Radial to axillary nerve neurotization for brachial plexus injury in children: a combined case series

Clinical article

Full access

Object

Axillary nerve palsy, isolated or as part of a more complex brachial plexus injury, can have profound effects on upper-extremity function. Radial to axillary nerve neurotization is a useful technique for regaining shoulder abduction with little compromise of other neurological function. A combined experience of this procedure used in children is reviewed.

Methods

A retrospective review of the authors' experience across 3 tertiary care centers with brachial plexus and peripheral nerve injury in children (younger than 18 years) revealed 7 cases involving patients with axillary nerve injury as part of an overall brachial plexus injury with persistent shoulder abduction deficits. Two surgical approaches to the region were used.

Results

Four infants (ages 0.6, 0.8, 0.8, and 0.6 years) and 3 older children (ages 8, 15, and 17 years) underwent surgical intervention. No patient had significant shoulder abduction past 15° preoperatively. In 3 cases, additional neurotization was performed in conjunction with the procedure of interest. Two surgical approaches were used: posterior and transaxillary. All patients displayed improvement in shoulder abduction. All were able to activate their deltoid muscle to raise their arm against gravity and 4 of 7 were able to abduct against resistance. The median duration of follow-up was 15 months (range 8 months to 5.9 years).

Conclusions

Radial to axillary nerve neurotization improved shoulder abduction in this series of patients treated at 3 institutions. While rarely used in children, this neurotization procedure is an excellent option to restore deltoid function in children with brachial plexus injury due to birth or accidental trauma.

Abbreviation used in this paper:OBPP = obstetric brachial plexus palsy.

Object

Axillary nerve palsy, isolated or as part of a more complex brachial plexus injury, can have profound effects on upper-extremity function. Radial to axillary nerve neurotization is a useful technique for regaining shoulder abduction with little compromise of other neurological function. A combined experience of this procedure used in children is reviewed.

Methods

A retrospective review of the authors' experience across 3 tertiary care centers with brachial plexus and peripheral nerve injury in children (younger than 18 years) revealed 7 cases involving patients with axillary nerve injury as part of an overall brachial plexus injury with persistent shoulder abduction deficits. Two surgical approaches to the region were used.

Results

Four infants (ages 0.6, 0.8, 0.8, and 0.6 years) and 3 older children (ages 8, 15, and 17 years) underwent surgical intervention. No patient had significant shoulder abduction past 15° preoperatively. In 3 cases, additional neurotization was performed in conjunction with the procedure of interest. Two surgical approaches were used: posterior and transaxillary. All patients displayed improvement in shoulder abduction. All were able to activate their deltoid muscle to raise their arm against gravity and 4 of 7 were able to abduct against resistance. The median duration of follow-up was 15 months (range 8 months to 5.9 years).

Conclusions

Radial to axillary nerve neurotization improved shoulder abduction in this series of patients treated at 3 institutions. While rarely used in children, this neurotization procedure is an excellent option to restore deltoid function in children with brachial plexus injury due to birth or accidental trauma.

The axillary nerve is the terminal branch of the posterior cord of the brachial plexus, receiving fibers from cervical nerve roots C-5 and C-6.29 After exiting the axillary fossa posteriorly, it passes through the quadrangular space with the posterior circumflex humeral artery, then winds around the surgical neck of the humerus deep to the deltoid. It then divides into 2 branches: posterior and anterior. The posterior branch innervates teres minor and posterior deltoid muscles and gives rise to the superior lateral brachial cutaneous nerve. The anterior branch passes anteriorly around surgical neck of the humerus and innervates the middle and anterior parts of the deltoid muscle.10,11,29,47

Damage to the axillary nerve leads to abduction and external rotation weakness.5,29,32 Blunt trauma to the shoulder is the most frequent cause of axillary nerve injury, with or without fracture or glenohumeral dislocation.5,7,11,29,38,51 Diagnosis is often initially overlooked due to concomitant injuries leading to immobilization and compensatory supraspinatus action.11,39 Injury can be discovered weeks or months after significant deltoid atrophy has ensued.11,39 Within the childhood and teenage population, the injury mechanism is most often traumatic secondary to motor vehicle collisions or sporting activities. In neonates, axillary nerve injury is seen as a part of obstetric brachial plexus palsy (OBPP). In cases of upper trunk lesions involving C5–6 nerve roots, commonly referred to as Erb's palsy, neonates are unable to abduct the shoulder and remain internally rotated.

Following brachial plexus injuries, restoration of shoulder abduction is a functional necessity, second only to elbow flexion.16 Neurotization, or nerve transfer, and nerve grafting are options for repairing axillary nerve lesions.7,19,21 Many options for donor nerves and surgical approaches exist. Possible donor nerves that have been described include the radial,16,18,23,25 thoracodorsal,42 intercostal,9,42 medial pectoral,42,43,52 and long thoracic nerves.42 The approach may be anterior axillary,5,34 posterior,22,23,53 deltopectoral,14,16 or through a sabre-cut incision,36 an incision from the deltopectoral groove over the clavicle posteriorly to the quadrangular space.36 The axillary nerve lies deep to the axillary artery from an anterior approach and can be challenging to access for repair; therefore, alternative approaches are critical. As experience has grown with axillary nerve injuries, transfer of triceps motor branches of the radial nerve to the axillary nerve has emerged as a safe, effective, and expedient means of restoring shoulder abduction.4,5,8,9,16,18,21–23,25 However, its use in children is less clear. This 3-institution series is the first detailing radial to axillary nerve neurotization in various brachial plexus injuries of childhood.

Methods

An institutional review board–approved retrospective review of all cases involving children undergoing radial to axillary nerve neurotization across 3 institutions was performed from 2000 to 2013 at Children's Hospital of Alabama, St. Louis Children's Hospital, and Monroe Carell Jr. Children's Hospital at Vanderbilt. Seven children were identified: 4 infants, an 8-year-old, a 15-yearold, and a 17-year-old. Patients 18 years and older but operated on by the authors were excluded to highlight the utility of the repair in pediatric patients. All infants (Cases 1–4) presented after shoulder dystocia during birth. The infants' ages at surgery were 0.6, 0.8, 0.8, and 0.6 years. The radial to axillary neurotization was the first surgical intervention in all patients; there was no previous surgical intervention. The median infant age at time of surgery was 0.7 years. Of the older children, one child presented after an explosion injury (previously reported case),28 one after a motor vehicle collision, and one after a football injury (ages 8, 15, and 17 years). Time to surgery was 6, 8, and 11 months in the older group. All patients were followed for a minimum of 8 months after surgery (median 15 months, range 8–59 months).

