**8. Plastic neural reconstruction**

#### **8.1. Nerve repair**

in shoulder internal contracture. Botulinum toxin injections can be considered for patients developing progressive internal rotation contracture [5, 18]. The failure to bring a cookie to the mouth without bending torso more than 45° (Cookie test) at 9 months mounts to an indi-

The role of electromyography (EMG) in BPBP is doubtful as it frequently gives optimistic results in a severe nonresolving clinical picture. One explanation for this is the reflex-activated contraction of muscles in young children. Another explanation for this discrepancy is 'Luxury Innervation' of muscles. Until the age of 3 months, children may have polyneuronal innervation, which may give

Although the isolated use of EMG has limitations in BPBP, according to few investigators, combining it with nerve action potentials (NAPs) may help in determining the nature and level of lesion. In selected cases, the authors have reported their ability to even differentiate

Imaging of shoulder and upper limb can be used to diagnose the birth trauma. Chest X-ray can also give evidence of hemi diaphragm paralysis associated with C4 or phrenic nerve palsy. The diaphragm routinely lies relatively higher by two ribs level on the right side owing

Dynamic ultrasonography (USG) can help in the diagnosis of hemi diaphragm paralysis. Vathana et al. found good interobserver and intraobserver reliability in diagnosing glenohumeral deformity by ultrasound [11, 23]. Donohue et al. found measurements of glenohumeral deformity by USG reliable, but there was poor agreement between USG and magnetic resonance imaging (MRI) for diagnosing it. They questioned the use of USG as a standalone

Computed **t**omography (CT) myelography was considered better modality than MRI to diagnose root avulsions before a decade. Root avulsions were diagnosed based on contrast-filled

to liver, but in hemidiaphragm paralysis, it lies at the level of the fifth or the sixth rib.

positive EMG findings in the absence of adequate nerve regeneration [7, 8, 20, 21].

cation for plexus exploration and reconstruction [6, 19].

**7. Investigations**

84 Treatment of Brachial Plexus Injuries

*7.1.1. Electromyography*

*7.1.2. Nerve action potentials*

**7.2. Radiologic imaging**

*7.2.2. Ultrasonography*

investigation for this purpose [12, 24].

*7.2.3. Computed tomography scan and magnetic resonance imaging*

*7.2.1. X-ray*

axonotmesis from neurotmesis [9, 10, 14, 22].

**7.1. Neurophysiologic investigations**

#### *8.1.1. Basis of nerve repair*

Gilbert and Tassin were the first to report the comparison of conservative and surgical treatment of brachial plexus birth palsy infants in 1984 [30]. Both the groups with a similar clinical neurologic examination were compared. Sixty-three (63%) patients achieved Mallet IV shoulder function in surgical group while maximum Mallet III recovery was seen in patients with spontaneous recovery. About 27% of conservatively managed infants who showed full spontaneous recovery had gained biceps strength of MRC grade 3 by 2 months of age. Endstage improvement was incomplete in children whose biceps recovery was delayed beyond 3 months. This chapter recommended surgical intervention at 3 months, if biceps muscle has not recovered by then.

Capek et al. [31] compared the outcome of graft repair (26 patients) versus neurolysis (16 patients) of conducting neuromas. End results were found to be more promising in nerve repair group.

In patients with global injury, achieving hand function is crucial. Pondaag and Melessy have shown improved hand function after lower trunk reconstruction in about 70% of patient [32]. Gilbert and colleagues suggested that unlike adults, infants with brachial plexopathy may have the potential to regain hand function after nerve reconstructions.

#### *8.1.2. Decision about nerve repair and its timing*

It is imperative to differentiate avulsion injuries from ruptures to make microsurgical recommendations. Microsurgery is advised before 3 months of age in avulsion injuries, as spontaneous recovery cannot be expected. Ruptures can recover at different degrees, and there exists debate about the ideal indication and the time of surgery.

