Download CME Restoration of Elbow Flexion after Brachial Plexus Injury: The

CME
Restoration of Elbow Flexion after Brachial
Plexus Injury: The Role of Nerve and
Muscle Transfers
Karol A. Gutowski, M.D., and Harry H. Orenstein, M.D.
New York, N.Y., and Dallas, Texas
Learning Objectives: After studying this article, the participant should be able to: 1. Perform appropriate diagnostic
evaluation of a brachial plexus injury. 2. Define goals of treatment in brachial plexus injuries resulting in loss of elbow
flexion. 3. Identify appropriate nerves and muscles for transfer procedures to regain elbow flexion. 4. Make an
appropriate selection of surgical procedures to achieve elbow flexion.
Brachial plexus trauma results in a variable loss of upper extremity function. The restoration of this function
requires elbow flexion of adequate strength and range of
motion. A proper evaluation of brachial plexus lesions is
a prerequisite to any reconstructive procedure, and appropriate guidelines are presented. One option for restoring elbow flexion is a nerve transfer. The best results
with this procedure are obtained in young patients treated
within 6 months of injury. Another option is a free or
pedicled muscle transfer, which should be considered in
older patients or patients treated more than 6 months
after an injury. Muscle transfers may also be used to augment the results of nerve transfer procedures. Choices
and clinical results of donor nerves and muscle for transfer are discussed, and an algorithm for treatment is presented. (Plast. Reconstr. Surg. 106: 1348, 2000.)
is elbow flexion. This review will cover the common patterns of nonobstetric brachial plexus
injuries, offer options for nerve and muscle
transfer reconstructive procedures, and provide treatment recommendations for elbow reanimation on the basis of an analysis of published data.
PATIENT CHARACTERISTICS
Most brachial plexus injuries are a result of
high velocity, traction-type trauma, as seen in
motor vehicle collisions, especially motorcycle
and motor scooter accidents. The victims are
usually young men who are unskilled or just
starting manual labor careers and, therefore,
the economic costs of these injuries is high.
One-quarter to one-third of those with severe
injuries will regain minimal or no function. In
the largest series of brachial plexus reconstructions in North America, good or excellent results were obtained in 75 percent of suprascapular reconstructions, 48 percent of biceps
reconstructions, 30 percent of triceps reconstructions, 35 percent of finger-flexion reconstructions, and 15 percent of finger-extension
reconstructions.1
Although uncommon, brachial plexus
trauma may be devastating because of the resulting severe upper extremity functional impairment. The difficulty in treating these injuries is compounded by the complex and
variable anatomy of the brachial plexus, the
long time intervals required for resolution after injury or improvement after surgical intervention, the need for a long-term patientphysician commitment, and the need for a
motivated patient to proceed with the difficult
rehabilitation. Goals of treatment depend on
the extent of remaining function and on the
nature of the injury itself. When a flail arm is
present, the most important function to regain
PATTERNS
OF INJURY
Figure 1 diagrams the brachial plexus, which
consists of contributions from the C5, C6, C7,
From the Institute of Reconstructive Plastic Surgery, New York University, and the Department of Plastic and Reconstructive Surgery, University
of Texas Southwestern. Received for publication January 7, 2000; revised April 18, 2000.
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RESTORING ELBOW FLEXION
FIG. 1. Anatomy of the brachial plexus.2
C8, and T1 nerve roots, with variable contribution from the C4 and T2 roots, and provides
motor and sensory innervation to the upper
extremity.2 Large reviews of the patterns of
injury show that 75 percent of the lesions are
supraclavicular at the root level, whereas the
remaining 25 percent are infraclavicular. Of
the supraclavicular lesions, 75 to 80 percent
involve the plexus from C5 to T1, with the most
common pattern being a C5-C6 rupture and a
C7-C8-T1 root avulsion from the spinal cord. A
total of 20 to 25 percent of supraclavicular
injuries involve C5-C6 or C5-C6-C7 and 2 to 3
percent involve C8-T1.3 Muscles affected by
each pattern of injury, resultant functional
loss, and reconstructive goals are listed in Table I.4 When the C5 and C6 nerve roots are
involved, the goal is to reproduce the elbow
TABLE I
Patterns of Brachial Plexus Injuries and Affected Muscles with Corresponding Functional Losses and Reconstructive Goals4
Nerve Roots
C5-C6
Muscles Affected
Subscapularis, subclavius, deltoid, supraspinatus,
infraspinatus, biceps brachialiscoracobrachialis, and
brachioradialis (⫾ radial wrist extensors and cavicular
pectoralis major)
C5-C6-C7
Same as C5-C6 and serratus anterior, extensor carpi radialis
longus and brevus, flexor carpi radialis, extensor
digitorum communis, extensor pollicus longus, extensor
pollicus brevus, and abductor pollicus longus
C7-C8-T1
Latissimus dorsi, extensor digitorum communis, extensor
pollicus longus flexor digitorum superficialis and
profundus, flexor pollicus longus, and all intrinsic hand
muscles
C5-C6-C7-C8-T1 All above muscles
Functional Loss
Reconstructive Goals
Shoulder rotation, abduction and
forward flexion, and elbow
flexion (⫾ wrist extension)
Stable shoulder and elbow
flexion
Same as C5-C6 and extension of
elbow wrist, fingers, and thumb
(presence of winged scapula)
Stable shoulder, elbow
flexion, and wrist
extension
Finger extension, finger and thumb Wrist extension and thumb
flexion, and intrinsic hand
pinch
functions
All above functions
Elbow flexion
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PLASTIC AND RECONSTRUCTIVE SURGERY,
flexion normally provided by the biceps muscle, which is innervated by the musculocutaneous nerve from the C5 and C6 roots.
