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Management of infraclavicular (Chuang Level IV) brachial plexus injuries: A single surgeon experience with 75 cases


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Unlabelled: Infraclavicular brachial plexus injuries (Level IV in Chuang's classification) have special characteristics, including high incidences of associated scapular fractures, glenohumeral dislocations, and vascular injuries. In addition, there are specific difficulties in surgical dissection and nerve repairs, especially if surgery is delayed (>3 months). A total of 153 patients with Level IV brachial plexus injuries underwent surgery between 1987 and 2008 with 75 patients (average age 29 years) available for a minimum of 4 years follow-up. Accompanying fractures/dislocations were suffered by 48 (64%) patients, and 17 (23%) had associated vascular injuries. The most common nerves to be injured were the axillary and musculocutaneous nerves. Nerve grafts to the axillary, musculocutaneous, and radial nerves achieved impressive results, but less reliable outcomes were achieved with the median and ulnar nerves. Decompression and/or external neurolysis were also beneficial for nerve recovery. Some surgical tips are presented, and the use of the C-loop vascularized ulnar nerve graft and functioning muscle transfers are discussed. Level of evidence: IV.
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The Journal of Hand Surgery
(European Volume)
XXE(X) 1 –10
© The Author(s) 2014
Reprints and permissions:
DOI: 10.1177/1753193414553753
Despite the numerous classifications that have been
proposed for adult brachial plexus injuries (BPI)
(Alnot, 1987; Chuang, 1999; Millesi, 1988; Narakas,
1993; Terzis et al., 1999), there is no single system
that yields both clinically and surgically useful infor-
mation. Chuang (2009) described a new classification
system for the different levels of BPI. This uses
numerical descriptions that both simplify the injury
types and add useful clinical information (Table 1).
This classification system expands the popular
descriptions of ‘supraclavicular’ and ‘infraclavicular’
BPI, with Levels I–III encompassing supraclavicular
and retroclavicular injuries, and Level IV limited to
infraclavicular injuries.
This study focuses on Level IV injuries. This is
the second most common BPI after Level I injuries
(Chuang, 2013). They usually occur in isolation, and
there is rarely any upward extension of Level IV
injuries to Level I or II. There are unique features of
this injury, both anatomical and surgical, which
justifies its separate description. Owing to the
juxtaposition of the subclavian and axillary vessels
with the plexus at this level, there is a high inci-
dence of concomitant vascular injuries, presenting
either with rupture or segmental occlusion of the
arteries. The infraclavicular plexus is also situated
immediately anterior to the scapula and the gleno-
humeral joint, and there is a high incidence of
associated fractures of the scapula or dislocations
of the shoulder (Alnot, 1988). During surgery, the
surgeon dissecting the infraclavicular plexus often
encounters badly scarred tissues in multiple
planes. Finally, multiple long nerve grafts (8 cm)
Management of infraclavicular (Chuang
Level IV) brachial plexus injuries: A
single surgeon experience with 75 cases
W. L. Lam, D. Fufa, N.-J. Chang and D.C.-C. Chuang
Infraclavicular brachial plexus injuries (Level IV in Chuang’s classification) have special characteristics,
including high incidences of associated scapular fractures, glenohumeral dislocations, and vascular injuries. In
addition, there are specific difficulties in surgical dissection and nerve repairs, especially if surgery is delayed
(3 months). A total of 153 patients with Level IV brachial plexus injuries underwent surgery between 1987
and 2008 with 75 patients (average age 29 years) available for a minimum of 4 years follow-up. Accompanying
fractures/dislocations were suffered by 48 (64%) patients, and 17 (23%) had associated vascular injuries.
The most common nerves to be injured were the axillary and musculocutaneous nerves. Nerve grafts to the
axillary, musculocutaneous, and radial nerves achieved impressive results, but less reliable outcomes were
achieved with the median and ulnar nerves. Decompression and/or external neurolysis were also beneficial
for nerve recovery. Some surgical tips are presented, and the use of the C-loop vascularized ulnar nerve graft
and functioning muscle transfers are discussed.
Level of Evidence: IV
Infraclavicular, Level IV, brachial plexus injury
Date received: 1st July 2013; revised: 5th June 2014; accepted: 1st September 2014
Division of Reconstructive Microsurgery, Chang Gung Memorial
Hospital, Chang Gung University, Tao-Yuan, Taiwan
Corresponding author:
D. C.-C. Chuang, Department of Plastic Surgery, Chang Gung
Memorial Hospital, Chang Gung University, 5 Fu-Hsing Street,
Kuei-Shan, Tao-Yuan 333, Taiwan.
553753JHS0010.1177/1753193414553753Journal of Hand SurgeryLam et al.
Full Length Article
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2 The Journal of Hand Surgery (Eur)
are often required to reconstruct long segments of
nerve injury in this region.
This retrospective study analyses our experience
with the different injury patterns and methods of
reconstruction of Level IV injuries. Over the years,
improved understanding of the characteristics of the
injury, anatomy, and surgical approaches has allowed
the development and refinement of the methods for
managing such injuries to produce optimal outcomes.
Patients and methods
From 1987 to 2008 (a 22-year period), the senior
author (DCCC) operated on 1328 patients with differ-
ent levels of BPI. A total of 153 were Level IV BPI
(153/1328, 12%). Of these, 75 cases were selected
with a minimum of 3 years follow-up (Figure 1). A
total of 67 of the surgically treated patients were
male and the remainder were female, with an aver-
age age of 29 years (range 16–61). Most patients were
referred after a delay of more than 3 months. The
majority of injuries (63 patients) were caused by
motor-vehicle accidents (Table 2).
Outcome assessments were focused on the
proximal muscle groups innervated by the five ter-
minal nerves of the infraclavicular plexus: muscu-
locutaneous, axillary, radial, median, and ulnar
nerves (Table 3). Recovery of function in the intrin-
sics was rarely achieved, and therefore did not con-
stitute a component of our assessment. The
modified Medical Research Council (MRC) scale
system (M0–M5) was used (Chuang, 2008). Recovery
of motor function was assessed by the strength of
joint movements and not on individual muscles,
making the assessment simple and practical. A
score of M 3 was considered a successful result,
except for the axillary nerve, since patients with
deltoid paralysis in Level IV injuries will usually
present with good shoulder abduction because of
compensation from the supraspinatus muscle
(innervated by the suprascapular nerve). The recov-
ery of deltoid muscle power was therefore meas-
ured by muscle palpation and overall degrees of
shoulder abduction. Palpation of muscle contrac-
tion and shoulder abduction of more than 90° were
considered a success.
Table 1. The Chuang classification of levels of BPI.
