Operative Brachial Plexus Surgery: Clinical Evaluation and Management Strategies

Foreword
Foreword
Preface
Acknowledgments
Contents
Contributors
1: Adult Brachial Plexus Injuries: A Historical Perspective
	History Background
		“Period of Recognizing” Brachial Plexus Injury: Before 1900
		“Period of Pessimism” for Clinical Brachial Plexus Injury Repair: Before Microscope Assistance (1964)
		“Period of Improvement (I)” by Microscopy Application (1964–1999)
		“Period of Improvement (II)” by Nerve Transfer and Free Functioning Muscle Transplantation Application, 2000–Till Now
	Revolution in Nerve Transfer
	Functioning Free Muscle Transplantation (FFMT)
	Perspectives on the Future of BPI Reconstructive Microsurgery
	One Proposal
		Level of Brachial Plexus Injury
	Comments on Two Major Debates
		In Total Root Avulsion BPI, Which Is the Treatment of Choice: Multiple Nerve Transfers or Free Functioning Muscle Transplantations?
		In Incomplete Root Avulsion BPI, Which Is the Treatment of Choice: Proximal Nerve Grafts/Transfers or Distal Nerve Transfers?
	Uncertainty and Questions with Need of Future Investigation
	Conclusion
	References
Part I: Surgical Anatomy
	2: Surgical Anatomy of the Brachial Plexus
		Supraclavicular Brachial Plexus and Collateral Branches
			Surgical Anatomy
		Roots, Spinal Nerve, and Branches
		Trunks and Divisions
		Cords and Terminal Branches
		Collateral Branches
		Types of Brachial Plexus
		Morphology and Anatomical Relationships
			Intraneural Anatomy
			Collateral Terminal Branches and Motor Points
		Nerves for Deep Neck Musculature (C2–C8)
		Phrenic Nerve (C3–C4)
		Subclavian Nerve (C5–C6)
		Suprascapular Nerve (C5–C6)
		Dorsal Scapular Nerve (C4–C5)
		Long Thoracic Nerve (C5-C6-C7)
			Sensory and Sympathetic Aspect
		Infraclavicular Brachial Plexus: Collateral and Terminal Branches
			Surgical Anatomy and Relationships of the Terminal Branches
			Intraneural Anatomy
			Collateral Branches and Motor Points
		Lateral Pectoral Nerve (C5–C7)
		Medial Pectoral Nerve (C8-T1)
		Upper Subscapular Nerve (C5-C6)
		Thoracodorsal Nerve (C6–C8)
		Lower Subscapular Nerve (C5–C6)
			Sensory and Sympathetic Aspect
		References
	3: Mechanisms of Injury
		Introduction
		Closed Trauma
			Supraclavicular Injury
			Infraclavicular Injury
			Combined Injuries
		Open Trauma
			Gunshot Wounds
			Lacerations
		Sports-Related
		Glenohumeral Dislocation
		Iatrogenic Injury
			Patient Positioning
			Regional Anesthesia
			Laparoscopic Surgery
			Cardiac Surgery
			Shoulder Arthroplasty
		Oncologic Etiology
			Primary Lesions
			Metastatic Lesions
			Radiation
		Neuralgic Amyotrophy
		References
	4: Biology of Nerve Injury
		Nerve Injury
		Nerve Recovery
		Reinnervation
		Temporal Degradation of the Healing Process
		Summary
		References
	5: Epidemiology of Adult Traumatic Brachial Plexus Injuries
		Patients
			Associated Injuries
			Psychosocial Impact of Brachial Plexus Injuries
		Etiology
			Closed Injuries
			Open Injuries
			Work-Related Injuries
		Type of Injury
		Conclusion
		References
	6: Brachial Plexus-Associated Injuries
		Introduction
		Vascular Injury
		Spine and Spinal Cord Trauma
		Chest Wall Trauma
		Scapulothoracic Dissociation
		Other Musculoskeletal Injuries
		Traumatic Brain Injury
		Conclusion
		References
Part II: Evaluation