CLINICAL EVALUATION
A clinical examination of the patient with a
brachial plexus injury should identify the affected muscles and look for signs of root avulsion and nerve regeneration. A winged scapula
with an intact spinal accessory nerve is highly
suggestive of a C5-C6-C7 avulsion, whereas the
presence of Horner’s syndrome (enophthalmos, myosis, ptosis, and absence of facial sweating on the affected side) suggests a cervical or
T1 root avulsion and interruption of sympathetic innervation.5 A sensory-sweating dissociation in an anesthetic and flail arm also suggests root avulsion.6 In these cases, recovery
cannot be expected, and surgical exploration is
warranted. A functioning supraspinatus muscle
predicts that C5 is not avulsed.7 A supraclavicular Tinel’s sign suggests a connection between
the involved nerve and the central nervous
system and, therefore, recovery of the affected
nerve may occur.5 A paralyzed diaphragm, as
determined by inspiratory/expiratory chest
x-rays or fluoroscopic studies, suggests a high
plexus lesion.1
Upper extremity angiograms should be used
in patients with a history of significant vascular
injury, especially if free tissue transfer is anticipated. Shoulder and arm muscles should be
tested individually and graded using the following system.8
M0: No contraction
M1: Flicker or trace of contraction
M2: Active movement with gravity eliminated
M3: Active movement against gravity
M4: Active movement against resistance
M5: Normal movement
Muscles must be grade M4 or M5 to be useful
for transfer because one grade of strength is
lost after transfer. Muscles with uncontrolled
spasticity should not be transferred. A datasheet
shown in Figure 2 is useful for documenting
functional recovery after serial examinations
and in identifying the location of lesions in the
brachial plexus.9
Further clinical studies include electrodiagnostics, which consist of an electromyogram
(which should be done at least 3 weeks after
injury) and the determination of nerve conduction velocities. Imaging studies traditionally
consisted of myelography and, later, computed
November 2000
tomography myelography; however, magnetic
resonance imaging is noninvasive and offers
multiplanar imaging without shoulder artifact.10 The decision of when to explore an injured brachial plexus depends on these clinical
findings, with functional recovery being looked
for during serial examinations. Figure 3 shows
an algorithm proposed by Brunelli and
Brunelli,6 which is based on their extensive
experience with these injuries.
GOALS
OF
TREATMENT
The goals of treatment are to restore grade
M4 or M4⫹ elbow flexion with a range of
motion that will allow the hand to reach the
face. Although many studies report obtaining
M5 elbow flexion, it is unlikely that full
strength is ever achieved. Realistically, M4⫹
strength is the best one can expect from a
reconstructive procedure. The resulting function of elbow flexion must outweigh the deficits caused by transferring functional nerves or
muscles. Furthermore, there should be a reasonable time to recovery of useful function. To
prevent dissipation of elbow flexion strength,
the shoulder must be stable. This can be
achieved by a nerve transfer of the spinal accessory or phrenic nerves, arthrodesis, or tendon transfers. After adequate elbow flexion has
been established, procedures to allow wrist and
finger extension may follow. Occasionally, active elbow extension or wrist and finger flexion
can also be achieved.
NERVE REPAIR
AND
RECONSTRUCTION PROCEDURES
Extremity reanimation may be achieved by
nerve repair or by nerve transfer, which is the
transfer of a nerve in continuity with the spinal
cord to the end of a nerve that has lost its
spinal cord connection. This is different from
neurotization, which is the process of reinnervating a muscle by placing a functional nerve
directly in contact with muscle tissue. When
dealing with nerve ruptures, neurorrhaphy is
the simplest method of repair. If a significant
nerve gap exists or if extensive scaring and
fibrosis are present, nerve grafts should be
used to bridge the gap or bypass the fibrotic
area. Common sources of grafts include the
sural and medial cutaneous nerves and, in
cases of C8 and T1 avulsion, the ulnar nerve
may also be used.11 Results tend to be better in
grafts placed in the upper trunk than in the
lower trunk. If a significant neuroma is present
at the site of injury, neurolysis or neuroma
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RESTORING ELBOW FLEXION
FIG. 2. Worksheet to document brachial plexus lesions and progression of recovery.9
excision and nerve grafting is indicated, depending on the amount of functional nerve
fibers.