Chuang levels of BPI Analogous to Anatomical and surgical characteristics
Level I Preganglionic (or supraganglionic)
root injury.
Inside the bone (and canal).
Requires laminectomy to visualize the nerves (roots).
Level II Postganglionic spinal nerve injury. Inside the scalene muscle.
Requires segmental resection of muscle.
Level III Trunk and division injury. Under the clavicle.
Requires osteotomy of clavicle.
Level IV Cord and terminal branches injury. Infraclavicular (after divisions) – see text.
BPI: brachial plexus injuries.
Figure 1. Distribution of patients in our series of BPI and infraclavicular injuries with at least 3 years follow-up.
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Lam et al. 3
Surgical technique
An incision in the deltopectoral groove is made rou-
tinely for Level IV plexus exploration. The incision is
usually extended downwards through the axillary
fossa to the upper medial arm (Figure 2). The cephalic
vein, clavicular part of the pectoralis major muscle
inferiorly, deltoid muscle superiorly, clavicle bone
medially, and pectoralis major insertion laterally are
fully exposed. In the exposed pectoralis major mus-
cle, an intermuscular septum, called the ‘white line’,
located between the clavicular (C-PM) and sternal
(S-PM) parts of the pectoralis major is identified and
separated (Figure 3). This white line is a relatively
avascular zone, and allows the exposure of the
underlying pectoralis minor muscle once the two
parts of the pectoralis major muscle are separated.
The pectoralis minor muscle is then retracted medi-
ally with seldom any need for division. Once the
underlying adipofascial tissue is removed, the infra-
clavicular brachial plexus and juxtaposed subclavian
artery and veins become visible. The surgeon often
encounters extensive scars in the subpectoral space,
which renders identification of the different cords and
branches extremely tedious and difficult. Therefore,
if no identifiable structures can be seen, the dissec-
tion should start from the identification of healthy
nerves, either proximally, distally, or both.
Bidirectional dissection then makes the complex dis-
section easy and safe. Proximally, the dissection can
commence in ‘Chuang’s triangle’ (Chuang, 2006,
2013) (Figure 4) to identify the three cords and ves-
sels. This is a space bounded by two limbs: one is the
cephalic vein and C-PM muscle, and the other is the
clavicle. Some of the C-PM and deltoid muscle
attachments can be detached from the clavicle to
increase this space. A relatively avascular space, the
triangle contains the subclavius muscle, underneath
which lies the lateral and posterior cords. Distally,
the dissection starts in the upper arm or axillary
fossa to find the terminal branches. It is advisable to
detach the insertion of S-PM through a Z-lengthening
incision to facilitate good exposure of all components
of the distal plexus.
Management of vessel injuries depends on the
acuteness of presentation. In an open injury, immedi-
ate exploration is carried out and any arterial injuries
that are encountered are repaired. If segmental
artery occlusions are observed, a by-pass vein graft-
ing procedure is done.
Management of nerve injuries depends on the
condition of the nerves as well as the presentation.
Cleanly divided nerves in open wounds as a result
of sharp penetrating objects are repaired primarily.
Table 2. Demographics for 75 patients with level IV bra-
chial plexus injuries.
Gender (M:F) 67:8
Average age (years) 29 (range 16–61)
Mechanism of injury Motor-vehicle accident: 63
Hit by falling object: 2
Falling accident: 3
Penetrating injury: 7
Time to surgery (months) 5 (range 0–14)
Length of operation (hours) 9 (range 4–17)
Arterial Injuries (n = 17,
Axillary artery with
segmental occlusion: 13
Open injury with arterial
rupture: 4
Fractures or dislocations
(n = 48, 64%)
Humerus (n = 21)
Clavicular (n = 12)
Scapular or glenoid (n = 8)
Radius/ulna (n = 7/7)
Shoulder dislocation (n = 3)*
*This only includes the patients that underwent surgery.
Table 3. Assessment of outcome after nerve repair.
Nerve involved and repaired Motor functional evaluation Definition of success
Musculocutaneous nerve Elbow flexion strength (biceps and/or brachialis) M 3
Axillary nerve Deltoid Palpation (+) and
shoulder elevation 90°
Radial nerve 1. Elbow extension strength (triceps) M 3
2. Wrist extension strength (ECR and/or ECU) M 3
3 MPJ extension strength (ED) M 3
Median nerve 1. Wrist flexion strength (FCR and PL) M 3
2. Finger flexion strength (FDS) M 3
Ulnar nerve 1. Wrist flexion strength (FCU) M 3
2. Finger flexion strength (ulnar three FDP) M 3
ECR, extensor carpi radialis; ECU, extensor carpi ulnaris; ED, extensor digitorum; FCR, flexor carpi radialis; FCU: flexor carpi ulnaris;
FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; MPJ: metacarpophalangeal joint; PL, palmaris longus.
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4 The Journal of Hand Surgery (Eur)
In open wounds, any reconstruction for nerve rup-
tures or obviously stretched nerves is delayed for a
few weeks. We do not routinely carry out nerve
resection and grafting at the primary exploration.
In delayed explorations, an injured nerve in conti-
nuity is treated by neurolysis. If the injured nerve is
ruptured with formation of a significant neuroma,
nerve grafting is done after resection of the nerve
ends to healthy fascicles. Once the extent of injury
is recognized, the lengths of nerve graft require-
ment are determined. Owing to the length of grafts
needed, donor nerve grafts from both sural
and saphenous nerves, as well as the lateral ante-
brachial cutaneous nerve and/or medial brachial
cutaneous nerve from the injured limb, are all
potential donors and their sites are marked.
Recently, consistently poor results after nerve
grafts to the ulnar nerve have been recognized,
which has encouraged the harvest of the ulnar
nerve as a vascularized ulnar nerve graft (VUNG).
This is especially useful in devastating total cord
injuries (all three cords damaged), each with a gap
of more than 15 cm. The VUNG can be used either
as a single graft to bridge defects in the median
nerve or as a ‘C’ looped graft to reconstruct the
median and radial nerves (Chuang, 2013; Terzis
1999). In the latter situation, the VUNG is harvested
on a proximally based pedicle via the superior col-
lateral ulnar artery. The nerve is then looped and
reversed, and the proximal and distal ends coapted
to the proximal ends of the median and radial
nerves in the upper arm. The loop is then posi-
tioned at the distal ends of the median and radial
nerves and divided, maintaining the vascular con-
nections via the connective tissues. The cut ends
are then coapted to the distal ends of the two
nerves (Figure 5). After repair of all nerves and/or
vessels, the divided S-PM is then repaired in a
lengthened fashion to cover the plexus.
Post-operative management and
Immediate post-operative neck splinting for 3 weeks
after nerve grafts or nerve transfer is used in all
patients, together with a light shoulder sling for
4 weeks if the S-PM has been detached and repaired.
