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Background:  The restoration of finger movement in total brachial plexus injuries (BPIs) is an ultimate challenge. Pedicled vascularized ulnar nerve graft (VUNG) connecting a proximal root to distal target nerves has shown unpredictable outcomes. We modified this technique by harvesting VUNG as a free flap to reinnervate median nerve (MN). We analyzed the long-term outcomes of these methods., Methods:  From years 1998 to 2015, 118 acute total brachial plexus patients received free VUNG to innervate the MN. Patients were followed up at least 5 years after the initial surgery. Donor nerves included the ipsilateral C5 root (25 patients) or contralateral C7 root (CC7 = 93 patients). Recovery of finger and elbow flexion was evaluated with the modified Medical Research Council system. Michigan Hand Score and Quick-DASH were used to represent the patient-reported outcomes., Results:  For finger flexion, ipsilateral C5 transfer to MN alone yielded similar outcomes to MN + MCN (musculocutaneous nerve), while CC7 had significantly better finger flexion when coapted to MN alone than to MN + MCN. Approximately 75% patients were able to achieve finger flexion with nerve transfer alone. For elbow flexion, best outcome was seen in the ipsilateral C5 to MCN and MN., Conclusion:  In acute total BPI, the priority is to identify the ipsilateral C5 root to innervate MN, with concomitant innervation of MCN to establish the best outcomes for finger and elbow flexion. CC7 is more reliable when used to innervate one target (MN)., Level of Evidence:  III., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: To evaluate functional outcomes after direct suturing of upper extremity nerve defects in high elbow or wrist flexion., Methods: A retrospective review was conducted in patients treated for median, ulnar, or radial nerve defects between 2011 and 2019. Inclusion criteria were a defect > 1 cm and a minimal follow-up period of 1 year. Nerve defects were bridged by an end-to-end suture in 90° elbow flexion or 70° wrist flexion for 6 weeks., Results: Nine patients with a mean age of 30.2 years were included. The patients presented with two ulnar nerve defects, four median nerve defects, and three radial nerve defects at various levels. The mean time to surgery was 13.5 weeks for recent injuries. The mean defect length was 2.9 cm, and the mean follow-up time was 22.4 months. Two patients had joint stiffness that was more likely related to the associated injuries than the 6-week immobilization. Successful outcomes were achieved in eight of the nine patients. Meaningful motor recovery was observed in seven patients, and all recovered meaningful sensation. Excellent nerve recovery was noted in pediatric patients and in those with distal nerve defects., Conclusion: Temporary high joint flexion allows for direct coaptation of upper extremity nerve defects up to 4 cm located near the elbow or wrist. In this small and heterogenous cohort, functional outcomes seemed to be comparable to those obtained with short autografting., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Introduction: In upper brachial plexus injuries (C5-C6-C7), selective nerve transfers appear as a favourable technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. In this paper we present our modified Oberlin technique, as well as a comparison of this method with the classic Oberlin procedure., Materials and Methods: We present two groups of patients that where operated by two different surgeons. The first group, consisting of 16 patients was treated with the classic Oberlin procedure. The second group included 5 patients treated with a modified Oberlin procedure, where two fascicles from the ulnar nerve were transferred to both the motor branch of the biceps and the motor branch of the brachialis muscles., Results: In the last follow-up of the 16 patients from the first group with the classic Oberlin procedure, 15 patients (93.75%) had Medical Research Council (MRC) grade of biceps strength 4 and 1 patient (6.25%) had MRC grade 3, whereas in the group where the modified Oberlin procedure was used the muscle strength was very durable with 4 out of 5 the patients reached MRC grade of 4+ and one MRC grade of 4, and with a mean elbow strength at 5.4 kg (3-8 kg). No sensitivity or motor problems were encountered on the ulnar territories for both groups., Conclusion: With the modified Oberlin technique, the median nerve is reserved and both elbow flexors are innervated. The results of this technique compare favourably with those of other methods. Thus, we propose using the double fascicle transfer from the ulnar nerve to both elbow flexors in order to restore a strong elbow flexion in patients with upper brachial plexus injuries., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Elbow flexion is the first goal in upper partial brachial plexus palsy treatment. However, elbow extension is essential for daily living activities. To recover this function, one fascicle of