Brachial Plexus Injury |1

Brachial Plexus Injury

Brachial plexus anatomy (refer to Brachial Plexus note)
Brachial plexus injury can be
Complete BPI (75-80%)
Upper plexus, C5,C6 (20-25%)
Lower plexus, C8, T1 (0.6-3%)
Preganglionic
Postganglionic

Ways to differentiate between pre- and post-ganglionic brachial plexus injury

Preganglionic : injury proximal to dorsal root ganglion for sensory and anterior horn
cell for motor
Postganglionic are amenable to repair since the nerve cell body is intact and can
regenerate
Upper plexus
Elevated hemidiaphragm in erect chest xray
Winging of scapula
Rhomboids paralysis
Histamine test
Lower plexus
Horner syndrome (loss of sympathetic from T1)
Partial ptosis
Miosis
Anhydrosis
Histamine test
Histamine test
Triple response = nerve body intact/preganglionic
Triple response
Redness
1 Brachial Plexus Injury

Wheal
Flare (involvement of adjacent area apart from the scratched area)
Flare is present because the intact nerve will secrete histamine at the
surrounding skin innervated by the nerve
Post ganglionic will be absent of flare
Perform by placing a drop of histamine on the skin and scratch the skin thru the
histamine
Page
 Brachial Plexus Injury |2

Investigations
Radiographs
Chest
Look for clavicle fracture, first/second rib fracture
Scapulothoracic dissociation
Elevated hemidiaphragm
Indication of phrenic nerve injury
Other rib fracture/malunion (if intercostal nerve transfer is planned)
Cervical
Look for transverse process fracture which may indicate a root avulsion
There are fibrous attachments that ties C4 to C7 spinal nerve to the transverse
process
CT myelography
Gold standard for defining level of nerve root injury
Root avulsion causes the dural sheath to heal with meningocele which should be
visible after 4 weeks of injury (earlier scan might be blocked by blood clots)
Only able to visualize up to intervertebral foramen
MRI
Can demonstrate level of nerve and brachial plexus injury
Scan should be done after 1 months to avoid artefacts due to edema which might be
misleading
Nerve conduction study
Electromyography
Should be done after 3-4 weeks

Management
Open or closed brachial plexus injury
Open
Explore and repair KIV nerve graft
If gunshot wound then can try observe first up to three months
Closed
Observe and wait for recovery
Surgical intervention if after 3months still no sign of recovery
Preganglionic or postganglionic (ganglion refer to the dorsal root ganglion)
Depending on the level of involvement and the time from the injury
Preganglionic
Neurotization, tendon transfer or muscle transfer
Postganglionic
2 Brachial Plexus Injury

Direct nerve repair, nerve graft, neurotization, muscle or tendon transfer

Non-Operative
Indicated for most patient
Aim
Maintain the ROM of extremity
Strengthen the remaining functional muscles
Protect the denervated dermatomes
Manage pain
Page

Observation for up to 3 months and assess for signs of recovery

Physiotheraphy: ROM, muscle power training, TENS, prevent joint stiffness, arm sling
 Brachial Plexus Injury |3

Adequate pain relief

There might be significant pain especially in root avulsions
NSAIDs and opioid may help during the first stages of injury
Neuropathic pain which remains after that should be treated with antiepileptic
drugs like gabapentin and carbamazepine or antidepressants such as amitriptyline
3-6 months (optimal time for reinnervation)
Assess recovery, if recovery plateau or no recovery then offer for surgery
Explore and repair kiv graft
Neurotization with intra or extra plexus nerve
If improving well then can continue observation
>6 months
Offer surgery
Operative
Immediate surgical exploration (<1 week)
Open wounds, vascular injury
Nerve can be repaired, grafted or neurotized
Total BPI that is proven to be preganglionic should be operated early as recovery is
poor
Early surgical intervention (3-6 weeks)
Indicated for complete BPI especially preganglionic lesion
Delayed surgical intervention (3-6 months)
Closed injury which has good prognosis of healing (Eg: upper plexus injury, low energy
mechanism)
Nerve reconstruction is not recommended for traumatic lesion more than 9 months
although there is report of successful procedure

Operations
Neurolysis
Neurolysis is a procedure to decompress the fascicles from a constricting fibrosis
This procedure is only done in a nerve which is in continuity
Use of direct nerve stimulation before and after neurolysis will demonstrate improvement
in nerve conductance
Direct nerve repair
Fascicular repair
Epineurial repair
Nerve graft
Nerve graft is used to bridge the proximal and distal stump in an injured nerve
Common nerve graft
3 Brachial Plexus Injury