Nerve root avulsions must be treated by
nerve or muscle transfer procedures. In these
cases, it is important to anticipate the functional result and to keep in mind the resulting
deficit from the donor nerve or muscle. Furthermore, studies of nerve and muscle transfer
outcomes must be critically examined because
some positive results may be due to spontaneous recovery by alternate neural pathways. Figure 4 shows the ideal donors for nerve transfer,
which should be in proximity to the brachial
plexus.12
Useful donor nerves are listed in Table II
with their corresponding number of myelinated axons.13 In comparison, the numbers of
myelinated axons in the recipient nerves are
listed in Table III.13 It is clear that most axons
in a peripheral nerve will not be functional
after a single donor nerve transfer because of
the unfavorable ratio of donor to recipient
axons. Fortunately, a simple action, such as
elbow flexion by the biceps, requires only hundreds of functioning axons to be useful.14 Complex actions, such as those of the intrinsic muscles, require thousands of axons, and useful
results should not be expected after nerve
transfers to these muscles. In a review of 107
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PLASTIC AND RECONSTRUCTIVE SURGERY,
November 2000
TABLE II
Potential Donor Nerves and Number of
Myelinated Axons13
FIG. 3. Algorithm for decision making in the treatment of
brachial plexus injuries.6 MRI indicates magnetic resonance
imaging.
FIG. 4. Proximity of donor nerves to brachial plexus.12
cases, Millesi15 found useful arm function was
obtained more often with neurolysis (72 percent), nerve grafts (70 percent), and neurorrhaphy (67 percent) than with nerve transfers
(41 percent).
Intercostal Nerve Transfer
Intercostal nerve transfer is one of the more
common methods of reanimating the arm.
Typically, the third, fourth, and fifth intercostal nerves are used; however, up to seven unilateral intercostal nerves have been used.16
When possible, the fourth intercostal nerve
Donor Nerve
Myelinated Axons
Intercostal
Cervical plexus motors
Spinal accessory
Long thoracic
Phrenic
C7
Ulnar (partial)
1300
4000
1700
1600
800
24,000
1600
should be spared in women. Candidates for
this procedure should have no history of rib
fractures, thoracotomies, or chest tube placement in the potential donor nerve region.
Electromyograms should be performed on intercostal nerves adjacent to previously fractured ribs to assure adequate function.1
The highest content of motor nerves can be
found just distal to the lateral cutaneous
branch. Sensory reinnervation may be
achieved by coapting the intercostal nerve sensory axons, which are located in the superior
portion of the nerve, with the sensory axons of
the musculocutaneous nerve, which are located in the superior and inferior poles of the
nerve. The intercostal nerve motor fibers,
which run in the inferior portion of the nerve,
are coapted to the motor fibers located in the
middle of the musculocutaneous nerve.17 Several large studies with a combined total of 377
patients treated by intercostal nerve transfer
found that 46 percent of patients achieved
grade M4 or M5 elbow flexion.17–23
Additionally, Millesi 24 found intercostal
nerve transfers were more likely to have a useful result when the spinal accessory nerve was
used to stabilize the shoulder by nerve transfer
to the axillary or suprascapular nerves. Nagano
et al.18 discovered that results were better when
patients were younger than 40 years old and
nerve transfer was undertaken within 6 months
TABLE III
Number of Myelinated Axons in Nerves of the
Upper Extremity13
Root/Nerve
Myelinated Axons
Brachial plexus
C5-T1 (each root)
Axillary
Musculocutaneous
Median
Ulnar
Radial
100,000 to 160,000
7000 to 41,000
6500
6000
18,000
16,000
19,000
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RESTORING ELBOW FLEXION
of injury. Generally, only two or three intercostal nerves are needed to achieve elbow flexion,
and nerve grafts should be avoided. If after
appropriate follow-up elbow flexion is grade
M3 or less, a muscle transfer procedure may be
used to supplement the biceps. In less than 10
percent of patients, uncontrolled elbow flexion
was reported with coughing, sneezing, or yawning, but none had a loss of pulmonary function.25
Spinal Accessory Nerve Transfer
The spinal accessory nerve is another potential donor to achieve elbow flexion. The segment distal to the trapezius ramus is used to
preserve sternocleidomastoid and trapezius
function. Advantages include its sole function
as a motor nerve and similar functional relationship with the musculocutaneous nerve.
However, its use does require a nerve graft and,
when needed, it is best saved for shoulder stabilization by nerve transfer. Songcharoen et
al.26 showed good results when nerve transfer
was undertaken within 6 to 9 months of injury
and when patients were younger than 40 years
old. Kawai et al.22 compared spinal accessory
and intercostal nerve transfers for elbow flexion and found strength was greater than M3 in
44 and 42 percent of patients, respectively. In a
prospective randomized trial, Waikakul et al.25
found very good or good power in 83 percent
of patients who underwent spinal accessory
nerve transfers using sural nerve grafts compared with 64 percent of those who had a
transfer of three intercostal nerves without
nerve grafts. However, the later group had earlier evidence of motor reinnervation, improvement in protective sensation, and a reduction
in arm pain.
