distribution.
SNAPs are absent in a postganglionic
or a combined pre- and postganglionic
lesion. For example, a patient with a
normal SNAP in the ulnar nerve,
with an insensate ulnar nerve distri-
bution, has avulsions (preganglionic
injury) of the C8-T1 roots.
There are limitations to electrodi-
agnostic studies. The EMG/NCV
study is only as good as the experi-
enced physician who is performing
the study and interpreting the re-
sults. EMG may demonstrate evi-
dence of early recovery in muscles
(eg, emergence of nascent potentials,
a decreased number of fibrillation
potentials, or the appearance of or an
increased number of motor unit po-
tentials); these findings may predate
clinically apparent recovery by
weeks to months. However, EMG
recovery does not always equate
with clinically relevant recovery ei-
ther in terms of quality of regenera-
tion or extent of recovery. EMG re-
covery merely indicates that an
unknown number of fibers have
reached muscles and have estab-
lished motor end plate connections.
Conversely, evidence of reinnerva-
tion may not be detected on EMG in
complete lesions, despite ongoing re-
generation, when target end organs
are more distal.
Volume 13, Number 6, October 2005
Intraoperative electrodiagnostic
studies also may play a part in bra-
chial plexus surgery. A combination
of intraoperative electrodiagnostic
techniques can be used to maximize
the information gathered before
making a surgical decision. These
techniques routinely include nerve
action potentials (NAPs) and soma-
tosensory evoked potentials (SSEPs),
as well as CMAPs. NAPs allow the
surgeon to test a nerve directly
across a lesion to detect reinnerva-
tion months before conventional
EMG techniques would demon-
strate activity and to determine
whether a lesion is neurapractic
(negative NAP) or axonotmetic (pos-
itive NAP). The presence of a NAP
across a lesion indicates preserved
axons or significant regeneration.
Primate studies have suggested that
the presence of a NAP indicates the
viability of thousands of axons rath-
er than the hundreds seen with oth-
er techniques.20 The presence of a
NAP suggests that recovery will oc-
cur after neurolysis alone without
the need for additional treatment
(eg, neuroma resection and grafting).
More than 90% of patients with a
preserved NAP will gain clinically
useful recovery.20 NAPs indirectly
can help distinguish between pre-
and postganglionic injury. A faster
conduction velocity with large am-
plitude and short latency, together
with severe neurologic loss, indicate
a preganglionic injury. A flat tracing
suggests that adequate regeneration
is not occurring; this is consistent
with either a reparable postganglion-
ic lesion or an irreparable combined
pre- and postganglionic lesion. With
the latter, sectioning the nerve back
to an intraforaminal level would not
reveal good fascicular structure.20
Intraoperative somatosensory-
evoked potentials (SSEPs) are also
used during brachial plexus surgery.
The presence of an SSEP suggests
continuity between the peripheral
nervous system and the central ner-
vous system via a dorsal root. A pos-
itive response is determined by the
Alexander Y. Shin, MD, et al
integrity of a few hundred intact
fibers. The actual state of the ventral
root is not tested directly with this
technique. Instead, it is inferred from
the state of the sensory nerve root-
lets, even though perfect correlation
between dorsal and ventral root avul-
sions does not always exist. SSEPs
are absent in postganglionic or
combined pre- and postganglionic
lesions. Motor-evoked potentials
assess the integrity of the motor
pathway via the ventral root. This
technique, which uses transcranial
electrical stimulation, has recently
been approved in the United States.21
CMAPs are not useful intraopera-
tively in complete distal lesions be-
cause of the time required for regen-
eration to occur into distal muscles.
However, CMAPs are useful in par-
tial lesions because the size of the le-
sion is proportional to the number of
functioning axons.
Concepts of Surgical
Management
The three most important concepts
in the surgical management of bra-
chial plexus injuries are patient se-
lection, the exact timing of surgery,
and the prioritization of restoration
of function in the upper arm.
Surgery should be performed in
the absence of clinical or electrical
evidence of recovery or when spon-
taneous recovery is impossible. De-
spite the improvements in electro-
diagnostic studies and imaging,
selecting when and on whom to op-
erate remains one of the most diffi-
cult decisions in peripheral nerve
surgery. During the observation peri-
od, physical therapy should be per-
formed to prevent contractures and
to strengthen functioning muscles.
Timing of surgery or intervention
depends on the mechanism of injury
as well as the type of injury. Imme-
diate exploration and primary repair
of the injured portion of the brachi-
al plexus is indicated in sharp open
injuries. This facilitates end-to-end
repair of the injured nerves. When
387
Adult Traumatic Brachial Plexus Injuries

Figure 4 duction and stability, hand sensibility,

wrist extension and finger flexion,
wrist flexion and finger extension,
and intrinsic function of the hand.

