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