Muscle strength was graded in children and infants with 2 separate grading scales. For noninfant children, strength was graded on a 0–5 scale, according to the Medical Research Council motor grading scale: 0, no contraction; 1, flicker of contraction; 2, active motion with gravity eliminated; 3, active motion against gravity; 4, active motion against resistance; and 5, normal strength.27 In several other reports, shoulder abduction was graded based on a scale described by Narakas and others4,31 with minimal modifications: M0, no contractility; M1, muscle contraction but no active motion; M2, abduction less than 60°; M3, abduction to 60° for 10 seconds; M4, abduction to 60° against resistance applied to the elbow; M5, abduction to 60 against resistance applied to the forearm. For infants, an alternative 4-grade scale was used, as infants cannot follow commands, thus making it difficult to distinguish between 4 and 5 strength. For pre- and postoperative examinations, it was important to distinguish between deltoid and supraspinatus function in assessing shoulder abduction. The first 15°–20° of shoulder abduction was generally attributed to supraspinatus action, and the remaining abduction to 90° was attributed to deltoid function.

In terms of surgical decision making, it was felt that neurotization provided the best chance for muscle recovery (rather than nerve grafting) in all 7 patients. An exact common surgical algorithm for all 3 primary surgeons (C.M.S., T.S.P., and J.C.W.) was not evident, and these patients had neurological findings suggestive of potential success (deltoid weakness with excellent triceps function in the older age group) or in the cases of the infants had previously failed primary surgery. For the older age group, the senior author (J.C.W.) combined the procedure with an Oberlin procedure for noted elbow flexion weakness. In treating infants, one common approach among all 3 surgeons was that the initial operation centered on direct exposure of the neuroma with either neurolysis, neurotization, or grafting performed, and in the case of C.M.S., often combined with an orthopedic adjunctive operation in the same sitting. At all institutions, multiple pediatric patients who were not candidates for radial to axillary nerve neurotization underwent traditional brachial plexus repair. Most of these cases have been reported in a previous paper3 or will be in one currently in progress (Allen LA, Safiano N, Falola M, et al., presented at the 40th Annual Meeting of the AANS/CNS Section on Pediatric Neurological Surgery, 2011).

Operative Procedures

All 3 surgeons (C.M.S., T.S.P., and J.C.W.) used either a transaxillary or posterior approach for radial to axillary nerve neurotization. In terms of surgical decision making, it was felt that neurotization provided a better chance for muscle recovery than nerve grafting. Direct nerve stimulation was used in all cases, so paralytic agents were not used after initial intubation.

For a posterior approach, the patient was placed in prone position with the involved upper limb placed over his or her thorax. An incision was made along the posterior arm, beginning at the lateral border of the scapula and running down the posterior deltoid muscle and lateral border of the long head of the triceps. After dissection down to the fascia overlying the triceps, the lateral cutaneous brachial nerve was traced down to the axillary nerve. The quadrangular space was located by following the axillary nerve down. The long and lateral heads of the triceps were separated to visualize the radial nerve and subsequent motor branches to each head. The axillary nerve was then sectioned proximally to the teres minor branch. The long or lateral head motor branch was flipped upward to be connected to the previously sectioned axillary nerve using microsutures. Direct neurotization was performed using 8-0 nylon sutures affixed directly to the epineurium of the sectioned radial nerve fascicle and the anterior fascicle of the axillary nerve responsible for innervation of the deltoid muscle. The cutaneous branch was removed from the axillary nerve stump.

When a transaxillary approach was used, the involved arm, axilla, chest, and flank were prepared and draped in a sterile fashion. An incision was made through the axilla and carried down to the split between the biceps and triceps as initially described by Bertelli et al.5 The branch of the long head of the triceps was stimulated and identified. The radial nerve was followed back to the tendon of the latissmus dorsi muscle, where the axillary nerve was identified medially. The 2 divisions of the axillary nerve were identified and stimulated for confirmation, specifically looking for the anterior branch. The nerve to the long head of the triceps was cut as distally as possible. The anterior branch of the axillary nerve was then severed as proximally as possible. Under the microscope, three 8-0 nylon sutures were used to connect each nerve.

After neurotization was complete with each approach, elbow and shoulder extension and/or flexion were performed without rupture of the neurotization site. The extremity was moved through its range of motion, ensuring that there was no significant pressure on the neurotization and good alignment was maintained. The wound was irrigated copiously. The incision was closed in layers followed by a subcuticular suture for skin closure. Following closure, the patient's arm was wrapped in an elastic bandage and placed in a sling to limit tension on the repair site for approximately 2 weeks, after which all patients underwent aggressive occupational therapy.

Results

All 7 cases are reviewed in further detail in Table 1. All infants presented at birth and the median age of surgical intervention was 0.7 years. Of the 7 children, 3 were female. No patient had significant shoulder abduction past 15° preoperatively. Three patients had additional neurotization performed in conjunction with the procedure of interest: in all 3 cases the additional procedure was an ulnar nerve to musculocutaneous neurotization procedures, also termed the Oberlin procedure.35 Two surgical approaches were used: posterior and transaxillary. The median duration of postoperative follow-up was 15 months (range 8–59 months). All patients displayed improvement in shoulder abduction. All were able to activate their deltoid muscle to abduct against gravity and 4 of 7 were able to abduct against resistance. The median duration of follow-up was 15 months. Of note, after transfer of the radial nerve branch to the long head of the triceps, arm extension remained full strength in all 7 patients.

TABLE 1:

Axillary nerve injuries, procedure, and examination findings*

Case No.Age at Presentation, SexMechanismPreop DiagnosisTime to Surgery (yrs)Preop ExamApproach, Additional ProceduresFollow-Up Exam
1birth, Mlarge for gestational ageshoulder dystocia0.6shoulder abduction 40°, 2/4 deltoid, 3/4 biceps, 4/4 triceps, 3/4 gripposterior18 mos: shoulder abduction >90°, 3/4 deltoid, 4/4 biceps, 4/4 triceps, 4/4 grip
2birth, Fdifficult deliveryshoulder dystocia0.8shoulder abduction <15°, 0/4 deltoid, 0/4 biceps, 2/4 triceps, 4/4 gripposterior48 mos: shoulder abduction >90°, 4/4 deltoid, 3/4 biceps, 4/4 triceps, 4/4 grip
3birth, Mdifficult deliveryshoulder dystocia0.8shoulder abduction <15°, deltoid 0/4, biceps 4/4, triceps 2/4, 3/4 gripposterior59 mos: shoulder abduction >90°, 4/4 deltoid, 4/4 biceps, 4/4 triceps, 4/4 grip
4birth, Fdifficult deliveryshoulder dystocia0.6shoulder abduction <15°, 1/4 deltoid, 1/4 biceps, 4/4 triceps, 4/4 gripposterior, Oberlin15 mos: shoulder abduction >15°, 3/4 deltoid, 4/4 biceps, 4/4 triceps, 4/4 grip
58 yrs, Mexplosionupper trunk brachial plexus injury0.5shoulder abduction <15°, 1/5 deltoid, 1/5 biceps, 4+/5 triceps, 4+/5 griptransaxillary, Oberlin8 mos: shoulder abduction 90°, 4+/5 deltoid, 4+/5 biceps, 4+/5 triceps, 4+/5 grip
615 yrs, FATV accidentbrachial plexus injury0.7shoulder abduction <15°, 0/5 deltoid, 0/5 biceps, 0/5 triceps, 5/5 griptransaxillary, Oberlin12 mos: shoulder abduction 90°, 4+/5 deltoid, 4+/5 biceps, 4+/5 triceps, 5/5 grip
717 yrs, Mfootballaxillary nerve palsy0.9shoulder abduction <15°, 0/5 deltoid, 5/5 biceps, 5/5 triceps, 5/5 gripposterior13 mos: shoulder abduction 90°, 3/5 deltoid, 5/5 biceps, 5/5 triceps, 5/5 grip