ulnar nerve can be transferred to the branch of the long head of the triceps, but this procedure has been previously published in only two patients. The goal of our study is to assess a larger series of transfers of one fascicle of ulnar nerve to the branch of the long head of the triceps to help patients recover elbow extension. Ten male patients with C5, C6 and C7 brachial plexus injuries underwent operation. For shoulder recovery, we transferred the spinal accessory nerve and rhomboid nerve. For elbow flexion, one fascicle of median nerve was transferred to the nerve of the biceps. For elbow extension, we transferred one fascicle of ulnar nerve to the branch of the long head of the triceps. Tendon transfers were performed for wrist and finger extension. Nine patients recovered M4 elbow flexion and extension. One patient had M3 elbow extension and flexion. Average active shoulder elevation was 85° and average active shoulder external rotation was 65° All patients recovered finger and wrist extension. The classical techniques of grafts or phrenic or intercostal nerve transfers to recover elbow extension are not always reliable, according to the literature. Because the harvested ulnar nerve motor fascicle is close to the branch of the long head of the triceps, the recovery time for this procedure is shorter than that of other described nerve transfers. The isolated recovery of the reinnervated long head of the triceps muscle excludes spontaneous recovery occasionally noted in upper root plexus injuries. The transfer of one fascicle of ulnar nerve to the branch of the long head of the triceps is reliable for active elbow extension recovery in C5, C6 and C7 brachial plexus palsies., (Copyright © 2019. Published by Elsevier Ltd.)

Background: In infant poliomyelitis or poliomyelitis-like paresis, there has been no means of treating residual paralysis and the policy has been to wait until an affected infant has grown sufficiently to enable tendon transfer or arthrodesis. However, recent reports have described relatively good results for early surgical intervention in the form of nerve transfer., Methods: In a 4-year and 6-month-old child we transferred a partial ulnar nerve for elbow flexor reconstruction even 3 years and 10 months after the onset of poliomyelitis-like palsy and also transferred partial accessory and radial nerves for shoulder function restoration 6 months after the first operation., Results: Elbow flexor restored M4 on the British Medical Research Council scale. The shoulder subluxation resolved, however, the strengths of the deltoid and infraspinatus remained almost M1. At the most recent clinical examination, the patient was 18 years old and the active range of motion of patient's left elbow was 0°-125°, and those of the whole shoulder girdle were abduction 35°, flexion 60°, extension 30° and external rotation 0°., Conclusions: The outcomes we achieved may support partial nerve transfer techniques as viable treatment options for persistent long-standing motor deficits following poliomyelitis-like palsy in children. However, we recommend performing partial nerve transfer as early as possible after recovery from flaccid paralysis and also use of nerves that derive from narrow spinal cord segments. After denervation, children's neuromuscular systems seem to have the ability to regenerate after a much longer period than has generally been believed. This speculation is based on only a single case report; thus, more experience is needed before this generalization can confidently be made., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Background and Importance: The use of nerve transfers to restore nerve function following traumatic avulsion injuries has been described, though there is still a paucity in the literature documenting technique and long-term outcomes for these procedures. The double Oberlin nerve transfer involves transferring fascicles from the median and ulnar nerves to the musculocutaneous nerve to restore elbow flexion in patients with a C5-C6 avulsion injury. The purpose of this case report is to present our indications and technique for a double Oberlin transfer in addition to exhibiting video footage at follow-up time points documenting the incremental improvement in elbow flexion following the injury., Clinical Presentation: The patient is a 25-yr old, left-hand dominant male who presented 5 mo following a motor vehicle accident. He had 0/5 biceps muscle strength on the left with a computed tomography myelogram that demonstrated pseudomeningoceles from C2-C3 to C7-T1 with root avulsions of C5 and C6. He was subsequently indicated for a double Oberlin nerve transfer to restore elbow flexion., Conclusion: In this case report, we present our technique and outcomes for a double Oberlin transfer with restoration of elbow flexion at 1-yr follow-up for a patient with traumatic brachial plexus injury. We believe that the double Oberlin transfer serves as a safe and effective method to restore elbow flexion in this patient population.