Thereafter, rehabilitation with muscle stimulation
and physiotherapy is started.
Figure 2. Incisions for Level IV plexus exploration: This
begins at the deltopectoral sulcus and extends downwards
to the upper medial arm.
Figure 3. Operative dissection showing the ‘white line’,
which allows separation of the clavicular and sternal part
of the pectoralis major muscles to access the underly-
ing pectoralis minor muscle and infraclavicular brachial
plexus and subclavian vessels.
Figure 4. Operative dissection showing ‘Chuang’s trian-
gle’ (upper arrow) and separation of the white line (lower
arrow). On opening the triangle, the underlying lateral and
posterior cord of the brachial plexus can be seen.
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Lam et al. 5
The timing of surgery varied from immediate explo-
ration in cases of penetrating wounds, to 14 months
when patients were referred from other hospitals,
with an average time of 5.2 months. Direct repairs
were only possible in five patients with open injuries,
with three axillary and two radial nerve divisions. The
average length of surgery was 9 hours (range 4–17).
Of the 75 cases, 23% (17/75) of patients had an
associated vascular injury, either an open injury with
axillary artery rupture requiring immediate explora-
tion and repair (four cases), or a closed injury with
subsequent segmental occlusion (12 cases) requiring
arterial reconstruction with prosthetic or vein grafts.
One patient with strong pectoralis muscles sustained
a penetrating injury, and was subsequently found to
have a spontaneously sealed injury of the subclavian
artery. This was discovered intraoperatively and
repaired 1 month after the injury.
A total of 64% (48/75) had an accompanying frac-
ture or joint dislocation (Table 2). This series did not
include those patients who had an initial plexopathy
secondary to shoulder dislocation but received no
subsequent surgical intervention. Only three patients
with continued plexus symptoms after shoulder dis-
location underwent exploration after an observation
period of 6 months. All of them were treated by
Most of the injured terminal branches involved
the axillary nerve (52 patients), followed by the mus-
culocutaneous (38 patients), the radial (21 patients),
the median (20 patients), and the ulnar nerves (nine
patients). The commonest pattern of injury was a
combination of axillary and musculocutaneous
nerve palsies (34 patients), followed by an isolated
axillary nerve injury (17 patients). The injury pattern
can probably be explained by the more superficial
location of certain nerves (the lateral cord or mus-
culocutaneous nerve), or the close location to a bone
(the posterior cord or axillary nerve), rendering
these nerves more susceptible to injuries. There
were four patients with a total cord injury (all cords
and branches) who presented with a flail limb.
Conventional nerve grafts were most commonly
used for reconstruction, followed by neurolysis, and
finally, VUNGs (Table 4).
At a minimum of 3 years follow-up, the number of
patients who achieved a recovery of M3 after conven-
tional nerve grafts was excellent for the musculocuta-
neous and radial nerves, but more disappointing for
the median and ulnar nerves (Table 5) (Figure 6). Most
achieved a good result after axillary nerve reconstruc-
tion. Recovery after nerve grafting in the axillary,
musculocutaneous, and radial nerves was evident at
1 year follow-up in most patients (Table 5). In contrast,
only one patient recovered function in the median
nerve at 1 year and no patient achieved recovery of the
ulnar nerve within the same period. The average time
for recovery of elbow flexion (lateral cord, musculocu-
taneous nerve) was 14 months, compared with
19 months for elbow extension (posterior cord, radial
nerve) and 25 months for wrist flexion (medial cord,
median, and ulnar nerves). A total of 13 patients had
decompression and/or external neurolysis, and all
except one achieved good recovery within 1 year.
No ulnar nerve or medial cord was injured in isola-
tion; such injuries were usually part of a total cord
injury. Therefore, the VUNG was considered as a
reconstructive option whenever the ulnar nerve was
extensively injured (more than 15 cm), and when
there was an accompanying median or radial nerve
Figure 5. The C-looped VUNG.
Table 4. Different methods for reconstruction used in the
Methods of reconstruction Numbers
Conventional nerve grafts 105
Vascularized ulnar nerve grafts 7
Neurolysis 13
Direct repair 5
Nerve transfer 2
Free functioning muscle transfers 10
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6 The Journal of Hand Surgery (Eur)
injury also with a large defect (more than 15 cm). Of
the seven patients who were treated by the VUNG,
four (with total cord injuries) were for reconstruction
of both median and radial defects using a ‘C’ loop,
and three were for reconstruction of a median nerve
gap (with extensive median and ulnar nerve injuries).
Of the four patients who received a ‘C-looped’ VUNG
for reconstruction of both radial and median nerve
defects, three showed good radial nerve recovery by
1 year, whereas only two showed good median nerve
recovery by 2 years.
Only two patients underwent nerve transfers. In
these patients, an intercostal (T3-5) nerve to muscu-
locutaneous nerve transfer was done after it was
found that the nerve gap measured more than 15 cm
after resection of the damaged ends.
A free functioning muscle transplant (FFMT)
was carried out in ten patients to increase func-
tion. Eight patients had a FFMT after failed nerve
reconstruction (M < 3 after 3 years follow-up)
and the remaining two were late presenters to
the unit (more than 1 year after injury). All the
muscles used were gracilis myocutaneous flaps.
The donor nerves included the spinal accessory
nerve (four for elbow flexion, two for extensor
digitorum reconstruction), and the intercostal
nerves (one for elbow flexion and three for flexor
digitorum profundus reconstruction).
Level IV injuries present with a wide degree of sever-
ity. Open Level IV injuries are usually caused by a
knife or other sharp objects, producing significant
motor and sensory deficits, which are immediately
apparent in the conscious patient. These require an
immediate or at the very least an early exploration
(within 2 weeks) to achieve optimal results. The ideal
scenario is immediate exploration and primary repair
of the cleanly divided nerves, in which case excellent
results can usually be expected (Chuang, 1999). In
gunshot wounds, unless a clear transection of the
nerves is found during exploration, the majority of
nerve palsies in Level IV injuries will improve sponta-
neously within 6 months. If there is no improvement
by 6 months, exploration and reconstruction can be
undertaken (Chuang, 1999). Similarly, when there are
isolated vessel ruptures or occlusions with a seem-
ingly intact plexus at exploration but accompanying
clinical nerve palsies, the nerve injury can be treated
expectantly, as most are likely to improve spontane-
ously (Table 6).
If there is any suspicion of traction involved with
an open wound, then a high likelihood of nerve rup-
ture is expected. This is different from simple nerve
division, as there is usually a longer length of dam-
aged nerve that requires resection until healthy
Table 6. Optimal repair time for Level IV BPI and artery injury.