Phrenic Nerve Transfer
Despite concerns of decreased pulmonary
function, the phrenic nerve has been successfully transferred. Gu and Ma27 found elbow
flexion of grade M4 or M5 in 49 percent of
their 49 patients. Although pulmonary capacity
was decreased for 1 year after surgery, this
normalized by 2 years. No respiratory complications were seen, even when intercostal nerves
were also used.
Cervical Plexus Transfer
Up to four of the motor branches from the
cervical plexus may be used for nerve transfer.28 Nerve grafts are required, and results are
unpredictable when used alone; therefore, it is
recommended that the spinal accessory or
phrenic nerve be used in combination with
cervical plexus nerve transfer to achieve better
results.12
Hypoglossal Nerve Transfer
An infrequent donor is the hypoglossal
nerve. Disadvantages include the need for a
nerve graft and the problem of the innervated
muscle being activated during eating.12 Narakas29 cautions that there are no convincing
reports that the functional donor deficit is insignificant.
C7 Spinal Nerve Transfer
Because the C7 spinal nerve may be sacrificed without significant loss of function, it is a
reasonable donor for transfer.12,30 Often, the
contralateral nerve is used.
Partial Ulnar Nerve Transfer
Oberlin et al.31 recently reported using a 10
percent cross-sectional area of the ulnar nerve
in performing a two fascicle coaptation to
branches of the musculocutaneous nerve in
four patients. Three patients achieved M4 elbow flexion, whereas the fourth patient had
M3 flexion by 9 months after surgery. Careful
testing revealed no loss in ulnar nerve motor or
sensory function.
MUSCLE TRANSFER PROCEDURES
The local and distant muscles that may be
transferred and used to provide elbow flexion
include the following: flexor-pronator mass,
pectoralis major, pectoralis minor, latissimus
dorsi, triceps, and sternocleidomastoid and the
gracilis, rectus femoris, and latissimus dorsi as
free muscle transfers. This may be done alone
or in combination with a nerve transfer procedure. Unlike nerve transfers, in which the original elbow flexor, the biceps muscle, is reactivated, muscle transfer procedures alter the
biomechanics of elbow flexion. Therefore, at
least M4 strength and the creation of at least 90
to 100 degrees of elbow flexion are needed to
provide useful function.
Steindler Flexorplasty
A commonly used muscle transfer procedure
for elbow reanimation is the flexorplasty, as
originally described by Steindler.32 The procedure involves transfer of the flexor pronator
mass (pronator teres, flexor carpi radialis,
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PLASTIC AND RECONSTRUCTIVE SURGERY,
November 2000
Hirayama et al.38 had 2 of 6 patients who could
raise their hands to their mouths. Berger and
Brenner39 found the maximal strength in elbow flexion for unipolar and bipolar latissimus
dorsi transfers was 10 to 15 kg and 5 to 8 kg,
respectively.
flexor carpi ulnaris, palmaris longus, and
flexor digitorum superficialis) from its insertion on the medial epicondyle to a point 4 to 6
cm more proximal on the humerus. An electromyogram study is recommended first to
evaluate flexor digitorum superficialis and
flexor carpi radialis muscle function. The flexorplasty may be technically easier if it is done
before shoulder fusion (when this is needed).
Generally, 1 to 2 kg of lift is achieved. This
procedure is better at increasing elbow
strength from M2 to M3 or M4 than from M0
or M1 to M3.
Brunelli et al.33 modified Steindler’s procedure by not including the flexor digitorum
superficialis in an effort to avoid hand pronation and finger flexion during active elbow
flexion. With this modification, 81 percent of
32 patients were able to lift 2 kg or more, and
56 percent had greater than 120 degrees of
elbow flexion. A dramatic increase in the overall results of the flexorplasty can be achieved by
performing additional tendon transfers for
wrist and finger extension.34
Good strength is obtained from a triceps
muscle transfer, but active elbow extension is
lost and a flexion contracture may occur. Hoang
et al.’s40 experience with 7 patients showed the
achievement of 90 to 140 degrees of flexion,
and 5 patients could bring their hands to their
mouths. Alnot36 suggests this transfer for C5-C6
palsy when elbow flexion is M0.
Pectoralis Major Transfer
Free Muscle Transfer
The sternocostal portion of the pectoralis
major muscle may be transferred and inserted
to the biceps tendon by way of a fascia lata
interposition graft. A stable shoulder is a prerequisite to prevent dissipation of power. This
procedure may have better functional results
than a flexorplasty, but the ability to hold objects against the body may be lost. In Brooks
and Seddon’s35 report, all patients achieved at
least 90 degrees of flexion and M3 or M4
strength.