All infant motor scores are on a scale of 0–4, as infants cannot follow commands and one cannot distinguish between 4 and 5 strength (Cases 1–4). All other cases are scored on a strength scale of 0–5 (Cases 5–7). ATV = all-terrain vehicle.

Illustrative Cases

Case 3 (infant)

Persistent inability to abduct the shoulder at 8–10 months is a relative indication to proceed with surgical treatment. This male infant was delivered at full term and presented with evidence of right OBPP secondary to shoulder dystocia thought to be due to macrosomia. On examination, he displayed shoulder abduction of less than 15°, 0/4 strength in deltoid, 4/4 in biceps, 2/4 in triceps, and 3/4 in grip. He underwent an axillary to radial nerve coaptation procedure at 1 year of age through a posterior approach. At 59 months' follow-up, evaluation of his right upper-extremity revealed shoulder abduction to more than 90°, 4/4 deltoid strength, 4/4 biceps strength, 4/4 triceps, and 4/4 grip. He had full range of motion in elbow extension, wrist extension, and finger extension as well as shoulder adduction. In addition, there was more than 50% range of motion in shoulder abduction and a good range of motion in elbow flexion. A photograph obtained during a postoperative examination at 59 months is shown in Fig. 1.

Fig. 1.
Fig. 1.

Case 3. Image obtained during follow-up examination 59 months after surgery.

Case 6 (child)

General tenets of peripheral nerve recovery are followed in this age group as well. After allowing 4–6 months to assess native recovery, rarely less than 3 months, surgery is pursued when the patient still lacks meaningful shoulder abduction. This 15-year-old female adolescent presented with a left-sided brachial plexus injury following an all-terrain vehicle (ATV) accident. On examination, deficits incurred included total loss of shoulder abduction, shoulder flexion, and elbow flexion, which did not recover by 8 months after injury. Neurotization of the branch to the long head of the triceps from the radial nerve to the axillary nerve was performed via a transaxillary approach. Due to absence of meaningful elbow flexion recovery, the patient also underwent neurotization of a fascicle of the ulnar nerve to the biceps branch of the musculocutaneous nerve as initially described by Oberlin et al.35 At 12-month follow-up, she demonstrated intact hand-to-mouth function, shoulder abduction to 90°, and 4 to 4+/5 strength in her biceps, deltoid, triceps, wrist, and grip.

Discussion

A significant proportion of axillary nerve injuries occur during obstetrical brachial plexus injuries. Incidences of OBPP range from 0.1% to 0.4% of live births, with rates climbing in recent years due to increasing birth weights.17 Risk factors for OBPP include shoulder dystocia, vacuum delivery, macrosomia, prolonged second stage of delivery, and breech delivery.6 Injuries occur when the abducted arm is placed in traction, which leads to stretching of the upper or lower plexus.12,17,37 Clavicle fractures are seen in 10%–15% of cases.17 OBPPs are classified according to location. Upper root level injuries occur most frequently, in 90% of patients, and result in Erb's palsy—paresis of the supraspinatus, infraspinatus, and deltoid muscles.17 The arm is internally rotated with limited abduction, the elbow in complete extension, and the thumb flexed. The majority of upper plexus OBPPs involve multiple nerves (axillary, suprascapular, and biceps). However, our group of neonatal patients had isolated axillary nerve injuries; thus, only axillary nerve neurotization was required. The data on isolated axillary nerve injury in OBPP are limited to one case series reported by Terzis and Kokkalis,49 who demonstrated good and excellent results, defined by deltoid strength of M3 or better in 49 (87.5%) of 56 plexuses. Postoperatively, the average shoulder abduction increased from 35° to 109°. The authors concluded that the best results were seen in early cases (in which surgery ws performed at the age of 3 months or younger) and when intraplexus donors were used to reconstruct the posterior cord. The following methods of axillary nerve reconstruction were used: posterior cord grafting (in 37 cases), intraplexus donors (in 12), intercostal nerve donor (in 5), and contralateral C-7 nerve graft (in 2). For the intraplexus donors, the article makes no mention of radial to axillary nerve neurotization and states that C-5, C-6, and T-1 stumps were used for intraplexus neurotization. Thus, despite the large, impressive case series, radial to axillary nerve neurotization was not performed in this cohort.

Non-OBPP axillary nerve injury most often occurs secondary to blunt trauma, but can be due to athletic injuries or iatrogenic causes.5,7,11,21,29,38,51 Patients are most often young and male. Kline and Kim19 described 4 distinct types of axillary nerve injuries: 1) isolated axillary palsy, 2) axillary with suprascapular palsy, 3) axillary and posterior cord palsies, and 4) axillary palsy with other plexus lesions.16,19 Our case series represents a combination of isolated axillary nerve injuries and upper brachial plexus injuries, and when necessary, musculocutaneous nerve repair was performed in the same setting. All 3 patients with upper trunk lesions had excellent results after their Oberlin procedures.

In 1948, Lurje25 was the first to describe radial to axillary nerve neurotization, reporting a case involving a 20-year-old woman who had been injured in a bomb explosion. The author completed neurotization of the long thoracic nerve to suprascapular nerve and motor branches of the radial nerve to the axillary nerve to restore shoulder function. Since this initial experience, several case series in adults have been reported. In one of the largest series of isolated axillary nerve injuries, Lee et al.21 reported on 21 patients, ages 13–79 years, who underwent triceps motor branch transfer. Mechanisms of injury included motor vehicle accidents (in 15 cases), falls or athletic injuries (in 5 cases), and proximal humerus fracture surgery (in 1 case).21 The patients' average postoperative deltoid strength was 3.5 ± 1.1. Of the 5 patients who did not achieve greater than M3 function, 4 were older than 50 years and 1 was treated 14 months postinjury.21 The authors' regression model revealed that “delay from injury to surgery” (treatment delay), age of patient, and BMI affected outcome of the procedure, although it is difficult to find robust predictors in a study of 21 cases.