Sural nerve
Medial brachial nerve
Medial antebrachial nerve
Superficial radial nerve
The donor nerve should be inverted so as to minimize any loss of nerve fibers at branching
points (still insufficient study to conclude that nerve polarity has an impact on nerve
regeneration and functional outcome)
Shorter nerve graft (less than 10cm) has a better functional outcome
Page

Neurotization/nerve transfer
 Brachial Plexus Injury |4

Transfer of a working but less important motor nerve to the motor branch of a more
important denervated muscle
Better outcome for younger patients and upper trunk injuries (shorter nerve gap to bridge)
Source of axons can be
Extraplexal
Spinal accessory nerve
Intercostal nerves
Contralateral C7
C3, C4 cervical root – might affect stability of scapula
Intraplexal
Phrenic nerve – may affect respiration especially if used together with intercostal
nerve
Portion of median or ulnar nerves
Pectoral nerve
Nerve to triceps
Muscle or tendon transfer or functioning free muscle transfer
Indicated in isolated C8-T1 injury in adult where the likelihood of reinnervation is unlikely
due to the long distance
Free functioning muscle transfer requires a donor motor nerve for reinnervation
Muscle/tendon/free muscle transfer can be done together with neurotization for better
outcome
Eg:
Trapezius to deltoid transfer
Gracilis free muscle transfer
Rectus femoris free muscle transfer
Latissimus dorsi free muscle transfer
Pectoralis tendon transfer
Transfer of common flexor origin to a more proximal section to provide elbow flexion
Transfer of triceps to biceps
Arthrodesis
Fusion of a joint to provide stabilization. Usually used in shoulder of a complete BPI to
preserve other potential donor for other procedure
Shoulder fusion should be used as a salvage procedure (nerve or tendon transfer should be
attempted first)
Contraindication: limited scapulothoracic motion
Pro: reserve donor nerve for other function

Important Donor Nerves

Intercostal nerve transfer to
4 Brachial Plexus Injury

Musculoutaneous nerve/deltoid/triceps/serratus anterior/free functioning muscle/hand

sensation
Careful with history of rib fracture/thoracotomy/chest tube as the nerve may be damaged
Usually 3rd to 6th intercostal nerve are used.
Consist of a motor and a sensory branch which could be identified using nerve stimulator
Contralateral C7 nerve transfer
C7 innervated muscles are cross innervated by other spinal nerves, primarily C6 and C8.
Isolated C7 division does not result in significant loss of any individual muscle function
Page

Posterior half contain more motor fiber than anterior half

Can be divided at the trunk or at the division
 Brachial Plexus Injury |5

Innervate to
Median nerve with ipsilateral ulnar nerve pedicled graft
Suprascapular nerve
Musculocutaneous nerve
Contraindication: stimulation of C7 produces contraction of hand muscles
Spinal accessory nerve (cranial nerve XI)
Phrenic nerve
Should not be used if intercostal nerve is paralysed

5 Brachial Plexus Injury

Specific procedures
Shoulder
Spinal accessory nerve to suprascapular nerve
Only distal part of the spinal accessory nerve is used therefore sparing the proximal
Page

