IC44-R: Reanimation of the Shoulder after Brachial Plexus ...

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

IC44-R: Reanimation of the Shoulder after

Brachial Plexus Injury

Moderator(s): Allen T. Bishop, MD

Faculty: Heather Baltzer, MD, MSc, FRCSC, Jayme A. Bertelli, MD, PhD, Bassem T.

Elhassan, MD, and Alexander Y. Shin, MD

Session Handouts

75TH VIRTUAL ANNUAL MEETING OF THE ASSH

OCTOBER 1-3, 2020

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

http://www.assh.org/

mailto:[email protected]

1

Bassem Elhassan, MDProfessor of Orthopedics

Mayo Clinic,Rochester, MN

Shoulder Anatomy and Biomechanics

Bassem T. Elhassan, MD

Speaker has no relevant financial relationships with commercial

interest to disclose.

ASSH Disclosures

75th Annual Meeting the ASSH

Shoulder Function Shoulder Consists of 3 Joints and 1 ArticulationMotion is both at the Glenohumeral Joint (~70%) and

Scapulothoracic Articulation (~30%)

14 Muscles move and stabilize the shoulder.8 work on the GH Joint

Deltoid

Supraspinatus

Infraspinatus

Teres Minor

Subscapularis

Teres Major

Latissimus Dorsi

Pectoralis Major

Innervation bylower Subscapular

Nerve C5-C6

Innervation by Axillary nerve C5,6

Innervation by medial and lateral pectoral n C5-8, T1

Innervation by Axillary nerve C5,6

Innervation by suprascapular

nerve C5,6Innervation by suprascapular

nerve C5,6

Innervation by upper and

lower Subscapular Nerves C5-C6

Innervation by Thoracodorsal nerve C5-7

6 Work on the Scapulo-Thoracic Articulation

Serratus Anterior Trapezius

Pectoralis MinorLevator ScapulaeRhomboid MajorRhomboid Minor Innervation by

medial pectoralNerve C6-8, T1Innervation by

Dorsal ScapularNerve C(3),C(4), C5

1 2

3 4

5 6

2

Basic Shoulder Biomechanics The Primary Dynamic Stabilizers of the GH Joint are the RC and Deltoid

InfraspinatusSupraspinatus

Subscapularis Teres Minor

Deltoid

RC Create a Fulcrum for Adequate Deltoid Function

Basic Biomechanics of Shoulder Motion

Lajtai, AitzeMuller and Joste

Don’t Forget the Importance of the Function And Stability of the ST Articulation

There are 6 Periscapular Muscles that Directly Affect Motion and Possibly Stability of the Scapula

7 8

9 10

11 12

3

Two Important Large Muscles that are Essential to Stabilize, Support and Allow Smooth Motion of the Scapula on the Chest Wall (and Secondary Normal Range of Motion

of the Shoulder)

Serratus Anterior TrapeziusInnervation byLong Thoracic

Nerve C5-7

Innervation bySpinal Accessory

Nerve (CN XI)

Serratus MuscleMost Challenging to Exam Because Most

Time You Can’t See or Feel (Because it is Hidden Deep to the Scapula)

Serratus Anterior

Trapezius MuscleThe only Muscle that Originates Partly from Base of the Neck and Inserts on the Acromion and Spine of Scapula

13 14

15 16

17 18

4

Levator Scapulae

Rhomboid Minor

Rhomboid Major

Three Additional Smaller Muscles Deep to Trapezius that Help Partly in Scapula Mobility but their Deficiency is Not as Detrimental for

Scapulothoracic Function

Tear in the Rhomboid MajorCan Cause Significant Pain

Rhomboid Major Internally Rotates the Scapula (Bring the Scapula Tip Close to the Thoracic Spine

Innervation bymedial pectoralNerve C6-8, T1

Pectoralis Minor

19 20

21 22

23 24

5

Shoulder with No Deltoid and Rotator Cuff

Glenohumeral Joint without RC or Deltoid

Inferior Subluxation of the Shoulder

Shoulder without RC but Functioning Deltoid

No Deltoid But Normal Rotator Cuff

Deltoid Paralysis with Normal Rotator Cuff

Deltoid Paralysis with Normal Rotator Cuff

25 26

27 28

29 30

6

Chronic BP Injury with No Deltoid, No Rotator Cuff

Understanding Anatomy and Biomechanics of the Shoulder is Essentially for Planning Reconstruction Especially in Patients with Brachial Plexus Injury

Thank you

31 32

33

Jayme A. Bertelli, MD, PhD

Speaker has no relevant financial relationships with commercial interest to disclose.

Suprascapular

Nerve Reconstruction

in Brachial Plexus Injury

Jayme A Bertelli, MD, PhD

Reconstruction of SS nerve by:

• Nerve Grafting

• Nerve Transfer

• SS to SS

• C5 to SS

Nerve Grafting

Shoulder Shoulder

SS-Sural Graft-SS

C5-Sural Nerve Graft-Suprascapular Nerve

Shoulder abduction is

coupled to elbow flexion

Stab Wound

Clean cut

No Stretch Injury

Superior Trunk

SS Nerve

Sural Grafts

3 years postop

XI to SS nerve Transfer

• Complete paralysis

• Upper type paralysis

XI to SS Nerve Transfer in Complete Paralysis

Abduction – 60º

ER – less than 5% of the patients recovered ER

Failures, less than 30º of recovery – 10%

Recovery Failure rate

Abd ER (number patients/rom

º)

Classical approach

45º (SD ±25.1º)

2 (20º, 120º) 25 % *

Staged/ extended approach

62º (SD ±25.3º) *

32 [(87º(SD±40.6º)]*

10 %

XI to SS Nerve Transfer in Complete Paralysis

EXTENDED EXPOSURE OF THE SUPRASCAPULAR

NERVE

Clavicular Fractures and Dislocations

XI to SS Nerve Transfer in Upper Type Lesions

70% patients recovered full external rotation and abduction.

Results

Abduction - 122(range,80-170)

External rotation -118(range,90-140)

Upper Type Lesions

Triceps to axillary nerve transfer

ect Major

Triceps

Boosting Effects by Preserved Muscles

Thank You

• Double lesions of the SS nerve

(healthy nerve between two lesions spots)

is possible, but very rare

• Extended lesions are more frequent

• Be sure that your distal stump is healthySCientifiC REPORTS | (2018) 8:12260 | DOI:10.1038/s41598-018-

29804-w

Stretch produces macro and microscopic

lengthy lesions to the nerve

Axillary Nerve Reconstruction by Graft or Transfer

Heather L. Baltzer, MD, MSc, FRCSC, FACS University Health Network

University of Toronto, Canada

DISCLOSURES

Heather Baltzer, MD, MSc, FRCSC


Background: Axillary Nerve Reconstruction

•  Restoration Abduction +/- External Rotation •  Shoulder stability •  Reduce pain

Options for Restoring Axillary Nerve Function

•  Nerve Grafts: •  Short: C5/6 nerve root to posterior division upper

trunk •  Long:

•  C5/6 nerve root axillary nerve •  Axillary Nerve grafting

•  Nerve Transfer: •  Triceps branch to axillary nerve •  Spinal accessory nerve, Medial Pectoral, Long

thoracic, FCU fascicle, Thoracodorsal

Deltoid Reinnervation: Sural Nerve Cable Grafting

•  Disadvantages •  ZOI dissection •  Two coaptation sites •  Long grafts >6cm

•  Advantages: •  Large number of

proximal axons •  No donor morbidity

from nerve transfer

Deltoid Reinnervation: Triceps Motor Branch to Axillary Nerve

•  Disadvantages: •  Triceps branch axons:

Axillary nerve axons ~ 0.5:1

•  Advantages: •  One incision •  No ZOI dissection •  One nerve coaptation •  Shorter distance

Long Nerve Grafts for Axillary Nerve Reconstruction

SCIENTIFIC ARTICLE

Long-Nerve Grafts and Nerve TransfersDemonstrate Comparable Outcomes for

Axillary Nerve InjuriesScott W. Wolfe, MD, Parker H. Johnsen, BS, Steve K. Lee, MD, Joseph H. Feinberg, MD

Purpose To compare the functional and EMG outcomes of long-nerve grafts to nerve transfersfor complete axillary nerve palsy.

Methods Over a 10-year period at a single institution, 14 patients with axillary nerve palsy weretreated with long-nerve grafts and 24 patients were treated with tricepsetoeaxillary nervetransfers by the same surgeon (S.W.W.). Data were collected prospectively at regular intervals,beginning before surgery and continuing up to 11 years after surgery. Prior to intervention, allpatients demonstrated EMG evidence of complete denervation of the deltoid. Deltoid recovery(Medical Research Council [MRC] grade), shoulder abduction (!), improvement in shoulderabduction (!), and EMG evidence of deltoid reinnervation were compared between cohorts.

Results There were no significant differences between the long-nerve graft cohort and the nervetransfer cohort with respect to postoperative range of motion, deltoid recovery, improvementin shoulder abduction, or EMG evidence of deltoid reinnervation.

Conclusions These data demonstrate that outcomes of long-nerve grafts for axillary nerve palsyare comparable with those of modern nerve transfers and question a widely held belief thatlong-nerve grafts do poorly. When healthy donor roots or trunks are available, long-nervegrafts should not be overlooked as an effective intervention for the treatment of axillary nerveinjuries in adults with brachial plexus injuries. (J Hand Surg Am. 2014;39(7):1351e1357.Copyright ! 2014 by the American Society for Surgery of the Hand. All rights reserved.)