Most axillary nerve repairs are not isolated procedures, as they are usually performed in patients with upper cord lesions that necessitate concomitant suprascapular and/or biceps nerve transfers. When conducting dual transfers to the suprascapular and axillary nerve in patients with upper cord palsies, Chuang et al.9 reported an average of 55° increase in shoulder abduction as compared with 45° when only suprascapular nerve transfer was performed. Similarly, Nagano30 showed that following dual nerve transfer to axillary and suprascapular nerve, 88% of patients achieved greater than 50° of shoulder abduction and 30° of external rotation. Bertelli and Ghizoni4 transferred the triceps motor branches to the axillary nerve in 10 adult males with C-5 and C-6 brachial plexus injuries, ages 19–32 years, after motor vehicle collisions, in addition to suprascapular nerve and biceps motor branch repair. Postoperatively, shoulder abduction scored M4 in 3 patients and M3 in the remaining 7 patients with an average of 92° of motion. External rotation strength was graded M4 in 2 patients, M3 in 5 patients, and M2 in 3 patients with an average of 93° of motion. No differences were observed when the axillary nerve was repaired with the long head or lateral triceps motor branches. Leechavengvongs et al.23 performed similar surgeries on 15 patients with C-5 and C-6 root avulsion injuries, all after motor vehicle collisions; the patients' ages ranged from 13 to 60 years. Neurotization of the long head of the triceps to the anterior branch of the axillary nerve was performed, in addition to repair of the suprascapular and biceps motor branch. Thirteen patients (87%) recovered M4 deltoid strength, and 2 patients (13%) scored M3 with a mean shoulder abduction of 115° (range 65°–120°). Shoulder external rotation was scored as M4 in 9 patients (60%), M3 in 4 patients (27%), and M2 in 2 patients (13%), with an average 97° range of motion (range 80°–120°). Excellent recovery was reported in 10 cases, and good recovery mentioned in the remaining 5. Additional case series are summarized in Table 2.

TABLE 2:

Published case series of radial to axillary nerve neurotization*

Authors & YearNo. of CasesAvg Pt Age in Yrs (range)Common Injury MechanismAvg Time to Op in Mos (range)Avg Preop Deltoid AbductionConcomitant Nerve TransfersDonor NerveAvg FU (mos)Median Postop Deltoid StrengthMean Postop Shoulder Abduction
Leechavengvongs et al., 2003725 (13–35)MVA6.3 (3–10)0/5CN XI to suprascapular nerve, Oberlinlong HTB204/5124º
Bertelli & Ghizoni, 20041028 (19–32)6.0 (5–7)0/5CN XI to suprascapular nerve, Oberlin7 long HTB, 3 lateral HTB244/592º
Kawai & Akita, 2004620 (15–27)2.3 (1.3–3)0/55/6 cases: CN XI to supra-scapular nerve, Oberlinradial3990o elevation in 5/6; 45º in 1/6
Leechavengvongs et al., 20061527 (13–62)MVA6.0 (3–10)0/5CN XI to suprascapular nerve, Oberlinlong HTB324/5115º
Bertelli et al., 2007323 (19–27)9.0 (8–10)0/5none2 long HTB, 1 medial HTB184/5abduction, improved strength by 50%
Jerome, 2011527 (—)— (1–6)CN XI to suprascapular nervelong HTB265/5120º
Dahlin et al., 2012312 (9–24)MVA18.3 (14–22)3/5noneradial124/5
Jerome, 2012628 (20–52)MVA4.2 (3–5)0/5CN XI to suprascapular nervelong HTB265/5133º
Jerome & Rajmohan, 2012926 (20–52)MVA3.8 (3–5)0/5nonelong HTB355/5134º
Lee et al., 20122138 (16–79)MVA, sports, iatrogenic7.6 (4–14)0/5nonelong HTB214/5119º
Lu et al., 2012927 (21–39)7.0 (3–11)0/5CN XI to suprascapular nerve, Oberlinlong HTB & medial HTB333/5–4/5full abduction in 6/9, 50–130º in 3/9
Kostas-Agnantis et al., 2013927 (21–35)MVA & falls7.2 (4–11)0/5CN XI to suprascapular nervelong HTB & medial HTB184/5112º

Avg = average; CN = cranial nerve; FU = follow-up; HTB = head of triceps brachii; MVA = motor vehicle accident; pt = patient.

The focus of our series is radial to axillary nerve neurotization in an exclusively pediatric population, where the literature remains sparse. Of the 103 cases summarized from 12 studies in Table 2, a total of 12 cases involved patients younger than 18 years and none involved infants. The large number of patients excluded was based on age, as most patients were in the adult age group. Moreover, it was rarely the case that a single radial to axillary neurotization was performed. Lee et al. reported on the only cohort that underwent radial to axillary nerve neurotization alone.21 Rather, this procedure was often done in conjunction with other brachial plexus neurotizations, such as spinal accessory to suprascapular nerve neurotization and ulnar to musculocutaneous nerve neurotization.20,22–24 A minority of patients received conservative management without surgery, and others underwent sural nerve grafting.11 Some patients underwent intercostal nerve grafting as well.16

Of the 12 pediatric patients identified in our literature search, 10 underwent surgery, and 8 of these 10 patients were treated with radial to axillary nerve neurotization procedures. Leechavengvongs et al.22,23 twice reported on a 13-year-old girl who suffered right brachial plexus injury after a motorcycle accident. Eight months postinjury she had 0/5 deltoid, biceps, and external rotation strength and thus underwent spinal accessory to suprascapular nerve neurotization, ulnar to musculocutaneous nerve neurotization, and radial to axillary nerve neurotization. Postoperatively, she had 4/5 deltoid strength, 3/5 external rotation strength, and 70° of shoulder abduction. The same authors performed the same procedures in a 17-year-old male patient with a left axillary nerve injury. By 9 months after surgery the patient had 4/5 strength, increase from 0/5 strength preoperatively, 8 months after injury.23 Kawai and Akita18 performed radial nerve transfer to the axillary nerve, accessory nerve transfer to the suprascapular nerve, and a partial median nerve transfer to the musculocutaneous nerve in a 15-year-old patient, although no preoperative or postoperative details were provided. Dahlin et al.11 evaluated 6 pediatric patients with axillary nerve injuries. One 9-year-old boy and two 13-year-old boys underwent radial to axillary nerve transfer after blunt shoulder trauma. At 11–14 months after surgery (11 and 12 months for the two 13-year-olds and 14 months for the 9-year-old), each of the patients had positive electromyography findings and had recovered 4/5 deltoid muscle function. In the same cohort, a 10-yearold boy and 16-year-old boy suffered shoulder dislocations and underwent sural nerve grafting to the axillary nerve with 4/5 and 2/5 deltoid strength, respectively. Two patients were treated conservatively (without surgery)—a 10-year-old and an 11-year-old, who sustained axillary nerve injury due to blunt trauma and shoulder dislocation, respectively—and both achieved 4/5 deltoid function. Lastly, Lee et al.21 evaluated two 16-year-old patients who had both suffered isolated axillary nerve injuries in motorcycle accidents. They both underwent triceps motor branch transfer to the axillary nerve, and at 41 months in 1 case and 12 months in the other, achieved 4.5/5 deltoid strength with 170° of shoulder abduction.

