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Brachial Plexus Hand Surgery Treatment & Management

  • Author: Alan Bienstock, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS  more...
 
Updated: Nov 11, 2013
 

Surgical Therapy

Primary exploration of the brachial plexus is performed if any of the following conditions are evident: (1) global injury that does not improve by 3 months of age, (2) lack of motor function of 1 or more muscles (elbow flexors, shoulder abductors and external rotators, and wrist and finger flexors) at 3-6 months, or (3) extremity-muscle units with no progress at 6 months or beyond.

Primary repair of the brachial plexus is a combined procedure involving a neurosurgeon, pediatric plastic surgeon, and a pediatric neurologist performing intraoperative EMG. Depending on the injury, neuroma excision and sural interpositional nerve grafting (or neurotization in patients with avulsion) are performed.

A supraclavicular approach to the proximal brachial plexus is made through standard lateral sternocleidomastoid incision. The omohyoid is often divided. The phrenic nerve is identified and stimulated to assess diaphragmatic function. Electrophysiologic tests are performed, and proximal evoked potentials are measured by stimulating exposed nerve roots.

A conducting neuroma-in-continuity is not excised if the decrease in amplitude across the lesion is less than 50%. The surgeon performs neurolysis with fascicular grafts across the neuroma to enhance the conduction of nerve signals. C4 sensory and great auricular nerves are usually harvested. The sural nerve can also serve as a conduit. The coaptations are all performed in a tension-free fashion with 9.0 or 10.0 nylon microsuture.

When the neuroma results in poor conduction on electrophysiologic studies (>50% decrease in signal amplitude across the lesion) and when the gross appearance suggests excessive scarring, the neuroma is carefully excised. C5 and C6 lesions are the most common lesions, followed by C5, C6, and C7, and C5-T1 lesions. Isolated C8 and T1 lesions are the least common injuries. Electrophysiologic testing helps in identifying proximal donor nerves for grafting. C5 and C6 are important as donor proximal nerves to graft across the resected neuroma.

Other surgeons graft as distally as possible to the terminal cord or the end of the distal nerve. Terzis prefers to use intraplexus vascularized grafts, such as the ulnar nerve, to bridge long gaps in the reconstruction of the brachial plexus with avulsion injuries of C8 and T1.[11]

For severe avulsions involving the upper trunk, or, less commonly, the lower trunk, neurotization from the intercostal, accessory, phrenic, contralateral C7, or pectoral nerves can be used.[12]

Secondary reconstruction

Secondary deformities may arise from incomplete recovery after nonsurgical management or from incomplete recovery or residual dysfunction after primary reconstructions. These deformities pertain to muscular imbalances and to persistent nerve deficits that produce the posture of internal rotation and adduction of the shoulder. This posture triggers contracture formation of the subscapularis and pectoralis major and minor muscles. The muscular imbalance stimulates posterior dislocation or subluxation of the glenohumeral joint.

The surgeon considers secondary intervention when rehabilitative therapy plateaus. This is usually when the patient is 18 months of age. The surgical procedure is tailored to the patient depending on his or her deficits and limitations.

In the secondary procedure, the axilla is entered through an L -shaped, or hockey-stick, incision. The latissimus dorsi and its pedicle are identified and dissected. The subscapularis space is entered while the thoracodorsal and long thoracic nerves and the nerve to the teres major are protected. The subscapularis muscle is released along the inferior border with extraperiosteal elevation up to the glenoid fossa.

In certain cases, myotenotomy of the pectoralis major near the humeral insertion is executed if restriction or capsular contracture is present. The myotenotomy is executed near the humeral insertion in the anterior aspect of the axillary fossa through several small, partial-thickness incisions to keep the muscle in continuity. After the contracture is released, the surgeon should test the shoulder range of motion to ensure the absence of residual contracture.

The quadrangular space is then entered to find the axillary nerve, and it is stimulated with a nerve stimulator. If the degree of deltoid contraction is diminished, neurolysis along the entire nerve is carried out until the muscular response or contracture increases in response to the electrical stimulus. If the deltoid contracture is absent or severely diminished, nerve transfer or neuroplasty with branches of either the thoracodorsal nerve or the nerve to teres major is achieved.

Finally, the latissimus dorsi and teres major are disinserted from their insertions on the humerus. They are anchored and transferred to the tendon of the teres minor to aggrandize and promote shoulder external rotation.

Each patient is splinted in shoulder abduction, full external rotation, and full elbow extension for 4-6 weeks. Physical therapy is then started.

Additional procedures

The shoulder and elbow should be treated before the forearm, wrist, and hand. Rehabilitation and continuous physical therapy are essential for recovery and muscle strengthening. Many patients require augmentation procedures to enhance nerve transfers and/or tendon transfers to manage avulsions of the upper roots and loss of the critical biceps function. Partial triceps transfers or triceps lengthening may augment arm function. Transfer of the latissimus dorsi muscle to augment biceps functions has also been used, with excellent results. The surgeon may also use selective nerve transfers to restore function of individual muscles. End-to-side radial sensory to median nerve transfer has been reported to improve sensation and to relieve pain in C5 and C6 nerve root avulsion.[13]

When severe avulsion injuries to the lower roots occur with no return of hand function, many reconstructive options are available (see the Table).