branch that supply the upper portion of trapezius

Somsak procedure
 Brachial Plexus Injury |6

Transfer of nerve to long head of triceps to anterior branch of axillary nerve

Upper trapezius transfer (Saha’s technique)
Trapezius detached from the spine of scapula and transferred with the acromion to the
proximal humerus just distal to greater tuberosity
Aim to provide shoulder stability, abduction and flexion
Elbow
Spinal accessory nerve to musculocutaneous nerve with interposition nerve graft
Oberlin procedure
Transfer of ulnar nerve fascicles to biceps motor branch
For patient with preserved C8-T1 function
Which fascicle of ulnar nerve to use?
Ulnar nerve fascicle that innervate flexor carpi ulnaris are used which generally
located posteromedially (can be identified with nerve stimulator)
Anterolateral fascicles generally innervate hand muscles
Contraindication
Patient with ulnar nerve distribution weakness/sensory deficit preoperatively
Complication
May have transient numbness over ulnar nerve distribution
May have transient weakness of intrinsic hand muscle
Occasionally may have permanent deficit
Median nerve fascicular transfer to brachialis motor branch
Usually done as a double nerve transfer together with Oberlin procedure to restore
elbow flexion
Can also be done alone if ulnar nerve has weakness
Modified Steindler procedure (flexor-pronator muscle transfer)
Flexor-pronator muscle arising from medial epicondyle are transposed to a more
proximal and anterior position on the humerus to increase the moment arm for elbow
flexion
Latissimus dorsi transfer for elbow flexion
Latissimus dorsi is supplied by thoracodorsal artery and vein and innervated by
thoracodorsal nerve
Insertion and origin of latissimus dorsi is divided
Insertion is fixed to coracoid process
Origin is tubularised and sewn into biceps tendon or ulna
Pectoralis major muscle transfer for elbow flexion
Can be bipolar transfer or unipolar transfer
Bipolar transfer
Both head of pectoralis major is dissected while preserving neurovascular bundle
Proximal humeral attachment is secured to clavicle
6 Brachial Plexus Injury

Pectoralis major muscle origin is sutured to biceps tendon

Wrist
Pronator teres to ECRB
Hand
Branch of musculocutaneous nerve to brachialis to median nerve for finger flexion
Zancolli’s lasso procedure
FDS tendon cut, looped through the A1 pulley and sutured both the slips to itself
Aim to flex MCPJ to prevent claw deformity
Page

Palmaris longus to Extensor pollicis longus (EPL)

To regain thumb extension
 Brachial Plexus Injury |7

Tendon transfer for Radial nerve injuries

Brand procedure
procedure
Wrist extension: PT to ECRB
Finger extension: Flexor carpi radialis (FCR) to extensor digitorum communis (EDC)
Thumb extension: PL to EPL
Sequence of transfer: wrist, finger then thumb
Jones procedure
Procedure
Wrist extension: PT to ECRB
Finger extension: Flexor carpi ulnaris (FCU) to extensor digitorum communis (EDC)
Thumb extension: PL to EPL
Just FCU is used instead of FCR compared to brand
Brand better because FCU is the most powerful wrist flexor and is critical in
hammering/throwing motion
Boyes
Procedure
Wrist extension: PT to ECRB
Thumb/finger extension
FDS (ring) to EIP/EPL
FDS (long) to EDC/EDM
FDS is taken through IOM
Ring finger flexor digitorum superficialis (FDS) to extensor digitorum communis (EDC)
To restore MCP extension
FDS has separate muscle belly for each finger and can be controlled separately
FDS is expendable as FDS can take its function
Tendon transfer for Median nerve injuries
Camitz: PL to abductor pollicis brevis
To restore thumb opposition (opponensplasty)
FDS (ring) to abductor pollicis brevis
To restore thumb opposition (opponensplasty)

7 Brachial Plexus Injury

Page
 Brachial Plexus Injury |8

Extra
Nerve repair or neurotization should be done within 6 months of injuries for better results
as muscle will lose its motor end plate at 20-24 months after injury and disorganization is
complete after 2 years of denervation where muscle will be replaced by fat tissue
Nerve healing starts after 1 month of injury
Nerve regeneration occurs at the rate of 1mm/day
Neurotization/repair shows best result if done within 3 months, good result if done within
3-6 months
Neurotization/repair has better recovery in young patient. Patient older than 40yo shows
reduced results
Preganglionic injury shows significantly poorer outcome
8 Brachial Plexus Injury

Primary coaptation without nerve graft has significantly better result than patient with
nerve graft
Priorities of repair or reconstruction
Priorities of repair is individualized and is based on functional priorities, extent of nerve
injury and availability of motor axon donors
Upper plexus injury
Priorities
Elbow flexion
Page