Presentation Management recommendation
Penetrating injury: sharp knife or objects with nerve
and arterial severance
Immediate vessel and nerve repair
Penetrating injury: sharp knife or objects with nerve
severance only (no vessel rupture)
Immediate nerve repair or repaired as soon as
possible (2 weeks)
Open wound: traction with arterial and nerve ruptures 1. Artery repair first and nerve inspection
2. Nerve grafts 2–3 weeks after
Closed injury: arterial occlusion and nerve palsy but
perfused upper limb
Repair artery and nerve simultaneously 3–4 months
after accident if nerve shows no sign of recovery
Closed injury: nerve palsy only Exploration and repair at 3–4 months after injury if no
recovery (unless shoulder dislocation – wait 6 months)
Table 5. Recovery rates in the first 3 years (number of patients achieving good results) after nerve grafts for different nerve
Nerve Year 1 Year 2 Year 3 Overall
Poor Good
Axillary 33 (70%) 7 0 6 40/46 (87%)
Musculocutaneous 22 (64%) 6 3 2 31/33 (94%)
Radial* 7 (54%) 4 1 1 12/13 (92%)
Median** 1 (9.1%) 4 1 5 6/11 (55%)
Ulnar 0 3 0 2 3/6 (50%)
*Four cases with radial nerve treated by vascularized ulnar nerve graft.
**Seven cases with median nerve treated by vascularized ulnar nerve graft.
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Lam et al. 7
fascicles are reached in the nerve stumps. The gaps
then require reconstruction with nerve grafts with-
out any tension. The treatment for such injuries fol-
lows that of the closed traction injury (see below).
Debridement and nerve grafts at the time of the ini-
tial injury are generally not recommended. Instead,
re-exploration of the wound after waiting for at least
3 weeks allows the extent of nerve injury to be better
demarcated and better defined, facilitating better
judgment of the length of nerve to be resected and a
higher chance of obtaining healthy nerve ends
(Chuang, 1999).
The debate continues about the management of
closed traction injuries (Birch, 2014; Hems, 2014). In
Asian countries, the most common aetiology of BPI
remains motorcycle accidents, usually presenting as
closed traction injuries. Extensive experience has been
gathered because of the unfortunately high volume of
these injuries, which has allowed the development of a
reliable protocol. When a patient presents with a Level
IV closed traction injury, the following staged manage-
ment strategy is recommended (Chuang, 1999):
Stage 1, stabilization stage (the first month)
Stage 2, diagnostic stage (second month)
Stage 3, surgical stage (third and fourth months)
Stage 4, rehabilitation stage (at least 2 years)
Stage 5, late reconstruction (third and fourth years
Figure 6. (A) and (B) A 24-year-old man with a total Level IV BPI, involving ruptures of all cords and terminal branches of the
left infraclavicular brachial plexus and subclavian artery after a car accident 1.5 months previously. He presents with a flail
left upper limb, except for shoulder abduction. (C), (D) and (E) Four years after nerve grafts to the musculocutaneous nerve
(8 cm nerve graft length x 2 nerve grafts), axillary (12 cm nerve graft length x 2 nerve grafts), radial (4 cm nerve graft length x
3 nerve grafts), median (4 cm nerve graft length x 4 nerve grafts), and ulnar (10 cm nerve graft length x 2 nerve grafts) nerves,
there is good restoration of elbow flexion and extension, wrist flexion and extension, and flexion of the fingers.
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8 The Journal of Hand Surgery (Eur)
Some authors, however, have disagreed and rec-
ommended urgent exploration and nerve repair
within weeks, so as to avoid difficult dissections at a
later stage (Birch, 1997; Burge et al., 1985; Narakas,
1978). We have found the judgment of both the degree
and extent of nerve injuries at such an early stage to
be difficult and uncertain, whether in open or closed
wounds. The injured nerve suffers extensive bruising
and often appears oedematous in the early days after
a traction injury. In the weeks and months that follow,
it undergoes a fibrosis reaction, which allows much
easier clinical determination of the length of nerve
for resection and grafting. There is only one chance
to obtain a successful nerve repair, and selection of
healthy stumps for nerve coaptation is crucial for a
successful outcome. Close supervision of the patient
with a closed injury for a period of 3–6 months has
therefore been recommended by other authors as
well as ourselves (Chuang 2006, 2013; Millesi, 1988;
Terzis et al., 1999), and we remain of the opinion that
the benefits of waiting outweigh the advantage of
early exploration.
Accurate diagnosis of the extent of a Level IV injury
can be difficult at times. An accurate localization of
the injured elements in the brachial plexus avoids
unnecessarily big incisions (from neck to upper
medial arm) with extensive dissection and trauma to
tissues. This also shortens the operative time,
decreases post-operative wound pain and therefore
speeds up rehabilitation. Distinguishing a total Level
IV injury (all cords and branches) from a total root
avulsion injury (Level I) is clinically relatively straight-
forward, especially with the aid of nerve conduction
and imaging studies that can usually diagnose relia-
bly a Level I root avulsion injury, and therefore rule
out a Level IV injury (Chuang, 1999). However, in a
Level II or III injury, which presents with weakness or
paralysis of shoulder and elbow function but preser-
vation of hand function (e.g. a ruptured upper trunk
lesion with incomplete traction of C8/T1), differentia-
tion from a partial Level IV injury may be difficult in
the early stages. Neuro-imaging studies generally
have a limited role in diagnosing Level IV BPI. The use
of Tinel’s sign as an examination aid is helpful, but is
often subjective and therefore not 100% accurate.
Clinically, the preservation of function in proximal
muscles innervated by branches given off supraclav-
icularly or retroclavicularly (such as the supraspina-
tus/infraspinatus, serratus anterior, clavicular part
of pectoralis major, teres major, and latissimus dorsi
muscles) should alert the surgeon to the likelihood of
a Level IV lesion. However, the mere palpation of
muscle contractions does not guarantee 100% accu-
racy in diagnosis. This is due to the complexity of
anatomy, degree of injury, and mixed innervations of
muscles from the brachial plexus. A study into the
reliability of various predictors for pre-operative dif-
ferentiation between Level IV and Level III/II lesions is
currently proceeding within our department.
A clue to diagnosing a Level IV injury may be the
higher frequency of accompanying injuries. In both
Asian and Western countries, Level IV injuries are
associated with a higher incidence of shoulder dislo-
cation than other levels. This is especially true in
older patients (50 years). As shoulder dislocation is
usually a low energy traction injury, the potential for
recovery is high. However, the timing of treatment
remains crucial, especially the time between disloca-
tion and reduction (Chuang, 1999). If the reduction
occurs within 2 hours, the palsy usually recovers
within 2–3 months. However, if it is delayed for longer
than 3 hours, recovery usually takes at least 6 or
more months. We agree that conservative treatment
is indicated for any brachial plexus palsy caused by
shoulder dislocation (Hems and Mahmood, 2012;
Leffert and Seddon, 1965). However, if recovery is
stagnant after 6 months, surgical exploration should
be considered.