Timing between the inciting trauma and operative intervention is an important factor for full recovery and remains controversial.11,41,50 Alnot and Valenti2 suggested waiting 12 months postinjury until surgical repair is explored. Leechavengvongs et al.23 reported satisfactory results with an average of 6 months from injury to operation. In their anatomical study and report of 3 cases, Bertelli et al.5 recommended surgery in patients with paralysis lasting more than 8 but less than 12 months. In cases in which the injury was not discovered until after 1 year, Dahlin et al.11 reported promising outcomes with radial nerve transfer at 14–22 months after injury, with all 3 patients achieving 4/5 deltoid strength. As previously mentioned, Lee et al.21 reported a delay to surgery as a predictor for poor recovery of shoulder abduction. In our series, all patients underwent surgery within 10 months of their initial injury.

Several donor nerve options exist. Samardzic et al.43 reported on 11 cases in which the medial pectoral nerve,52 sometimes combined with the first intercostal nerve, was used for axillary nerve neurotization; 82% of the patients achieved a functional recovery. Several years earlier, the same authors observed that 74% of their patients recovered shoulder abduction over 45° when the thoracodorsal or subscapular nerve was used as donor to the axillary nerve.42 Intercostal nerves were some of the earliest options available for nerve transfer in avulsed brachial plexus injuries.33,46 Limitations included increased distance between site of anastomosis, denervated muscles, use of nerve grafts, and mixing motor and sensory axons.44 Results with intercostal donor nerves vary widely, depending on how many intercostal nerves are used, with one case series achieving 63.2% recovery of axillary nerve function.44 Reports suggest that taking 3 or 4 intercostal nerves is an accepted practice with good results.13,26,33,44 If the spinal accessory nerve is used for axillary nerve neurotization, although the trapezius is synergistic to deltoid function, an interposition graft is required due to distance.5 The thoracodorsal nerve, responsible for shoulder adduction, has also been used, but deltoid contraction was seen during shoulder adduction, which defeats the purpose of restoring shoulder abduction.5,31

Numerous options exist for recovery of shoulder abduction. A major strength of this particular neurotization is that the radial nerve is adjacent to the axillary nerve, thus no graft is needed. Superior results have been shown in transfer compared with grafting.1,8,23 Furthermore, the radial nerve is mostly a motor nerve with minor sensory input; thus, sensory deficit after surgery is rare. Moreover, the radial nerve is a similar size to the axillary nerve. In terms of function, the optimal candidate for donor nerve is one that innervates a muscle synergistic to the target muscle. The triceps works in tandem with the deltoid, making reinnervation and retraining of the muscle natural. The long head of the triceps is one of 3 heads and thus relatively redundant. Losing it appears to have negligible effect on triceps function.22 The long head of the triceps is also used in musculocutaneous flaps and muscle transfers.40,45,48 No patient in any series, including the current study, was found to have elbow extension deficits after this procedure.

Conclusions

We have reviewed our experience with axillary nerve injuries across 3 institutions. Excellent results were imparted after radial to axillary nerve neurotization, with all patients achieving shoulder abduction against gravity and most against resistance, with a negligible effect on arm extension via triceps function. Radial to axillary nerve neurotization appears to be a safe, effective, and expedient operation to restore shoulder abduction in children. Our series highlights its role in pediatric patients representing a broad range of ages, from neonates to young adults.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. There were no external sources of financial support for this manuscript.

Author contributions to the study and manuscript preparation include the following. Conception and design: Zuckerman, Park, Wellons. Acquisition of data: Zuckerman, Eli, Shah, Bradley, Park, Wellons. Analysis and interpretation of data: Zuckerman, Eli, Shah, Park, Wellons. Drafting the article: Zuckerman, Eli, Shah. Critically revising the article: Zuckerman, Eli, Shah, Stutz, Park, Wellons. Reviewed submitted version of manuscript: Zuckerman, Eli, Shah, Stutz, Park, Wellons. Approved the final version of the manuscript on behalf of all authors: Zuckerman. Statistical analysis: Stutz, Wellons. Administrative/technical/material support: Bradley, Stutz, Park, Wellons. Study supervision: Park, Wellons.

This article contains some figures that are displayed in color online but in black-and-white in the print edition.

Three of the cases described in this paper were previously presented in an oral abstract at the 37th Annual Meeting of the AANS/CNS Section on Pediatric Neurological Surgery, December 2–5, 2008, in Spokane, Washington.

References

  • 1

    Alnot JYRostoucher POberlin CTouam C: [C5-C6 and C5-C6-C7 traumatic paralysis of the brachial plexus of the adult caused by supraclavicular lesions]. Rev Chir Orthop Reparatrice Appar Mot 84:1131231998. (Fr)

    • Search Google Scholar
    • Export Citation
  • 2

    Alnot JYValenti P: [Surgical repair of the axillary nerve. Apropos of 37 cases]. Int Orthop 15:7111991. (Fr)

  • 3

    Ashley WW JrBaty JDHollander TNoetzel MJPark TS: Long-term motor outcome analysis using a motor score composite following surgical brachial plexus repair. J Neurosurg 106:4 Suppl2762812007

    • Search Google Scholar
    • Export Citation
  • 4

    Bertelli JAGhizoni MF: Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve. J Hand Surg Am 29:1311392004

    • Search Google Scholar
    • Export Citation
  • 5

    Bertelli JAKechele PRSantos MADuarte HGhizoni MF: Axillary nerve repair by triceps motor branch transfer through an axillary access: anatomical basis and clinical results. J Neurosurg 107:3703772007

    • Search Google Scholar
    • Export Citation
  • 6

    Birch R: Surgical Disorders of the Peripheral Nerves ed 2LondonSpringer-Verlag2011

  • 7

    Bonnard CAnastakis DJvan Melle GNarakas AO: Isolated and combined lesions of the axillary nerve. A review of 146 cases. J Bone Joint Surg Br 81:2122171999

    • Search Google Scholar
    • Export Citation
  • 8

    Brown JMShah MNMackinnon SE: Distal nerve transfers: a biology-based rationale. Neurosurg Focus 26:2E122009