Surgery
Brachial plexus surgery can be divided
into primary and secondary recon-
struction. Primary reconstruction is
the initial surgical management and
may include nerve surgery/recon-
struction (eg, direct repair, neuroly-
sis, nerve grafting, nerve transfers)
and/or soft-tissue procedures (eg, free
functioning muscle transfer). Second-
ary reconstruction may be necessary
to improve function, either to aug-
ment partial recovery or to obtain
function when none has been
achieved. This may include soft-
tissue reconstruction (eg, tendon/
muscle transfer, free muscle transfer)
and bony procedures (eg, arthrodesis,
Intraplexal nerve grafting with donor nerves can be performed in the setting of osteotomy), but typically not nerve
postganglionic injury with viable nerve root stumps available. With postganglionic
surgery. Often a combination of these
injuries on C5, C6, and C7, nerve grafts can be used to target shoulder abduction
techniques can be used, necessitating
(C5 to the suprascapular nerve [A] and posterior division of the upper trunk [B]),
elbow flexion (C6 to the anterior division of the upper trunk [C]), and wrist extension a broad surgical armamentarium.
and elbow extension (C7 to the posterior division of the middle trunk, targeting
radial nerve function [D]). SSN = suprascapular nerve. (Adapted by permission of Primary Reconstruction
Mayo Foundation.) Direct repair of nerve ends can be
done after sharp injuries (eg, lacera-
tions), but it cannot be applied to
the open injury is secondary to a time for spontaneous reinnervation, stretch injuries. External neurolysis
blunt object with avulsion of the but waiting too long before operating is a necessary prerequisite for intra-
nerve, the ends of the lacerated may unnecessarily lead to failure of operative electrical studies. Neurol-
nerve should be tagged and a delayed the motor end plate and thus failure ysis alone may be performed when
repair performed 3 to 4 weeks later. of reinnervation. Early exploration the nerve is in continuity and a NAP
By 3 to 4 weeks, the injured nerve and reconstruction (between 3 and 6 is obtained.22
ends will have demarcated, enabling weeks) is indicated when there is a
better access to the zone of nerve in- high suspicion of root avulsion. Rou- Intraplexal Nerve Grafting
jury. Low-velocity gunshot wounds tine exploration is performed 3 to 6 Nerve grafting can be performed
should be observed because most of months after injury in patients who with ruptures or postganglionic neu-
these injuries are neurapraxic; how- have not demonstrated adequate rein- romas that do not conduct a NAP
ever, high-velocity gunshot wounds nervation. Results from delayed (6 to across the lesion. In such cases, the
are associated with significant soft- 12 months) or late (>12 months) sur- nerve root—because of its connec-
tissue damage and usually mandate gery are poorer because the time for tion to the spinal cord—has main-
surgical exploration. the nerve to regenerate to the target tained viable motor axons that can
For stretch injuries, the exact tim- muscles is greater than the survival be grafted to specific targets. Interpo-
ing of surgery is more controversial. time of the motor end plate after de- sitional grafts (typically using cable
The timing is determined somewhat enervation. grafts of sural or other cutaneous
by the mechanism and type of injury, Most surgeons consider elbow nerves) are coapted between nerve
physical examination and imaging flexion the highest priority when re- stumps without undue tension. For
findings, and surgeon preference. Op- storing function to the flail extrem- example, C5 is targeted for shoulder
erating early may not allow sufficient ity. Next in priority are shoulder ab- abduction (suprascapular nerve, axil-