	7: Examination of the Adult Brachial Plexus Patient
		Clinical Exam
		Sensory Exam
			Tinel’s Sign
			Sensory Outcomes and Monitoring Recovery
		Motor Exam
		Vascular Exam
			Deafferentation Pain
			Spinal Cord Injury
		References
	8: Adult Brachial Plexus Injuries: Neurodiagnostic Evaluation
		Introduction
		Anatomy
		Nerve Conduction Studies
			Basic Concepts
			Measurements
			Late Responses
		Needle EMG
			Technique
			Spontaneous Activity
			Voluntary Activation
		Application to Brachial Plexus Assessment
			Evolution and Timing of EMG Abnormalities
			Brachial Plexopathy Neurodiagnostic Assessment
			Neurodiagnostics to Assist in Selection of Nerve Donor for Transfer
			Follow-Up Neurodiagnostic Evaluations
		Summary
		References
	9: Intraoperative Brachial Plexus Neurophysiological Monitoring
		Introduction
		IOM Techniques
			Somatosensory Evoked Potentials
			Motor Evoked Potentials
			Nerve Action Potentials
			Triggered EMG
		Technical Issues
		Interpretation
		Application to Brachial Plexus Reconstruction
		Summary
		References
	10: Adult Brachial Plexus Injuries: Evaluation: Radiologic Evaluation
		Introduction
		Conventional Myelography
		CT Myelography
		MRI
		CTM vs MRI
		Normal Imaging Anatomy
		Primary Imaging Findings of Preganglionic BPI
		Associated Imaging Findings of Preganglionic BPI
		Summary
		References
	11: Adult Brachial Plexus Injuries: Determinants of Treatment (Timing, Injury Type, Injury Pattern)
		Injury Type
			Preganglionic Versus Postganglionic Injury
			Supraclavicular, Retroclavicular, and Infraclavicular
		Injury Pattern
			C5–C6 Root Injury
			C5–C7 Root Injury
			C5–C8 Root Injury
			C5-T1 Root Injury with Partially Preserved Finger Flexion and Horner’s Sign
			C8-T1 Root Injury
			C7-T1 Root Injury
			C8-T1 Root Injury
			C5-T1 Palsy
		Timing of Surgery
		Other Determinants of Treatment
			Body Mass Index
			Patient Age
			Rehabilitation
		References
	12: Priorities of Treatment and Rationale in Adult Brachial Plexus Injuries
		Goals of Chapter: To Provide a Framework for the Initial Neurosurgical Management of Adult BPI
			Why Set Priorities?
				High-Energy Mechanism of Injury
				Limited Sources of Autologous Nerve Graft
				Problems with Autograft Alternatives: Nerve Conduits and Allograft
				Limited Sources for Intra- or Extraplexal Nerve Transfer Donors
				Time-Related Muscle Changes in Lower-Motor Neuron Injury
				Slow and Imperfect Regeneration of Nerve Axons
				Proximal Neuron Death
				Associated Injury
				Technical Factors
			Brachial Plexus Injury Priorities
				Elbow Flexion
					Elbow Flexion in Pan-plexal Injury
						Nerve Transfers for Elbow Flexion
						Functioning Free Muscle Transfer for Elbow Flexion
					Elbow Flexion in C5–6 or C5–7 Pattern
				Shoulder Stability and External Rotation
					Goals
					Shoulder in Pan-Plexal Injury
						Nerve Graft
						Nerve Transfers
						Arthrodesis
						Tendon Transfer
					Shoulder in C5–6 or C5–7 Injury
				Grasp and Release
					Goals
					Indications
					Contraindications
						Stiff Hand
						Vascular Injury
					Grasp and Release in Pan-plexal Injury
						Contralateral C7
						Free Muscle for Grasp
						Double Free Muscle Procedure
						Single Gracilis Muscle for Grasp
						Triple Muscle Transfer for Grasp and Wrist Extension
						Amputation and Prosthetic Fitting