Type of study/level of evidence Therapeutic III.Key words Axillary nerve, brachial plexus, nerve graft, nerve transfer, outcomes.

B RACHIAL PLEXUS INJURIES in adults are mostcommonly the result of high-speed vehiculartrauma and can debilitate a predominantly

young, healthy, active group of individuals. A numberof surgical treatment options have been described,including nerve repair, nerve graft, and nerve trans-fer.1,2 Several authors have demonstrated relativelypoor outcomes in patients treated with long-nervegrafts for brachial plexus injuries.3e5 Terzis andBarmpitsioti6 reported that patients who receivednerve grafts longer than 6 cm experienced signifi-cantly worse outcomes than those with short nervegrafts (P < .02). In a 2011 systematic analysiscomparing the results of nerve transfers and nervegrafts in patients with traumatic upper plexus (C5-6or C5-6-7) palsy, Garg et al7 demonstrated superioroutcomes of shoulder and elbow function in patientstreated with nerve transfers over those treated withnerve grafts. Indeed, nerve transfers for axillary nerve

From the Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for SpecialSurgery, New York, NY.

Received for publication September 16, 2013; accepted in revised form February 27, 2014.

The authors gratefully acknowledge Adele Mirbey, BA, for her efforts in assisting with datacollection, Ronald Emerson, MD, for his careful assessment of intraoperative somatosensory-evoked potentials, and Edward DiCarlo, MD, for his expertise with intraoperative root histology.

No benefits in any form have been received or will be received related directly orindirectly to the subject of this article.

Corresponding author: Scott W. Wolfe, MD, The Hospital for Special Surgery, 535 E.70th St., New York, NY 10021; e-mail: [email protected].

0363-5023/14/3907-0016$36.00/0http://dx.doi.org/10.1016/j.jhsa.2014.02.032

! 2014 ASSH r Published by Elsevier, Inc. All rights reserved. r 1351

SCIENTIFIC ARTICLE

Long-Nerve Grafts and Nerve TransfersDemonstrate Comparable Outcomes for

Axillary Nerve InjuriesScott W. Wolfe, MD, Parker H. Johnsen, BS, Steve K. Lee, MD, Joseph H. Feinberg, MD

Purpose To compare the functional and EMG outcomes of long-nerve grafts to nerve transfersfor complete axillary nerve palsy.

Methods Over a 10-year period at a single institution, 14 patients with axillary nerve palsy weretreated with long-nerve grafts and 24 patients were treated with tricepsetoeaxillary nervetransfers by the same surgeon (S.W.W.). Data were collected prospectively at regular intervals,beginning before surgery and continuing up to 11 years after surgery. Prior to intervention, allpatients demonstrated EMG evidence of complete denervation of the deltoid. Deltoid recovery(Medical Research Council [MRC] grade), shoulder abduction (!), improvement in shoulderabduction (!), and EMG evidence of deltoid reinnervation were compared between cohorts.

Results There were no significant differences between the long-nerve graft cohort and the nervetransfer cohort with respect to postoperative range of motion, deltoid recovery, improvementin shoulder abduction, or EMG evidence of deltoid reinnervation.

Conclusions These data demonstrate that outcomes of long-nerve grafts for axillary nerve palsyare comparable with those of modern nerve transfers and question a widely held belief thatlong-nerve grafts do poorly. When healthy donor roots or trunks are available, long-nervegrafts should not be overlooked as an effective intervention for the treatment of axillary nerveinjuries in adults with brachial plexus injuries. (J Hand Surg Am. 2014;39(7):1351e1357.Copyright ! 2014 by the American Society for Surgery of the Hand. All rights reserved.)

Type of study/level of evidence Therapeutic III.Key words Axillary nerve, brachial plexus, nerve graft, nerve transfer, outcomes.

B RACHIAL PLEXUS INJURIES in adults are mostcommonly the result of high-speed vehiculartrauma and can debilitate a predominantly

young, healthy, active group of individuals. A numberof surgical treatment options have been described,including nerve repair, nerve graft, and nerve trans-fer.1,2 Several authors have demonstrated relativelypoor outcomes in patients treated with long-nervegrafts for brachial plexus injuries.3e5 Terzis andBarmpitsioti6 reported that patients who receivednerve grafts longer than 6 cm experienced signifi-cantly worse outcomes than those with short nervegrafts (P < .02). In a 2011 systematic analysiscomparing the results of nerve transfers and nervegrafts in patients with traumatic upper plexus (C5-6or C5-6-7) palsy, Garg et al7 demonstrated superioroutcomes of shoulder and elbow function in patientstreated with nerve transfers over those treated withnerve grafts. Indeed, nerve transfers for axillary nerve

From the Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for SpecialSurgery, New York, NY.

Received for publication September 16, 2013; accepted in revised form February 27, 2014.

The authors gratefully acknowledge Adele Mirbey, BA, for her efforts in assisting with datacollection, Ronald Emerson, MD, for his careful assessment of intraoperative somatosensory-evoked potentials, and Edward DiCarlo, MD, for his expertise with intraoperative root histology.


Corresponding author: Scott W. Wolfe, MD, The Hospital for Special Surgery, 535 E.70th St., New York, NY 10021; e-mail: [email protected].


! 2014 ASSH r Published by Elsevier, Inc. All rights reserved. r 1351

Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

www.PRSJournal.com256e

Isolated axillary nerve injuries with resultant paralysis of the deltoid muscle have significant implications for shoulder function and stabil-

ity.1–3 These types of lesions most commonly arise following trauma but can also be iatrogenic.4–6 The most common zones of injury are either distal to the takeoff of the axillary nerve from the posterior cord

or proximal to the quadrilateral space.5 Although range of motion of the shoulder may be normal secondary to function of the rotator cuff muscles, power of shoulder motion and overhead activity can be severely affected. Surgical intervention is indicated for axillary nerve lesions that do not have evidence of recovery by 3 to 6 months.2,3,5 Transfer of a triceps branch of the radial nerve to the axil-lary nerve, as described by Leechavengvongs et al.,7

Disclosure: The authors have no financial interest to declare in relation to the content of this article.Copyright © 2016 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0000000000002368

Heather L. Baltzer, M.D.Michelle F. Kircher, B.S.Robert J. Spinner, M.D.

Allen T. Bishop, M.D.Alexander Y. Shin, M.D.

Rochester, Minn.

Background: Deltoid paralysis following isolated axillary nerve injury can be managed with triceps motor branch transfer or interpositional grafting. No consensus exists on the treatment that results in superior deltoid function. The purpose of this study was to review the authors’ experience with axillary nerve injury management and compare functional outcomes following these two treatment options.Methods: Twenty-nine adult isolated axillary nerve injury patients that had either interpositional nerve grafting or triceps motor branch transfer with greater than 1 year of follow-up between 2002 and 2013 were reviewed for demographic and clinical factors and functional outcomes of deltoid reinner-vation, including clinical examination (shoulder abduction and forward flex-ion graded by the Medical Research Council system) and electromyographic recovery. Disabilities of the Arm, Shoulder, and Hand scale grades were also compared.Results: Twenty-one patients had a triceps motor transfer and eight had interpositional nerve grafting. At a mean follow-up of 22 months, Medi-cal Research Council scores were greater in the grafting group compared with the nerve transfer group (4.3 versus 3.0), and more graft patients achieved useful deltoid function (Medical Research Council score ≥3) re-covery (100 percent versus 62 percent); however, both groups had similar improvement in self-reported disability: change in Disabilities of the Arm, Shoulder, and Hand score of 11 following nerve transfer versus 15 follow-ing nerve graft.Conclusions: Although the question of nerve transfer versus grafting for resto-ration of axillary nerve function is controversial, this study demonstrates that grafting can result in good objective functional outcomes, particularly during an earlier time course after injury. This question requires further investigation in a larger, prospective patient population. (Plast. Reconstr. Surg. 138: 256e, 2016.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

From the Orthopedic Department, Mayo Clinic. Received for publication August 26, 2015; accepted March 21, 2016.

A Comparison of Outcomes of Triceps Motor Branch–to–Axillary Nerve Transfer or Sural Nerve Interpositional Grafting for Isolated Axillary Nerve Injury

HAND/PERIPHERAL NERVE







DOI: 10.1097/PRS.0000000000002368



Rochester, Minn.











DOI: 10.1097/PRS.0000000000002368



Rochester, Minn.





Nerve Transfer vs. Graft: Key Considerations

•  Level of Injury •  C7 nerve root/posterior cord injury –

•  triceps strength •  Pre-operative EMG triceps

•  Patient age •  Time from injury •  Body habitus

Nerve Transfer vs. Graft: Supraclavicular Upper Plexus Injury

Injury Transfer GraftPreganglionicC5-6

✔ ✗

PostganglionicC5-6*

✔

✔

PostganglionicC5-6-7**

✗

✔

*PtAge/Injurytiming**Tricepsfunction/EMG

the open injury is secondary to ablunt object with avulsion of thenerve, the ends of the laceratednerve should be tagged and a delayedrepair performed 3 to 4 weeks later.By 3 to 4 weeks, the injured nerveends will have demarcated, enablingbetter access to the zone of nerve in-jury. Low-velocity gunshot woundsshould be observed because most ofthese injuries are neurapraxic; how-ever, high-velocity gunshot woundsare associated with significant soft-tissue damage and usually mandatesurgical exploration.