Background: With complete plexus injuries or late presentation, free functional muscle transfer (FFMT) becomes the primary option of functional restoration. Our purpose is to review cases over a 10-year period of free functioning gracilis muscle transfer after brachial plexus injury to evaluate the effect of different donor nerves used to reinnervate the FFMT on functional outcome., Methods: A retrospective study from April 2001 to January 2011 of a single surgeon's practice was undertaken. During this time period 22 patients underwent FFMT at Washington University in St Louis, Missouri for elbow flexion., Results: Thirteen patients for whom FFMT was performed for elbow flexion met all of the requirements for inclusion in this study. Average time from injury to first operation was 12.8 months (range 4-60), and average time from injury to FFMT was 29 months (range 8-68). Average follow-up was 31.8 months (range 11-84). The nerve donors utilized included the distal accessory nerve, intercostal with or without rectus abdominis nerves, medial pectoral nerves, thoracodorsal nerve, and flexor carpi ulnaris fascicle of ulnar nerve. Functional recovery of elbow flexion was measured using the MRC grading system which showed 1 M5/5, 5 M4, 4 M3, and 3 M2 outcomes., Conclusion: Intraplexal donor motor nerves if available will provide better transferred muscle function because they are higher quality donors closer to the muscle and can be done in one stage without a nerve graft. Otherwise, intercostal, rectus abdominis, or the distal accessory nerve should be used in a staged fashion. © 2016 Wiley Periodicals, Inc. Microsurgery 37:377-382, 2017., (© 2016 Wiley Periodicals, Inc.)

Background: Nerve transfer surgery has revolutionized the management of traumatic brachial plexus injures. However, the optimal size ratio of donor to recipient nerve has yet to be elucidated. The authors investigated the axon count ratios of ulnar and median fascicular transfers to restore elbow flexion. The authors hypothesized that donor nerve axon counts would be correlated with historical success of various nerve transfers used to restore elbow flexion., Methods: Ten cadaveric specimens were used for a histomorphologic analysis of fascicular nerve transfers. Review of previously published axon counts and clinical results following transfer to the musculocutaneous nerve to restore elbow flexion was performed for the following donor nerves: medial pectoral, spinal accessory, intercostal, thoracodorsal, ulnar, and median fascicular., Results: The average number of fascicles identified was 7.9 in the ulnar nerve and 8.0 in the median nerve. The mean fascicular axon count was 1318 for the ulnar nerve and 1860 for the median nerve. Mean recipient nerve axon count was 1826 for the musculocutaneous biceps branch and 1840 for the brachialis branch. A significant correlation between axon count and clinical results of transfers to restore elbow flexion was observed. Donor-to-recipient nerve axon count ratios below 0.7:1 were associated with a decreased likelihood of a successful outcome., Conclusions: In nerve transfers to restore elbow flexion, an appropriate size match between donor and recipient nerves appears to be a factor affecting clinical success. These data support a donor-to-recipient axon count ratio greater than 0.7:1 as the goal for brachial plexus nerve transfers to restore elbow flexion.

Purpose: Prophylactic release of the ulnar nerve to reduce the incidence of postoperative nerve symptoms in stiff elbows has been recommended. However, the necessity for routine anterior transposition remains unclear. In this study, we aim to gain an insight into the value of routine transposition in open release of stiff elbows., Methods: We retrospectively reviewed 94 patients suffering from elbow stiffness with no pre-operative ulnar nerve symptoms. Simple decompression (with in situ decompression or epicondylectomy) and subcutaneous anterior transposition were chronologically performed in 53 and 37 patients, respectively. Another four patients were treated by a single lateral approach with no intervention of the ulnar nerve. Pre- and postoperative range of motion and incidence of ulnar nerve symptoms were recorded. The function of ulnar nerve was measured by Amadio rating scale., Results: The incidence of ulnar nerve dysfuction was 18.9% (ten of 53) and 8.1% (three of 37) in the simple decompression and transposition groups, respectively. The mean Amadio scores were 7.62 and 8.22, respectively. All these data showed a statistically significant difference (P < 0.05). In the lateral approach group, 50 % (two of four) of patients developed nerve symptoms with a mean Amadio score of 6.50., Conclusions: The transposition group exhibited a superior nervous outcomes compared with the simple decompression group. No comparison was conducted between the transposition and lateral approach groups because of too few patients in the latter. According to related literature and our experience, we conclude that routine transposition is necessary to prevent postoperative nerve symptoms.