						Outcome
				Sensation
					Goals
					Sensation in Pan-plexal Injury
					Sensation in C5–6 or C5–7 Injury
				Intrinsic Function
		Conclusions
		References
Part III: Treatment Options in Adults
	13: Root Grafting in Adult Brachial Plexus Injuries
		Preoperative Judgment of Root Availability
			Clinical Examination and Root Availability in BPI (Tinel’s Sign and Protraction Sign)
			Imaging Evaluation and Root Availability
		Intraoperative Evaluation and Root Availability
		Nerve Grafting Strategies in BPI
			C5-C6+/-C7 BPI
			C5-T8 BPI (T-1 Hand)
			Complete Paralysis
		References
	14: Nerve Transfers to Shoulder and Elbow
		Introduction
		Indications for Nerve Transfers
			Donor Selection
			Timing
		Perioperative Considerations
		Nerve Transfers to Restore Shoulder Function
			Spinal Accessory to Suprascapular Nerve Transfer
			Triceps to Axillary Nerve Transfer
			Medial Pectoral to Axillary Nerve Transfer
		Nerve Transfers to Restore Elbow Flexion
			Single and Double Fascicular Nerve Transfers
			Thoracodorsal to Musculocutaneous Nerve Transfer
			Intercostal to Musculocutaneous Nerve Transfer
			Medial Pectoral to Musculocutaneous Nerve Transfer
		Nerve Transfers to Restore Elbow Extension
			Ulnar Nerve Fascicle to Long Head of Triceps Nerve Transfer
			Thoracodorsal to Triceps Nerve Transfer
			Intercostal to Triceps Nerve Transfer
		Pediatric Implications
		Conclusion
		References
	15: Free-Functioning Muscle Transfer
		Introduction
		Prerequisites for Functioning Free Muscle Transfer
			Preoperative Planning
			Donor Muscle Selection
				Gracilis Harvest
			Intraoperative Planning
			Postoperative Planning
		Free-Functioning Muscle Transfer in Acute Brachial Plexus Injuries
		Functioning Free Muscle Transfer in Chronic Brachial Plexus Injuries
		Summary
		References
	16: Tendon Transfers of the Shoulder, Elbow, Wrist, and Hand
		Tendon Transfers After Brachial Plexus Injury: Shoulder and Elbow
		Upper Trunk: Shoulder Stability
		Upper Trunk: External Rotation +/− Abduction
		Posterior Cord: Axillary Nerve
		Long Thoracic Nerve
		Spinal Accessory Nerve
		Elbow: Upper Radial Nerve and Musculocutaneous Nerve
		Tendon Transfers After Brachial Plexus Injury: Forearm and Hand
		Radial Nerve
			Wrist Extension
				PT to ECRB
				Finger Extension
				Thumb Extension
			Median Nerve
				Wrist Flexion
				Thumb Flexion
				Finger Flexion
				Thumb Opposition
				Ring FDS
				PL
				EIP
				Huber
			Ulnar Nerve
				Intrinsic Muscle Function
				Key Pinch
		References
	17: Glenohumeral Arthrodesis in Brachial Plexus Palsy
		Introduction
		Operative Techniques
		Author’s Preferred Technique
		Discussion
		Indications
		Contraindications
		Conclusion
		Bibliography
	18: Reconstructive Options for the Thumb Axis in a Brachial Plexus Injury
		Introduction
		History
		Surgical Technique
			Complete Plexus Injury
				Contralateral C7 Use
				Free Innervated Gracilis Muscle Use
			Partial Plexus Injury
			Nerve Transfers
			Sensory Nerve Transfers
			Alternatives to Nerve Transfers
				Tendon Transfer
		Discussion
		References
	19: Wrist Arthrodesis in the Adult Brachial Plexus Patient
		Introduction
		Indications for Wrist Arthrodesis in Brachial Plexus Patients
		Surgical Technique
		Advantages of Wrist Arthrodesis in Brachial Plexus Patients
		Potential Complications