For stretch injuries, the exact tim-ing of surgery is more controversial.The timing is determined somewhatby the mechanism and type of injury,physical examination and imagingfindings, and surgeon preference. Op-erating early may not allow sufficient

time for spontaneous reinnervation,but waiting too long before operatingmay unnecessarily lead to failure ofthe motor end plate and thus failureof reinnervation. Early explorationand reconstruction (between 3 and 6weeks) is indicated when there is ahigh suspicion of root avulsion. Rou-tine exploration is performed 3 to 6months after injury in patients whohave not demonstrated adequate rein-nervation. Results from delayed (6 to12 months) or late (>12 months) sur-gery are poorer because the time forthe nerve to regenerate to the targetmuscles is greater than the survivaltime of the motor end plate after de-enervation.

Most surgeons consider elbowflexion the highest priority when re-storing function to the flail extrem-ity. Next in priority are shoulder ab-

duction and stability, hand sensibility,wrist extension and finger flexion,wrist flexion and finger extension,and intrinsic function of the hand.

Surgery

Brachial plexus surgery can be dividedinto primary and secondary recon-struction. Primary reconstruction isthe initial surgical management andmay include nerve surgery/recon-struction (eg, direct repair, neuroly-sis, nerve grafting, nerve transfers)and/or soft-tissue procedures (eg, freefunctioning muscle transfer). Second-ary reconstruction may be necessaryto improve function, either to aug-ment partial recovery or to obtainfunction when none has beenachieved. This may include soft-tissue reconstruction (eg, tendon/muscle transfer, free muscle transfer)and bony procedures (eg, arthrodesis,osteotomy), but typically not nervesurgery. Often a combination of thesetechniques can be used, necessitatinga broad surgical armamentarium.

Primary ReconstructionDirect repair of nerve ends can be

done after sharp injuries (eg, lacera-tions), but it cannot be applied tostretch injuries. External neurolysisis a necessary prerequisite for intra-operative electrical studies. Neurol-ysis alone may be performed whenthe nerve is in continuity and a NAPis obtained.22

Intraplexal Nerve GraftingNerve grafting can be performed

with ruptures or postganglionic neu-romas that do not conduct a NAPacross the lesion. In such cases, thenerve root—because of its connec-tion to the spinal cord—has main-tained viable motor axons that canbe grafted to specific targets. Interpo-sitional grafts (typically using cablegrafts of sural or other cutaneousnerves) are coapted between nervestumps without undue tension. Forexample, C5 is targeted for shoulderabduction (suprascapular nerve, axil-

Figure 4

Intraplexal nerve grafting with donor nerves can be performed in the setting ofpostganglionic injury with viable nerve root stumps available. With postganglionicinjuries on C5, C6, and C7, nerve grafts can be used to target shoulder abduction(C5 to the suprascapular nerve [A] and posterior division of the upper trunk [B]),elbow flexion (C6 to the anterior division of the upper trunk [C]), and wrist extensionand elbow extension (C7 to the posterior division of the middle trunk, targetingradial nerve function [D]). SSN = suprascapular nerve. (Adapted by permission ofMayo Foundation.)

Adult Traumatic Brachial Plexus Injuries

388 Journal of the American Academy of Orthopaedic Surgeons

C5 root à Post. Division Grafting

the open injury is secondary to ablunt object with avulsion of thenerve, the ends of the laceratednerve should be tagged and a delayedrepair performed 3 to 4 weeks later.By 3 to 4 weeks, the injured nerveends will have demarcated, enablingbetter access to the zone of nerve in-jury. Low-velocity gunshot woundsshould be observed because most ofthese injuries are neurapraxic; how-ever, high-velocity gunshot woundsare associated with significant soft-tissue damage and usually mandatesurgical exploration.

For stretch injuries, the exact tim-ing of surgery is more controversial.The timing is determined somewhatby the mechanism and type of injury,physical examination and imagingfindings, and surgeon preference. Op-erating early may not allow sufficient

time for spontaneous reinnervation,but waiting too long before operatingmay unnecessarily lead to failure ofthe motor end plate and thus failureof reinnervation. Early explorationand reconstruction (between 3 and 6weeks) is indicated when there is ahigh suspicion of root avulsion. Rou-tine exploration is performed 3 to 6months after injury in patients whohave not demonstrated adequate rein-nervation. Results from delayed (6 to12 months) or late (>12 months) sur-gery are poorer because the time forthe nerve to regenerate to the targetmuscles is greater than the survivaltime of the motor end plate after de-enervation.

Most surgeons consider elbowflexion the highest priority when re-storing function to the flail extrem-ity. Next in priority are shoulder ab-

duction and stability, hand sensibility,wrist extension and finger flexion,wrist flexion and finger extension,and intrinsic function of the hand.

Surgery

Brachial plexus surgery can be dividedinto primary and secondary recon-struction. Primary reconstruction isthe initial surgical management andmay include nerve surgery/recon-struction (eg, direct repair, neuroly-sis, nerve grafting, nerve transfers)and/or soft-tissue procedures (eg, freefunctioning muscle transfer). Second-ary reconstruction may be necessaryto improve function, either to aug-ment partial recovery or to obtainfunction when none has beenachieved. This may include soft-tissue reconstruction (eg, tendon/muscle transfer, free muscle transfer)and bony procedures (eg, arthrodesis,osteotomy), but typically not nervesurgery. Often a combination of thesetechniques can be used, necessitatinga broad surgical armamentarium.

Primary ReconstructionDirect repair of nerve ends can be

done after sharp injuries (eg, lacera-tions), but it cannot be applied tostretch injuries. External neurolysisis a necessary prerequisite for intra-operative electrical studies. Neurol-ysis alone may be performed whenthe nerve is in continuity and a NAPis obtained.22

Intraplexal Nerve GraftingNerve grafting can be performed

with ruptures or postganglionic neu-romas that do not conduct a NAPacross the lesion. In such cases, thenerve root—because of its connec-tion to the spinal cord—has main-tained viable motor axons that canbe grafted to specific targets. Interpo-sitional grafts (typically using cablegrafts of sural or other cutaneousnerves) are coapted between nervestumps without undue tension. Forexample, C5 is targeted for shoulderabduction (suprascapular nerve, axil-

Figure 4

Intraplexal nerve grafting with donor nerves can be performed in the setting ofpostganglionic injury with viable nerve root stumps available. With postganglionicinjuries on C5, C6, and C7, nerve grafts can be used to target shoulder abduction(C5 to the suprascapular nerve [A] and posterior division of the upper trunk [B]),elbow flexion (C6 to the anterior division of the upper trunk [C]), and wrist extensionand elbow extension (C7 to the posterior division of the middle trunk, targetingradial nerve function [D]). SSN = suprascapular nerve. (Adapted by permission ofMayo Foundation.)

Adult Traumatic Brachial Plexus Injuries

388 Journal of the American Academy of Orthopaedic Surgeons

C5 root à Post Cord / Axillary Nerve Grafting

C5 root à Post. Division Grafting

1 Year Post C5 root à Post. Division Grafting

EMG: Early reinnervation middle/ant deltoid, supraspinatus & infraspinatus

Nerve Transfer vs. Graft: Infraclavicular Plexus Injury

Posterior Cord Injury •  Pull through Cable Graft Reconstruction •  Nerve transfers:

•  Long thoracic •  Thoracodorsal* •  Ulnar/Median Fascicles

Nerve Transfer vs. Graft: Infraclavicular Plexus Injury

Axillary Nerve Injury •  Pull through Cable Graft Reconstruction •  Triceps br à Axillary Nerve Transfer

*PtAge/Injurytiming

Nerve Graft vs. Transfer: Isolated Axillary Nerve Injury


www.PRSJournal.com 953

As our understanding of traumatic periph-eral nerve injuries has grown, methods for reconstructing nerve defects not amenable

to primary repair have evolved. Nerve grafting is considered the standard of care1,2 and depends on neurotization from the donor to target nerve, two sites of nerve coaptation, and an adequate vascular bed in the zone of injury. Nerve transfer techniques have recently gained momentum for their ability to reduce the neurotization distance to the motor endplate target, focus microsurgery

to a single nerve coaptation, and bypass the zone of injury.3–5 Presently, there remains little consen-sus as to whether interpositional nerve grafting or nerve transfer procedures provide for better func-tional recovery.

The management of isolated axillary nerve injuries can potentially provide some insight into this reconstructive dilemma. These injuries most commonly occur from fractures and dislocations of the proximal humerus, as the axillary nerve passes through the quadrangular space to inner-vate the deltoid muscle. Although initiation of abduction is preserved through the supraspinatus muscle vis-à-vis the suprascapular nerve, overhead reach is significantly limited in the absence of deltoid function. Surgical intervention is typically


DOI: 10.1097/PRS.0000000000003749

John C. Koshy, M.D.Nikhil A. Agrawal, M.D.

Mitchel Seruya, M.D.Houston, Texas; and Los Angeles, Calif.