Birch et al. [14] published the results of nerve repair in 100 infants at mean postoperative follow-up of 85 months (30–152). They utilized Gilbert score, Mallet score and Raimondi score as outcome measures. Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. They suggested the utility of preoperative electrodiagnosis and intraoperative somatosensory-evoked potentials to detect occult intradural (pre-ganglionic) injury. Results of hand function were largely reassuring after complete paralysis. In spite of only 35% of children having a useful hand at 2 years, 76% of children enjoyed a useful hand after 8 years of follow-up and along with several tendon transfers. These results revealed the importance of repairing lower-root avulsions. Birch et al. summarized their results of nerve repairs in 100 infants after a mean follow-up of 85 months (30–152) by utilizing Gilbert score, Mallet score and Raimondi score as outcome measures. They obtained good results in 33% of C5 repairs, 55% of C6 repairs, 24% of C7 repairs and 57% of C8 and T1 repairs. They also recommended the use of preoperative electrodiagnosis and intraoperative somatosensory-evoked potentials in identifying occult intradural (pre-ganglionic) injury.

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When nerve root is avulsed from spinal cord, nerve repair is not possible. In such a case, nerve transfer connects extra brachial plexus or intraplexus functioning nerve to the nerve whose function is desired. Nerve transfer has an advantage that it permits faster reinnervation of muscle. Various extraplexus sources like distal branch of spinal accessory nerve (SAN), intercostal nerves, hypoglossal nerve, cervical plexus, phrenic nerve and contralateral C7 root can be used for nerve transfer. In case of injury affecting C5–6 nerve roots, a fascicle from median, ulnar nerve, medial pectoral or thoracodorsal nerve can be used as donor for nerve transfer. These intraplexus nerves receive contribution predominantly from C8 and T1 roots. In global lesions, local transfers are unavailable so extraplexus nerves like intercostal nerve transfers are preferred. The commonly used nerve transfers target to improve shoulder external rotation, abduction,

External rotation is primarily carried out by infraspinatus muscle that is supplied by suprascapular nerve (SSN). SSN can be neurotized with SAN which can be considered an alluring extraplexal option for reviving shoulder function as it is a pure motor donor and it remains

The outcomes of SAN to SSN have been published in multiple series. Nevertheless, different scoring systems were used in different papers for evaluating shoulder function; all of them implied improved shoulder functions. Only 14% of patients achieved more than 20° of active external rotation. Functional outcomes were measured by the Mallet hand to mouth and hand to neck scores. Ninety percent could reach the mouth (Mallet grade 3 or higher) and that 72% could reach the head (Mallet grade 3 or higher). These data suggest that even though there

elbow flexion, elbow extension and sensory function of the hand.

*8.2.2. Transfer to augment external rotation of shoulder*

**8.2. Nerve transfers**

*8.2.1. Basis of nerve transfers*

next to suprascapular nerve.

Gilbert and Tassin [30] considered the absence of return of biceps function by 3 months as an indication for microsurgery. Poorer global shoulder function was reported at 5 years and was associated with the further need of secondary surgeries in patients who regained biceps after 3 months. Although other researchers have followed more conservative guidelines, they have found that absent elbow flexion alone at 3 months can overestimate the poor final recovery and can lead to unneeded plexus exploration [17, 22]. They also documented that those patients who achieved biceps recovery between 4 and 6 months of age gained good global shoulder function with secondary interventions [34].

Clarke and Curtis routinely used return of biceps function at 9 months of age to determine microsurgical intervention [19, 33]. The child's ability to bring a cookie (the 'cookie test') to his or her mouth without bending the torso forward to more than 45° is a defining factor guiding treatment. Chuang et al. reported poor results of hand function while microsurgery was performed after infancy [35].

#### *8.1.3. Technique of nerve repair*

The spectrum of nerve surgery historically includes neurolysis, neuroma resection, and nerve grafting. Nerve transfers [36] and nerve conduits have led to an expansion of procedures available for nerve reconstruction. Neurolysis alone is no longer indicated in BPBP. Although few authors have reported good outcome in younger patients, direct repair of nerve endings is seldom performed after neuroma excision [37]. Nerve grafts replace the injured nerve tissue and connect the proximal and distal viable nerve endings. A number of donor grafts from the ipsilateral limb have been used; however, autologous sural nerve grafts are most commonly used [38]. Excision of neuroma with primary nerve grafting is the accepted management of nerve ruptures.