388 Journal of the American Academy of Orthopaedic Surgeons


Figure 5
Neurotization for shoulder abduction with the spinal accessory nerve29 (A) or the phrenic nerve24 (B) can be performed in the
supraclavicular exposure. (Adapted by permission of Mayo Foundation.)
lary nerve), C6 for elbow flexion
(musculocutaneous nerve), and C7
for elbow extension and wrist exten-
sion (radial nerve)22 (Fig. 4).
Nerve Transfer (Neurotization)
Nerve transfer can be performed
for preganglionic injury or to acceler-
ate recovery by reducing the time for
reinnervation by decreasing the dis-
tance between the site of nerve re-
pair and the end organ. A function-
ing nerve of lesser importance is
transferred to the more important
denervated distal nerve. Ideally,
nerve transfers should be performed
within 6 months of injury; however,
even after the preferred 6-month
time frame, nerve transfers may be
more suitable than grafting because
nerve transfers have faster recovery
than grafting.
Several donor nerves are sources
for neurotization. Some of the more
common include the spinal accesso-
ry nerve (cranial nerve XI), intercos-
tal nerves (motor and sensory), and
medial pectoral nerve. More recent-
Volume 13, Number 6, October 2005
ly, using a fascicle of a functioning
ulnar nerve (Oberlin transfer) or the
median nerve in patients with intact
C8 and T1 nerves has allowed rapid
and powerful return of elbow flex-
ion, with 94% of patients achieving
M4 strength.23 The phrenic nerve24
and the contralateral C7 (or hemi-
contralateral C7)25 nerve also have
been used to expand the pool of ex-
traplexal donors and to improve out-
comes. The deep cervical plexus and
hypoglossal nerve (cranial nerve XII)
have been used, but poor motor re-
covery has been reported.26
The average number of myelinat-
ed axons in these donor nerves var-
ies. The spinal accessory nerve has
approximately 1,700 axons; the
phrenic nerve, 800 axons; a single in-
tercostal motor nerve, 1,300 axons;
and the contralateral C7 nerve,
23,780 axons.26 The goal is to maxi-
mize the number of myelinated ax-
ons per target function and mini-
mize donor site morbidity. Several
series have reported an acceptable
morbidity with transfer of the con-
Alexander Y. Shin, MD, et al
tralateral C7 and phrenic nerves, but
long-term studies are not avail-
able.25,27
Neurotization for shoulder abduc-
tion can be easily obtained by nerve
transfer of either the spinal accesso-
ry nerve or the phrenic nerve to the
suprascapular nerve.24,26,28 The bene-
fit of these two transfers is that no
additional interposition nerve grafts
are needed, and a direct coaptation of
the nerves is possible (Fig. 5). When
additional nerve sources are avail-
able, neurotization of the axillary
nerve (nerve grafting from C5) is rec-
ommended to provide further shoul-
der stability and abduction.
Neurotization for elbow flexion
can be performed using either inter-
costal nerves (Fig. 6) directly or the
spinal accessory nerve with an inter-
positional graft29 directly targeting
the biceps motor branch (rather than
the entire musculocutaneous nerve).
Separating the biceps motor branch
from the lateral antebrachial cutane-
ous nerve in a retrograde manner al-
lows the maximum number of mo-
389
Adult Traumatic Brachial Plexus Injuries

Figure 6 tor axons to be transferred directly to This technique is an excellent alter-

Neurotization for elbow flexion with
intercostal nerves. The motor branches
from the intercostal nerves can be
easily harvested and neurotized to the
motor branch of the musculocutaneous
nerve to the biceps. (Adapted by
permission of Mayo Foundation.)
the biceps muscle. This also helps
gain length for the transfer, thus
eliminating the need for interposi-
tional grafts in the case of intercos-
tal nerves and shortening the length
of the graft for the accessory nerve.
Some have advocated using the
phrenic nerve with an interposition-
al graft to the musculocutaneous
nerve.24
In the event of an upper trunk
avulsion injury, two popular options
exist for restoring elbow flexion.
The medial pectoral nerve may be
transferred to the musculocutane-
ous nerve or the biceps branch.26 Al-
ternatively, a fascicle from the ulnar
nerve (Oberlin transfer) can be trans-
ferred to the motor branch of the bi-
ceps with excellent results (94% of
patients achieved M4 strength)23
(Fig. 7). Before separating the fasci-
cles from the ulnar nerve, they are
tested with a nerve stimulator. Fas-
cicles that stimulate the intrinsic
muscles of the hand are avoided;
those that stimulate wrist flexion
(flexor carpi ulnaris) are chosen.
native to the intercostal neurotiza-
tions or spinal accessory nerve with
an interpositional graft.
The contralateral C7 or a hemi-
contralateral C7 nerve can be used
via a vascularized ulnar nerve graft
(in the case of a complete plexus
avulsion injury) or via sural nerve
grafts to bring a large number of mo-
tor axons to the injured side.25,27
When used with the vascularized ul-
nar nerve graft, the contralateral or
hemicontralateral C7 nerve can be
used to innervate the median nerve,
with the goal of obtaining useful fin-
ger flexion (29% of patients achieved
M3 or M4 finger flexion) and protec-
tive sensation in the median nerve
distribution (81% of patients)27 (Fig.
8).
Outcomes of Nerve Transfers
Neurotization for elbow flexion
and shoulder stability has been
shown to be an effective means of re-
storing muscle function.28 In a criti-
cal meta-analysis of the English-
language literature, Merrell et al28

Figure 7

A, When the ulnar nerve is normal (ie, upper trunk injury sparing C8 and T1), a fascicle can be transferred to the motor branch
of the biceps to obtain elbow flexion. Top left: Transection (dashed line) of the motor branch to the biceps muscle. Top center:
Fascicle(s) obtained from normal ulnar nerve (dashed line). Top right: Fascicle(s) transferred to the motor branch of the
musculocutaneous nerve. B, Intraoperative photograph demonstrating the fascicle from the ulnar nerve transferred to the motor
branch of the biceps. MC n = musculocutaneous nerve, Transferred fascicle = portion of ulnar nerve, Ulnar n = ulnar nerve.
(Part A adapted by permission of Mayo Foundation. Part B reproduced by permission of Mayo Foundation.)

