Restoration of Active Grasp Function in Total Brachial Plexus Avulsion Injury

Abstract

Patients with total brachial plexus avulsion injuries first underwent modified multiple nerve transfers in one stage. These included transfer of the accessory nerve onto the suprascapular nerve to recover shoulder abduction, contralateral C7 nerve onto the lower trunk or medial cord via the shortest prespinal route with direct coaptation to restore finger flexion and onto the musculocutaneous nerve with interpositional bridging by medial antebrachial cutaneous nerve arising from lower trunk together with the sural graft to restore elbow flexion, and the phrenic nerve onto the posterior division of lower trunk to recover elbow and finger extension. At least 3 years in adults or 2 years in children after the modified multiple nerve transfers, the additional secondary hand reconstruction surgery was only indicated in cases when the nerve transfers had resulted in effective recovery, including a degree of shoulder abduction of 30° or better; elbow, wrist, and finger flexion strength grade of M4 or better; and elbow and finger extension strength grade of M3 or better and normal passive activity of the MP and interphalangeal joints. The secondary hand reconstruction procedures including wrist fusion, thumb opposition, and claw finger correction, could the patients complete active pick-up objects in daily life.

Between 2006 and 2009, 40 patients with total brachial plexus avulsion injuries underwent modified multiple nerve transfers and were followed up for 53 months (range 37–76 m.s). Twelve patients (30%) achieved elbow, wrist, and finger flexion strength of M4 or better, elbow and finger extension strength of M3 or better, and 50–90°shoulder abduction. These patients underwent secondary hand reconstruction. Overall, active pick-up function was recovered in 10 patients (25%).