Brachial Plexus Hand Surgery Workup

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

Imaging Studies

Initial management

  • After brachial plexus injury is initially diagnosed, an immediate neurologic evaluation is performed.
  • Digital imaging and video may be beneficial to document function in children.
  • Radiographic studies in the neonatal period are used to evaluate any concomitant injuries. These studies include chest radiographs to depict an elevated hemidiaphragm secondary to phrenic nerve injury and shoulder and arm radiographs to identify fractures and dislocations.

Additional study

  • CT myelography is the best method to visualize the nerve roots and detect avulsions and ruptures. CT has a sensitivity of 95% and specificity of 98%.
  • MRI may be used to diagnose large pseudomeningoceles, and recent studies have shown its promise in diagnosing nerve root avulsion.
  • MRI is reportedly superior to CT because of its multiplanar capability, which allows clinicians to view the components of the brachial plexus in their own optimal planes (axial plane for roots, oblique coronal for trunks, sagittal plane for cords). However, controversy surrounds the superiority of MRI versus CT myelography. Some suggest that MRI is not as sensitive as CT and that it reduces visualization of rootlets, whereas MRI proponents claim that it has great promise in diagnosing nerve root avulsion.

Other Tests

Terzis et al have suggested that electromyelography (EMG) is one of the most valid techniques for assessing a brachial plexus lesion.[3]

  • When experts perform the study and analyzed the results, EMG can help in determining the location and extent of the injury and the likelihood of recovery. This ability is exemplified in supraganglionic lesions, in which sensory perception is lost but sensory potentials remain intact.
  • In practice, EMG has several limitations related to difficulties in administering this test in infants, in localizing the lesion along the length of the nerve, and in interpreting the results and correlating them with clinical findings. For these reasons, EMG has largely been abandoned as a first-line study for diagnosis, but remains useful during and after surgery.
Contributor Information and Disclosures

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.


John Y S Kim, MD, FACS Professor, Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University, The Feinberg School of Medicine; Consulting Staff, Northwestern Medicine

John Y S Kim, MD, FACS 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.


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.

  1. Gilbert A, Tassin JL. Surgical repair of the brachial plexus in obstetric paralysis [in French]. Chirurgie. 1984. 110(1):70-5. [Medline].

  2. Narakas AO. Lesions found when operating traction injuries of the brachial plexus. Clin Neurol Neurosurg. 1993. 95 Suppl:S56-64. [Medline].

  3. Terzis JK, Liberson WT, Levine R. Obstetric brachial plexus palsy. Hand Clin. 1986 Nov. 2(4):773-86. [Medline].

  4. Kawabata H, Masada K, Tsuyuguchi Y, et al. Early microsurgical reconstruction in birth palsy. Clin Orthop. 1987 Feb. (215):233-42. [Medline].

  5. Boome RS, Kaye JC. Obstetric traction injuries of the brachial plexus. Natural history, indications for surgical repair and results. J Bone Joint Surg Br. 1988 Aug. 70(4):571-6. [Medline].

  6. Alanen M, Halonen JP, Katevuo K, Vilkki P. Early surgical exploration and epineural repair in birth brachial palsy. Z Kinderchir. 1986 Dec. 41(6):335-7. [Medline].

  7. Laurent JP, Lee R, Shenaq S, et al. Neurosurgical correction of upper brachial plexus birth injuries. J Neurosurg. 1993 Aug. 79(2):197-203. [Medline].

  8. Clarke HM, Curtis CG. An approach to obstetrical brachial plexus injuries. Hand Clin. 1995 Nov. 11(4):563-80; discussion 580-1. [Medline].

  9. Limthongthang R, Bachoura A, Songcharoen P, Osterman AL. Adult brachial plexus injury: evaluation and management. Orthop Clin North Am. 2013 Oct. 44(4):591-603. [Medline].

  10. Michelow BJ, Clarke HM, Curtis CG, et al. The natural history of obstetrical brachial plexus palsy. Plast Reconstr Surg. 1994 Apr. 93(4):675-80; discussion 681. [Medline].

  11. Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr Surg. 1999 Oct. 104(5):1221-40. [Medline].

  12. Gao KM, Lao J, Zhao X, Gu YD. Outcome of contralateral C7 nerve transferring to median nerve. Chin Med J (Engl). 2013 Oct. 126(20):3865-8. [Medline].