390 Journal of the American Academy of Orthopaedic Surgeons

 Alexander Y. Shin, MD, et al

Figure 8

Contralateral C7 (or a hemicontralateral C7 [A and B]) nerve transfer via a vascularized ulnar nerve graft (in cases of complete
C5-T1 avulsions) can be used to bring a large number of motor axons into the injured side. The hemicontralateral C7 transfer can
be used effectively with a vascularized ulnar nerve graft to reinnervate the median nerve for finger flexion and sensation. (A) The
portion of the C7 (contralateral) that primarily innervates pectoral function is isolated, and half of the nerve is isolated (B). The
ipsilateral distal ulnar nerve is coapted with the hemicontralateral portion of C7 (C). The proximal ulnar nerve (*) is divided
(dashed line). The injured side median nerve (D) is identified and divided (dashed line). The proximal ulnar nerve is transferred to
the distal median nerve stump of the injured side (E). (Adapted by permission of Mayo Foundation.)

evaluated the results of 1,088 nerve
transfers in 27 studies to determine
the outcome of nerve transfers of the
shoulder and elbow.
For restoration of elbow flexion, 26
studies with a total of 965 nerve
transfers were evaluated. Overall,
71% of transfers to the musculocuta-
neous nerve achieved ≥M3 (antigrav-
ity) flexion on the Medical Research
Council grading scale, and 37%
achieved ≥M4 (against gravity, not
normal) flexion. The two most com-
mon donor nerves were the intercos-
tal (54%) and spinal accessory (39%).
Overall, the intercostal achieved ≥M3
in 72% of patients. When an interpo-
sition nerve graft was used, only 47%
achieved ≥M3 strength. When the spi-
nal accessory nerve was transferred to
the musculocutaneous nerve, 77% of
patients had restoration of elbow flex-
ion ≥M3 and 29% had restoration of
function ≥M4. Use of the Oberlin
transfer (two fascicles of the ulnar
nerve transferred to the musculocu-
taneous nerve) resulted in 97% ≥M3
flexion and 94% ≥M4 flexion.28
For restoration of shoulder abduc-
tion, 8 studies with a total of 123
transfers were evaluated. Overall,
73% of patients achieved ≥M3 shoul-
der abduction, and 26% achieved
≥M4 abduction. The spinal accessory
nerve was used in 41% of transfers
and the intercostal nerves in 26%.
The spinal accessory nerve per-
formed significantly (P < 0.001) bet-
ter than the intercostals in achieving
≥M3 abduction (98% and 56%, re-
spectively). However, even with good
results, shoulder abduction reached
only 45°.
Further research is still needed in
the field of outcomes analysis of bra-
chial plexus injuries. Unfortunately,
it is not known which treatment pro-
duces the best outcomes for C5 and
C6 ruptures or severe neuromas. To
be determined, for example, is
whether it is best to graft from C5