We report a case of a 10-month-old boy with a left extended upper type (C5-C7) obstetric brachial plexus injury that was treated with double nerve transfer (partial ulnar and partial median nerve transfer) to restore elbow flexion and spinal accessory nerve transfer to the suprascapular nerve to restore shoulder abduction. At 60 months' follow-up, shoulder abduction was 0-150° (M4) and elbow flexion was 0-140° (M5). Elbow, wrist and finger extension improved to M5. However, shoulder external rotation was only 0-30° (from full internal rotation). No weakness on finger and wrist flexion was observed. Double nerve transfers to restore elbow flexion can be safely done in obstetric brachial plexus injuries with good results. Secondary surgeries may be needed to improve external rotation., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: Restoration of elbow flexion is an important goal in brachial plexus injuries. Double nerve transfers using fascicles from ulnar and median nerves have consistently produced good results without causing functional compromise to the donor nerve. According to conventional practice, these double nerve transfers are dependent on the careful isolation of ulnar and median nerve fascicles, which are responsible for wrist flexion, using a handheld nerve stimulator. Here we suggest that fascicular selection by nerve stimulation might not be a necessity when executing double nerve transfers for restoration of elbow flexion in brachial plexus injuries., Methods: This is a retrospective case control study in 26 patients with C5, C6 brachial plexus injuries that were managed with double nerve transfers between March 2005 and January 2008. Our technique consisted of transferring 2 fascicles, one each from the ulnar and the median nerve, directly onto the biceps and brachialis motor branches. Contrary to the standard practice, the ulnar or median nerve fascicles were selected without using a handheld nerve stimulator. Results were compared to 21 cases (control group) in which a nerve stimulator was used for fascicular selection. The denervation period ranged from 3 to 9 months., Results: Twenty-four patients of the study group experienced full restoration of elbow flexion, and 2 had an antigravity flexion of 120° and 110°. The EMG revealed the first sign of reinnervation of biceps and brachialis muscle at 9 ± 2 weeks and 11 ± 2 weeks, as compared to 9 ± 2 weeks and 12 ± 4 weeks in the control group. After surgery, the appearance of initial evidence of elbow flexion, the range and mean of elbow flexion strength, and the difference between preoperative and postoperative grip and pinch strengths were comparable in both groups. At 24 to 28 months follow-up, 19 patients of the study group had M4 power and 7 had M3, compared to 18 and 3 cases, respectively, in the control group. The P values for Medical Research Council grade, strength of elbow flexion, and range of elbow flexion between the 2 groups did not reveal any significant statistical difference., Conclusions: Double nerve transfer is a reliable technique for restoring elbow flexion in brachial plexus injuries. There is no advantage of using a nerve stimulator in selecting fascicles before performing the nerve transfer., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level. Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss.

Background: Injuries to the upper trunk of the brachial plexus are debilitating, affecting primarily shoulder abduction and elbow flexion. Treatment is aimed at restoring shoulder stabilization, shoulder abduction, and elbow flexion and may be accomplished by nerve grafting, nerve transfer, or functional muscular transfer., Objective: To describe the double fascicular nerve transfer with the goal of restoring elbow flexion., Methods: The double fascicular nerve transfer involves transferring an ulnar nerve fascicle to the musculocutaneous nerve innervating the biceps muscle and a median nerve fascicle transfer to a branch of musculocutaneous nerve supplying the brachialis muscle., Results: The double fascicular nerve transfer is effective in restoring elbow flexion after severe upper-trunk brachial plexus injuries., Conclusion: Advantages of this procedure are that the nerve repair is done very close to the target muscle for reinnervation, so time to reinnervation is minimized, and the surgery takes place distal to the site of injury in nontraumatized tissue.