Table. Surgical Treatments and Secondary Procedures (Open Table in a new window)

Condition or Deficit Surgical Treatment and Secondary Procedures
Internal rotation, shoulder adduction Muscle releases: subscapularis, pectoralis major and minor



Muscle transfers to the teres minor: latissimus dorsi, teres major



Neurolysis and decompression of the axillary nerve



Poor elbow extension Nerve exploration and neuroplasty of the radial nerve with or without tendon transfers
Poor extension of the wrist and digits Muscle transfers
  • Pronator teres to the extensor carpi radialis brevis
  • Flexor carpi radialis to the extensor digitorum communis
  • Palmaris longus to the extensor pollicis longus
Poor extension of the wrist and fingers if flexors are weak Musculocutaneous nerve transfer



Placation or tenodesis of the extensor digitorum communis



Wrist fusion and tendon transfers



Free muscle transfer



Poor elbow flexion, poor supination Exploration and neuroplasty of the radial and musculocutaneous nerves with or without nerve transfers



Oberlin technique



Double nerve transfer



Fascicular transfers



  • Ulnar nerve to the biceps
  • Median nerve to the brachialis
Elbow flexion contracture Lengthening of the biceps if serial casting is unsuccessful
Poor flexion of the wrist and fingers Nerve exploration and neuroplasty of the median and order nerves



Once muscle transfer



Forearm supination contracture Rerouting of the biceps



Rerouting of the supinator



Forearm pronation contracture Rerouting of the pronator teres

Microsurgical free muscle transplantation with muscles such as the gracilis is used to restore finger and thumb flexion and extension when tendon transfer is impossible or ineffective.[14]

When all other options are exhausted, palliative tenodesis of the wrist extensors and wrist and interphalangeal arthrodesis may need to be considered.

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Postoperative Details

Patients are admitted for a mean stay of 2 days. During this time, the patient is monitored and the drain is removed on the second postoperative day. The therapist designs an orthoplastic splint to maintain the shoulder with sufficient abduction and external rotation.

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Complications

Surgical complications occur relatively infrequently and include wound infection, hematoma, and seroma. Depending on the severity of the original injury, various degrees of functional improvement can be expected.

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Future and Controversies

Early intervention can be preventive in some patients with obstetrical brachial plexus palsy. Prompt evaluation and management revolves around diligent education of both pediatricians and parents. The creation of multidisciplinary centers has greatly improved treatment outcomes in patients with brachial plexus palsy. A wide array of both primary and secondary procedures has evolved over the past 2 decades to combat the sine que non and deficits of brachial plexus palsy.

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Contributor Information and Disclosures
Author

Alan Bienstock, MD Consulting Staff, Division of Plastic and Reconstructive Surgery, Department of Surgery, Lennox Hill Hospital, St Luke's/Roosevelt Hospital

Alan Bienstock, MD is a member of the following medical societies: American Medical Association, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

John Y S Kim, MD, MA Assistant Professor, Department of Surgery, Division of Plastic Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Northwestern Plastic Surgery

John Y S Kim, MD, MA is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons

Disclosure: Received grant/research funds from Musculoskeletal Transplant Foundation for principal investigator.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David W Chang, MD, FACS Associate Professor, Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas Medical School at Houston

Disclosure: Nothing to disclose.

Chief Editor

Joseph A Molnar, MD, PhD, FACS Medical Director, Wound Care Center, Associate Director of Burn Unit, Professor, Department of Plastic and Reconstructive Surgery and Regenerative Medicine, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Undersea and Hyperbaric Medical Society, Peripheral Nerve Society, Wound Healing Society, American Burn Association, American College of Surgeons

Disclosure: Received grant/research funds from Clinical Cell Culture for co-investigator; Received honoraria from Integra Life Sciences for speaking and teaching; Received honoraria from Healogics for board membership; Received honoraria from Anika Therapeutics for consulting; Received honoraria from Food Matters for consulting.

Acknowledgements

Milton B Armstrong, MD, FACS Associate Professor of Clinical Surgery, Associate Professor of Clinical Orthopedics, Department of Surgery, University of Miami, Leonard M Miller School of Medicine

Milton B Armstrong, MD, FACS is a member of the following medical societies: American Association for Hand Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons, and National Medical Association

Disclosure: Nothing to disclose.

References
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Table. Surgical Treatments and Secondary Procedures
Condition or Deficit Surgical Treatment and Secondary Procedures
Internal rotation, shoulder adduction Muscle releases: subscapularis, pectoralis major and minor



Muscle transfers to the teres minor: latissimus dorsi, teres major



Neurolysis and decompression of the axillary nerve



Poor elbow extension Nerve exploration and neuroplasty of the radial nerve with or without tendon transfers
Poor extension of the wrist and digits Muscle transfers
  • Pronator teres to the extensor carpi radialis brevis
  • Flexor carpi radialis to the extensor digitorum communis
  • Palmaris longus to the extensor pollicis longus
Poor extension of the wrist and fingers if flexors are weak Musculocutaneous nerve transfer



Placation or tenodesis of the extensor digitorum communis



Wrist fusion and tendon transfers



Free muscle transfer



Poor elbow flexion, poor supination Exploration and neuroplasty of the radial and musculocutaneous nerves with or without nerve transfers



Oberlin technique



Double nerve transfer



Fascicular transfers



  • Ulnar nerve to the biceps
  • Median nerve to the brachialis
Elbow flexion contracture Lengthening of the biceps if serial casting is unsuccessful
Poor flexion of the wrist and fingers Nerve exploration and neuroplasty of the median and order nerves



Once muscle transfer



Forearm supination contracture Rerouting of the biceps



Rerouting of the supinator



Forearm pronation contracture Rerouting of the pronator teres
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