		Conclusion
		References
Part IV: Surgical Approaches
	20: Supraclavicular Exposure of the Brachial Plexus
		Operating Room Set-Up/Positioning
		Exposure
		Spinal Accessory Nerve
		Reference
	21: Infraclavicular Exposure of the Brachial Plexus
		Indications for Use
		Operating Room Set-Up and Positioning
		Exposure
		Complication Avoidance
		References
	22: Posterior Approach for Spinal Accessory to Suprascapular Nerve Transfer
		Rationale
		Technique
		Outcomes
		References
	23: Surgical Approach: Axillary Posterior
		Surgical Approach for Axillary Nerve (Posterior)
		Relevant Anatomy
		Preoperative Planning
		Preparation and Patient Positioning
		Surgical Approach and Procedure
		Postoperative Care and Rehabilitation
		Clinical Results
		References
	24: Anterior Approach for Axillary Nerve Reconstruction
		Principles
		History
		Clinical Evaluation
		Surgical Anatomy
		Surgery
		Postoperative
		Discussion
		Conclusion
		References
	25: Upper Brachium Approach: The “Ulnar-Biceps Median-Brachialis” Double Nerve Transfer
		Principles
		Operative Technique
		References
	26: Intercostal Nerve Harvest in Brachial Plexus Injuries
		Technique of Harvest
			Repair
			Postoperative Care
		Utility of Intercostal Transfers in Reconstruction of Brachial Plexus Injuries
			Elbow Flexion
			Elbow Extension
			Pectoral Nerve
			Long Thoracic Nerve
			Axillary Nerve
		Outcomes (Intercostals to MC for Elbow Flexion Function)
		References
	27: Sural Nerve Harvest
		Introduction
		Anatomy
		Blood Supply
		Operative Techniques
		Complications
		References
	28: Contralateral C7 Nerve Transfer in the Treatment of Adult Brachial Plexus Injuries and Spastic Hemiplegia
		Introduction
		Part I: Adult Brachial Plexus Injuries: Restoration of Hand Function in the Pan Plexus Injury— CC7
			Brief History of Contralateral C7 Nerve Root Transfer
			Surgical Anatomy of C7 Nerve
			Indications for Contralateral C7 Transfer
			Preparation of Contralateral C7 Nerve Root
			Preparation of Nerve Grafts
			Selection of Recipient Nerves
			Postoperative Monitoring
			Potential Complications
			Results and Outcomes from the Literature
			Brain Plasticity After Contralateral C7 Transfer
		Part II: Contralateral C7 Nerve Transfer in the Treatment of Spastic Hemiplegia
			The Mechanism of Contralateral C7 Nerve Transfer in Treating of Spastic Hemiplegia
			Clinical Trials of Contralateral C7 Nerve Transfer in Treating of Spastic Hemiplegia
			Indications for Contralateral C7 Transfer
			Exclusion
			Surgical Technique
			Postoperative Monitoring
			Recovery Process Following Surgery
			Complications
		Progresses
		References
	29: The Harvest of a Free Innervated Functional Gracilis Muscle and Its Use in Brachial Plexus Injuries
		Introduction
		Gracilis Muscle Anatomy
		Gracilis Muscle Vascular Anatomy
		Gracilis Muscle Neural Anatomy
		Gracilis Muscle Flap and Myocutaneous Flap
			Gracilis Muscle Flap Dimensions
		Gracilis Muscle Flap Skin Territory
		Innervated Free Functional Gracilis Flap
		The Technique of Gracilis Muscle Flap Harvest
			Distal Dissection First (Full-Length Myocutaneous Innervated Flap) Technique
			Insetting of the Free Innervated Gracilis Flap
		Advantages of the Gracilis Flap
		Disadvantages of the Gracilis Flap
		Indications for the Gracilis Flap
		Elbow Flexion in Brachial Plexus Patients