Background: The purpose of this study was to compare functional outcomes between nerve grafting and nerve transfer procedures in the setting of isolated, posttraumatic axillary nerve injuries.Methods: A systematic review was performed using the PubMed, Scopus, and Cochrane databases to identify all cases of isolated, posttraumatic axillary nerve injuries in patients aged 18 years or older. Patients who underwent axil-lary nerve reconstruction were included and categorized by technique: graft or transfer. Demographics were recorded, including age, time to operation, and presence of concomitant injuries. Functional outcomes were evaluated, including British Medical Research Council strength and range of motion for shoulder abduction.Results: Ten retrospective studies met criteria, for a total of 66 patients (20 nerve grafts and 46 nerve transfers). Median time from injury to operation was equivalent across the nerve graft and nerve transfer groups (8.0 months versus 7.0 months; p = 0.41). Postoperative follow-up was 24.0 months for nerve graft-ing versus 18.5 months for nerve transfer (p = 0.13). Clinically useful shoulder abduction, defined as British Medical Research Council grade M3 or greater, was obtained in 100 percent of nerve graft patients versus 87 percent of nerve trans-fer patients (p = 0.09). Grade M4 or better strength was obtained in 85 percent of nerve graft patients and 73.9 percent of nerve transfer patients (p = 0.32).Conclusions: Significant differences in functional outcomes between nerve graft and transfer procedures for posttraumatic axillary nerve injuries are not appar-ent at this time. Prospective outcomes studies are needed to better elucidate whether functional differences do exist. (Plast. Reconstr. Surg. 140: 953, 2017.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

From the Division of Plastic Surgery, Baylor College of Medi-cine; and the Children’s Hospital of Los Angeles.Received for publication February 3, 2017; accepted April 4, 2017.Presented at Plastic Surgery The Meeting 2016, Annual Meeting of the American Society of Plastic Surgeons, in Los Angeles, California, September 23 through 27, 2016.

Nerve Transfer versus Interpositional Nerve Graft Reconstruction for Posttraumatic, Isolated Axillary Nerve Injuries: A Systematic Review

2017









DOI: 10.1097/PRS.0000000000003749


Mitchel Seruya, M.D.Houston, Texas; and Los Angeles, Calif.




2017









DOI: 10.1097/PRS.0000000000003749


Mitchel Seruya, M.D.

Houston, Texas; and Los Angeles, Calif.




2017


•  No significant difference in outcomes between transfer and graft patients

•  Stratifying by: •  age >40 did not influence results •  delay >6 months to surgery Did not influence outcome between treatments

Sural Nerve Cable Grafting Posterior Cord à Axillary Nerve

Dow

nloadedfrom

https://journals.lww.com

/techhandsurgby

BhDMf5ePH

Kav1zEoum1tQ

fN4a+kJLhEZgbsIH

o4XMi0hC

ywCX1AW

nYQp/IlQ

rHD3lO

0fy3QXco9eG

6GRxYhoVm

QErsG

VSPyvmWzAKR

sviZEa4g50KBDPFw

==on

07/07/2020

Downloadedfromhttps://journals.lww.com/techhandsurgbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3lO0fy3QXco9eG6GRxYhoVmQErsGVSPyvmWzAKRsviZEa4g50KBDPFw==on07/07/2020

Axillary Nerve Reconstruction: Anterior-Posterior ExposureWith Sural Nerve Cable Graft Pull-Through Technique

Heather L. Baltzer, MD, Robert J. Spinner, MD, Allen T. Bishop, MD, andAlexander Y. Shin, MD

Abstract: Deltoid paralysis after axillary nerve injury results in

limitations in shoulder function and stability. In the setting of an iso-

lated axillary nerve injury with no clinical or electromyographic evi-

dence of recovery that is within 6 to 9 months postinjury, the authors’

preferred technique to reinnervate the deltoid is to reconstruct the

axillary nerve with sural nerve grafting. Intraoperative neuromuscular

electrophysiology is critical to determine the continuity of the axillary

nerve before proceeding with reconstruction. The majority of the time,

both an anterior and posterior incision and dissection of the axillary

nerve is required to adequately delineate the zone of injury. This also

ensures that both proximally and distally, uninjured axillary nerve is

present before graft inset and also facilitates the ability to perform a

meticulous microsurgical inset of the nerve graft posteriorly. The nerve

graft must be pulled through from posterior to anterior to span the zone

of injury and reconstruct the axillary nerve. Careful infraclavicular

brachial plexus dissection is necessary to prevent further injury to

components of the brachial plexus in the setting of a scarred bed.

Patients will require postoperative therapy to prevent limitations in

shoulder range of motion secondary to postoperative stiffness. This

paper presents a detailed surgical technique for axillary nerve recon-

struction by an anterior-posterior approach with a pull-through tech-

nique of a sural nerve cable graft.

Key Words: axillary nerve injury, brachial plexus injury, deltoid

paralysis

(Tech Hand Surg 2015;19: 168–175)

Axillary nerve injuries with resultant deltoid paralysis aremost commonly posttraumatic or iatrogenic in nature1–3

and lead to limited shoulder function and stability.4–6 Althoughrange of motion may not be affected with a functioningsupraspinatus muscle, patients may experience pain fromdownward traction on the glenohumeral joint and fatigabilityand weakness with overhead activities. There will also beesthetic implications secondary to the atrophied and hollowedappearance of the deltoid (Fig. 1). In the absence of sponta-neous recovery of deltoid function, the conventional approachto deltoid reinnervation as described by Bonnard and Terzis,has been interpositional nerve grafting to span the zone ofinjury to reconstruct an isolated axillary nerve injury or C5-6nerve root ruptures.6–8 An alternative to interpositional nervegrafting is the transfer of a triceps branch of the radial nerve to

the axillary nerve, as described by Leechavengvong et al.9 TheLeechavengvong procedure is performed through a single,posterior incision with dissection outside of the zone of injuryand does not require a graft. Controversy exists over which ofthese techniques, nerve transfer or axillary nerve recon-struction using interpositional grafting, produces improvedfunctional outcomes.

There have been several studies reporting outcomes ofdeltoid reinnervation using interpositional nerve grafting of theaxillary nerve.5–8,10–12 The different reports provide varyinglevel of detail for this reconstructive technique and the use of aposterior incision varied, but was most common if the lesionwas at the level of, or extended to, the quadrilateral space. Themost common zones of injury are either distal to the takeoff ofthe axillary nerve from the posterior cord or proximal to thequadrilateral space.2 Inset of the nerve graft through an ante-rior infraclavicular approach at the level of the quadrilateralspace is technically challenging and may compromise thequality of the distal nerve-graft coaptation, ultimately com-promising the potential to have optimal deltoid reinnervation.In the circumstance of axillary nerve injury that is distalenough to compromise the ability to perform distal nerve-graftcoaptation, it is currently our preference to make a second,posterior incision and perform a posterior-to-anterior pull-through grafting technique to reconstruct the axillary nerve.Although this technique has been presented in the context of aresearch study,11 a detailed description has been has not beenprovided. The purpose of this technique paper is to detail theposterior-to-anterior cable graft pull-through technique as ameans of improving outcomes by giving the surgeon thegreatest technical advantage during the nerve reconstruction.

ANATOMY OF THE AXILLARY NERVEThe axillary nerve is a terminal branch of the posterior cord ofthe infraclavicular brachial plexus formed by fibers of the C5and C6 nerve roots. The axillary nerve can be found posteriorto the axillary artery, anterior to the subscapularis, and lateralto the radial artery through an anterior dissection. At theinferior border of the subscapularis, the axillary nerve takes aposterior trajectory to pass through the quadrangular spaceaccompanied by the posterior circumflex humeral artery(superior: teres minor; inferior: teres major; lateral: lateralhead of Triceps brachii; medial: long head of Triceps brachii)(Fig. 2). Within this interval, the nerve divides into the anteriorbranch passes around the surgical neck of the humerus with theposterior circumflex humeral artery innervating the anteriorand middle parts of the deltoid muscle and 91% of the time thisanterior branch will innervate the posterior deltoid.9 The pos-terior division is a mixed motor-sensory branch that suppliesthe posterior deltoid 97%13 of the time and the teres minorterminating as the lateral brachial cutaneous nerve providingsensation over the deltoid and glenohumeral joint.

From the The Department of Orthopedic Surgery, Mayo Clinic, Rochester,MN.No funding was received for this work from National Institutes of Health

(NIH), Wellcome Trust, Howard Hughes Medical Institute (HHMI), orany other institution.

Conflicts of Interest and Source of Funding: The authors report no conflictsof interest and no source of funding.

Address correspondence and reprint requests to Alexander Y. Shin, MD,Department of Orthopedic Surgery, Mayo Clinic, 200 First St., SW,Rochester, MN 55905. E-mail: [email protected].

Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

TECHNIQUE

168 | www.techhandsurg.com Techniques in Hand & Upper Extremity Surgery ! Volume 19, Number 4, December 2015


Dow

nloadedfrom

https://journals.lww.com

/techhandsurgby

BhDMf5ePH

Kav1zEoum1tQ

fN4a+kJLhEZgbsIH

o4XMi0hC

ywCX1AW

nYQp/IlQ

rHD3lO

0fy3QXco9eG

6GRxYhoVm

QErsG

VSPyvmWzAKR

sviZEa4g50KBDPFw

==on

07/07/2020

Downloadedfromhttps://journals.lww.com/techhandsurgbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3lO0fy3QXco9eG6GRxYhoVmQErsGVSPyvmWzAKRsviZEa4g50KBDPFw==on07/07/2020

Axillary Nerve Reconstruction: Anterior-Posterior ExposureWith Sural Nerve Cable Graft Pull-Through Technique

Heather L. Baltzer, MD, Robert J. Spinner, MD, Allen T. Bishop, MD, andAlexander Y. Shin, MD

Abstract: Deltoid paralysis after axillary nerve injury results in

limitations in shoulder function and stability. In the setting of an iso-

lated axillary nerve injury with no clinical or electromyographic evi-

dence of recovery that is within 6 to 9 months postinjury, the authors’

preferred technique to reinnervate the deltoid is to reconstruct the

axillary nerve with sural nerve grafting. Intraoperative neuromuscular

electrophysiology is critical to determine the continuity of the axillary

nerve before proceeding with reconstruction. The majority of the time,

both an anterior and posterior incision and dissection of the axillary

nerve is required to adequately delineate the zone of injury. This also

ensures that both proximally and distally, uninjured axillary nerve is

present before graft inset and also facilitates the ability to perform a

meticulous microsurgical inset of the nerve graft posteriorly. The nerve

graft must be pulled through from posterior to anterior to span the zone

of injury and reconstruct the axillary nerve. Careful infraclavicular

brachial plexus dissection is necessary to prevent further injury to

components of the brachial plexus in the setting of a scarred bed.

Patients will require postoperative therapy to prevent limitations in

shoulder range of motion secondary to postoperative stiffness. This

paper presents a detailed surgical technique for axillary nerve recon-

struction by an anterior-posterior approach with a pull-through tech-

nique of a sural nerve cable graft.

Key Words: axillary nerve injury, brachial plexus injury, deltoid

paralysis

(Tech Hand Surg 2015;19: 168–175)

Axillary nerve injuries with resultant deltoid paralysis aremost commonly posttraumatic or iatrogenic in nature1–3

and lead to limited shoulder function and stability.4–6 Althoughrange of motion may not be affected with a functioningsupraspinatus muscle, patients may experience pain fromdownward traction on the glenohumeral joint and fatigabilityand weakness with overhead activities. There will also beesthetic implications secondary to the atrophied and hollowedappearance of the deltoid (Fig. 1). In the absence of sponta-neous recovery of deltoid function, the conventional approachto deltoid reinnervation as described by Bonnard and Terzis,has been interpositional nerve grafting to span the zone ofinjury to reconstruct an isolated axillary nerve injury or C5-6nerve root ruptures.6–8 An alternative to interpositional nervegrafting is the transfer of a triceps branch of the radial nerve to

the axillary nerve, as described by Leechavengvong et al.9 TheLeechavengvong procedure is performed through a single,posterior incision with dissection outside of the zone of injuryand does not require a graft. Controversy exists over which ofthese techniques, nerve transfer or axillary nerve recon-struction using interpositional grafting, produces improvedfunctional outcomes.

There have been several studies reporting outcomes ofdeltoid reinnervation using interpositional nerve grafting of theaxillary nerve.5–8,10–12 The different reports provide varyinglevel of detail for this reconstructive technique and the use of aposterior incision varied, but was most common if the lesionwas at the level of, or extended to, the quadrilateral space. Themost common zones of injury are either distal to the takeoff ofthe axillary nerve from the posterior cord or proximal to thequadrilateral space.2 Inset of the nerve graft through an ante-rior infraclavicular approach at the level of the quadrilateralspace is technically challenging and may compromise thequality of the distal nerve-graft coaptation, ultimately com-promising the potential to have optimal deltoid reinnervation.In the circumstance of axillary nerve injury that is distalenough to compromise the ability to perform distal nerve-graftcoaptation, it is currently our preference to make a second,posterior incision and perform a posterior-to-anterior pull-through grafting technique to reconstruct the axillary nerve.Although this technique has been presented in the context of aresearch study,11 a detailed description has been has not beenprovided. The purpose of this technique paper is to detail theposterior-to-anterior cable graft pull-through technique as ameans of improving outcomes by giving the surgeon thegreatest technical advantage during the nerve reconstruction.

ANATOMY OF THE AXILLARY NERVEThe axillary nerve is a terminal branch of the posterior cord ofthe infraclavicular brachial plexus formed by fibers of the C5and C6 nerve roots. The axillary nerve can be found posteriorto the axillary artery, anterior to the subscapularis, and lateralto the radial artery through an anterior dissection. At theinferior border of the subscapularis, the axillary nerve takes aposterior trajectory to pass through the quadrangular spaceaccompanied by the posterior circumflex humeral artery(superior: teres minor; inferior: teres major; lateral: lateralhead of Triceps brachii; medial: long head of Triceps brachii)(Fig. 2). Within this interval, the nerve divides into the anteriorbranch passes around the surgical neck of the humerus with theposterior circumflex humeral artery innervating the anteriorand middle parts of the deltoid muscle and 91% of the time thisanterior branch will innervate the posterior deltoid.9 The pos-terior division is a mixed motor-sensory branch that suppliesthe posterior deltoid 97%13 of the time and the teres minorterminating as the lateral brachial cutaneous nerve providingsensation over the deltoid and glenohumeral joint.

From the The Department of Orthopedic Surgery, Mayo Clinic, Rochester,MN.No funding was received for this work from National Institutes of Health

(NIH), Wellcome Trust, Howard Hughes Medical Institute (HHMI), orany other institution.

Conflicts of Interest and Source of Funding: The authors report no conflictsof interest and no source of funding.

Address correspondence and reprint requests to Alexander Y. Shin, MD,Department of Orthopedic Surgery, Mayo Clinic, 200 First St., SW,Rochester, MN 55905. E-mail: [email protected].


TECHNIQUE

168 | www.techhandsurg.com Techniques in Hand & Upper Extremity Surgery ! Volume 19, Number 4, December 2015


1 Year Post Posterior Cord à Axillary Nerve Grafting

Triceps Branch To Axillary Nerve Transfer

Which Triceps Branch Should I Use? SCIENTIFIC ARTICLE

Axon Counts Yield Multiple Options for TricepsFascicular Nerve to Axillary Nerve Transfer

M. Michael Khair, MD,* Joseph J. Schreiber, MD,* Lauren Rosenblatt, BA,*David J. Byun, BS,* Steve K. Lee, MD,* Scott W. Wolfe, MD*

Purpose To evaluate the relative axonal match between potential donor and recipient nerves, sothat maximal reinnervation potential may be reachedwith the least chance of donor sitemorbidity.

Methods In 10 fresh-frozen cadaveric specimens, the main trunk and anterior, posterior,sensory and teres minor branches of the axillary nerve were identified, as were the radial nervebranches to the long, medial, and lateral heads of the triceps. The swing distances ofthe triceps fascicular nerve branches and the axillary nerve branches relative to the inferiorborder of the teres major muscle were recorded. Histomorphological analysis and axon countswere performed on sections of each branch.

Results The median number of axons in the main axillary trunk was 7,887, with 4,052, 1,242,and 1,161 axons in the anterior, posterior, and teres minor branches, respectively. All spec-imens had a single long head triceps branch (median, 2,302 axons), a range of 1 to 3 branchesto the medial head of the triceps (composite axon count, 2,198 axons), and 1 to 3 branches tothe lateral head of the triceps (composite average, 1,462 axons). The medial and lateral headbranches had sufficient swing distance to reach the anterior branch of the axillary nerve in all10 specimens, with only 4 specimens having adequate long head branch swing distances.

Conclusions It is anatomically feasible to transfer multiple branches of the radial nerve sup-plying the medial, lateral, and sometimes, long head of the triceps to all branches of theaxillary nerve in an attempt to reinnervate the deltoid and teres minor muscles.

Clinical relevance Understanding the axon counts of the different possible transfer combinationswill improve operative flexibility and enable peripheral nerve surgeons to reinnervate for bothabduction and external rotation with the highest donor/recipient axon count ratios. (J HandSurg Am. 2016;41(11):e405ee410. Copyright! 2016 by the American Society for Surgery ofthe Hand. All rights reserved.)Key words Brachial plexus, axillary nerve, nerve injury, nerve transfer, radial nerve.

U PPER TRUNK INJURIES OF THE BRACHIAL plexusresult in denervation of the deltoid, rotatorcuff (supraspinatus, subscapularis, infra-

spinatus, teres minor), biceps, and brachialis muscles,with a resultant loss of shoulder and elbow function.Shoulder function can also be severely compromisedfollowing isolated axillary nerve injury.1,2 Just asdirect fascicular transfers from the ulnar and/or me-dian nerve can successfully restore biceps and bra-chialis function,3e5 nerve transfers to the axillarynerve can restore function of the deltoid muscle.6e8

From the *Hand and Upper Extremity Center for Brachial Plexus and Traumatic NerveInjury, Hospital for Special Surgery, New York, NY.

Received for publication April 9, 2016; accepted in revised form July 25, 2016.


M.M.K. received a Surgeon-In-Chief Grant from the Hospital for Special Surgery, NewYork, NY.

Corresponding author: M. Michael Khair, MD, 9301 N. Central Expressway, Dallas, TX75231; e-mail: [email protected].


! 2016 ASSH r Published by Elsevier, Inc. All rights reserved. r e405

SCIENTIFIC ARTICLE

















SCIENTIFIC ARTICLE

















nerve branch as well as its anatomical ability to reachits target. Six of 10 specimens in this study had insuf-ficient length of the long head triceps branches to reachthe anterior division of the axillary nerve. This insuf-ficient length has been previously noted and, occa-sionally, necessitates dividing the inferior portion ofthe teres major in order to reach the axillary nerve.1,17

In contrast, the medial and lateral head brancheshad significantly longer swing distances, which were

sufficient to allow for direct transfer to the anteriorbranch of the axillary nerve in all specimens.