In cases of delayed nerve reconstruction with
target muscle atrophy and motor endplate degeneration, a free gracilis, rectus femoris, or
contralateral latissimus dorsi muscle transfer is
useful. Other indications include injury to the
flexor muscle mass, lack of local donor muscles, and as a salvage procedure in complete
brachial plexus avulsions or in failures of nerve
transfer. Chuang et al.41 achieved M4 strength
in 25 of 31 patients who had two or three
intercostal nerve transfers to a free gracilis
muscle transfer; however, this strength was not
achieved in four patients who had spinal accessory nerve transfers with nerve grafts to the free
gracilis muscle. Akasaka et al.’s42 experience
with free rectus femoris transfer innervated by
two intercostal nerves yielded four patients
with M4 and four patients with M3 strength out
of 11 patients. Berger and Brenner39 also used
free unipolar and bipolar latissimus dorsi transfers and achieved 2 to 4 kg and 1 to 2 kg of
strength in elbow flexion, respectively.
Pectoralis Minor Transfer
There are few reports on the use of the
pectoralis minor for elbow reanimation. It is
suggested for C5-C6 palsy and provides M3
strength without donor functional loss. This
transfer has been used to supplement a flexorplasty when initial elbow flexion is less than
M2.36
Latissimus Dorsi Transfer
The powerful latissimus dorsi muscle can
provide more lift strength than a flexorplasty,
but cortical retraining may be more difficult.
Because of its C5-C6-C7 innervation, muscle
strength must be assessed before transfer. Moneim and Omer37 could achieve only 65 to 115
degrees of flexion in their patients, whereas
Triceps Transfer
Sternocleidomastoid Transfer
Although excellent results were reported
with the sternocleidomastoid muscle transfer,
it is no longer used because of the resultant
neck deformity and the need for grotesque
facial and neck manipulations to achieve flexion.4
Comparisons of Muscle Transfer Procedures
Marshall et al.43 reported 19 of their 23 patients had good or fair results with a flexorplasty, and their best elbow flexion was 130
degrees. All six patients with latissimus dorsi
and all five with triceps transfer had good or
Vol. 106, No. 6 /
RESTORING ELBOW FLEXION
fair results, with the best flexion being 130 and
120 degrees, respectively. Only 6 of the 11
patients who had pectoralis major transfers
had good or fair results; their best flexion was
120 degrees. Although all patients with latissimus dorsi and triceps transfers achieved
greater than 90 degrees of elbow flexion, only
74 percent of those who had flexorplasties and
55 percent of those with pectoralis major transfers reached this goal. A lack of shoulder stabilization was cited as the cause of poor results
in these muscle transfers.
Chuang et al.44 found about half of their
patients who had a flexorplasty or latissimus
dorsi or free gracilis transfer could achieve
greater than M3 strength, whereas all flexorplasty patients who underwent the procedure
after previous unsatisfactory nerve or muscle
transfers achieved this goal.
In a large series, Berger and Brenner39 demonstrated that the latissimus dorsi transfer provided the strongest force of lift; this was followed by the triceps transfer and then the
flexorplasty. Eggers et al.45 also found the latissimus dorsi transfer was stronger than the flexorplasty, but both yielded at least M4 strength.
The flexorplasty, however, had a lesser degree
of elbow flexion. When the flexorplasty was
compared with a pectoralis major transfer,
Beaton et al.46 found no statistical difference in
function, strength, range of motion, or activities of daily living in their patients.
COMBINED TREATMENT: NERVE
MUSCLE TRANSFERS
AND
Various combinations of nerve and muscle
transfers have been proposed. Berger et al.47
suggest an initial nerve transfer procedure supplemented at least 1 year later by a triceps
transfer or flexorplasty to achieve elbow flexion. Doi et al.48 used latissimus dorsi transfers
for elbow flexion together with nerve transfers
for wrist and finger extension. Alnot36 reported
good results by adding muscle transfers to
nerve graft and neurolysis procedures, either
concurrently or as a secondary procedure.
1355
FIG. 5. Guidelines for selecting treatment for C5-C6 brachial plexus ruptures or severe traction injuries to achieve
elbow flexion.
the nerve lesion. Primary neurorrhaphy is performed when possible, and nerve grafts are
reserved for extensive scaring and fibrosis.
Neuromas may be treated by neurolysis or neuroma excision followed by nerve grafting.
If minimal or no improvement occurs after
an appropriate waiting period, a muscle transfer is indicated. If elbow flexion is less than M2,
a triceps transfer is preferred or, alternatively, a
flexorplasty combined with a pectoralis minor
transfer. If elbow flexion is M2 or greater, a
flexorplasty alone should provide adequate
strength. Other options include a pectoralis
major or latissimus dorsi transfer or a free muscle transfer if the previous muscles are not
available or do not have at least M4 strength.