  13. Leechavengvongs S, Ngamlamiat K, Malungpaishrope K, Uerpairotkit C, Witoonchart K, Kulkittiya S. End-to-Side Radial Sensory to Median Nerve Transfer to Restore Sensation and Relieve Pain in C5 and C6 Nerve Root Avulsion. J Hand Surg Am. 2011 Feb. 36(2):209-15. [Medline].

  14. Soldado F, Bertelli J. Free gracilis transfer reinnervated by the nerve to the supinator for the reconstruction of finger and thumb extension in longstanding C7-T1 brachial plexus root avulsion. J Hand Surg Am. 2013 May. 38(5):941-6. [Medline].

  15. Brown KL. Review of obstetrical palsies. Nonoperative treatment. Clin Plast Surg. 1984 Jan. 11(1):181-7. [Medline].

  16. Chuang DC, Ma HS, Borud LJ, Chen HC. Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy. Plast Reconstr Surg. 2002 May. 109(6):1934-46. [Medline].

  17. Chuang DC, Mardini S, Ma HS. Surgical strategy for infant obstetrical brachial plexus palsy: experiences at Chang Gung Memorial Hospital. Plast Reconstr Surg. 2005 Jul. 116(1):132-42; discussion 143-4. [Medline].

  18. Clarke HM, Al-Qattan MM, Curtis CG, Zuker RM. Obstetrical brachial plexus palsy: results following neurolysis of conducting neuromas-in-continuity. Plast Reconstr Surg. 1996 Apr. 97(5):974-82; discussion 983-4. [Medline].

  19. Gilbert A. Long-term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin. 1995 Nov. 11(4):583-94; discussion 594-5. [Medline].

  20. Greenwald AG, Schute PC, Shiveley JL. Brachial plexus birth palsy: a 10-year report on the incidence and prognosis. J Pediatr Orthop. 1984 Nov. 4(6):689-92. [Medline].

  21. Liverneaux PA, Diaz LC, Beaulieu JY, et al. Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies. Plast Reconstr Surg. 2006 Mar. 117(3):915-9. [Medline].

  22. Malessy MJ, Thomeer RT, Marani E. The dorsoscapular nerve in traumatic brachial plexus lesions. Clin Neurol Neurosurg. 1993. 95 Suppl:S17-23. [Medline].

  23. Mallet J. Obstetrical paralysis of the brachial plexus. II. Therapeutics. Treatment of sequelae. Must transplants be performed? [in French]. Rev Chir Orthop Reparatrice Appar Mot. 1972. 58:Suppl 1:186. [Medline].

  24. Metaizeau JP, Prevot J, Lascombes P. Obstetrical paralysis. Spontaneous development and results of early microsurgical treatment [in French]. Ann Pediatr (Paris). 1984 Feb. 31(2):93-102. [Medline].

  25. Panasci DJ, Holliday RA, Shpizner B. Advanced imaging techniques of the brachial plexus. Hand Clin. 1995 Nov. 11(4):545-53. [Medline].

  26. Sever JW. Obstetric paralysis: its etiology, pathology, clinical aspects and treatment, with a report of four hundred cases. Am J Dis Child. 1916. 12(6):541-78.

  27. Shenaq SM, Kim JY, Armenta AH, et al. The Surgical Treatment of Obstetric Brachial Plexus Palsy. Plast Reconstr Surg. 2004 Apr 14. 113(4):54E-67E. [Medline].

  28. Sunderland S. Mechanisms of cervical nerve root avulsion in injuries of the neck and shoulder. J Neurosurg. 1974 Dec. 41(6):705-14. [Medline].

  29. Zhao X, Lao J, Hung LK, et al. Selective neurotization of the median nerve in the arm to treat brachial plexus palsy. An anatomic study and case report. J Bone Joint Surg Am. 2004 Apr. 86-A(4):736-42. [Medline].

Table. Surgical Treatments and Secondary Procedures
Condition or DeficitSurgical Treatment and Secondary Procedures
Internal rotation, shoulder adductionMuscle 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 extensionNerve exploration and neuroplasty of the radial nerve with or without tendon transfers
Poor extension of the wrist and digitsMuscle 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 weakMusculocutaneous nerve transfer

Placation or tenodesis of the extensor digitorum communis

Wrist fusion and tendon transfers

Free muscle transfer

Poor elbow flexion, poor supinationExploration 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 contractureLengthening of the biceps if serial casting is unsuccessful
Poor flexion of the wrist and fingersNerve exploration and neuroplasty of the median and order nerves

Once muscle transfer

Forearm supination contractureRerouting of the biceps

Rerouting of the supinator

Forearm pronation contractureRerouting of the pronator teres
Medscape Consult
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.