Purpose
A C5–C8 brachial plexus root injury, also known as a T1 hand, is associated with paralysis
of shoulder abduction or external rotation and elbow flexion, accompanied by variable
elbow, wrist, thumb, or finger extension deficits. We report the results of reconstruction
for C5–C8 brachial plexus paralysis in 52 patients operated upon within 12 months
of injury and having at least 24 months of follow-up.
Methods
We considered surgery to be indicated if, by the fifth month after trauma, shoulder
abduction and external rotation and elbow flexion remained paralyzed. Root grafting
was possible in 35% of the patients and was performed concomitantly with nerve transfers.
Shoulder motion was reconstructed by transferring the spinal accessory to the suprascapular
nerve. Elbow flexion was restored by transferring fascicles from either the median
or ulnar nerve to the biceps motor branch. When needed, elbow extension was reconstructed
by transferring 1 motor branch of the flexor carpi ulnaris to the triceps lower medial
head motor branch. Wrist extension was restored by transferring the distal anterior
interosseous nerve to the extensor carpi radialis brevis motor branch.
Results
Within 12 months of injury, we observed preserved or spontaneous recovery of elbow,
wrist, finger, and thumb extension in 25%, 12%, 50%, and 68% of patients, respectively.
After surgical reconstruction, improved range of motion for shoulder, elbow flexion,
and wrist extension scoring at least M3 was present in 90% of our patients. All 10
patients in whom a motor branch of the flexor carpi ulnaris was used for triceps reconstruction
recovered elbow extension, while flexor carpi ulnaris function was preserved.
Conclusions
In approximatively 90% of our patients, distal nerve transfers resulted in functional
recovery of shoulder abduction, elbow flexion or extension, and wrist extension.
Type of study/level of evidence
Therapeutic IV.
Key words
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References
- C5–8 brachial plexus root injury: the “T-1 hand.”.J Neurosurg. 2012; 116: 409-413
- Traction injuries of the brachial plexus in adults.J Bone Joint Surg Br. 1949; 31B: 10-16
- Clinical findings in C5–C6 and C5–C7 root palsies with brachial plexus traction lesions.J Hand Surg Eur Vol. 2013; 38: 237-241
- Electrophysiological study of the dominant motor innervation to the extensor digitorum communis muscle and long head of triceps brachii at posterior divisions of brachial plexus.Microsurgery. 2011; 31: 535-538
- Complications of contralateral C-7 transfer through the modified prespinal route for repairing brachial plexus root avulsion injury: a retrospective study of 425 patients.J Neurosurg. 2015; 122: 1421-1428
- Transfer of the phrenic nerve to the posterior division of the lower trunk to recover thumb and finger extension in brachial plexus palsy.J Neurosurg. 2011; 114: 212-216
- Direct coaptation of the phrenic nerve with the posterior division of the lower trunk to restore finger and elbow extension function in patients with total brachial plexus injuries.Neurosurgery. 2016; 78: 208-215
- Tendon palpation during agonist contraction and antagonist co-contraction to assess wrist flexor and extensor muscle function.Chir Main. 2015; 34: 79-85
- Results of wrist extension reconstruction in C5-8 brachial plexus palsy by transferring the pronator quadratus motor branch to the extensor carpi radialis brevis muscle.J Neurosurg. 2016; 124: 1442-1449
- Modifying the Medical Research Council grading system through Rasch analyses.Brain. 2012; 135: 1639-1649
- Results of spinal accessory to suprascapular nerve transfer in 110 patients with complete palsy of the brachial plexus.J Neurosurg Spine. 2016; 24: 990-995
- Grafting the C5 root to the musculocutaneous nerve partially restores hand sensation in complete palsies of the brachial plexus.Neurosurgery. 2012; 71 (discussion 262–253): 259-262
- Transfer of a terminal motor branch nerve to the flexor carpi ulnaris for triceps reinnervation: anatomical study and clinical cases.J Hand Surg Am. 2015; 40: 2229-2235.e2
- Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy.J Rehabil Med. 2008; 40: 665-671
- Abduction in internal rotation: a test for the diagnosis of axillary nerve palsy.J Hand Surg Am. 2011; 36: 2017-2023
- Nerve root grafting and distal nerve transfers for C5–C6 brachial plexus injuries.J Hand Surg Am. 2010; 35: 769-775
- Indications for peripheral nerve and brachial plexus surgery.Neurol Clin. 1992; 10: 935-951
- Use of long autologous nerve grafts in brachial plexus reconstruction: factors that affect the outcome.Acta Neurochir (Wien). 2011; 153: 2231-2240
- Functional contribution of T1 to the brachial plexus in infants.J Hand Surg Eur Vol. 2012; 37: 237-243
- Nerve reconstruction: a cohort study of 93 cases of global brachial plexus palsy.Indian J Orthop. 2011; 45: 153-160
- Functional outcome of spinal accessory nerve transfer to the suprascapular nerve to restore shoulder function: results in upper and complete traumatic brachial plexus palsy in adults.Neurol India. 2019; 67: S77-S81
- Functional outcome of oberlin procedure.Acta Ortop Bras. 2019; 27: 294-297
- A quantitative assessment of the functional recovery of flexion of the elbow after nerve transfer in patients with a brachial plexus injury.Bone Joint J. 2016; 98-B: 1517-1520
- Transposition of local muscles to restore elbow flexion in brachial plexus palsy.Injury. 2002; 33: 597-609
- Median nerve fascicle transfer versus ulnar nerve fascicle transfer to the biceps motor branch in C5–C6 and C5–C7 brachial plexus injuries: nonrandomized prospective study of 23 consecutive patients.Microsurgery. 2014; 34: 511-515
- Free reverse gracilis muscle combined with Steindler flexorplasty for elbow flexion reconstruction after failed primary repair of extended upper-type paralysis of the brachial plexus.J Hand Surg Am. 2019; 44: 112-120
- Pain after avulsion injuries and complete palsy of the brachial plexus: the possible role of nonavulsed roots in pain generation.Neurosurgery. 2008; 62 (discussion 1113–1104): 1104-1113
- Results of grafting the anterior and posterior divisions of the upper trunk in complete palsies of the brachial plexus.J Hand Surg Am. 2008; 33: 1529-1540
- Transfer of a single flexor carpi ulnaris tendon for treatment of radial nerve palsy.J Hand Surg Br. 2006; 31: 542-546
- Pronator quadratus to extensor carpi radialis brevis nerve transfer in C5–C7 or C5–C8 brachial plexus injuries for independent wrist extension.Indian J Plast Surg. 2020; 53: 36-41
- Brachialis muscle transfer to the forearm muscles in obstetric brachial plexus palsy.J Hand Surg Br. 2006; 31: 261-265
- Use of clinical signs and computed tomography myelography findings in detecting and excluding nerve root avulsion in complete brachial plexus palsy.J Neurosurg. 2006; 105: 835-842
- Diagnostic accuracy of imaging studies for diagnosing root avulsions in post-traumatic upper brachial plexus traction injuries in adults.Acta Neurochir (Wien). 2020; 162: 3189-3196
Article info
Publication history
Published online: January 08, 2022
Accepted:
November 3,
2021
Received:
January 11,
2021
Footnotes
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Identification
Copyright
© 2022 by the American Society for Surgery of the Hand. All rights reserved.