Volume 13, Number 6, October 2005 391

Adult Traumatic Brachial Plexus Injuries
Figure 9
Free gracilis muscle transfer for elbow flexion. The proximal end of the gracilis is
secured to the clavicle (A). The vascular inflow and outflow is via the
thoracoacromial trunk, and the muscle is powered by the spinal accessory or
intercostal motor nerves (inset). Distally, the gracilis tendon is woven into the biceps
tendon (B). (Adapted by permission of Mayo Foundation.)
and C6, or whether nerve transfers
should be performed closer to the end
organ.
Free Functioning Muscle
Transfer
Advances in microsurgical tech-
niques have led to innovations in sur-
gical reconstruction of the upper ex-
tremity following brachial plexus
injury. Free functioning muscle
transfer is the transplantation of a
muscle and its neurovascular pedicle
to a new location to assume a new
function. The muscle is powered by
neurotizing the motor nerve by a do-
392
nor motor nerve; circulation is re-
stored to the transferred muscle via
microsurgical anastomosis of the do-
nor and recipient vessels. Within sev-
eral months, the transferred muscle
begins to become reinnervated by the
donor nerve; it eventually begins to
contract and then gains independent
function.
Free functioning muscle transfers
were first done either in patients who
presented late (>12 months after in-
jury) or as a salvage procedure in
those who had failed earlier nerve
reconstruction.30-32 Based on the suc-
cess with free muscle transfer in
Journal of the American Academy of Orthopaedic Surgeons
these late situations, it has been in-
corporated into a strategy for early re-
construction in patients for whom
other donors of tendon transfers are
unavailable.
Most commonly, free muscle
transfer is used to provide reliable el-
bow flexion.5,33-37 A variety of free
functioning muscles can be trans-
ferred, including the latissimus dorsi
(thoracodorsal nerve), the rectus fem-
oris (femoral nerve), and the gracilis
(anterior division of the obturator
nerve). The gracilis has become one
of the most commonly used muscles
in brachial plexus reconstruction be-
cause of its proximally based neu-
rovascular pedicle (which allows ear-
lier reinnervation) and its long tendon
length (which reaches into the fore-
arm for hand reanimation). The gra-
cilis can be used for restoring biceps
function,38,39 wrist extension, or fin-
ger flexion, or as a double muscle
transfer in the two-stage Doi proce-
dure.5,6,40
For elbow flexion, it is desirable to
place the major vascular pedicle of
the gracilis in proximity to the tho-
racoacromial trunk in the infraclavic-
ular fossa. The proximal gracilis ten-
don is passed beneath the clavicle
and secured to its superior border. It
is then tunneled subcutaneously to
the antecubital fossa in preparation
for securing it to the biceps tendon.
The obturator nerve branch to the
gracilis may be repaired to the spinal
accessory nerve or to the two inter-
costal motor nerves, either of which
should be harvested at as great a
length as possible to allow direct
nerve repair distal to the clavicle.
Distally, the gracilis tendon is woven
into the biceps tendon (Fig. 9).
Doi et al5 recently described using
a double free functioning gracilis
muscle transfer, which has provided
hope of achieving prehension to pa-
tients with complete brachial plexus
lesions. The goals of this two-stage
operation are to restore both elbow
flexion and extension as well as wrist
extension and finger flexion. In stage
I, the brachial plexus is explored and
 Alexander Y. Shin, MD, et al

a free functioning gracilis muscle is Figure 10

harvested and neurotized by the spi-
nal accessory nerve (Fig. 10). The gra-
cilis is proximally attached to the
clavicle and routed distally under the
brachioradialis to the radial wrist
digit extensors. The gracilis vessels
are anastamosed to the thoracoacro-
mial artery and venae comitantes or
other available venous outflow.
Stage II is performed approxi-
mately 6 to 8 weeks after stage I (Fig.
11). The second gracilis muscle and
the motor and sensory intercostal
nerves from the third to sixth inter-
costal spaces are harvested. The gra-
cilis is attached proximally to the sec-
ond rib, routed subcutaneously along
the medial side of the arm, and at-
tached to the flexor tendons. It is then
neurotized with two of the motor in-
tercostal nerves, while the sensory in-
tercostals are neurotized to the me-
dian nerve to provide hand sensation.
The gracilis is vascularized by the
thoracodorsal vessels. The remaining
two motor intercostal nerves are neu-
rotized to the radial nerve innervat-
ing the triceps.
At our institution, we have
slightly modified the double free mus-
cle transfer as originally described by
Doi and colleagues.5,6,34,35,37,39-42 We
prefer to secure the stage I gracilis
muscle to wrist extensors rather than Stage I Doi free gracilis muscle transfer.5 A free functioning gracilis is harvested
to finger extensors, believing that this and neurotized by the spinal accessory nerve and anastamosed to the
helps promote finger flexion through thoracoacromial trunk. The gracilis is attached proximally to the clavicle (A) and
routed distally under the brachioradialis and flexor carpi ulnaris pulley (B), then
a tenodesis effect. To create a more ef-
woven into the wrist extensors (C). (Adapted by permission of Mayo Foundation.)
fective pulley with diminished bow-
stringing of the tendon, we route the
gracilis tendon posterior to the biceps ion alone. Seventy-nine percent of of some triceps function to stabilize
tendon and underneath the brachio- the free functioning muscle transfers the elbow during contraction of the
radialis muscle. A more effective pul- for elbow flexion alone (single trans- gracilis muscle. Grasp function also
ley should improve muscle excursion fer) and 63% of similarly innervated relies on adequate muscle strength
and strengthen wrist extension. muscles transferred for combined and the absence of significant adhe-
Using a double free muscle trans- motion (stage I Doi procedure) sions. In the series of Doi et al,5 65%
fer, Doi et al5 restored excellent to achieved ≥M4 elbow flexion (17 patients) achieved >30° of total
good elbow flexion in 96% of pa- strength (P > 0.05). This is not sur- active motion of the fingers with the
tients (25/26). At our institution, prising in that the muscles must use second muscle transfer. Such func-
eight patients have been followed for some of their strength and excursion tion allows only rudimentary grasp
at least 1 year after the stage II trans- to extend the wrist or digits and in- in many patients, but grasp function
fer. Transfer for combined elbow variably lose some effect because of is difficult to achieve with other
flexion and wrist extension lowered bowstringing at the elbow.43 methods. Previous efforts at restor-
the overall results for elbow flexion Grasp function in the double free ing prehension in the setting of a
strength compared with elbow flex- muscle procedure relies on recovery brachial plexus injury have been un-