Once the decision had been made to explore a
Level IV injury, the surgeon may face a difficult and
tedious dissection due to the dense scarring and the
proximity of the major vessels. In an injury involving
multiple nerves, the need to decide which nerves to
be reconstructed and the method of nerve recon-
struction further complicates these operations. To
facilitate dissection, the exploration should always
start from areas where there is little or no scarring.
The use of well-defined landmarks helps in this: the
proximal stumps are reliably exposed through
Chuang’s triangle, and the distal stumps through the
medial part of the upper arm after division of the pec-
toralis major muscle. Once these are identified, bidi-
rectional dissection should make the anatomy much
clearer and the operative field wider, allowing identi-
fying of the lesions and functional preservation of the
pectoralis major and minor muscles. Finally, con-
comitant harvest of donor nerves from all four
extremities using a two-team approach saves time
and allows the harvest of multiple long nerve grafts.
Choosing the optimal method of nerve reconstruc-
tion remains a challenge. Recently, there is an
increasing popularity with the use of distal nerve
transfer techniques in treating BPIs. These tech-
niques are most commonly used for musculocutane-
ous (Mackinnon and Novak, 1999; Midha, 2004;
Oberlin et al., 1994) or axillary nerve reconstruction
(Garcia-Lopez and Perea, 2012; Witoonchart et al.,
2003). With such techniques, there is now a gradual
move towards the avoidance of dissection in the injury
zone, especially in Level I and II injuries. In Level IV
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Lam et al. 9
injuries, however, surgical exploration of the injured
plexus should still be strongly advocated. The nature
of Level IV traction injuries is such that there is often
a higher percentage of nerve-in-continuity lesions
than in supraclavicular injuries. These cases in our
series (n = 13) were managed by simple neurolysis
with good clinical outcomes. Distal nerve transfers
without exploration of the site of injury may lead to
unnecessary iatrogenic sacrifice of donor nerves and
a result that is less optimal than neurolysis. In our
opinion, distal nerve transfer is only indicated for dis-
tal nerve avulsion at the point of entry into muscles,
which can only be revealed after surgical exploration
(Chuang, 1999).
Nerve grafts are needed for neuromas and rup-
tures with gaps of varying distances. Results follow-
ing nerve grafting are usually excellent for the
axillary, musculocutaneous, and radial nerves, per-
haps because of the less aberrant reinnervation at
this level of the plexus. Restoration of function after
injury to the median and ulnar nerves is less satisfac-
tory. There have been almost no reports of intrinsic
hand function recovery in most series (Alnot, 1988;
Kim et al., 2004). In the present series, only 55% and
60% of patients obtained recovery of the median and
ulnar nerves, respectively, and usually after a delay
of more than 12 months. The recovery markers were
limited to the proximal muscle groups (wrist and fin-
ger flexors). This is why in a total Level IV lesion the
use of the VUNG in the primary operation is an option
to improve the prognoses of median and radial nerve
reconstructions. Reconstruction of the ulnar nerve is
a futile operation for recovery in the intrinsic muscles
of the hand, and the vascularized nerve graft may
allow quicker and more reliable recovery of the
important functions of the median and radial nerves
(Terzis and Kostopoulos, 2009).
Functioning free muscle transplantation remains
a valuable option to restore or improve elbow flexion
when nerve reconstruction has failed or is not possi-
ble (Chuang, 2010). Level IV injuries usually spare the
spinal accessory nerve and/or intercostal nerves,
which remain available to power a free muscle trans-
fer at a later stage. Additional strategies to improve
function include tendon transfers, arthrodeses, and
tenodeses, or a combination of different methods.
For example, a combination of wrist and thumb car-
pometacarpophalangeal joint arthrodesis, in con-
junction with a subsequent free muscle transfer to
finger flexors, may permit the hand to regain some
degree of useful prehension (Chuang, 2010; Terzis
and Kostopoulos, 2009).
Conflict of interests
None declared.
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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... It consists of anterior nerve roots C5, C6, C7, C8, and T1. The C5 and C6 nerve roots unite to form upper trunk, C7 to form the middle trunk, and C8 and T1 to form lower trunk [8], [9], [12], [13], [14], [15], [16] [17] (Figure 1). ...
... Other branches join the medial fascicles to form the median nerve. The medial fascicles provide the ulnar nerve and branches that form the median nerve [14], [18]. ...
... Chuang has refined the classification method for various degrees of brachial plexus injury. The most common injuries are Level I injury [8], [9], [14], [40], [41], [42], [43], [44] ( Table 2). ...
Full-text available
Brachial plexus injury is known to be one of the most serious upper limb injuries, causes paralysis of the upper limbs and changes in activity of daily living, with the consequence disruption of activity of daily living, socioeconomic problems, depression, and hopelessness. Management must be done properly. The evaluation and examination consist of detailed anamnesis on chronological events, complete physical examination, imaging studies, and electrophysiology study. Management can be done nonsurgically and surgically. Knowledge of the history of injury, timing of surgery, priority in restoring function, and managing patient expectations are important concepts in treating patient with brachial plexus injury. Timing is a very important thing. The results of these interventions vary depending on several parameters. Recognizing the basic principles of managing brachial plexus injuries is indispensable for all clinicians who treat these injuries.
... Elevated risk of neurological injury after shoulder dislocation is associated with a number of variables. The most important of them is higher patient age [5,10,12,14,77]. Several studies confirmed that mean age of the patients who sustained isolated shoulder dislocation was lower than those who suffered neurological complications [18,22,23,27,28]. ...
... When disruption of nerve continuity is observed or regenerative NAPs are absent in a continuous nerve, grafting (usually with the use of sural nerve) should be implemented. However, according to some authors, nerve resection and grafting are not recommended during primary operative intervention, because in certain injury patterns improvement in nerve function after operation is possible only after axon regeneration (enabled by restoration of blood flow to the nerve by means of neurolysis) has been completed [77,78,94]. During operative exploration of the injured brachial plexus, anatomic relations of particular structures are usually altered due to the presence of a fibrous scar [94]. ...
... The results depended also on the most affected cord-they were best for lateral cord, medium for posterior cord and least favourable for medial cord, especially the ulnar nerve [95]. Inferior results and longer time required for recovery of the median and ulnar nerves have been observed by many authors [9,18,31,37,77,78]. ...