		Hand Function Restoration in Brachial Plexus Patients
		Conclusion
		References
Part V: Management of Specific Injury Patterns
	30: Management of C5–6 Injuries
		Spinal Accessory Nerve Transfer to Suprascapular Nerve
		Surgical Technique
		The Nerve to Long Head Triceps Transfer to the Anterior Branch of the Axillary Nerve
		Double Fascicular Nerve Transfer (Double Oberlin Nerve Transfer)
		Surgical Technique
		Thoracodorsal Nerve Transfer to Long Thoracic Nerve in Case of Winged Scapula
		Surgical Technique
		End-to-Side Nerve Transfer from Superficial Radial Nerve to Median Nerve
		Surgical Technique
		References
	31: Management of C5–7 Injuries
		Strategies for Reconstruction of the Elbow Flexion in C5–C7 Root Injury
		Double Oberlin Nerve Transfer
		Intercostal Nerve Transfer to the Musculocutaneous Nerve
		Phrenic Nerve Transfer to the Biceps Motor Branch
		Strategies for the Reconstruction of the Shoulder Function in C5–C7 Root Injury
			Surgical Technique: Spinal Accessory Nerve Transfer to Suprascapular Nerve
			Surgical Technique: The 6th and 7th Intercostal Nerve Transfer to Long Thoracic Nerve
			Surgical Technique: The 3rd and 4th Intercostal Nerve Transfer to the Anterior Axillary Nerve
		Strategies for Reconstruction of the Elbow Extension in C5–C7 Root Injury
			Surgical Technique: The 3rd, 4th, and 5th Intercostal Nerve Transfer to the Nerve of Long Head Triceps
		Strategies for Reconstruction of the Wrist and Finger Extension in C5–C7 Root Injury
			Group 1: C5–C7 Root Avulsion with Normal C8–T1 Root
			Group 2: C5–C7 Root Avulsion with C8–T1 Root Involvement
		References
	32: Strategies for Pan-Brachial Plexus Reconstruction: The Mayo Clinic Brachial Plexus Team Approach
		Preoperative Evaluation
		Available Options in the Pan-Plexus Patient
		Common Presentations and Our Strategies
			Pan-plexus: C5 Available
			Pan-plexus: C5 and C6 Available
			Pan-plexus: No Roots
			Pan-plexus: No Roots, No SPA
		Author’s Preferences
		Conclusion
		References
	33: Lower-Type Injuries of the Brachial Plexus (C6–T1, C7–T1, and C8–T1 Root Involvement)
		Diagnosis
		Treatment
			Motor reconstruction
				Acute and subacute cases
				Elbow Extension
				Thumb and Finger Extension
				Finger Flexion
			Intrinsic Muscle Reconstruction
				Chronic Cases
					Elbow Extension
					Thumb and Finger Extension
					Finger and Thumb Flexion
		Ancillary Procedures
		Sensory Reconstruction
			Pain and Touch
		References
Part VI: Restoration of Hand Function in Pan Plexus Injury
	34: Restoration of Hand Function in Pan Plexus Injury – Double Free Functioning Muscle Transfer
		Rationale
		Outline of Current Double Free Muscle Transfer
		Indication
		Surgical Procedure
			Stage 1: Shoulder Reconstruction
			Stage 2: 1st FFMT for Elbow Flexion and Finger Extension (Fig. 34.1)
				Harvesting the Gracilis Muscle
				Transfer the 1st Muscle Graft (Fig. 34.1)
			Stage3: Nerve Transfer for Elbow Extension and Sensory Restoration (Fig. 34.3)
				Stage 4: 2nd FFMT for Elbow Flexion and Finger Flexion (Fig. 34.2)
				Transfer of the 2nd Muscle Graft
		Postoperative Monitoring of the Muscle Vascularity
		Postoperative Management
		Rehabilitation
		Secondary Reconstruction
			Wrist Fusion
			Correction of Intrinsic-Minus Deformity
		Current Outcomes Summarized
			Illustrated Case
		Discussion