#### *8.1.4. Outcomes of nerve repair*

Clarke et al. demonstrated [39] that early improvements in neurolysis group did not sustain for a longer period of time. Patients who underwent nerve repair show significant improvement in Active Movement Scale scores at 4 years of follow-up. Erb's palsy grafting patients had improved function in seven movements, while the total palsy-grafted patients demonstrated better function in 11 of 15 movements.

Gilbert et al. have demonstrated promising long-term results in patients who have undergone nerve repair [40]. At 4 years of follow-up, 80% children with C5 C6 lesions showed good or excellent shoulder function, whereas it was 61% for children with C5–C7 lesions. Eighty-one percent of patients were graded good or excellent elbow functions at 8 years of follow-up.

After complete paralysis, the results of hand functions were quite encouraging. Although at 2 years, only 35% of children have a useful hand, after 8 years and several tendon transfers, 76% of children have a useful hand. This reflected that even lower-root avulsion should be repaired.

Birch et al. [14] published the results of nerve repair in 100 infants at mean postoperative follow-up of 85 months (30–152). They utilized Gilbert score, Mallet score and Raimondi score as outcome measures. Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. They suggested the utility of preoperative electrodiagnosis and intraoperative somatosensory-evoked potentials to detect occult intradural (pre-ganglionic) injury. Results of hand function were largely reassuring after complete paralysis. In spite of only 35% of children having a useful hand at 2 years, 76% of children enjoyed a useful hand after 8 years of follow-up and along with several tendon transfers. These results revealed the importance of repairing lower-root avulsions. Birch et al. summarized their results of nerve repairs in 100 infants after a mean follow-up of 85 months (30–152) by utilizing Gilbert score, Mallet score and Raimondi score as outcome measures. They obtained good results in 33% of C5 repairs, 55% of C6 repairs, 24% of C7 repairs and 57% of C8 and T1 repairs. They also recommended the use of preoperative electrodiagnosis and intraoperative somatosensory-evoked potentials in identifying occult intradural (pre-ganglionic) injury.

#### **8.2. Nerve transfers**

spontaneous recovery cannot be expected. Ruptures can recover at different degrees, and

Gilbert and Tassin [30] considered the absence of return of biceps function by 3 months as an indication for microsurgery. Poorer global shoulder function was reported at 5 years and was associated with the further need of secondary surgeries in patients who regained biceps after 3 months. Although other researchers have followed more conservative guidelines, they have found that absent elbow flexion alone at 3 months can overestimate the poor final recovery and can lead to unneeded plexus exploration [17, 22]. They also documented that those patients who achieved biceps recovery between 4 and 6 months of age gained good global

Clarke and Curtis routinely used return of biceps function at 9 months of age to determine microsurgical intervention [19, 33]. The child's ability to bring a cookie (the 'cookie test') to his or her mouth without bending the torso forward to more than 45° is a defining factor guiding treatment. Chuang et al. reported poor results of hand function while microsurgery

The spectrum of nerve surgery historically includes neurolysis, neuroma resection, and nerve grafting. Nerve transfers [36] and nerve conduits have led to an expansion of procedures available for nerve reconstruction. Neurolysis alone is no longer indicated in BPBP. Although few authors have reported good outcome in younger patients, direct repair of nerve endings is seldom performed after neuroma excision [37]. Nerve grafts replace the injured nerve tissue and connect the proximal and distal viable nerve endings. A number of donor grafts from the ipsilateral limb have been used; however, autologous sural nerve grafts are most commonly used [38]. Excision of neuroma with primary nerve grafting is the accepted management of

Clarke et al. demonstrated [39] that early improvements in neurolysis group did not sustain for a longer period of time. Patients who underwent nerve repair show significant improvement in Active Movement Scale scores at 4 years of follow-up. Erb's palsy grafting patients had improved function in seven movements, while the total palsy-grafted patients demon-

Gilbert et al. have demonstrated promising long-term results in patients who have undergone nerve repair [40]. At 4 years of follow-up, 80% children with C5 C6 lesions showed good or excellent shoulder function, whereas it was 61% for children with C5–C7 lesions. Eighty-one percent of patients were graded good or excellent elbow functions at 8 years of follow-up.