Full-text available
Brachial plexus injuries are among the rarest but at the same time the most severe complications of shoulder dislocation. The symptoms range from transient weakening or tingling sensation of the upper limb to total permanent paralysis of the limb associated with chronic pain and disability. Conflicting opinions exist as to whether these injuries should be treated operatively and if so when surgery should be performed. In this review, available literature dedicated to neurological complications of shoulder dislocation has been analysed and management algorithm has been proposed. Neurological complications were found in 5.4-55% of all dislocations, with the two most commonly affected patient groups being elderly women sustaining dislocation as a result of a simple fall and young men after high-energy injuries, often multitrauma victims. Infraclavicular part of the brachial plexus was most often affected. Neurapraxia or axonotmesis predominated, and complete nerve disruption was observed in less than 3% of the patients. Shoulder dislocation caused injury to multiple nerves more often than mononeuropathies. The axillary nerve was most commonly affected, both as a single nerve and in combination with other nerves. Older patient age, higher energy of the initial trauma and longer period from dislocation to its reduction have been postulated as risk factors. Brachial plexus injury resolved spontaneously in the majority of the patients. Operative treatment was required in 13-18% of the patients in different studies. Patients with suspected neurological complications require systematic control. Surgery should be performed within 3-6 months from the injury when no signs of recovery are present.
... In such cases, the symptoms of BPI tend to persist causing compromise of the upper limb function. These patients should be considered candidates for operative intervention after a mean observation period of 6 months [2,6,[32][33][34][35][36][37]. In clinical practice, the mean time to operation in cases with no recovery is usually longer due to organizational reasons and patient-dependent factors. ...
... It is worth noticing that the mean age of patients with neurologic deficit resulting from shoulder dislocation, including our patient group, is significantly higher than that of patients sustaining isolated shoulder dislocation in the majority of the studied groups (e.g., mean age in patients with isolated dislocation: Perron [9,10,14,19,21,38]. High patient age is considered one of the major risk factors for neurologic complications of shoulder dislocation, especially above 50 years of age [9,11,18,22,24,34]. According to Visser et al., the probability of neurologic injury increases with a factor of 1.3 per ten-year period and older age is also associated with slower and incomplete recovery [30]. ...
... Particular nerves have different potential for spontaneous recovery depending on the distance to the effector, with the highest recovery rates observed in the study by Hems and Mahmood for the axillary, musculocutaneous, and radial nerves and inferior results for the median and ulnar nerves (incomplete or no recovery), especially regarding intrinsic muscles of the hand [38]. The time periods required for obtaining recovery after operative intervention in the study by Lam et al. also varied from 14 months for elbow flexion to 25 months for wrist flexion [34]. Functional improvement in the interossei can be expected, if at all present, after a substantially longer period of time (18-36 months, according to Leffert and Seddon) [5]. ...
Full-text available
Brachial plexus injuries (BPIs) caused by shoulder dislocation usually have a transient character and tend to resolve spontaneously. However, in some patients the symptoms can persist and require operative intervention. This work aims to determine the risk factors for persistent BPIs resulting from shoulder dislocation. The study comprised 73 patients (58 men, 15 women; mean age: 50 years) treated operatively between the years 2000 and 2016 for persistent BPIs resulting from shoulder dislocation. Patient age, gender, type of initial trauma, number of affected nerves, presence of accompanying injuries, and time interval from dislocation to its reduction were analysed. Elderly patients more often sustained multiple-nerve injuries, while single nerve injuries were more often observed in younger patients. Injury to a single nerve was diagnosed in 30% of the patients. Axillary nerve was most commonly affected. Fracture of the greater tuberosity of humerus coincided with total BPI in 50% of the cases. Longer unreduced period caused injury to multiple nerves. Analysis of our patient group against relevant literature revealed that persistent BPI after shoulder dislocation is more common in older patients. Injuries to ulnar and median nerves more often require operative intervention due to low potential for spontaneous recovery of these nerves.
... 25 The majority of nerve-in-continuity lesions after trauma, due to compression by scar tissue, occur at level IV of the brachial plexus. 26 At this level of the brachial plexus, terminal nerve branches course through the MBFC in close proximity to vascular and bony structures. The tight compartmental space and rigid surrounding connective tissue predispose underlying nerves to a compression neuropathy, which may be triggered after trauma to the brachium. ...
... Although the role of external neurolysis was previously thought to be limited to pain relief, more recent evidence indicates that it has a sizeable impact on sensory and motor function recovery. 26,32,[57][58][59][60][61] Moreover, simple decompression and external neurolysis for nerve-in-continuity lesions have demonstrated much greater outcomes than any operative technique employed for other lesions of the brachial plexus. 58 In a study on nerve repair outcomes in traumatic brachial plexus injuries, Rasulić et al found useful functional recovery after neurolysis in 89.7% of all cases; including the axillary nerve (100%), median nerve (100%), radial nerve (84%), and ulnar nerve (69.2%) ...
Full-text available
Background Brachial plexopathy causes pain and loss of function in the affected extremity. Entrapment of the brachial plexus terminal branches within the surrounding connective tissue, or medial brachial fascial compartment, may manifest in debilitating symptoms. Open fasciotomy and external neurolysis of the neurovascular bundle in the medial brachial fascial compartment were performed as a surgical treatment for pain and functional decline in the upper extremity. The aim of this study was to evaluate pain outcomes after surgery in patients diagnosed with brachial plexopathy. Methods We identified 21 patients who met inclusion criteria. Documents dated between 2005 and 2019 were reviewed from electronic medical records. Chart review was conducted to collect data on visual analog scale (VAS) for pain, Semmes-Weinstein monofilament test (SWMT), and Medical Research Council (MRC) scale for muscle strength. Pre- and postoperative data was obtained. A paired sample t-test was used to determine statistical significance of pain outcomes. Results Pain severity in the affected arm was significantly reduced after surgery (pre: 6.4 ± 2.5; post: 2.0 ± 2.5; p < 0.01). Additionally, there was an increased response to SWMT after the procedure. More patients achieved an MRC rating score ≥3 and ≥4 in elbow flexion after surgery. This may be indicative of improved sensory and motor function. Conclusion Open fasciotomy and external neurolysis at the medial brachial fascial compartment is an effective treatment for pain when nerve continuity is preserved. These benefits were evident in patients with a prolonged duration elapsed since injury onset.
... There have been several studies reporting outcomes of deltoid reinnervation using interpositional nerve grafting of the axillary nerve. [5][6][7][8][10][11][12] The different reports provide varying level of detail for this reconstructive technique and the use of a posterior incision varied, but was most common if the lesion was at the level of, or extended to, the quadrilateral space. The most common zones of injury are either distal to the takeoff of the axillary nerve from the posterior cord or proximal to the quadrilateral space. 2 Inset of the nerve graft through an anterior infraclavicular approach at the level of the quadrilateral space is technically challenging and may compromise the quality of the distal nerve-graft coaptation, ultimately compromising the potential to have optimal deltoid reinnervation. ...