Volume 13, Number 6, October 2005 393

Adult Traumatic Brachial Plexus Injuries

Figure 11

Stage II Doi free gracilis muscle transfer.5 A, Vascularity is supplied via the thoracodorsal artery and vein. The gracilis muscle is
attached proximally to the second rib. B, The gracilis is neurotized with two of the intercostal motor nerves (1), while the sensory
intercostal nerves are neurotized to the median nerve for hand sensation (2). The remaining two motor intercostals are used
to neurotize the triceps (3). Lat = lateral cord, M = motor intercostal nerve, Med = medial cord, Post = posterior cord, S =
sensory intercostal nerve. C, Intraoperative photograph. Motor and sensory intercostal nerves are harvested from beneath the
third to sixth ribs. (Parts A and B adapted by permission of Mayo Foundation. Part C reproduced by permission of Mayo
Foundation.)

successful because of the long dis-
tance between nerve repair and mo-
tor end plates and the resultant
prolonged reinnervation time.
Therefore, these results must still
be regarded as an advance in these
otherwise irreparable avulsion inju-
ries. The only alternative currently
offering the possibility of hand func-
tion in root avulsion injuries is com-
bining the contralateral C7 nerve
with a vascularized ulnar nerve con-
duit.27
Postoperative Follow-up
After any surgical intervention of
the brachial plexus, it is imperative
that the patient and his or her fami-
ly understand that the recovery of
nerve function is a slow and arduous
process. The newly reapproximated
nerve graft or nerve transfer grows at
rate of 1 mm a day or 1 inch per
month. For long transfers, such as a