Our axon count data also demonstrate notable dif-ferences in donor-to-recipient axon count ratios for thevarious tricepsbranches relative to the anterior branchofthe axillary nerve. The optimal donor-to-recipient nerveaxon count ratio for restoring function is controversial.Animal studies of partial nerve sectioning suggest thatas few as 20% of remaining motor units can provide

TABLE 1. Median Axon Count and Branching Data of Radial Nerve Triceps Branches and Components of theAxillary Nerve*

NerveCompositeAxon Count

Single-BranchSpecimens

Two-BranchSpecimens

Three-BranchSpecimens

Donor Nerves

Long head triceps 2,302 (553e2,771) 2,302 (553e2,771)n ¼ 10

- -

Medial head triceps 2,198 (679e4,428) 1,351 (679e3,636)n ¼ 6

4,289 (2,663e4,428)n ¼ 3

2,451n ¼ 1

Lateral head triceps 1,462 (211e4,187) 477 (211e1,899)n ¼ 5

1,462 (936e2,163)n ¼ 3

3,097 (2,006e4,187)n ¼ 2

Recipient Nerves

Main axillary trunk 7,887 (5,613e9,280)

Anterior division 4,052 (1,541e5,768)

Posterior division 1,242 (610e3,181)

Sensory division 1,239 (588e2,165)

Teres minor 1,161 (467e1,656)

-, not applicable; n, the number of specimens with that branching pattern.*Ranges are in parentheses.

TABLE 2. Mean Swing Distances of Studied Donor and Recipient Nerves*

NerveBranch #1 Swing Distance, mm

Mean (Range)Branch #2 Swing Distance


Mean (Range)

Donor Nerves

Long head triceps 12 m (3e27)n ¼ 10

- -

Medial head triceps 49 (20e90)n ¼ 10

48 (35e65)n ¼ 3

-

Lateral head triceps 28 (5e70)n ¼ 10

41 (23e53)n ¼ 5

62 (48e75)n ¼ 2

Recipient Nerves (n ¼ 10)

Main axillary trunk e13 (e23 to 12)

Anterior division e12 (e30 to 7)

Posterior division e12 (e33 to 9)

Teres minor e11mm (e34 to 22)

-, not applicable; n, the number of specimens with that branching pattern.*The inferior border of the teres major was used as the reference line. Negative values reflect distance proximal to the reference line, and positive

values reflect distal position relative to the reference line.

e408 AXON COUNTS YIELD OPTIONS FOR TRANSFER

J Hand Surg Am. r Vol. 41, November 2016

Nerve Transfer: Which Triceps Branch Should I Use? SCIENTIFIC ARTICLE

















SCIENTIFIC ARTICLE

















SCIENTIFIC ARTICLE

















nerve branch as well as its anatomical ability to reachits target. Six of 10 specimens in this study had insuf-ficient length of the long head triceps branches to reachthe anterior division of the axillary nerve. This insuf-ficient length has been previously noted and, occa-sionally, necessitates dividing the inferior portion ofthe teres major in order to reach the axillary nerve.1,17

In contrast, the medial and lateral head brancheshad significantly longer swing distances, which were

sufficient to allow for direct transfer to the anteriorbranch of the axillary nerve in all specimens.

Our axon count data also demonstrate notable dif-ferences in donor-to-recipient axon count ratios for thevarious tricepsbranches relative to the anterior branchofthe axillary nerve. The optimal donor-to-recipient nerveaxon count ratio for restoring function is controversial.Animal studies of partial nerve sectioning suggest thatas few as 20% of remaining motor units can provide

TABLE 1. Median Axon Count and Branching Data of Radial Nerve Triceps Branches and Components of theAxillary Nerve*

NerveCompositeAxon Count

Single-BranchSpecimens

Two-BranchSpecimens

Three-BranchSpecimens

Donor Nerves

Long head triceps 2,302 (553e2,771) 2,302 (553e2,771)n ¼ 10

- -

Medial head triceps 2,198 (679e4,428) 1,351 (679e3,636)n ¼ 6

4,289 (2,663e4,428)n ¼ 3

2,451n ¼ 1

Lateral head triceps 1,462 (211e4,187) 477 (211e1,899)n ¼ 5

1,462 (936e2,163)n ¼ 3

3,097 (2,006e4,187)n ¼ 2

Recipient Nerves

Main axillary trunk 7,887 (5,613e9,280)

Anterior division 4,052 (1,541e5,768)

Posterior division 1,242 (610e3,181)

Sensory division 1,239 (588e2,165)

Teres minor 1,161 (467e1,656)

-, not applicable; n, the number of specimens with that branching pattern.*Ranges are in parentheses.

TABLE 2. Mean Swing Distances of Studied Donor and Recipient Nerves*

NerveBranch #1 Swing Distance, mm



Mean (Range)

Donor Nerves

Long head triceps 12 m (3e27)n ¼ 10

- -

Medial head triceps 49 (20e90)n ¼ 10

48 (35e65)n ¼ 3

-

Lateral head triceps 28 (5e70)n ¼ 10

41 (23e53)n ¼ 5

62 (48e75)n ¼ 2

Recipient Nerves (n ¼ 10)

Main axillary trunk e13 (e23 to 12)

Anterior division e12 (e30 to 7)

Posterior division e12 (e33 to 9)

Teres minor e11mm (e34 to 22)

-, not applicable; n, the number of specimens with that branching pattern.*The inferior border of the teres major was used as the reference line. Negative values reflect distance proximal to the reference line, and positive

values reflect distal position relative to the reference line.

e408 AXON COUNTS YIELD OPTIONS FOR TRANSFER

J Hand Surg Am. r Vol. 41, November 2016

2 Years Post Triceps Branch à Axillary Nerve

Summary

•  Restoration of Axillary Nerve function is an important component of brachial plexus recon

•  Existing evidence does not clearly demonstrate superiority of nerve grafting or transfers

•  Decision making is multi-factorial but surgeon comfort with grafting techniques and nerve transfer is recommended!

Thank you!

ASSH IC44-R: Glenohumeral Arthrodesis in BPI

October 2020

Alexander Y. Shin, MD 1

Reanimation of the Shoulder after Brachial Plexus Injury

IC44-R

Shoulder Arthrodesis in Adult Brachial Plexus

Alexander Y. Shin, MDMayo Clinic

Rochester, Minnesota

Introduction• Role of Shoulder Arthrodesis• Indications & Contraindications• Optimal Position• Surgical Nuances• Outcomes

Shoulder Arthrodesis•Orthopedics

• Failure to Reconstruct = Arthrodesis

• Reluctance to consider glenohumeral arthrodesis

Shoulder Biomechanics - Nuances

•A floating girdle suspended by

• Ligaments• Sternoclavicular• Acromioclavicular• Coracoclavicular• Coricoacromial

• Glenohumeral capsule

Shoulder Biomechanics - Nuances

•A floating girdle suspended by•Muscles

•4 cuff•9 others


October 2020


Shoulder Innervation

•Upper Trunk•Suprascapular

nerve•Axillary nerve

•Spinal Acc n.•Others

Brachial Plexus Injury

C5-6 C5-C7 Pan Plexus

Role of Arthrodesis

•Failed nerve reconstruction•Painful subluxation • Poor functional position

•Staged arthrodesis•Primary arthrodesis

Rationale for Primary Arthrodesis

•Use valuable donor nerves for other purposes

•Overhead activity rarely achieved with nerve transfers

•Patients with parascapular control have excellent function

Rationale for Secondary Arthrodesis

•Failed nerve reconstruction

•Painful glenohumeralsubluxation

•Improves elbow flexion strength

Shoulder Arthrodesis Acceptance•Routine part of

reconstruction in some practices

•Huge reluctance in USA


October 2020


Indications•Failed nerve reconstruction

•Painful subluxation

•Adequate scapular control/stability

•To allow use of donor nerves for other purposes

Contraindications

•Treatment for neuropathic pain

Contraindications•Scapulothoracic dissociation + BPI

Contraindications•Absent parascapular control

Contraindications•Unrealistic expectations

Position of Fusion•To reach mouth•Many variations•Recommendation

•30 Abduction•30 forward flexion•30 internal rotation


October 2020


Surgical Considerations

•Prefabricated shoulder immobilizer

Surgical Considerations•Fixation

Consideration of prior surgery and bone quality

Surgical Considerations

•Chronic BP shoulders•Osteoporotic•Humeral head

•Cystic Voids•Thin cortical bone

Surgical Consideration

•Bone Graft•Autograft•Allograft•RIA

Surgical Technique• Lateral decubitus

• Allows for ICBG harvest

• Allows for RIA

Surgical Technique• Saw decortication – glenoid, humeral head, subacromial

• Planar surfaces• Less bone graft need


October 2020


Surgical Technique• 4.5 mm LC-DCP

• Spine of Scapula

Surgical Technique• Autologous bone graft

• Fill in all surfaces

Post Operative•6-8 weeks immobilization

•Shoulder Immobilizer Orthosis

Expected Outcomes

•Outcomes depend on preoperative periscapular function

•Very difficult to compare series•Too many different types of BPI•Degree of periscapular function

not adequately addressed

Predictors of Good Outcomes

•Preop scapular motion•Functional elbow flexion•Good hand function•Well controlled neuropathic pain