In cases of C5-C6 avulsion (Fig. 6), a nerve
transfer may be attempted. The intercostal
nerve should be considered first and then the
ipsilateral and contralateral C7 nerve root or
the ulnar nerve in a partial fashion. The spinal
accessory and phrenic nerves should be re-
TREATMENT RECOMMENDATIONS
On the basis of the expected outcomes of
the many nerve and muscle transfer procedures, the following recommendations are offered to help guide treatment and achieve useful elbow flexion. In cases of C5-C6 rupture or
severe traction injury (Fig. 5), the nerve root is
intact and so treatment should be directed at
FIG. 6. Guidelines for selecting treatment for brachial
plexus avulsions to achieve elbow flexion. *If needed, these
nerves should be saved to stabilize the shoulder.
1356
PLASTIC AND RECONSTRUCTIVE SURGERY,
served for shoulder stabilization, if needed. If
at least M4 strength is not achieved, a flexorplasty or triceps transfer (if C7 is not involved)
may be added; a free muscle transfer may be
done if local muscles are unavailable. Nerve
transfer may also be attempted if no muscles
are available for transfer. However, if more
than 6 months have passed since the time of
injury, if the patient is older than 30 to 40
years, or if significant biceps muscle atrophy is
present, elbow flexion is best achieved by proceeding directly to a muscle transfer procedure, because nerve transfer procedures are
unlikely to provide useful function. If local
muscles for transfer have less than M4
strength, a free muscle transfer is necessary.
TREATMENT HORIZONS
Nerve root avulsions were originally thought
to be irreparable injuries because reimplanting
the avulsed root in the spinal cord was not
considered possible. After much research,
Carlstedt et al.49 challenged this notion. In a
single patient, the C6 and C7 nerve roots were
reimplanted in the spinal cord and, at 3 years
follow-up, voluntary deltoid, biceps, and triceps activity was achieved. Although only one
case has been reported, a new option for the
treatment of avulsions may soon be possible.
Other novel avenues in improved treatment
for brachial plexus lesions have focused on
sensory and cortical re-education, technical improvements in nerve repair, and the elimination of neuromas. Nerve growth factors may
also provide better results for these difficult
injuries.
Karol A. Gutowski, M.D.
Institute of Reconstructive Plastic Surgery
New York University Medical Center
550 First Avenue
New York, N.Y. 10016
[email protected]
ACKNOWLEDGMENTS
The authors thank Mihye Choi, M.D., and Michael R.
Hausman, M.D., for their review of and insightful input into
the manuscript.
REFERENCES
1. Terzis, J. K., Vekris, M. D., and Soucacos, P. N. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast. Reconstr. Surg.
104: 1221, 1999.
2. Matloub, H. S., and Yousif, N. J. Peripheral nerve anatomy and innervation pattern. Hand Clin. 8: 201, 1992.
3. Alnot, J. Traumatic brachial plexus lesions in the adult.
Hand Clin. 11: 623, 1995.
November 2000
4. Leffert, R. D. Brachial Plexus. In D. P. Green, R. N.
Hotchkiss, and W. C. Pederson (Eds.), Operative Hand
Surgery, Vol. 2, 4th Ed. Philadelphia: Churchill Livingstone, 1999.
5. Leffert, R. D. Clinical diagnosis, testing, and electromyographic study in brachial plexus traction injuries.
Clin. Orthop. 237: 24, 1988.
6. Brunelli, G., and Brunelli, G. Preoperative assessment
of the adult plexus patient. Microsurgery 16: 17, 1995.
7. Sedel, L. The management of supraclavicular lesions.
Clin. Plast. Surg. 11: 121, 1984.
8. Medical Research Council. Aids to the Investigation of
Peripheral Nerve Injuries. In War Memorandum No. 7,
2nd Ed. London: His Majesty’s Stationery Office,
1943.
9. Leffert, R. D. Rehabilitation of the Patient with an Injury to the Brachial Plexus. In J. M. Hunter, E. J.
Mackin, and A. D. Callahan (Eds.), Rehabilitation of the
Hand: Surgery and Therapy, Vol. 1, 4th Ed. St. Louis:
Mosby, 1995.
10. Panasci, D. J., Holliday, R. A., and Shpizner, B. Advanced imaging techniques of the brachial plexus.
Hand Clin. 11: 545, 1995.
11. Terzis, J. K., and Breidenbach, W. The Anatomy of Free
Vascularized Nerve Grafts. In J. K. Terzis (Ed.), Microreconstruction of Nerve Injuries. Philadelphia: Saunders, 1987.
12. Chuang, D. C. Neurotization procedures for brachial
plexus injuries. Hand Clin. 11: 633, 1995.
13. Narakas, A. O. Thoughts on neurotization or nerve
transfers in irreparable nerve lesions. Clin. Plast. Surg.
11: 153, 1984.