  • 9

    Chuang DCLee GWHashem FWei FC: Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 96:1221281995

    • Search Google Scholar
    • Export Citation
  • 10

    Colbert SHMackinnon S: Posterior approach for double nerve transfer for restoration of shoulder function in upper brachial plexus palsy. Hand (NY) 1:71772006

    • Search Google Scholar
    • Export Citation
  • 11

    Dahlin LBCöster MBjörkman ABackman C: Axillary nerve injury in young adults—an overlooked diagnosis? Early results of nerve reconstruction and nerve transfers. J Plast Surg Hand Surg 46:2572612012

    • Search Google Scholar
    • Export Citation
  • 12

    Doumouchtsis SKArulkumaran S: Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia?. Ann N Y Acad Sci 1205:1351432010

    • Search Google Scholar
    • Export Citation
  • 13

    Friedman AHNunley JA IIGoldner RDOakes WJGoldner JLUrbaniak JR: Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries. J Neurosurg 72:59641990

    • Search Google Scholar
    • Export Citation
  • 14

    Jerome JT: Anterior deltopectoral approach for axillary nerve neurotisation. J Orthop Surg (Hong Kong) 20:66702012

  • 15

    Jerome JT: Long head of the triceps branch to axillary nerve in C5, C6 brachial plexus injuries: anterior approach. Plast Reconstr Surg 128:7407412011

    • Search Google Scholar
    • Export Citation
  • 16

    Jerome JTRajmohan B: Axillary nerve neurotization with the anterior deltopectoral approach in brachial plexus injuries. Microsurgery 32:4454512012

    • Search Google Scholar
    • Export Citation
  • 17

    Jobe MTMartinez SFPeripheral nerve injuries. Canale STBeaty JH: Campbell's Operative Orthopaedics ed 12PhiladelphiaMosby2013. 30623123

    • Search Google Scholar
    • Export Citation
  • 18

    Kawai HAkita S: Shoulder muscle reconstruction in the upper type of the brachial plexus injury by partial radial nerve transfer to the axillary nerve. Tech Hand Up Extrem Surg 8:51552004

    • Search Google Scholar
    • Export Citation
  • 19

    Kline DGKim DH: Axillary nerve repair in 99 patients with 101 stretch injuries. J Neurosurg 99:6306362003

  • 20

    Kostas-Agnantis IKorompilias AVekris MLykissas MGkiatas IMitsionis G: Shoulder abduction and external rotation restoration with nerve transfer. Injury [epub ahead of print]2013

    • Search Google Scholar
    • Export Citation
  • 21

    Lee JYKircher MFSpinner RJBishop ATShin AY: Factors affecting outcome of triceps motor branch transfer for isolated axillary nerve injury. J Hand Surg Am 37:235023562012

    • Search Google Scholar
    • Export Citation
  • 22

    Leechavengvongs SWitoonchart KUerpairojkit CThuvasethakul P: Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases. J Hand Surg Am 28:6336382003

    • Search Google Scholar
    • Export Citation
  • 23

    Leechavengvongs SWitoonchart KUerpairojkit CThuvasethakul PMalungpaishrope K: Combined nerve transfers for C5 and C6 brachial plexus avulsion injury. J Hand Surg Am 31:1831892006

    • Search Google Scholar
    • Export Citation
  • 24

    Lu JXu JXu WXu LFang YChen L: Combined nerve transfers for repair of the upper brachial plexus injuries through a posterior approach. Microsurgery 32:1111172012

    • Search Google Scholar
    • Export Citation
  • 25

    Lurje A: Concerning surgical treatment of traumatic injury to the upper division of the brachial plexus (Erb's type). Ann Surg 127:3173261948

    • Search Google Scholar
    • Export Citation
  • 26

    Malessy MJThomeer RT: Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery. J Neurosurg 88:2662711998

    • Search Google Scholar
    • Export Citation
  • 27

    Medical Research Council: Aids to the Investigation of Peripheral Nerve Injuries ed 2LondonHer Majesty's Stationery Office1943

  • 28

    Miller JHGarber STMcCormick DEEskandari RWalker MLRizk E: Oberlin transfer and partial radial to axillary nerve neurotization to repair an explosive traumatic injury to the brachial plexus in a child: case report. Childs Nerv Syst 29:210521092013

    • Search Google Scholar
    • Export Citation
  • 29

    Moore KLDalley AFAgur AMR: Clinically Oriented Anatomy ed 5BaltimoreLippincott Williams & Wilkins2006

  • 30

    Nagano A: Treatment of brachial plexus injury. J Orthop Sci 3:71801998

  • 31

    Narakas AOBrachial plexus lesions. Leung PCGu YDIkuta Y: Microsurgery in Orthopaedic Practice SingaporeWorld Scientific1995. 188254

    • Search Google Scholar
    • Export Citation
  • 32

    Narakas AO: Paralytic disorders of the shoulder girdle. Hand Clin 4:6196321988

  • 33

    Narakas AOHentz VR: Neurotization in brachial plexus injuries. Indication and results. Clin Orthop Relat Res 237:43561988

  • 34

    Nath RKMackinnon SE: Nerve transfers in the upper extremity. Hand Clin 16:131139ix2000

  • 35

    Oberlin CBéal DLeechavengvongs SSalon ADauge MCSarcy JJ: Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am 19:2322371994

    • Search Google Scholar
    • Export Citation
  • 36

    Ochiai NNagano AMikami YYamamoto S: Full exposure of the axillary and suprascapular nerves. J Bone Joint Surg Br 79:5325331997

    • Search Google Scholar
    • Export Citation
  • 37

    Okby RSheiner E: Risk factors for neonatal brachial plexus paralysis. Arch Gynecol Obstet 286:3333362012

  • 38

    Payne MWDoherty TJSequeira KAMiller TA: Peripheral nerve injury associated with shoulder trauma: a retrospective study and review of the literature. J Clin Neuromuscul Dis 4:162002

    • Search Google Scholar
    • Export Citation
  • 39

    Perlmutter GS: Axillary nerve injury. Clin Orthop Relat Res 36828361999

  • 40

    Piquilloud GVillani FCasoli V: The medial head of the triceps brachii. Anatomy and blood supply of a new muscular free flap: the medial triceps free flap. Surg Radiol Anat 33:4154202011

    • Search Google Scholar
    • Export Citation
  • 41

    Saito HDahlin LB: Expression of ATF3 and axonal outgrowth are impaired after delayed nerve repair. BMC Neurosci 9:882008

  • 42

    Samardzic MGrujicic DAntunovic V: Nerve transfer in brachial plexus traction injuries. J Neurosurg 76:1911971992

  • 43

    Samardzic MGrujicic DRasulic LBacetic D: Transfer of the medial pectoral nerve: myth or reality?. Neurosurgery 50:127712822002