		References
	35: Restoration of Active Grasp Function in Total Brachial Plexus Avulsion Injury
		Modified Multiple Nerve Transfers
			Supraclavicular Exploration
			Infraclavicular Brachial Plexus Exploration – Mobilization of Lower Trunk and Posterior Division of the Lower Trunk Through the Infraclavicular Approach
			The Harvest of the CC7 Nerve Root
				Avoiding Mis-identification of the CC7 Nerve Root
				Prevention of Iatrogenic Injury of the Posterior Division of Lower Trunk
				Prevention of Iatrogenic Injury of the Long Thoracic Nerve
				Contraindication of Contralateral C7 Harvest
			Preparation of Shortest Presipnal Route
			Sequence of Nerve Anastomosis and Postoperative Management
		Secondary Hand Function Reconstruction
			Prerequisites for Secondary Hand Function Reconstruction Procedures
			Secondary Hand Function Reconstruction Procedures
				Wrist Arthrodesis
				Wrist Fusion
				Wrist Tenodesis in Children
				Correction of Claw Finger
				Reconstruction of Thumb Opposition
		Results of This Surgical Procedures
		Overall Evaluation and Problems of this Surgical Procedure
		References
	36: Intercostal Nerve Transfer for Sensory Reconstruction of the Hand Following Complete Avulsion of the Brachial Plexus
		Introduction
		Surgical Technique
		Discussion
		References
	37: Management of Neuropathic Pain
		Introduction
		Avulsion Injuries
		Demographics
		Mechanisms
		Treatment
		Neuropathic Pain
		Central Pain
		Surgical Treatment
		Spinal Cord Stimulation
		Brain Stimulation
		Peripheral Nerve Stimulation
		Amputation
		Treatment of Mechanical Pain
		Conclusion
		References
	38: Prosthetics and Orthotics in Brachial Plexus Injury: Background, Historical Perspective, and Role of Amputation and Prosthetic Fitting
		Prosthetics in Brachial Plexus – Background and Historical Perspective
		Prosthetic Advances and Application to Patients with Upper Motor Neuron Injury
			Further Considerations
		Orthotics in Brachial Plexus Injury
		Multidisciplinary Approach
		References
	39: The Role of Therapy: Pre- and Post-surgery Protocols
		Introduction
		Preoperative Rehabilitation
		Postoperative Rehabilitation
		Therapy Programs for Specific Neurotizations
			Spinal Accessory Nerve (SAN) to Suprascapular Nerve (SSN)
			Triceps Branch to Axillary Nerve
			Ulnar Nerve to Biceps Musculocutaneous Nerve Branch/Median Nerve to Brachialis Musculocutaneous Branch
			Intercostal Nerve to Musculocutaneous Nerve
			Free Functioning Muscle Transfers for Elbow Flexion
			Surgical Reconstructions that Fall Outside the Norm
		Other Rehabilitation Considerations
		Conclusion
		References
Part VII: Pediatric Brachial Plexus Injury
	40: Historical Perspectives
		Clinical Description
		Cause of the Lesion
		Emergence of Treatment by Nerve Surgery
		Nerve Surgery for BPBI Declines
		Summary
		References
	41: Brachial Plexus Birth Injury: Mechanism of Injury
		Introduction
		Maternal Factors
		Intrauterine Factors
		Fetal Factors
		Labor-Related Factors
		Early Postnatal Brachial Plexus Injury Mechanisms
		References
	42: The Biology of Brachial Plexus Birth Injuries
		Introduction
		The Neonatal Nervous System
			Synaptogenesis
			Redundant Innervation
			Myelination
			Primitive Reflexes
		Effects of BPBI on the Developing Neuromusculoskeletal System
			Peripheral Nerve
			Spinal Cord