394 Journal of the American Academy of Orthopaedic Surgeons


hemicontralateral C7 nerve graft,
clinical results may not be seen for 2
to 3 years. The shorter the distance
to the target muscle, the more rapid
the time to reinnervation.
It is essential that the patient,
while waiting for reinnervation, be
enrolled in physical therapy to keep
the joints of the upper extremity sup-
ple and to prevent joint contractures.
This can be done with custom-made
plastic resting splints as well as a
daily range-of-motion protocol for
the shoulder, elbow, wrist, and digits.
The efficacy of electrical stimulation
in preserving muscle (motor) end
plates remains controversial. How-
ever, its use is psychologically bene-
ficial to patients who like to see mus-
cles contract during the long
recovery period. Dedicated follow-up
at 3- to 4-month intervals for a min-
imum of 2 to 3 years (preferably 5
years) is recommended to assess for
full recovery.
Secondary Reconstruction
Secondary reconstruction should
be considered when there has been
no further recovery of motor function
or when function can be further im-
proved or refined with a relatively
minor surgical intervention. Second-
ary reconstructive options include
tendon transfer,9 free functioning
muscle transfer,5,36 shoulder arthro-
desis,10 and wrist and hand arthro-
desis.10
Tendon transfer is commonly de-
layed until maximal motor recovery
has occurred. Such transfers repre-
sent a spectrum of procedures that
provide a gratifying result to a pa-
tient who has made a partial recov-
ery and who would benefit from ad-
ditional function. Free functioning
muscle transfer can be performed as
secondary reconstructive surgery to
improve the strength of a weakly
reinnervated biceps or triceps mus-
cle or of finger flexors (provided that
the joints are supple).
Finally, arthrodesis may be useful
for secondary reconstructive surgery
of the shoulder, wrist, and hand.
Volume 13, Number 6, October 2005
Shoulder fusion can be performed as
a salvage procedure for the persis-
tently painful subluxating shoulder
should the nerve surgery fail to re-
sult in shoulder stability. Shoulder
fusion as a primary reconstructive
technique is less frequently done be-
cause recent studies have shown
that patients prefer voluntary shoul-
der abduction when it can be
achieved through nerve reconstruc-
tion.44 Other bony procedures, such
as humeral rotational osteotomy,
thumb axis arthrodesis, bone-block
opponensplasty, or finger joint ar-
throdesis, can improve function.
Summary
Injuries to the adult brachial plexus
are often intimidating to the ortho-
paedic surgeon who may be manag-
ing concomitant injuries. The injury
can be devastating to the patient and
is often difficult for the patient and
family to comprehend. A thorough
understanding of the anatomy, clin-
ical evaluation, radiographic and
electrodiagnostic studies, treatment
options, and proper timing of surgi-
cal intervention will enable the
treating surgeon to offer optimal
care. Surgical options include neu-
rolysis, nerve grafting, neurotiza-
tion, and free muscle transfers.
These treatment options offer pa-
tients with brachial plexus injuries
the ability to obtain elbow flexion,
limited shoulder abduction with
shoulder stability, and hope for lim-
ited but potentially useful hand
function.
References
1. Allieu Y, Cenac P: Is surgical inter-
vention justifiable for total paralysis
secondary to multiple avulsion inju-
ries of the brachial plexus? Hand Clin
1988;4:609-618.
2. Azze RJ, Mattar Junior J, Ferreira MC,
Starck R, Canedo AC: Extraplexual
neurotization of brachial plexus. Mi-
crosurgery 1994;15:28-32.
3. Brandt KE, Mackinnon SE: A tech-
nique for maximizing biceps recovery
in brachial plexus reconstruction.
J Hand Surg [Am] 1993;18:726-733.
Alexander Y. Shin, MD, et al
4. Brunelli G, Monini L: Direct muscu-
lar neurotization. J Hand Surg [Am]
1985;10(6 pt 2):993-997.
5. Doi K, Muramatsu K, Hattori Y, et al:
Restoration of prehension with the
double free muscle technique follow-
ing complete avulsion of the brachial
plexus: Indications and long-term re-
sults. J Bone Joint Surg Am 2000;82:
652-666.
6. Doi K, Kuwata N, Muramatsu K, Hot-
tori Y, Kawai S: Double muscle trans-
fer for upper extremity reconstruction
following complete avulsion of the
brachial plexus. Hand Clin 1999;15:
757-767.
7. Malone JM, Leal JM, Underwood J,
Childers SJ: Brachial plexus injury
management through upper extremi-
ty amputation with immediate post-
operative prostheses. Arch Phys Med
Rehabil 1982;63:89-91.
8. Allieu Y: Evolution of our indications
for neurotization: Our concept of
functional restoration of the upper
limb after brachial plexus injuries.
Chir Main 1999;18:165-166.
9. Narakas AO: The treatment of brachi-
al plexus injuries. Int Orthop 1985;9:
29-36.
10. Hendry AM: The treatment of residu-
al paralysis after brachial plexus inju-
ries. J Bone Joint Surg Br 1949;31:42-
49.
11. Yeoman PM, Seddon HJ: Brachial
plexus injuries: Treatment of the flail
arm. J Bone Joint Surg Br 1961;43:493-
500.
12. Fletcher I: Traction lesions of the bra-
chial plexus. Hand 1969;1:129-136.
13. Kerr AT: The brachial plexus of nerves
in man, the variations in its formation
and branches. Am J Anat 1918;23:285-
395.
14. Carvalho GA, Nikkhah G, Matthies
C, Penkert G, Samii M: Diagnosis of
root avulsions in traumatic brachial
plexus injuries: Value of computer-