Deltoid paralysis after axillary nerve injury results in limitations in shoulder function and stability. In the setting of an isolated axillary nerve injury with no clinical or electromyographic evidence of recovery that is within 6 to 9 months postinjury, the authors' preferred technique to reinnervate the deltoid is to reconstruct the axillary nerve with sural nerve grafting. Intraoperative neuromuscular electrophysiology is critical to determine the continuity of the axillary nerve before proceeding with reconstruction. The majority of the time, both an anterior and posterior incision and dissection of the axillary nerve is required to adequately delineate the zone of injury. This also ensures that both proximally and distally, uninjured axillary nerve is present before graft inset and also facilitates the ability to perform a meticulous microsurgical inset of the nerve graft posteriorly. The nerve graft must be pulled through from posterior to anterior to span the zone of injury and reconstruct the axillary nerve. Careful infraclavicular brachial plexus dissection is necessary to prevent further injury to components of the brachial plexus in the setting of a scarred bed. Patients will require postoperative therapy to prevent limitations in shoulder range of motion secondary to postoperative stiffness. This paper presents a detailed surgical technique for axillary nerve reconstruction by an anterior-posterior approach with a pull-through technique of a sural nerve cable graft.
The leading cause of adult brachial plexus injuries is trauma resulting from a closed traction injury secondary to a high-velocity motor vehicle accident. Ninety percent of patients suffer supraclavicular lesions. A widened shoulder-neck angle at the time of injury with an adducted shoulder predisposes upper trunk injury, while shoulder abduction predisposes lower trunk injury. Penetrating open injuries, such as gunshot wounds and lacerations, are less common and usually result in infraclavicular injury with concomitant vascular injury. Glenohumeral dislocations and sports-related brachial plexus lesions also represent other causes of closed traction injuries. Nontraumatic brachial plexus injuries include iatrogenic injuries related to patient positioning and regional anesthetics, primary and metastatic brachial plexus tumors, and neuralgic amyotrophy.
Objectives: To investigate functional outcome from reconstructive surgery in adult traumatic brachial plexus injury (AT-BPI) with associated vascular lesions. Methods: A retrospective review was performed of 325 patients with AT-BPI who underwent reconstructive surgery between 2001 and 2012. Patients with (vascular) and without (control) vascular injuries were identified by review of medical documentation. Patient presentation, characteristics of nerve and associated lesions, and surgical management were evaluated to identify prognostic variables. Postoperative muscle strength, range of motion, and patient-reported disability scores were analyzed to determine long-term outcome. Results: Sixty-eight patients had a concomitant vascular injury. There were no significant differences in age or sex between the control and vascular groups. Vascular patients were more likely to have pan-plexus lesions (p<0.0001), with significantly more associated upper extremity injuries (p<0.0001). The control group underwent more nerve transfers whereas vascular patients underwent more nerve grafting (p=0.003). Complete outcomes data were obtained in 139 patients, which included 111 control (43% of all controls) and 28 vascular patients (41%). There was no significant difference in patient-reported disability scores between the two groups. However, 73% of controls had grade 3 or greater postoperative elbow flexion while only 43% of vascular patients achieved these strengths (p=0.003). Control patients demonstrated a greater increase in strength of shoulder abduction as well (p=0.004). Shoulder external rotation strength was grade 0 in the majority of patients, with no difference between the two groups. Conclusions: Concomitant vascular injury leads to worse functional outcome following reconstructive surgery of traumatic brachial plexus injury.
Full-text available
Axillary nerve injury is a well-recognized complication of glenohumeral dislocation. It is often a low-grade injury which progresses to full recovery without intervention. There is, however, a small number of patients who have received a higher-grade injury and are less likely to achieve a functional recovery without surgical exploration and reconstruction. Following a review of the literature and consideration of local practice in a regional peripheral nerve injury unit, an algorithm has been developed to help identification of those patients with more severe nerve injuries. Early identification of patients with high-grade injuries allows rapid referral to peripheral nerve injury centres, allowing specialist observation or intervention at an early stage in their injury, thus aiming to maximize potential for recovery. Cite this article: EFORT Open Rev 2018;3:70-77. DOI:10.1302/2058-5241.3.170003.
Many surgical techniques are available for the repair of peripheral nerve defects. Autologous nerve grafts are the gold standard for most clinical conditions. In selected cases, alternative types of reconstructions are performed to fill the nerve gap. Non-nervous autologous tissue-based conduits or synthetic ones are alternatives to nerve autografts. Allografts represent another new field of interest. Decision making in the treatment of nerve defects is based on timing of referral, level of the injury, type of lesion, and size of any gap. This review focuses on current clinical practice, influenced by the numerous new experimental researches.
Background Injury to the infraclavicular brachial plexus is an uncommon but serious complication of shoulder dislocation. This work aims to determine the effectiveness of operative treatment in patients with this type of injury. Methods Thirty-three patients (26 males,7 females; mean age 45 years 3 months) treated operatively for brachial plexus injury resulting from shoulder dislocation between the years 2000-2013 were included in this retrospective case series. Motor function of affected limbs was assessed pre- and postoperatively with the use of BMRC (British Medical Research Council) scale. Sensory function in the areas innervated by ulnar and median nerves was evaluated with BMRC scale modified by Omer and Dellon and in the remaining areas with Highet’s classification. Follow-up lasted 2-10 years (mean,5.1 years). Results Good postoperative recovery of nerve function was observed in 100% of musculocutaneous, 93.3% of radial, 66.7% of median, 64% of axillary and 50% of ulnar nerve injuries. No recovery was observed in 5.6% of median, 6.7% of radial, 10% of ulnar and 20% of axillary nerve injuries. Injury to a single nerve was associated with worse treatment outcome than multiple nerve injury. Conclusions Obtaining improvement in peripheral nerve function after injury resulting from shoulder dislocation may require operative intervention. The type of surgical procedure depends on intraoperative findings: sural nerve grafiting in cases of neural elements’ disruption, internal neurolysis when itraneural fibrosis is observed and external neurolysis in the remaining cases. The outcomes of surgical treatment are good and the risk of intra- and postoperative complications is low.
While it is widely accepted that cases of traumatic injury to the brachial plexus benefit from early surgical exploration and repair, with results deteriorating with long delays, policies vary regarding the exact timing of intervention. This is one of a pair of review articles considering the clinical issues, investigations, and surgical factors relating to management of injuries to the supraclavicular brachial plexus, as well as evidence from experimental work and clinical outcomes. In this article Mr Hems outlines when waiting may be advantageous, allowing for further investigation to help clarify the extent of the injury and thus the best surgical options.
