Goals
1. Shoulder abduction and ER
2. Elbow flexion
3. Wrist extension
4. Median nerve / C67 / lateral cord sensation
5. Finger flexion
Options
1. Nerve repair / neurorrhaphy
2. Neurolysis
3. Nerve graft
4. Nerve transfer / neurotisation
5. Tendon / muscle transfer
Open injury / laceration
Immediate surgery
- can tag ends and return later
- primary repair / nerve graft
GSW
- can continue to improve over time
- blast injury to plexus
Surgical Approaches
Supraclavicular
Z incision
- longitudinal along posterior border SCM
- transverse along inferior clavicle
- longitudinal in deltopectoral groove
Supraclavicular approach
- posterior triangle
- SCM / omo-hyoid / clavicle / trapezius
Superficial dissection
- subcutaneous Tissue
- platysma
- elevate clavicular head of SCM
Deep dissection
- may need to divide omo-hyoid
- identify scalenius anterior and medius
- ligate external jugular vein
- suprascapular and transverse cervical arteries
Uses
- identify nerve roots / nerve stimulation
- nerve graft C5, C6, C7
- phrenic or accessory to SSN
Infraclavicular
Deltopectoral approach
- P. major tendon divided
- P. minor reflected from coracoid (leave stump to repair)
Uses
- nerve stimulate medial pectoral nerve
- if working transfer to MCN
- or ICN / Oberlin
Pre ganglionic lesion / Nerve root avulsions
Options
- spinal cord level nerve root reimplantation
- nerve transfers
Spinal Cord Level Nerve Root Reimplanation
Results
Carlsted et al Neurosurgical Focus 2004
- reimplanation of nerve root avulsion in 9 year old boy
- C5 - T1
- regained motor function in arm and hand use
Carlsted et al J Neurosurg 2000
- nerve reimplantation in 10 patients
- surgery from 10 days to 9 months
- 3/10 recovered MRC grade 3 power
- better with higher lesions and earlier reimplantation
Shoulder Nerve Transfers
A. Accessory nerve to SSN
Technique
- test trapezius
- surgery performed in the posterior triangle
Suzuki et al J Reconstruct Microsurg 2007
- accessory nerve to SSN in 12 patients
- average shoulder flexion 70o
- average shoulder abduction 77o
B. Consider ICN to axillary nerve
Biceps Nerve Transfers
Connect to motor unit MCN
A. Medial pectoral nerve to MCN
Issue
- much simpler than ICN
- often not intact
- test with nerve stimulator
B. ICN to MCN
Issue
- problem is disparity in axon number
- T3-6 in males
- T3,4,7,9 in females to avoid breast denervation
Merrell et al J Hand Surg Am 2001
- 90% achieved MRC grade 3 power
- 70% grade 4 power
C. Motor branch ulna nerve to MCN / Oberlin transfer
Technique
- use nerve stimulator
- isolate motor branch to FCU, preserving intrinsics
Sensation median nerve
ICN to lateral median
Hatori et al Plast Reconstr Surg 2009
- 17 patients
- none recovered 2 point discrimination
- 13 had perception of cold, 8 had perception of head
Post ganglionic lesion
Timing
A. Late / 3 months
- evaluate recovery on EMG
- look for renervation potentials
B. Immediate repair
Options
- neurolysis
- nerve repair
- nerve grafting
Neurolysis
Indication
- nerve functioning with nerve stimulator
- release nerve
Nerve repair
Indication
- ruptured
- able to perform tensionless repair
Nerve graft
Indication
- non functioning on nerve stimulator
- long segment of clearly severely damaged nerve
- rupture unable to be repaired primarily
Graft Options
- sural nerve (30cm)
- saphenous
- MCNFA
Options
- C5 to SSN for shoulder abduction
- C5 to posterior division upper trunk (axillary)
- C6 to anterior division upper trunk for elbow flexion
- C7 to posterior division middle trunk (wrist and elbow extension)
Late salvage
Options
- shoulder fusion
- elbow flexion / tendon transfers
- wrist fusion
- amputation
Shoulder fusion
Need functioning serratus anterior and trapezius
- for scapula control
Elbow Flexion
1. Lat Dorsi transfer
- entire muscle mobilised on NV pedicle
- attached proximally & distally to replace biceps
2. Triceps to Biceps transfer
3. Steindler flexorplasty
- transfer of CFO to more proximally on anterior humerus
- need power of wrist flexors
- will often get some pronation deformity
- also need wrist extensors to prevent excessive wrist flexion
4. Clark Pectoralis major transfer
- transfer of sternocostal P. major
5. Free Gracilis transfer
- innervated by ICN
Wrist arthrodesis
Mid humeral amputation
Indications
- flail limb
- limb is a hazard
Shouldn't be performed for pain relief