ized tomography myelography and
magnetic resonance imaging. J Neuro-
surg 1997;86:69-76.
15. Nagano A, Ochiai N, Sugioka H, Hara
T, Tsuyama N: Usefulness of myelog-
raphy in brachial plexus injuries.
J Hand Surg [Br] 1989;14:59-64.
16. Walker AT, Chaloupka JC, de Lot-
biniere AC, Wolfe SW, Goldman R,
Kier EL: Detection of nerve rootlet
avulsion on CT myelography in pa-
tients with birth palsy and brachial
plexus injury after trauma. AJR Am J
Roentgenol 1996;167:1283-1287.
17. Doi K, Otsuka K, Okamoto Y, Fujii H,
Hattori Y, Baliarsing AS: Cervical
nerve root avulsion in brachial plexus
395
Adult Traumatic Brachial Plexus Injuries
injuries: Magnetic resonance imaging
classification and comparison with
myelography and computerized to-
mography myelography. J Neurosurg
2002;96:277-284.
18. Gupta RK, Mehta VS, Banerji AK, Jain
RK: MR evaluation of brachial plexus
injuries. Neuroradiology 1989;31:
377-381.
19. Nakamura T, Yabe Y, Horiuchi Y,
Takayama S: Magnetic resonance my-
elography in brachial plexus injury.
J Bone Joint Surg Br 1997;79:764-769.
20. Tiel RL, Happel LT Jr, Kline DG:
Nerve action potential recording
method and equipment. Neurosur-
gery 1996;39:103-109.
21. Burkholder LM, Houlden DA, Midha
R, Weiss E, Vennettilli M: Neurogenic
motor evoked potentials: Role in bra-
chial plexus surgery. Case report.
J Neurosurg 2003;98:607-610.
22. Kim DH, Cho YJ, Tiel RL, Kline DG:
Outcomes of surgery in 1019 brachial
plexus lesions treated at Louisiana
State University Health Sciences
Center. J Neurosurg 2003;98:1005-
1016.
23. Teboul F, Kakkar R, Ameur N, Beua-
lieu JY, Oberlin C: Transfer of fasci-
cles from the ulnar nerve to the nerve
to the biceps in the treatment of upper
brachial plexus injury. J Bone Joint
Surg Am 2004;86:1485-1490.
24. Gu YD, Ma MK: Use of the phrenic
nerve for brachial plexus reconstruc-
tion. Clin Orthop 1996;323:119-121.
25. Gu YD, Chen DS, Zhang GM, et al:
Long-term functional results of con-
tralateral C7 transfer. J Reconstr Mi-
crosurg 1998;14:57-59.
26. Chuang DC: Neurotization proce-
dures for brachial plexus injuries.
Hand Clin 1995;11:633-645.
27. Songcharoen P, Wongtrakul S, Ma-
haisavariya B, Spinner RJ: Hemi-
contralateral C7 transfer to median
396
nerve in the treatment of root avul-
sion brachial plexus injury. J Hand
Surg [Am] 2001;26:1058-1064.
28. Merrell GA, Barrie KA, Katz DL,
Wolfe SW: Results of nerve transfer
techniques for restoration of shoulder
and elbow function in the context of a
meta-analysis of the English litera-
ture. J Hand Surg [Am] 2001;26:303-
314.
29. Songcharoen P, Mahaisavariya B,
Chotigavanich C: Spinal accessory
neurotization for restoration of elbow
flexion in avulsion injuries of the bra-
chial plexus. J Hand Surg [Am] 1996;
21:387-390.
30. Ruch DS, Friedman A, Nunley JA:
The restoration of elbow flexion with
intercostal nerve transfers. Clin Or-
thop 1995;314:95-103.
31. Mikami Y, Nagano A, Ochiai N,
Yamamoto S: Results of nerve grafting
for injuries of the axillary and supra-
scapular nerves. J Bone Joint Surg Br
1997;79:527-531.
32. Chuang DC, Yeh MC, Wei FC: Inter-
costal nerve transfer of the musculo-
cutaneous nerve in avulsed brachial
plexus injuries: Evaluation of 66 pa-
tients. J Hand Surg [Am] 1992;17:822-
828.
33. Akasaka Y, Hara T, Takahashi M: Free
muscle transplantation combined
with intercostal nerve crossing for re-
construction of elbow flexion and
wrist extension in brachial plexus in-
juries. Microsurgery 1991;12:346-351.
34. Doi K, Sakai K, Fuchigami Y, Kawai S:
Reconstruction of irreparable brachi-
al plexus injuries with reinnervated
free-muscle transfer: Case report.
J Neurosurg 1996;85:174-177.
35. Doi K, Shigetomi M, Kaneko K, et al:
Significance of elbow extension in
reconstruction of prehension with
reinnervated free-muscle transfer
following complete brachial plexus
Journal of the American Academy of Orthopaedic Surgeons
avulsion. Plast Reconstr Surg 1997;
100:364-374.
36. Manktelow RT, Zuker RM, McKee
NH: Functioning free muscle trans-
plantation. J Hand Surg [Am] 1984;
9A:32-39.
37. Doi K, Sakai K, Kuwata N, Ihara K,
Kawai S: Double free-muscle transfer
to restore prehension following com-
plete brachial plexus avulsion. J Hand
Surg [Am] 1995;20:408-414.
38. Chung DC, Carver N, Wei FC: Results
of functioning free muscle transplan-
tation for elbow flexion. J Hand Surg
[Am] 1996;21:1071-1077.
39. Doi K, Sakai K, Ihara K, Abe Y, Kawai
S, Kurafuji Y: Reinnervated free mus-
cle transplantation for extremity re-
construction. Plast Reconstr Surg
1993;91:872-883.
40. Doi K: New reconstructive procedure
for brachial plexus injury. Clin Plast
Surg 1997;24:75-85.
41. Doi K, Sakai K, Kuwata N, Ihara K,
Kawai S: Reconstruction of finger and
elbow function after complete avul-
sion of the brachial plexus. J Hand
Surg [Am] 1991;16:796-803.
42. Doi K, Hattori Y, Kuwata N, et al: Free
muscle transfer can restore hand func-
tion after injuries of the lower brachi-
al plexus. J Bone Joint Surg Br 1998;80:
117-120.
43. Barrie KA, Steinmann SP, Shin AY,
Spinner RJ, Bishop AT: Gracilis free
muscle transfer for restoration of
function after complete brachial plex-
us avulsion. Neurosurg Focus
2004;16:E8.
44. Doi K, Hattori Y, Ikeda K, Dhawan V:
Significance of shoulder function in
the reconstruction of prehension with
double free-muscle transfer after com-
plete paralysis of the brachial plexus.
Plast Reconstr Surg 2003;112:1596-
1603.