    • Search Google Scholar
    • Export Citation
  • 44

    Samardzić MRasulić LGrujicić DMilicić B: Results of nerve transfers to the musculocutaneous and axillary nerves. Neurosurgery 46:931032000

    • Search Google Scholar
    • Export Citation
  • 45

    Schulz BNyland JKeen JMalkani A: Self-reported shoulder function following massive rotator cuff tear reconstruction using a triceps brachii interposition flap. Acta Orthop Belg 74:5825892008

    • Search Google Scholar
    • Export Citation
  • 46

    Seddon HJ: Nerve grafting. J Bone Joint Surg Br 45:4474611963

  • 47

    Steinmann SPMoran EA: Axillary nerve injury: diagnosis and treatment. J Am Acad Orthop Surg 9:3283352001

  • 48

    Sundine MJMalkani AL: The use of the long head of triceps interposition muscle flap for treatment of massive rotator cuff tears. Plast Reconstr Surg 110:126612742002

    • Search Google Scholar
    • Export Citation
  • 49

    Terzis JKKokkalis ZT: Shoulder function following primary axillary nerve reconstruction in obstetrical brachial plexus patients. Plast Reconstr Surg 122:145714692008

    • Search Google Scholar
    • Export Citation
  • 50

    Tsuda YKanje MDahlin LB: Axonal outgrowth is associated with increased ERK 1/2 activation but decreased caspase 3 linked cell death in Schwann cells after immediate nerve repair in rats. BMC Neurosci 12:122011

    • Search Google Scholar
    • Export Citation
  • 51

    Visser CPCoene LNBrand RTavy DL: The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg Br 81:6796851999

    • Search Google Scholar
    • Export Citation
  • 52

    Wellons JCTubbs RSPugh JABradley NJLaw CRGrabb PA: Medial pectoral nerve to musculocutaneous nerve neurotization for the treatment of persistent birth-related brachial plexus palsy: an 11-year institutional experience. Clinical article. J Neurosurg Pediatr 3:3483532009

    • Search Google Scholar
    • Export Citation
  • 53

    Witoonchart KLeechavengvongs SUerpairojkit CThuvasethakul PWongnopsuwan V: Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study. J Hand Surg Am 28:6286322003

    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Address correspondence to: Scott L. Zuckerman, M.D., Department of Neurological Surgery, Vanderbilt University Medical Center, 2220 Children's Way, 9226 Doctors' Office Tower, Nashville, TN 37232-9557. email: scott.zuckerman@vanderbilt.edu.

Please include this information when citing this paper: published online September 5, 2014; DOI: 10.3171/2014.7.PEDS13435.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 3. Image obtained during follow-up examination 59 months after surgery.

References

  • 1

    Alnot JYRostoucher POberlin CTouam C: [C5-C6 and C5-C6-C7 traumatic paralysis of the brachial plexus of the adult caused by supraclavicular lesions]. Rev Chir Orthop Reparatrice Appar Mot 84:1131231998. (Fr)

    • Search Google Scholar
    • Export Citation
  • 2

    Alnot JYValenti P: [Surgical repair of the axillary nerve. Apropos of 37 cases]. Int Orthop 15:7111991. (Fr)

  • 3

    Ashley WW JrBaty JDHollander TNoetzel MJPark TS: Long-term motor outcome analysis using a motor score composite following surgical brachial plexus repair. J Neurosurg 106:4 Suppl2762812007

    • Search Google Scholar
    • Export Citation
  • 4

    Bertelli JAGhizoni MF: Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve. J Hand Surg Am 29:1311392004

    • Search Google Scholar
    • Export Citation
  • 5

    Bertelli JAKechele PRSantos MADuarte HGhizoni MF: Axillary nerve repair by triceps motor branch transfer through an axillary access: anatomical basis and clinical results. J Neurosurg 107:3703772007

    • Search Google Scholar
    • Export Citation
  • 6

    Birch R: Surgical Disorders of the Peripheral Nerves ed 2LondonSpringer-Verlag2011

  • 7

    Bonnard CAnastakis DJvan Melle GNarakas AO: Isolated and combined lesions of the axillary nerve. A review of 146 cases. J Bone Joint Surg Br 81:2122171999

    • Search Google Scholar
    • Export Citation
  • 8

    Brown JMShah MNMackinnon SE: Distal nerve transfers: a biology-based rationale. Neurosurg Focus 26:2E122009

  • 9

    Chuang DCLee GWHashem FWei FC: Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 96:1221281995

    • Search Google Scholar
    • Export Citation
  • 10

    Colbert SHMackinnon S: Posterior approach for double nerve transfer for restoration of shoulder function in upper brachial plexus palsy. Hand (NY) 1:71772006

    • Search Google Scholar
    • Export Citation
  • 11

    Dahlin LBCöster MBjörkman ABackman C: Axillary nerve injury in young adults—an overlooked diagnosis? Early results of nerve reconstruction and nerve transfers. J Plast Surg Hand Surg 46:2572612012

    • Search Google Scholar
    • Export Citation
  • 12

    Doumouchtsis SKArulkumaran S: Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia?. Ann N Y Acad Sci 1205:1351432010

    • Search Google Scholar
    • Export Citation
  • 13

    Friedman AHNunley JA IIGoldner RDOakes WJGoldner JLUrbaniak JR: Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries. J Neurosurg 72:59641990

    • Search Google Scholar
    • Export Citation
  • 14

    Jerome JT: Anterior deltopectoral approach for axillary nerve neurotisation. J Orthop Surg (Hong Kong) 20:66702012

  • 15

    Jerome JT: Long head of the triceps branch to axillary nerve in C5, C6 brachial plexus injuries: anterior approach. Plast Reconstr Surg 128:7407412011

    • Search Google Scholar
    • Export Citation
  • 16

    Jerome JTRajmohan B: Axillary nerve neurotization with the anterior deltopectoral approach in brachial plexus injuries. Microsurgery 32:4454512012

    • Search Google Scholar
    • Export Citation
  • 17

    Jobe MTMartinez SFPeripheral nerve injuries. Canale STBeaty JH: Campbell's Operative Orthopaedics ed 12PhiladelphiaMosby2013. 30623123

    • Search Google Scholar
    • Export Citation
  • 18

    Kawai HAkita S: Shoulder muscle reconstruction in the upper type of the brachial plexus injury by partial radial nerve transfer to the axillary nerve. Tech Hand Up Extrem Surg 8:51552004

    • Search Google Scholar
    • Export Citation
  • 19

    Kline DGKim DH: Axillary nerve repair in 99 patients with 101 stretch injuries. J Neurosurg 99:6306362003