14. Narakas, A. Surgical treatment of traction injuries of
the brachial plexus. Clin. Orthop. 133: 71, 1978.
15. Millesi, H. Brachial plexus injuries: Management and
results. Clin. Plast. Surg. 11: 115, 1984.
16. Dolenc, V. V. Intercostal neurotization of the peripheral nerves in avulsion plexus injuries. Clin. Plast. Surg.
11: 143, 1984.
17. Chuang, D. C., Yeh, M. C., and Wei, F. C. Intercostal
nerve transfer of the musculocutaneous nerve in
avulsed brachial plexus injuries: Evaluation of 66 patients. J. Hand Surg. (Am.) 17: 822, 1992.
18. Nagano, A., Tsuyama, N., Ochiai, N., et al. Direct nerve
crossing with the intercostal nerve to treat avulsion
injuries of the brachial plexus. J. Hand Surg. (Am.) 14:
980, 1989.
19. Ruch, D. S., Friedman, A., and Nunley, J. A. The restoration of elbow flexion with intercostal nerve transfers. Clin. Orthop. 314: 95, 1995.
20. Malessy, M. J. A., and Thomeer, R. T. W. M. Evaluation
of intercostal to musculocutaneous nerve transfer in
reconstructive brachial plexus surgery. J. Neurosurg.
88: 266, 1998.
21. Minami, M., and Ishii, S. Satisfactory elbow flexion in
complete (preganglionic) brachial plexus injuries:
Produced by suture of third and fourth intercostal
nerves to musculocutaneous nerve. J. Hand Surg.
(Am.) 12: 1114, 1987.
22. Kawai, H., Kawabata, H., Masada, K., et al. Nerve repairs
for traumatic brachial plexus palsy with root avulsion.
Clin. Orthop. 237: 75, 1988.
23. Takahashi, T. Studies on conversion of motor function
in intercostal nerves crossing for complete brachial
plexus injuries of root avulsion type. J. Jpn. Orthop.
Assoc. 57: 1799, 1983.
Vol. 106, No. 6 /
1357
RESTORING ELBOW FLEXION
24. Millesi, H. Brachial plexus injuries. Clin. Orthop. 237:
36, 1988.
25. Waikakul, S., Wongtragul, S., and Vanadurongwan, V.
Restoration of elbow flexion in brachial plexus avulsion injury: Comparing spinal accessory nerve transfer
with intercostal nerve transfer. J. Hand Surg. (Am.) 24:
571, 1999.
26. Songcharoen, P., Mahaisavariya, B., and Chotigavanich,
C. Spinal accessory neurotization for restoration of
elbow flexion in avulsion injuries of the brachial
plexus. J. Hand Surg. (Am.) 21: 387, 1996.
27. Gu, Y., and Ma, M. Use of the phrenic nerve for brachial
plexus reconstruction. Clin. Orthop. 323: 119, 1996.
28. Brunelli, G., and Monini, L. Neurotization of avulsed
roots of brachial plexus by means of anterior nerves of
cervical plexus. Clin. Plast. Surg. 11: 149, 1984.
29. Narakas, A. O. Axon Disorders in Brachial Plexus Injury. In Scientific Program of the 11th Symposium of the
International Society of Reconstructive Microsurgery, Vienna, Austria, 1993.
30. Gu, Y. D., Zhang, G. M., Chen, D. S., et al. Cervical nerve
root transfer from contralateral normal side for treatment of brachial plexus root avulsion. Chin. Med. J.
104: 208, 1991.
31. Oberlin, C., Beal, D., Leechavengvongs, S., et al. Nerve
transfer to biceps muscle using a part of ulnar nerve
for C5–C6 avulsion of the brachial plexus: Anatomical
study and report of four cases. J. Hand Surg. (Am.) 19:
232, 1994.
32. Steindler, A. A muscle plasty for the relief of flail elbow
in infantile paralysis. Interstate Med. J. 25: 235, 1918.
33. Brunelli, G. A., Vigasio, A., and Brunelli, G. R. Modified
Steindler procedure for elbow flexion restoration.
J. Hand Surg. (Am.) 20: 743, 1995.
34. Liu, T., Yang, R. S., and Sun, J. S. Long-term results of
the Steindler flexorplasty. Clin. Orthop. 296: 104, 1993.
35. Brooks, D. M., and Seddon, H. J. Pectoral transplantation for paralysis of the flexors of the elbow: A new
technique. J. Bone Joint Surg. (Br.) 41: 36, 1959.
36. Alnot, J. Y. Elbow flexion palsy after traumatic lesions of
the brachial plexus in adults. Hand Clin. 5: 15, 1989.
37. Moneim, M. S., and Omer, G. E. Latissimus dorsi muscle transfer for restoration of elbow flexion after bra-
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
chial plexus disruption. J. Hand Surg. (Am.) 11: 135,
1986.