			Brain
			Muscle
			Bone
		Summary
		References
	43: Epidemiology of Obstetrical Brachial Plexus Injury
		Introduction
		Incidence
		Risk Factors
			Shoulder Dystocia
			Macrosomia
			Diabetes
			Assisted Vaginal Delivery
			History of BPBI
			Breech Position
			Birth Hypoxia
			Prolonged Labor
			Multiple Gestation Birth
		Prevention
			Induction of Labor
			Cesarean Delivery
			Shoulder Dystocia Training
		References
	44: Associated Concomitant Injuries
		Introduction
		Phrenic Nerve Injury
		Clavicle Fracture
		Shoulder Dislocation/Subluxation
		Torticollis
		Plagiocephaly
		Contracture
		Limb Length Differences
		Sensation, Proprioception, and Limb Dominance
		Cognitive and Psychosocial Effects
		Discussion/Conclusion
		Bibliography
	45: Clinical Examination of the Child with Brachial Plexus Birth Injury
		Introduction
		Taking the History
		Stages of Child Development
			0–3 Months
			3–12 Months
			1–5 Years
			5–12 Years
			13–18 Years
		Specific Examination for the Child with BPBI
			Observation
			Inspection
		Active Range of Motion
			The Active Movement Scale
			The Toronto Test Score
			The Mallet Score
		Passive Range of Motion
		Synthesis of Clinical Information
		References
	46: Operative Brachial Plexus Surgery: Brachial Plexus Birth Injury – Neurodiagnostic Evaluation
		Introduction
		Electromyography
		Nerve Conduction Studies
		Intraoperative Neurophysiology
		Conclusion
		References
	47: Brachial Plexus Birth Injuries: Evaluation—Radiologic Evaluation
		Introduction
		CTM vs. MRI in Pediatric Patients
		Rational Approach to Modality Choice in Pediatric Patients
		Pediatric Imaging Technical Considerations
		Summary
		References
	48: Priorities of Treatment and Rationale (Babies Are Not Small Adults)
		Diagnosis and Classification
		Timing of Recovery
		Diagnostic Tests
		Timing of Surgical Reconstruction
		Priorities of Surgical Reconstruction
		Global Brachial Plexus Birth Palsies
		Extended Upper Brachial Plexus Birth Palsies
		Upper Brachial Plexus Birth Palsies
		Surgical Options to Obtain Priorities
			Nerve Grafting
			Nerve Transfer
				Selection of the Donor Nerve
				Selection of the Recipient Nerve
		Surgical Techniques to Obtain Priorities
			Nerve Graft Harvesting
				Sural Nerve Harvesting
				Sural Nerve Anatomy
				Medial Antebrachial Cutaneous Nerve (MABCN) Harvesting
				Radial Sensory Nerve
		Nerve Transfer [40, 63, 35]
			Spinal Accessory Nerve (SAN) to Suprascapular Nerve (SSN) Transfer
				Anterior Approach
				Posterior Approach [48]
				Spinal Accessory Nerve to the Infraspinatus Motor Nerve [48, 49]
				Ulnar to Biceps Motor Nerve [50, 51, 52]
				Triceps to Axillary and Triceps to Teres Minor Transfer [53]
				Intercostal to Musculocutaneous Nerve Transfers [42, 57]
				Intercostal to Axillary Nerve Transfers
				Contralateral C7 Nerve Transfer [37, 58, 59]
		Rehabilitation
			Nerve Grafting
			Nerve Transfer
		Outcomes
			Nerve Grafts
			Nerve Transfers
		References
	49: Specificity and Controversies in the Management of Obstetric Brachial Plexus Lesions
		Introduction
		Causation, Risk Factors, and Types
		Natural History
		Therapy
		Diagnostic Ancillary Procedures
		Timing and Surgical Strategy
			Timing
			Surgical Strategy
			Technique
			Nerve Transfer Techniques (Table 49.2)
			Analysis of the Lesion (Drawings)