After complete paralysis, the results of hand functions were quite encouraging. Although at 2 years, only 35% of children have a useful hand, after 8 years and several tendon transfers, 76% of children have a useful hand. This reflected that even lower-root avulsion should be repaired.

there exists debate about the ideal indication and the time of surgery.

shoulder function with secondary interventions [34].

was performed after infancy [35].

*8.1.3. Technique of nerve repair*

86 Treatment of Brachial Plexus Injuries

*8.1.4. Outcomes of nerve repair*

strated better function in 11 of 15 movements.

nerve ruptures.

#### *8.2.1. Basis of nerve transfers*

When nerve root is avulsed from spinal cord, nerve repair is not possible. In such a case, nerve transfer connects extra brachial plexus or intraplexus functioning nerve to the nerve whose function is desired. Nerve transfer has an advantage that it permits faster reinnervation of muscle.

Various extraplexus sources like distal branch of spinal accessory nerve (SAN), intercostal nerves, hypoglossal nerve, cervical plexus, phrenic nerve and contralateral C7 root can be used for nerve transfer. In case of injury affecting C5–6 nerve roots, a fascicle from median, ulnar nerve, medial pectoral or thoracodorsal nerve can be used as donor for nerve transfer. These intraplexus nerves receive contribution predominantly from C8 and T1 roots. In global lesions, local transfers are unavailable so extraplexus nerves like intercostal nerve transfers are preferred.

The commonly used nerve transfers target to improve shoulder external rotation, abduction, elbow flexion, elbow extension and sensory function of the hand.

#### *8.2.2. Transfer to augment external rotation of shoulder*

External rotation is primarily carried out by infraspinatus muscle that is supplied by suprascapular nerve (SSN). SSN can be neurotized with SAN which can be considered an alluring extraplexal option for reviving shoulder function as it is a pure motor donor and it remains next to suprascapular nerve.

The outcomes of SAN to SSN have been published in multiple series. Nevertheless, different scoring systems were used in different papers for evaluating shoulder function; all of them implied improved shoulder functions. Only 14% of patients achieved more than 20° of active external rotation. Functional outcomes were measured by the Mallet hand to mouth and hand to neck scores. Ninety percent could reach the mouth (Mallet grade 3 or higher) and that 72% could reach the head (Mallet grade 3 or higher). These data suggest that even though there is not much improvement in external rotation, there is improvement in shoulder function. Pondaag et al. [41] determined active external rotation and functional outcome score post SAN to SSN transfers in a series of 21 patients.

to innervations of axillary nerve, one case had SAN to SSN transfer and the other had decompression of SSN. Post SAN to SSN transfer, the respective scores were 5 and 6, illustrating

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Currently, dual transfer to innervate both biceps and brachialis is preferred for better elbow flexion strength [47]. Elbow flexion is a crucial upper limb function which can be obtained by

In C5–6 or C5-6-7 palsy, elbow flexion is affected; however, ulnar nerve function is normal. For such case, Oberlin transfer can be of great help for the recovery of the biceps. A fascicle of the ulnar nerve supplying the flexor carpi ulnaris muscle is cut and sutured end to end to the biceps nerve in the upper arm. Oberlin et al. [48] described this transfer in adults and

Noaman et al. [50] reported this transfer in seven children with obstetric brachial plexus palsy. Two motor fascicles out of the ulnar nerve were transferred to the nerve to biceps. The average age at the time of operation was 16 months (range 11-24 months). The average follow-up was 19 months (range 13–30 months). Five children had biceps muscle > or = M (3) with active

Siqueira et al. [51] performed Oberlin's procedure in 17 infants with brachial plexus birth palsy. The mean age at the time of surgery was 12.9 months (range 4–26 months). The minimum follow-up was of 19 months. The strength of elbow flexion was measured by modified British Medical Research Council scale. Three children obtained grade 3, and 11 children had

Alternatively, biceps can be innervated through a fascicle of median nerve. Al-Qattan in 2014 reported their results of 10 cases of obstetric brachial plexus palsy in which median nerve to

Age at the time of presentation ranged from 13 to 19 months. There were seven cases of C 5–6 palsy and three cases of C5–6–7 palsy. The preoperative AMS of elbow flexion ranged from 0 to 2. At the final follow-up (1–2 years after surgery), all seven C5–6 palsy cases obtained a score of 7 out of 7 for elbow flexion. Two cases with C5–6–7 palsy had a score of 6 and 7.