While it is widely accepted that cases of traumatic injury to the brachial plexus benefit from early surgical exploration and repair, with results deteriorating with long delays, policies vary regarding the exact timing of intervention. This is one of a pair of review articles considering the clinical issues, investigations, and surgical factors relating to management of injuries to the supraclavicular brachial plexus, as well evidence from experimental work and clinical outcomes. In this article Professor Birch argues for early exploration of the brachial plexus as the optimum both to delineate the pathology and undertake reconstructive surgery.
In infraclavicular lesions of brachial plexus, severe lesions of the posterior cord often occur when medial and lateral cord function is preserved to a greater or lesser extent. In these cases, shoulder function may be preserved by activity of the muscles innervated by the suprascapular nerve, but complete paralysis exists in the deltoid, triceps, and brachioradialis, and all wrist and finger extensors. Classical reconstruction procedures consist of nerve grafts, but their results in adults are disappointing. We report an approach transferring: (1) an ulnar nerve fascicle to the motor branch of the long portion of the triceps brachii muscle, (2) a median nerve branch from the pronator teres to the motor branch of the extensor carpi radialis longus, and (3) a median nerve branch from the flexor carpi radialis to the posterior interosseous nerve. We describe the procedure and report 2 clinical cases showing the effectiveness of this technique for restoring extension of the elbow, wrist, and fingers in the common infraclavicular lesions of the brachial plexus affecting the posterior cord.
We reviewed 101 patients with injuries of the terminal branches of the infraclavicular brachial plexus sustained between 1997 and 2009. Four patterns of injury were identified: 1) anterior glenohumeral dislocation (n = 55), in which the axillary and ulnar nerves were most commonly injured, but the axillary nerve was ruptured in only two patients (3.6%); 2) axillary nerve injury, with or without injury to other nerves, in the absence of dislocation of the shoulder (n = 20): these had a similar pattern of nerve involvement to those with a known dislocation, but the axillary nerve was ruptured in 14 patients (70%); 3) displaced proximal humeral fracture (n = 15), in which nerve injury resulted from medial displacement of the humeral shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension of the arm (n = 11): these were characterised by disruption of the musculocutaneous nerve. There was variable involvement of the median and radial nerves with the ulnar nerve being least affected. Surgical intervention is not needed in most cases of infraclavicular injury associated with dislocation of the shoulder. Early exploration of the nerves should be considered in patients with an axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is needed in cases of nerve injury resulting from fracture of the humeral neck to relieve pressure on nerves.
Adult brachial plexus reconstruction remains a dilemma to the reconstructive microsurgeon, especially when attempting to reconstruct cases of total root avulsion. A significant improvement in results has been achieved by a better understanding of various methods of reconstruction and prolonged postoperative rehabilitation. This study was based on review of the literature and personal experience with 819 patients operated on between 1986 and 2003. To better understand these improved results, the author classified patients into four levels of injury: level 1, preganglionic root; level 2, postganglionic spinal nerve; level 3, preclavicular and retroclavicular; and level 4, infraclavicular brachial plexus injury. Neurolysis, nerve repair, nerve graft, vascularized ulnar nerve graft, nerve transfer, and functioning free-muscle transplantation were used for early reconstructions. Tendon transfer, functional or functioning muscle transfer, arthrodesis, or orthotics were used for late palliative reconstructions. Results accomplished by means of different reconstructive strategies with different levels of injury are summarily listed. Personal opinions regarding the controversial strategies are discussed. Brachial plexus surgery, consisting of primary nerve and late palliative reconstruction, is now a worthy surgical pursuit that makes a useless limb useful.
Adult brachial plexus injury remains a dilemma to a reconstructive microsurgeon, especially when attempting to reconstruct cases of total root avulsion. Different degrees and different levels of injury require different strategies of reconstruction. The purpose of this article is to illustrate the author's reconstructive strategy in correlation with the injury level of classification. Nerve transfer, functioning free muscle transplantation, and other palliative surgery are reconstructive options for level 1 injuries. Neurolysis, nerve repair, nerve grafts (free nerve graft or vascularized ulnar nerve graft), nerve transfer if associated with level 1 lesion in other spinal nerves, and palliative reconstruction are chosen options for level 2, 3, and 4 lesions. A clavicle osteotomy is often required in level 3 lesions. Nerve grafts are frequently applied in level 4 lesions, which result in less aberrant reinnervation and a better prognosis.
Vascularized nerve grafts were introduced in 1976. Subsequent studies have suggested the superiority of vascularized nerve grafts. In this study, the authors present 23 years' experience with vascularized ulnar nerve graft. The factors influencing outcomes and a comparison with conventional nerve grafts are presented. Between 1981 and 2003, 151 reconstructions with ulnar nerve were performed in 67 patients for brachial plexus injuries. Patients were divided into four groups: those with vascularized ulnar nerve graft from ipsilateral donors, pedicled or free, and those with vascularized ulnar nerve graft from contralateral donors to median nerve or to single motor targets (e.g., axillary, musculocutaneous, triceps) (n = 25, 21, 13, and 8, respectively). Patients with long denervation times yielded inferior results compared with those operated on early. Pedicle and free ipsilateral ulnar nerve grafts yielded comparable results for biceps muscle neurotization. Neurotization of biceps with a vascularized ulnar nerve graft from the contralateral root was not as effective as neurotization from ipsilateral donors. There was a difference in muscle grading when the target was the median nerve versus single motor targets such as axillary, musculocutaneous, or triceps, but there were no differences between preoperative and postoperative muscle grading of median innervated muscles. Vascularized ulnar nerve grafting is the appropriate solution for brachial plexus injuries with C8 and T1 root avulsion, with outcomes that are superior to those achieved with conventional nerve grafts. Although few changes have been made over time, the use of ulnar nerve grafts for neurotization of multiple motor targets of the median nerve from contralateral donors is under consideration.
In this article, the author focuses on functioning free muscle transplantation (FFMT), an advanced microneurovascular technique indicated in patients who have an advanced injury with a major brachial muscle or muscle group loss or denervation and in whom no locally available or ideal musculotendinous donor unit exists. FFMTs have been successfully applied clinically in cases involving adult brachial plexus palsy, obstetric brachial plexus palsy, facial palsy, severe Volkmann's ischemia, and severe crushing and traction injuries of the forearm or arm with major muscle loss. As the author notes, FFMT is a new challenge for the reconstructive surgeon. He outlines the eight major principles for nerve transfer with FFMT, basing his conclusions on the more than 333 patients who received FFMT between 1995 and 2005 in his hospital.