Specific to BP Position Results

Year Author Number Abd FF Int Rot Abd FF Int Rot

Particularities

1988 Richards N=1 30 30 30 75 85 Poor hand function

1991 Rouholamin N=6 23 27 47 65 51

2004 Chammas N=16 31 27 28 63 62 45 Flail hand

2012 Atlan N=32 30 30 30 57 46

2017 Lenoir N=3 30 30 30 50 80


October 2020


Arthrodesis vs Nerve Surgery

•Le Hanneur et al 2019•24 arthrodesis vs 14 nerve recon•Arthrodesis: 23/24 good results•Nerve Recon: 6/14 good results

Musculoskeletal Surg

Arthrodesis vs Nerve Transfer•Degeorges et al 2019

•20 SPA to SSN vs 38 arthrodesis•46 mo follow-up•DASH & ROM similar•Strength better in arthrodesis group•Nerve transfer – poor predictability•Arthrodesis – predictable/uniform

Orthop Traumatol Surg Res

Arthrodesis vs Tendon Transfer•Ruhmann et al

• 63 trapezius transfer vs 14 arthrodesis•Persistent BP •Trapezius transfer

• increased abd/ff to 30°-36°• Instability improved in 60/63

•Arthrodesis• Increased abd/ff to 30°-90°

Injury

Complications

•28% complication rate•Higher in screw alone•Nonunion•Infection•Humeral fracture

Ruhmann et al JSES, 2005

Arthrodesis as a Primary Treatment

•Trends point to a viable option

•Consistent outcomes•Improved strength & motion

Glenohumeral Arthrodesis•Option for failed nerve reconstruction

•Option for primary reconstruction

•Outcome dependent on parascapular motion•Technically challenging

•Very rewarding for patients


October 2020


Example & References

Courtesy of Idriss Gharbaoui

Thank You

Mayo Clinic Brachial Plexus Team

ReferencesLe Hanneur M, Lafosse T, Cambon-Binder A, Belkheyar Z. Surgical strategy in extensive proximal brachial plexus palsies. Musculoskelet Surg. 2019 Aug;103(2):139-148.

Degeorge B, Lazerges C, Chammas PE, Coulet B, Lacombe F, Chammas M. Comparison of spinal accessory nerve transfer to supra-scapularnerve vs. shoulder arthodesis in adults with brachial plexus injury. Orthop Traumatol Surg Res. 2019 Dec;105(8):1555-1561.

Rouholamin E, Wootton JR, Jamieson AM. Arthrodesis of the shoulder following brachial plexus injury. Injury (1991) 22, (4), 271-274.

Emmelot CH, Nielsen HKL, Eisma WH. Shoulder fusion for paralysed upper limb.Clinical Orthopaedics and Related Research 1997, 340:95-101.

Atlan F, Durand S, Fox M, Levy P, Belkheyar Z, Oberlin C. Functional outcome of glenohumeralfusion in brachial plexus palsy: a report of 54 cases.J Hand Surg Am. 2012 Apr;37(4):683-8.

Belkheyar Z, Belkacem Djeffel A, Cambon-Binder A. Glenohumeral fusion in adults with sequelae of obstetrical brachial plexus injury: a report of eight cases J Hand Surg Eur Vol. 2019 Mar;44(3):248-255.

References

Van Der Lingen MAJ, De Joode SGCJ, Schotanus MGM, Grimm B, Van Nie FA, Speth LAWM, Samijo, SK. Satisfied patients after shoulder arthrodesis for brachial plexus lesions even after 20 years of follow-up. European Journal of Orthopaedic Surgery & Tranmatologt (2018) 28:1089-1094.

Rtaimate M, Henry E, Lariviere J, Farez E, Laffargue P. Arthrodese d'epaule pour sequelles se paralysies du plexus brachial. Revue de Chirurgie Orthopedique 2002, 88:35-40.

Ruhmann O, Gosse F, Wirth CJ, Schmolke S. Reconstructive Operations for the paralysedshoulder in brachial plexus Palsy: concept of treatment. Injury, Int. J. Care Injured 30 (1999) 609-618.

1

Tendon Transfer Options to Reconstruct Elbow and Shoulder Function in Patients with BPI

Bassem Elhassan, MDProfessor of Orthopedics

Mayo ClinicRochester, MN

Bassem T. Elhassan, MD

Speaker has no relevant financial relationships with commercial

interest to disclose.

ASSH Disclosures

75th Annual Meeting the ASSH

Tendon Transfer Options to Restore Shoulder Function in Patients with Brachial Plexus Injury ??

1

2

3

2

How Do we Plan the Appropriate Tendon Transfer to Restore Shoulder Function in Patients with Brachial Plexus Injury????

Biomechanically It is Essential to Restore the Rotator Cuff Function and Deltoid Assuming the Scapulo‐Thoracic Articulation is Stable

When Patients are Asked: If we Could Restore One Shoulder Function that Makes you Happier What would you Chose: More

than 90% Chose Shoulder External Rotation

4

5

6

3

To Reconstruct Shoulder External Rotation: Our Tendon Transfer of Choice is Lower Trapezius Transfer

LowerTrapezius

Additional Potential Transfer Options that May Improve Other Shoulder Functions

UpperSerratus:SubscapInternal Rot

Lower Trapezius

Middle and Upper Trapezius:Shoulder Stabilization And Abduction

Levator Scapulae:ScapulaStabilization

Pedicled Latissimus to Anterior Deltoid

7

8

9

4

Pedicled Pectoralis Transfer for Anterior Deltoid

Levator Scapulae (+/‐Rhomboid Minor and Major For Scapula Stabilization)

We Can Try to Reconstruct every Rotator Cuff Muscle and Deltoid, but is this really beneficial to the patient???

The Answer is: No

10

11

12

5

Tendon Transfer Options About the Shoulderin Patients with Brachial Plexus Injury

• Levator to Supraspinaut

• Upper Serratus to Subscap

• Lower trap to Infraspinatus

• Upper/middle transfer with their acromial insertion to Proximal humerus for abduction

Bassem Elhassan, MD, Allen T. Bishop, MD, Robert U. Hartzler, MD, Alexander Y. Shin, MD, and Robert J. Spinner, MD

Investigation performed at the Mayo Clinic, Rochester, Minnesota

J Bone Joint Surg Am. 2012;94:1391-8

Outcome

•There was significant improvement of shoulder external rotation and shoulder stabilization but minimal improvement of shoulder flexion/abduction

The Most Important Deformity to Correct is: Reduction of Inferior Shoulder Subluxation and Restoration of Shoulder Stability

And Most Important Function to Restore is: Shoulder Ext Rotation

13

14

15

6

The Most Common Tendon TransferReconstruction that We Perform Now

• Isolated lower trapezius transfer if the shoulder is stable with no inferior subluxation

Among the Tendon Transfer Options Available, why do We Favor Lower Trapezius Transfer to Reconstruct an Irreparable Posterior Superior RCT more Favorable??

The Lower Trapezius Muscle Fibers have very Similar Line of Pull to the Infraspinatus

Lower Trapezius

Infraspinatus

16

17

18

7

Lower Trapezius

HumeralHead

(No Deltoid)

Infraspinatus

EMG Study Showed Synergistic Activation of Lower Trapezius During Shoulder External Rotation

19

20

21

8

LT

Lat TeresMajor

Rob Hartzler et al

Lower trapezius transfer superior to latissimus transfer at restoring native glenohumeral

kinematics and joint reaction forces

22

23

24

9

Improvement of Shoulder External Rotationis Achieved in 87% of Patients with BPI

25

26

27

10

1- Levator Scapulae to the Spine of the scapula to stabilize the scapula

2- Upper/middle Trap: for shoulder stabilization and some abduction

3- Lower trap for ER

The Second Most Common Tendon Transfer Reconstruction is 3 Muscles Transfers in Patients with Symptomatic Inferior Subluxation of the Shoulder

Associated with Lack of Shoulder External Rotation

LevatorScapulae

LowerTrapezius

Upper/middleTrapezius

Three Muscle Transfer Reconstruction: Levator Scapulae to Lateral Spine of Scapula, Lower trap to Infraspinatus and Upper/Middle Trap to Proximal Humerus

28

29

30

11

Most Patients Achieve Successful Shoulder Stabilization and External Rotation

Most Patients Achieve Successful Shoulder Stabilization and External Rotation

Additional Use of the Mayo ElbowPro to Improve the Shoulder Function in Those with Minimal Improvement

in Elbow Flexion after Nerve Reconstruction

31

32

33

12

If Ipsilateral Trapezius is Not Available to Transfer, The Backup Option we Have is

Transfer of the Origin of the Contralateral Trapezius Augmented with Lumbar Fascia

Contralateral Trapezius Transfer

34

35

36

13

Can we be Optimistic to Try to Improve Shoulder Flexion with

Additional Muscle Transfer????

Yes with Pedicled Pectoralis Transfer for Anterior Deltoid

37

38

39

14

First Case of Lower Trapezius Transfer Done 2007 for BPI

1 Year Follow-up

Pedicled Pectoralis Transfer

40

41

42

15

Outcome > 10 years after Lower Trap Transfer Followed by Pedicled Pectoralis Transfer

Also if Available Pedicled Latissimus to Anterior Deltoid

Another Example ofPedicledLatissimusTransfer

43

44

45

16

46

47

48

17

49

50

51

18

52

53

54

19

1 Year Follow-up after Lower Trap Transfer and Pedicled Latissimus Transfer

6 Years Follow-up after Lower Trap Transfer and Pedicled Latissimus Transfer

What about Patients with No Rotator Cuff, Deltoid Paralysis and

Glenohumeral Joint Pathology??