To innervate both biceps and brachialis muscles, one fascicle of both ulnar and median nerve

In a recently published paper, authors used a combined transfer in five patients and a single transfer by median or ulnar nerve fascicle in 26 patients [47]. The outcome measures were postoperative elbow flexion and supination measured with the Active Movement Scale (AMS). The mean age at surgery was 8.4 months (range 3–20 months). Patients were followed up for at least 18 months postoperatively or till they achieved full recovery of elbow flexion. Combined nerve transfer patients resulted in elbow flexion of AMS = 7 and supination of

antigravity shoulder abduction.

*8.2.4. Nerve transfer for elbow flexion*

biceps nerve transfer was used [52].

*8.2.5. Transfer for elbow flexion and supination*

are taken.

nerve transfers to brachialis or biceps or both the muscles.

Al-Qattan [49] described it for the first time for obstetric palsy in 2002.

elbow flexion against gravity, and two children had biceps muscle <M (3).

grade 4 elbow flexion power. Hand function did not deteriorate due to transfer.

Grossman [42] reported result in 26 infants who underwent SAN to SSN transfer using a nerve graft, as part of the repair of a brachial plexus birth injury. At a minimum follow-up of 2.5 years, all children had shoulder function of grade 4 or better using a modified Gilbert scale.

In another study, 54 children without return of active shoulder external rotation underwent transfer of SAN to SSN. Thirty-nine of 54 patients achieved more than 20° of active external rotation by 4 months postoperatively [25].

Terzis and Kostas [43] carried out SAN to SSN transfer in 25 children with brachial plexus birth injury. They observed improvement in abduction and external rotation component of Mallet score.

Schaakxs et al. [44] studied the results of SAN to SSN in 65 patients, the age ranging between 5 and 35 months (average 19 months) and the mean postoperative observation period of 2.5 years. They assessed their results by evaluating the recovery of passive and active external rotation with the arm in abduction and in adduction. Results were better for the external rotation with the arm in abduction compared to adduction. In 71.5% of patients, they observed active external rotation between 60 and 90°. The influence of nerve transfer on glenohumeral joint dysplasia was also assessed, and this operation has a positive influence on the glenohumeral joint.

Ruchelsman [45] reported their result of the SAN to SSN in 25 infants with brachial plexus birth injuries as part of the primary surgical reconstruction. At minimum follow-up of 24 months, the mean active external rotation was 69.6°; the mean Gilbert score was 4.1 and the mean Miami score was 7.1. These results suggest good shoulder functional outcomes.

What is the effect of age on the result? It is likely that as the denervation time increases, muscle atrophy also increases. Therefore, the delay may have negative impact on the result. Three papers analyzed this point and provided contradictory suggestions [25, 43, 45].

Satisfactory passive external rotation at shoulder is mandatory for SAN to SSN transfer. Any internal rotation contracture should be rectified surgically prior to this transfer.

#### *8.2.3. Nerve transfer for shoulder abduction*

The nerve supplying one of the heads of triceps can be transferred to the axillary nerve to improve shoulder abduction. SAN to SSN transfer aids in attaining infraspinatus and supraspinatus function. Since isolated supraspinatus is a weak abductor, deltoid activity is also required for good abduction. Neurotization of axillary nerve can help in attaining deltoid function. Each of the three heads of triceps is innervated separately by a radial nerve.

Axillary nerve passes through the quadrangular space above the teres major while the radial nerve passes through the triangular space below the teres minor. Both these nerves are in close proximity, so anastomosis is possible without nerve graft.

In a small case series of five patients, McRae reported the results of this procedure in two BPBP cases [46]. Shoulder abduction was preoperatively rated at 2 and 3 by AMS. In addition to innervations of axillary nerve, one case had SAN to SSN transfer and the other had decompression of SSN. Post SAN to SSN transfer, the respective scores were 5 and 6, illustrating antigravity shoulder abduction.