Hirayama, T., Takemitsu, Y., Atsuta, Y., et al. Restoration of elbow flexion by complete latissimus dorsi
muscle transposition. J. Hand Surg. (Br.) 12: 194, 1987.
Berger, A., and Brenner, P. Secondary surgery following brachial plexus injuries. Microsurgery 16: 43, 1995.
Hoang, P. H., Mills, C., and Burke, F. D. Triceps to
biceps transfer for established brachial plexus palsy.
J. Bone Joint Surg. (Br.) 71: 268, 1989.
Chuang, D. C., Carver, N., and Wei, F. Results of functioning free muscle transplantation for elbow flexion.
J. Hand Surg. (Am.) 21: 1071, 1996.
Akasaka, Y., Hara, T., and Takahashi, M. Free muscle
transplantation combined with intercostal nerve crossing for reconstruction of elbow flexion and wrist extension in brachial plexus injuries. Microsurgery 12:
346, 1991.
Marshall, R. W., Williams, D. H., Birch, R., et al. Operations to restore elbow flexion after brachial plexus
injuries. J. Bone Joint Surg. (Br.) 70: 577, 1988.
Chuang, D. C., Epstein, M. D., Yeh, M. C., et al. Functional restoration of elbow flexion in brachial plexus
injuries: Results in 167 patients (excluding obstetric
brachial plexus injuries). J. Hand Surg. (Am.) 18: 285,
1993.
Eggers, I. M., Mennen, U., and Matime, A. M. Elbow
flexorplasty: A comparison between latissimus dorsi
transfer and Steindler flexorplasty. J. Hand Surg. (Br.)
17: 522, 1992.
Beaton, D. E., Dumont, A., Mackay, M. B., et al. Steindler and pectoralis major flexorplasty: A comparative
analysis. J. Hand Surg. (Am.) 20: 747, 1995.
Berger, A., Schaller, E., and Mailander, P. Brachial
plexus injuries: An integrated treatment concept.
Ann. Plast. Surg. 26: 70, 1991.
Doi, K., Sakai, K., Kuwata, N., et al. Reconstruction of
finger and elbow function after complete avulsion of
the brachial plexus. J. Hand Surg. (Am.) 16: 796, 1991.
Carlstedt, T., Grane, P., Hallin, R. G., et al. Return of
function after spinal cord implantation of avulsed spinal nerve roots. Lancet 346: 1323, 1995.
Self-Assessment Examination follows on
page 1358.
Self-Assessment Examination
Restoration of Elbow Flexion after Brachial Plexus Injury: The Role of Nerve
and Muscle Transfers
by Karol A. Gutowski, M.D., and Harry H. Orenstein, M.D.
1. ALL OF THE FOLLOWING STATEMENTS ARE TRUE EXCEPT:
A) Elbow flexion is primarily a function of the C5 and C6 nerve roots
B) Horner’s syndrome suggests a nerve root avulsion
C) Lower brachial plexus root (C8-T1) injuries are more common in adult trauma than are upper brachial plexus root injuries (C5-C6-C7)
D) A nondescending Tinel’s sign suggests the need for surgical exploration of the brachial plexus
2. CURRENT RECOMMENDATIONS FOR DIAGNOSTIC EVALUATION OF NONPENETRATING BRACHIAL
PLEXUS INJURIES INCLUDE ALL OF THE FOLLOWING EXCEPT:
A) Serial examinations of upper extremity motor function
B) Contrast-enhanced tomography
C) Magnetic resonance imaging
D) Electrodiagnostic studies (electromyogram)
E) Elicitation of Tinel’s sign
3. POTENTIAL DONORS FOR NERVE TRANSFER PROCEDURES TO PROVIDE ELBOW FLEXION IN BRACHIAL
PLEXUS INJURIES INCLUDE ALL OF THE FOLLOWING EXCEPT:
A) Intercostal nerve
B) Spinal accessory nerve
C) Musculocutaneous nerve
D) Contralateral C7 nerve
E) Partial ulnar nerve
4. COMMON DONORS FOR MUSCLE TRANSFER PROCEDURES TO PROVIDE ELBOW FLEXION IN BRACHIAL
PLEXUS INJURIES INCLUDE ALL OF THE FOLLOWING EXCEPT:
A) Latissimus dorsi
B) Gracilis as a free tissue transfer
C) Flexor-pronator mass of the forearm
D) Sternocleidomastoid
E) Pectoralis major
5. FACTORS ASSOCIATED WITH POOR OUTCOME AFTER PROCEDURES TO TREAT BRACHIAL PLEXUS
INJURIES INCLUDE ALL OF THE FOLLOWING EXCEPT:
A) Nerve transfer procedures in patients older than 40 years
B) Transfer of muscles that are grade M3 in strength
C) Nerve transfer procedures preformed more than 12 months after injury
D) Use of muscle transfers after initial nerve transfer procedures
E) Avoiding shoulder stabilization procedures
To complete the examination for CME credit, turn to page 1449 for instructions and the response form.