Aim
 Brachial Plexus Injury |9

Reinnervation of biceps and brachialis muscle (via anterior division of

upper trunk/musculocutaneous nerve proper/motor branches to biceps
and brachialis)
Transfer option
Oberlin procedure
Median nerve fascicles to brachialis motor branch
Median nerve fascicles to biceps motor branch
C6 root to musculocutaneous nerve with nerve graft
Shoulder stability, abduction and external rotation
Aim
Reinnervation of deltoid (via posterior division of upper trunk/axillary
nerve proper/anterior division of axillary nerve)
Reinnervation of supraspinatus and infraspinatus (via suprascapular nerve)
Transfer option
Interpositional graft between C5 (postganglionic functional stump) stump
and posterior division of upper trunk and suprascapular nerve
Spinal accessory nerve to suprascapular nerve
Somsak procedure (if C7 intact)
Patient with C5-C7 injuries has deficit in elbow extension and wrist extension as well
Somsak procedure cannot be used
Intercostal nerve transfer to axillary nerve
C7 stump to triceps or radial nerve with nerve graft
For patient with good flexor compartment
Wrist: pronator teres to ECRB
ECRB is chosen rather than ECRL because it is more center at the wrist so
that it is balanced (reduce risk of radial deviation)
Finger:
flexor carpi radialis to extensor digitorum communis
palmaris longus to extensor pollicis longus
flexor digitorum superficialis of ring finger to extensor digitorum
communis
Lower plexus injury
Patient has weakness in extrinsic and intrinsic muscle of hand with variable wrist
weakness
Nerve grafting is not feasible due to the long distance of reinnervation
Aim: thumb flexion, finger flexion, opposition, intrinsic minus claw correction, finger
and thumb extension
Surgical option
Nerve to brachialis transfer to median or ulnar nerve
9 Brachial Plexus Injury

Nerve to brachioradialis (C5/C6) or supinator (C5/C6/C7) transfer to posterior

interosseous nerve (C7/C8)
Pan plexus injury
Aim:
Elbow flexion
Shoulder stabilization, abduction and external rotation
Hand sensation (lateral cord C6, C7 reinnervation)
Wrist extension and finger flexion
Page

Wrist flexion and finger extension

Hand intrinsic function
 B r a c h i a l P l e x u s I n j u r y | 10

Surgical options
Gracilis free functional muscle transfer neurotized by intercostal nerve/SAN for
elbow flexion
Gracilis free functional muscle transfer can also be used for elbow flexion and
finger flexion
Sensation of median nerve distribution of hand by transfer of sensory branch of
intercostal nerve to lateral cord contribution of median nerve
Selective fusion and soft tissue balancing
Wrist arthrodesis
Thumb CMCJ arthrodesis to put thumb in palmar abduction and pronation
Thumb IPJ arthrodesis
FDS lasso procedure to create a contracture to flex MCPJ to prevent clawing
Shoulder fusion if shoulder unstable
Pectoralis major tendon transfer
Contralateral C7 to
Lateral cord – biceps, pectoralis major
Posterior cord – deltoid, triceps, ECRL
Trapezius transfer to stabilize shoulder

SSEP, MEP and NAP

Both SSEP and MEP are used to evaluate integrity of intraforaminal and intraspinal sensory
and motor pathway to the spinal cord in a pre and postganglionic BPI intraoperatively to
look for functional nerve stump for reinnervation
Negative SSEP and MEP signify a root avulsion
Somatosensory evoked potential (SSEP)
Very low amplitude potentials on the scalp over parietal cortex is recorded after
stimulating a contralateral peripheral nerve in upper or lower limb (sensory only)
Motor Evoked Potential (MEP)
Transcranial electrical stimulation is used and neurogenic motor evoked potentials is
recorded from brachial plexus (motor only)
Nerve action potentials (NAP)
Evaluates presence of functioning axons for both sensory and motor
Useful to assess postganglionic neuromas in continuity
Electrodes are placed directly on nerve proximal and distal to a neuroma in continuity
(with electrode placed at least 4cm apart for reliable NAP) and then the nerve is
stimulated and recorded
Good NAP across a neuroma in continuity signifies likelihood of recovery over time
and nerve should not be resected
10 Brachial Plexus Injury

No NAP across a neuroma in continuity signifies lesion has minimal potential for
recovery and the nerve should be resected and grafted

Motor Innervation
C5
Mainly forms axillary nerve to innervate deltoid
Shoulder abduction (deltoid) and elbow flexion
C6
No pure motor exam for C6 as there is cross innervation by C5 and C7
Page

Best to test is biceps (also innervated by C5) and wrist extensor (ECRL and ECRB) by C6
(ECU by C7)
 B r a c h i a l P l e x u s I n j u r y | 11

Brachioradialis reflex purely by C6, biceps reflex C5 and C6

C7
Mainly forms radial nerve to innervate triceps
Finger extensor by C7 ± C8
FCR by C7
ECU by C7
C8
Mainly forms median nerve to innervate flexor digitorum
T1
Mainly forms ulnar nerve to innervate intrinsic muscle of hand

11 Brachial Plexus Injury

Page