#### *8.2.4. Nerve transfer for elbow flexion*

is not much improvement in external rotation, there is improvement in shoulder function. Pondaag et al. [41] determined active external rotation and functional outcome score post

Grossman [42] reported result in 26 infants who underwent SAN to SSN transfer using a nerve graft, as part of the repair of a brachial plexus birth injury. At a minimum follow-up of 2.5 years,

In another study, 54 children without return of active shoulder external rotation underwent transfer of SAN to SSN. Thirty-nine of 54 patients achieved more than 20° of active external

Terzis and Kostas [43] carried out SAN to SSN transfer in 25 children with brachial plexus birth injury. They observed improvement in abduction and external rotation component of Mallet score. Schaakxs et al. [44] studied the results of SAN to SSN in 65 patients, the age ranging between 5 and 35 months (average 19 months) and the mean postoperative observation period of 2.5 years. They assessed their results by evaluating the recovery of passive and active external rotation with the arm in abduction and in adduction. Results were better for the external rotation with the arm in abduction compared to adduction. In 71.5% of patients, they observed active external rotation between 60 and 90°. The influence of nerve transfer on glenohumeral joint dysplasia

was also assessed, and this operation has a positive influence on the glenohumeral joint.

mean Miami score was 7.1. These results suggest good shoulder functional outcomes.

Three papers analyzed this point and provided contradictory suggestions [25, 43, 45].

function. Each of the three heads of triceps is innervated separately by a radial nerve.

close proximity, so anastomosis is possible without nerve graft.

internal rotation contracture should be rectified surgically prior to this transfer.

Ruchelsman [45] reported their result of the SAN to SSN in 25 infants with brachial plexus birth injuries as part of the primary surgical reconstruction. At minimum follow-up of 24 months, the mean active external rotation was 69.6°; the mean Gilbert score was 4.1 and the

What is the effect of age on the result? It is likely that as the denervation time increases, muscle atrophy also increases. Therefore, the delay may have negative impact on the result.

Satisfactory passive external rotation at shoulder is mandatory for SAN to SSN transfer. Any

The nerve supplying one of the heads of triceps can be transferred to the axillary nerve to improve shoulder abduction. SAN to SSN transfer aids in attaining infraspinatus and supraspinatus function. Since isolated supraspinatus is a weak abductor, deltoid activity is also required for good abduction. Neurotization of axillary nerve can help in attaining deltoid

Axillary nerve passes through the quadrangular space above the teres major while the radial nerve passes through the triangular space below the teres minor. Both these nerves are in

In a small case series of five patients, McRae reported the results of this procedure in two BPBP cases [46]. Shoulder abduction was preoperatively rated at 2 and 3 by AMS. In addition

all children had shoulder function of grade 4 or better using a modified Gilbert scale.

SAN to SSN transfers in a series of 21 patients.

88 Treatment of Brachial Plexus Injuries

rotation by 4 months postoperatively [25].

*8.2.3. Nerve transfer for shoulder abduction*

Currently, dual transfer to innervate both biceps and brachialis is preferred for better elbow flexion strength [47]. Elbow flexion is a crucial upper limb function which can be obtained by nerve transfers to brachialis or biceps or both the muscles.

In C5–6 or C5-6-7 palsy, elbow flexion is affected; however, ulnar nerve function is normal. For such case, Oberlin transfer can be of great help for the recovery of the biceps. A fascicle of the ulnar nerve supplying the flexor carpi ulnaris muscle is cut and sutured end to end to the biceps nerve in the upper arm. Oberlin et al. [48] described this transfer in adults and Al-Qattan [49] described it for the first time for obstetric palsy in 2002.

Noaman et al. [50] reported this transfer in seven children with obstetric brachial plexus palsy. Two motor fascicles out of the ulnar nerve were transferred to the nerve to biceps. The average age at the time of operation was 16 months (range 11-24 months). The average follow-up was 19 months (range 13–30 months). Five children had biceps muscle > or = M (3) with active elbow flexion against gravity, and two children had biceps muscle <M (3).

Siqueira et al. [51] performed Oberlin's procedure in 17 infants with brachial plexus birth palsy. The mean age at the time of surgery was 12.9 months (range 4–26 months). The minimum follow-up was of 19 months. The strength of elbow flexion was measured by modified British Medical Research Council scale. Three children obtained grade 3, and 11 children had grade 4 elbow flexion power. Hand function did not deteriorate due to transfer.