		Secondary Surgery
		Results and Outcome Measures
		Prevention and Medicolegal Issues
		Further Developments
		Ongoing Controversy
		Conclusion
		References
	50: Surgical Approaches for Brachial Plexus Birth Injuries
		Introduction
		Perioperative Factors Pertinent to Surgery on an Infant
			Anesthesia Risk
			Vital Signs
			Fluids
		Classification
			Injuries Affecting the Upper Plexus (Partial)
			Injuries Affecting the Lower Plexus (Total)
		Surgical Approach
			Anatomy
			Surgical Approach (Path and Access) for Upper (Partial) Plexus Lesions
			Surgical Approach for Lower (Total) Lesions
		Nerve Transfers
			Nerve Transfers to Restore Shoulder Function
				Incision, Exposure, Technique (Anterior Axillary)
			Nerve Transfers to Restore Elbow Flexion
			Nerve Transfer for Elbow Extension
		Bibliography
			Perioperative Factors
			Anatomy Arteries
			Surgical Approach Technique
			Variations, Lower Trunk
			Infraclavicular Exposure
			Nerve Transfer Root Contribution Variations; Thoughts
			Anterior Approach to SAN to SSN
			Posterior Approach to SAN to SSN
			Axillary Nerve: Anterior Infraclavicular Approach
			Anterior Deltopectoral Approach
			Approach to the Axillary Nerve: Anterior, Axillary
			Posterior Approach to Axillary Nerve
			Nerve Transfer for Elbow Flexion
			Intercostal Nerve Transfer for Elbow Flexion
			Nerve Transfer for Elbow Extension
	51: Management of Brachial Plexus Birth Injuries: Erbs and Extended Erbs Palsy
		Introduction
		Nonoperative Management
		Surgical Management
			Indications
			Imaging
			Electrodiagnostics
			Surgical Procedures
				Neurolysis
				Neuroma Excision and Nerve Grafting
				Nerve Transfer
		Concomitant Surgery
			Shoulder Realignment for Treatment of Glenohumeral Dysplasia
		Postoperative Care
		References
	52: Management of Brachial Plexus Birth Injuries: Pan Plexus
		Initial Management
		Preoperative Evaluation
		Surgical Treatment
		Surgical Technique
		Extra-Plexal Nerve Transfers
		Post-Operative Care
		Secondary Reconstruction
		Derotation Osteotomy of the Humerus
		Results
		Indications for Free Functioning Muscle Transfers
		Illustrative Cases
		References
	53: Expected Outcomes of Surgical Treatment in Obstetrical Brachial Plexus Injuries
		Introduction
		Outcomes of Nerve Grafting
			Upper and Middle Trunk BPBI
			Global BPBI
		Outcomes of Neurolysis
		Outcomes of Nerve Transfer
			Upper and Middle Trunk BPBI
			Global BPBI
		Conclusions
		References
	54: Brachial Plexus Birth Injury: Late Complications and Treatment (Shoulder, Forearm, and Hand)
		Introduction
			Clinical Assessment
		Shoulder Deformity
			Bony Deformity
			Pathogenesis of Contractures and Bony Deformity
			Investigations
			Nonoperative Treatment
			Indications for Surgery
				Author’s Preferred Surgical Techniques
			Alternative Techniques
				Arthroscopic Release
				Subscapularis Slide
				Glenoid Osteotomy
			Salvage Procedures
			Outcomes
				Restoration of Shoulder Abduction
		Elbow Deformity
			Flexion Contracture of the Elbow
		Restriction of Forearm Rotation
			Supination Deformity
				Author’s Preferred Technique
				Outcomes
				Alternative Surgical Approaches
				Pronation Deformity
				Radial Head Dislocation
		Wrist and Hand
			Wrist and Digital Extension
			Ulnar Deviation of the Wrist
			Hand Function
		References
Index