  • 20

    Kostas-Agnantis IKorompilias AVekris MLykissas MGkiatas IMitsionis G: Shoulder abduction and external rotation restoration with nerve transfer. Injury [epub ahead of print]2013

    • Search Google Scholar
    • Export Citation
  • 21

    Lee JYKircher MFSpinner RJBishop ATShin AY: Factors affecting outcome of triceps motor branch transfer for isolated axillary nerve injury. J Hand Surg Am 37:235023562012

    • Search Google Scholar
    • Export Citation
  • 22

    Leechavengvongs SWitoonchart KUerpairojkit CThuvasethakul P: Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases. J Hand Surg Am 28:6336382003

    • Search Google Scholar
    • Export Citation
  • 23

    Leechavengvongs SWitoonchart KUerpairojkit CThuvasethakul PMalungpaishrope K: Combined nerve transfers for C5 and C6 brachial plexus avulsion injury. J Hand Surg Am 31:1831892006

    • Search Google Scholar
    • Export Citation
  • 24

    Lu JXu JXu WXu LFang YChen L: Combined nerve transfers for repair of the upper brachial plexus injuries through a posterior approach. Microsurgery 32:1111172012

    • Search Google Scholar
    • Export Citation
  • 25

    Lurje A: Concerning surgical treatment of traumatic injury to the upper division of the brachial plexus (Erb's type). Ann Surg 127:3173261948

    • Search Google Scholar
    • Export Citation
  • 26

    Malessy MJThomeer RT: Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery. J Neurosurg 88:2662711998

    • Search Google Scholar
    • Export Citation
  • 27

    Medical Research Council: Aids to the Investigation of Peripheral Nerve Injuries ed 2LondonHer Majesty's Stationery Office1943

  • 28

    Miller JHGarber STMcCormick DEEskandari RWalker MLRizk E: Oberlin transfer and partial radial to axillary nerve neurotization to repair an explosive traumatic injury to the brachial plexus in a child: case report. Childs Nerv Syst 29:210521092013

    • Search Google Scholar
    • Export Citation
  • 29

    Moore KLDalley AFAgur AMR: Clinically Oriented Anatomy ed 5BaltimoreLippincott Williams & Wilkins2006

  • 30

    Nagano A: Treatment of brachial plexus injury. J Orthop Sci 3:71801998

  • 31

    Narakas AOBrachial plexus lesions. Leung PCGu YDIkuta Y: Microsurgery in Orthopaedic Practice SingaporeWorld Scientific1995. 188254

    • Search Google Scholar
    • Export Citation
  • 32

    Narakas AO: Paralytic disorders of the shoulder girdle. Hand Clin 4:6196321988

  • 33

    Narakas AOHentz VR: Neurotization in brachial plexus injuries. Indication and results. Clin Orthop Relat Res 237:43561988

  • 34

    Nath RKMackinnon SE: Nerve transfers in the upper extremity. Hand Clin 16:131139ix2000

  • 35

    Oberlin CBéal DLeechavengvongs SSalon ADauge MCSarcy JJ: Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am 19:2322371994

    • Search Google Scholar
    • Export Citation
  • 36

    Ochiai NNagano AMikami YYamamoto S: Full exposure of the axillary and suprascapular nerves. J Bone Joint Surg Br 79:5325331997

    • Search Google Scholar
    • Export Citation
  • 37

    Okby RSheiner E: Risk factors for neonatal brachial plexus paralysis. Arch Gynecol Obstet 286:3333362012

  • 38

    Payne MWDoherty TJSequeira KAMiller TA: Peripheral nerve injury associated with shoulder trauma: a retrospective study and review of the literature. J Clin Neuromuscul Dis 4:162002

    • Search Google Scholar
    • Export Citation
  • 39

    Perlmutter GS: Axillary nerve injury. Clin Orthop Relat Res 36828361999

  • 40

    Piquilloud GVillani FCasoli V: The medial head of the triceps brachii. Anatomy and blood supply of a new muscular free flap: the medial triceps free flap. Surg Radiol Anat 33:4154202011

    • Search Google Scholar
    • Export Citation
  • 41

    Saito HDahlin LB: Expression of ATF3 and axonal outgrowth are impaired after delayed nerve repair. BMC Neurosci 9:882008

  • 42

    Samardzic MGrujicic DAntunovic V: Nerve transfer in brachial plexus traction injuries. J Neurosurg 76:1911971992

  • 43

    Samardzic MGrujicic DRasulic LBacetic D: Transfer of the medial pectoral nerve: myth or reality?. Neurosurgery 50:127712822002

    • Search Google Scholar
    • Export Citation
  • 44

    Samardzić MRasulić LGrujicić DMilicić B: Results of nerve transfers to the musculocutaneous and axillary nerves. Neurosurgery 46:931032000

    • Search Google Scholar
    • Export Citation
  • 45

    Schulz BNyland JKeen JMalkani A: Self-reported shoulder function following massive rotator cuff tear reconstruction using a triceps brachii interposition flap. Acta Orthop Belg 74:5825892008

    • Search Google Scholar
    • Export Citation
  • 46

    Seddon HJ: Nerve grafting. J Bone Joint Surg Br 45:4474611963

  • 47

    Steinmann SPMoran EA: Axillary nerve injury: diagnosis and treatment. J Am Acad Orthop Surg 9:3283352001

  • 48

    Sundine MJMalkani AL: The use of the long head of triceps interposition muscle flap for treatment of massive rotator cuff tears. Plast Reconstr Surg 110:126612742002

    • Search Google Scholar
    • Export Citation
  • 49

    Terzis JKKokkalis ZT: Shoulder function following primary axillary nerve reconstruction in obstetrical brachial plexus patients. Plast Reconstr Surg 122:145714692008

    • Search Google Scholar
    • Export Citation
  • 50

    Tsuda YKanje MDahlin LB: Axonal outgrowth is associated with increased ERK 1/2 activation but decreased caspase 3 linked cell death in Schwann cells after immediate nerve repair in rats. BMC Neurosci 12:122011

    • Search Google Scholar
    • Export Citation
  • 51

    Visser CPCoene LNBrand RTavy DL: The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg Br 81:6796851999

    • Search Google Scholar
    • Export Citation
  • 52

    Wellons JCTubbs RSPugh JABradley NJLaw CRGrabb PA: Medial pectoral nerve to musculocutaneous nerve neurotization for the treatment of persistent birth-related brachial plexus palsy: an 11-year institutional experience. Clinical article. J Neurosurg Pediatr 3:3483532009

    • Search Google Scholar
    • Export Citation
  • 53

    Witoonchart KLeechavengvongs SUerpairojkit CThuvasethakul PWongnopsuwan V: Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study. J Hand Surg Am 28:6286322003

    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 268 264 12
PDF Downloads 244 216 6
EPUB Downloads 0 0 0

PubMed

Google Scholar