55

56

57

20

68 yo S/P Removal of Infected TSA, antibiotic Spacer and No Rotator Cuff and

Deltoid Paralysis

58

59

60

21

61

62

63

22

Post Op

2 Years Post OP

64

65

66

23

Thank you

67

1

Allen T. Bishop, MD


Case 1

Patient DM

Patient DM

• 45 year-old

• 9 months after motorcycle injury:• C5-6 facet fracture, incomplete spinal cord

injury requiring C6 corpectomy, anterior cage + posterior C5-C7 fusion

• hemopneumothorax• Initially flail left upper extremity• Variable burning pain in hand + mechanical pain

left shoulder, requiring OxyContin, Neurontin and oxycodone; Ambien for sleep

1

2

3

2

Patient DM

• Post-injury course• No recovery of left shoulder, elbow function• No recovery of left wrist, finger extension• Recovered substantial left wrist and finger

flexion in the initial 2-3 months- hold a cup• 3 months post-injury: progressive loss of finger

and wrist flexion• 6 months: shoulder dislocation diagnosed• Now (9 months): loss if ‘95% of initially

recovery’

Patient DM

• Exam:• No LE hyper-reflexia, weakness or other

findings of cervical myelopathy• Shoulder fixed at the side• Stiff hand with palpable function of ulnar and

median-innervated intrinsics, as well as extrinsic finger and wrist flexors.

• Absent shoulder or elbow motor function

Patient DM Motor exam

4

5

6

3

Patient DM

• EMGsevere plexal injury most severely affecting

upper and middle trunks

CT myelogram

• No evidence of avulsion at any level

C5

C6

C7

C8

T1

7

8

9

4

Patient DM

Surgical plan?

Patient DM

• Plan• Strong FCU: Oberlin transfer for elbow flexion• At 9 months, no plan for immediate hand

reconstruction• Loss of recovered hand, wrist function likely

the result of shoulder dislocation• Further recovery possible with shoulder

correction• Urgent need to relocate shoulder: arthrodesis

Patient DM

10

11

12

5

Patient DM

Patient DM

• Recovered grade 4 elbow flexion

• Improved finger flexion without wrist extension at 3 years

• Continued neuropathic pain in hand• Burning quality 7-8/10• Pain specialist involved using gabapentin,

oxycodone and morphene

Patient DM

At 3 years postop:• 15º of shoulder

abduction and forward flexion

• 115º elbow flexion• Wrist flexed• Fingers in a tight fist• Spasticity from SCI• Fixed 90º MP

contracture

13

14

15

6

Patient DM

• Planned PRC/wrist arthrodesis, possible flexor/pronator slide

• Alternative: forearm amputation and myoelectric prosthetic fitting

• Evaluation by prosthetist confirmed potential

• Subsequent forearm amputation

Case 2

Patient SG

16

17

18

7

Patient SG

• 29 year-old male

• Struck by falling tree while riding a motorcycle

• Injuries• Mild CHI with loss of consciousness• Left humerus fracture• Left C5-7 injury pattern (Erb’s + triceps, wrist

extension weakness)

• Evaluated 4 months post-injury

Patient SG

Patient SGCT myelogram

• Radiology report:• “Avulsion of C5,

C6 ventral rootlets”•Remainder of

brachial plexus roots appeared intact

19

20

21

8

Patient SG

Plan?

Patient SGSurgery at 5 months

• Explored supraclavicular plexus• Markedly thickened, heavily scarred C5 nerve

root and upper trunk• Phrenic nerve functioning, scarred to plexus• C5 and C6 roots dissected from scar to

foramina, followed by SSEP, MEP• No response detected at C5 or C6

• Normal spinal accessory nerve

Patient SG

• Plan:• Spinal accessory transfer to suprascapular

nerve• Leechavengvong (triceps long head motor

branch transfer to anterior division, axillary nerve)

• Oberlin transfer (ulnar fascicle to biceps motor branch)

22

23

24

9

Patient SG

• Returned at 7 months postop:• Reported some biceps activation at 3 months• At 7 months, actively flexed elbow to 90º

against gravity (grade 2 or 2+)• Early recovery of deltoid and supraspinatus: a

few degrees of abduction.• No donor weakness

Patient SG7 month postop EMG

Patient SG

• Continued to improve on return visit examinations and EMG

• At last visit, biceps was graded 4+ or 5-, deltoid grade 4, infraspinatus grade 2+ with external rotation to -10º

25

26

27

10

CASE 3

Patient ER

28

29

30

11

Patient E.R.

• 32 year-old truck driver

• heavy machinery fell off oncoming truck and entered the cab of his vehicle striking Rtshoulder

• Open proximal humerus fracture

• Avulsed deltoid

• no shoulder or elbow flexion

• Weak UN, initially absent MN

Patient E.R.

• Presented 4 months post injury

• Great ORIF!

• UN and MN recovered

• No MCN, deltoid muscle, SSN function

• EMG: no deltoid, spinati, Biceps, BR, PT

Patient E.R.

• Soft tissues healed

31

32

33

12

Patient ER

• Possible phrenic nerve injury

• No other indication of root-level injury

• Plan: • Oberlin transfer• Deltoid injury likely precludes

axillary nerve reconstruction

• How to best reconstruct suprascapular nerve?

Patient E.R.

• Surgery at 4.5 months:• Neurolysis C5, C6, UT, SSN• Nerve graft (sural autograft) from C5 to SSN• Evaluation of UN, MN and MCN in mid-forearm

Brachialis motor branch

MC

Bicep motor branch

LABC

34

35

36

13

Patient ER

• 4 months post-op• Grade 2+ biceps recovery

• 8 months post-op• Grade 4+ elbow flexion• Shoulder rests in internal rotation• Plan: await possible SSN recovery

ERPostop EMG

• 3 months:• Early partial biceps reinnervation. • Nothing in SS, IS

• 8 months:• Ongoing biceps reinervation• Nothing in SS, IS

Patient ESPostop

• EMG at 12 months:• Convincing evidence of SS, IS reinnervation

37

38

39

14

Patient ES

• 12 months post-op• Biceps grade 5-• Shoulder• 10º abduction• some useful external rotation: positioning of

hand away from chest with elbow flexion

• 4 years postop• Phone call: patient stated ‘motor function now

equal to the other side’

Patient ES12 month video

40

41

42

15

Case 4

Patient RK

Patient RS

• 23 year-old man

• Motorcycle accident• Right carotid artery dissection• Traumatic brain injury: diffuse axonal injury• Left brachial plexus injury• Left rib, clavicle, occipital fractures• Right forearm fracture

Patient RK

• Exam • Consistent with upper trunk injury. FCU, FCR,

Triceps 4+; normal hand• Weak/asymmetric trapezius strength

• EMG• Severe BPI with no reinnervation of C5/C6

motors; partial SAN injury• Probable avulsions (rhomboid paralysis,

paraspinal fibs)• phrenic palsy on inspiration/expiration CXR

43

44

45

16

Patient RKCT MyelogramC5 avulsion

C6 avulsion

Preoperative video

Patient RK

• Surgery at 7 months

• Anticipated findings• C5, C6 avulsed• Normal SAN

• Plan?

46

47

48

17

Patient RK

• Surgery:• Oberlin transfer• Leechavengvongs to deltoid• No exploration of supraclavicular fossa:• C5, C6 avulsed• Decision to spare SAN/trapezius to enable

later lower trapezius tendon transfer for reliable external rotation

Patient RK5 months postop

• Trace (grade 1) biceps recovery• Positive biceps squeeze test; no deltoid

Patient RKPostop course

• At 5 month visit:• Advised waiting at least 4 months for evidence

of deltoid recovery before planning tendon transfer.

• Rationale: only lower trapezius procedure if deltoid recovering. Potential for additional stabilizing/deltoid replacing transfers if not.

49

50

51

18

Patient RK12 month post-nerve transfer

• Grade 3+ biceps: 0-135º against gravity. Weak deltoid activation.

• Trapezius now grade 4+

• Decision made to wait further

Patient RK12 month post-nerve transfer

Patient RK16 months post nerve transfer

• No further recovery

• Proceeded with lower trapezius transfer

• Rehabilitation/re-education begun at 6 weeks

• Active ER 0º at 4 mo

52

53

54

19

Patient RK

• At 6 months post trapezius transfer (22 months post nerve transfer)• 10º abduction• 30º forward flexion• 10º external rotation• Grade 4 biceps function

• EMG: minimal deltoid reinnervation

• Interested in more shoulder functioon

Patient RK6 months s/p trapezius transfer

Patient RK

• 2nd shoulder procedure at 24 months post nerve transfer:• Pedicled

pectoralis transfer to anterior deltoid

55

56

57

20

Patient RK

• Seen 6 months later:• Patient pleased with results• Still strengthening pectoralis transfer• Shoulder • external rotation 25º• Forward flexion 70º

• Has not returned for further follow-up

58

IC44-R: Reanimation of the Shoulder after Brachial Plexus ...

Documents

Transcript of IC44-R: Reanimation of the Shoulder after Brachial Plexus ...