Alternatively, biceps can be innervated through a fascicle of median nerve. Al-Qattan in 2014 reported their results of 10 cases of obstetric brachial plexus palsy in which median nerve to biceps nerve transfer was used [52].

Age at the time of presentation ranged from 13 to 19 months. There were seven cases of C 5–6 palsy and three cases of C5–6–7 palsy. The preoperative AMS of elbow flexion ranged from 0 to 2. At the final follow-up (1–2 years after surgery), all seven C5–6 palsy cases obtained a score of 7 out of 7 for elbow flexion. Two cases with C5–6–7 palsy had a score of 6 and 7.

#### *8.2.5. Transfer for elbow flexion and supination*

To innervate both biceps and brachialis muscles, one fascicle of both ulnar and median nerve are taken.

In a recently published paper, authors used a combined transfer in five patients and a single transfer by median or ulnar nerve fascicle in 26 patients [47]. The outcome measures were postoperative elbow flexion and supination measured with the Active Movement Scale (AMS). The mean age at surgery was 8.4 months (range 3–20 months). Patients were followed up for at least 18 months postoperatively or till they achieved full recovery of elbow flexion. Combined nerve transfer patients resulted in elbow flexion of AMS = 7 and supination of AMS ≥ 5. Single-fascicle transfer resulted in elbow flexion of AMS ≥ 6 and supination of AMS grades 2–5. Thus, the combined transfer achieved better function.

**9.2. Role of soft-tissue release**

*9.2.1. Open subscapularis slide from the lateral border of scapula*

**Figure 1.** The arm is internally rotated to make the medial border of scapula prominent.

*9.2.2. Minimally invasive subscapularis release*

Subscapularis is considered as the main element responsible for shoulder internal rotation contracture. Different methods of subscapularis lengthening are described in various studies with their positive and negative aspects. Gilbert reported that isolated subscapularis lengthening was enough to balance the shoulder joint in about 50% patients in their study [21, 58]. Thus, he recommended performing tendon transfer surgery in the second stage if required.

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Subscapularis slide was introduced by Caroliz and Brahimi [58]. It involves an incision along the lateral border of scapula, approaching scapular ridge through the interval between Teres major and Teres minor. Recurrence rate was 50–70% when it was done in isolation [21, 22, 58–60]. Grossman et al. reported no recurrence when it was coupled with tendon transfer surgery [23]. Reports of ischemic necrosis of subscapularis after lateral slide pose question of safety of artery to subscapularis owing to its vicinity to the entry point for release [24, 61].

Since 2013, we have started performing subscapularis slide from the medial border of scapula through a centimeter incision placed at the junction of the upper one-third and lower twothirds. The arm is internally rotated and the shoulder is pressed backward to make the medial border of scapula prominent (**Figure 1**). Artery forceps are advanced to make a plane between rhomboids (**Figure 2**). A small periosteal elevator is introduced in the submuscular and extra periosteal space, and subscapularis slide is done in a clockwise fashion (**Figure 3**). A larger periosteal elevator is then introduced to release stronger muscle attachments at supero-medial and inferior angle of scapula. The arm is externally rotated to achieve 90° external rotation (**Figure 4**). Conventional conjoined tendon transfer surgery was performed after minimally invasive subscapularis release (MISR). Thirty-five patients with congruent glenohumeral joint constructed the study group and were followed up for a minimum of 18 months. Improvements

#### *8.2.6. Nerve transfer for elbow extension*

To restore elbow extension, one possible solution is to reinnervate motor branches of radial nerve to the triceps muscle. Depending on the severity and extent of brachial plexus lesion, the radial nerve can be neurotized by means of intercostal nerves when the palsy involves the whole brachial plexus (thus, inferior roots are damaged), while in upper two or three radicular palsy, the use of fascicles of the ulnar nerve (modified Oberlin's procedure) is advisable [53].

#### *8.2.7. Extraplexus transfer*

One or two branches to the pectoralis major can be taken for the transfer so that some pectoralis major supply can be preserved and a direct repair without intervening graft can be performed to the MCN [54] or nerve to biceps [55], in the distal axilla. Intercostal nerves are an extraplexus source. They can be cut 1 cm distal to the mammary line and their stumps can be coapted directly to the MCN in the axilla.
