Brachial Plexus Exploration and Reconstruction

Indication. Operative exploration and reconstruction of a traumatic brachial plexus injury. The timing depends on mechanism: a sharp or penetrating injury is explored within days to two weeks (primary repair or early grafting before retraction); a closed traction injury without recovery is explored at 3 to 6 months (allowing neurapraxia to resolve while staying inside the reinnervation window); a complete flail arm with imaging and EMG confirming avulsion proceeds to exploration and transfer planning at about 3 months; and a progressive neurological deficit or expanding haematoma mandates urgent exploration regardless of mechanism. Absolute indications

• Traumatic root avulsion confirmed by pseudomeningoceles, preserved SNAPs, and paraspinal denervation
• Postganglionic rupture with no clinical or electrodiagnostic recovery by 3 to 6 months
• Associated vascular injury requiring repair, explored together with the plexus Relative indications
• Incomplete recovery with a plateau on serial examination and EMG
• A patient who wants reconstruction after being counselled on realistic outcomes and donor morbidity
• Paediatric brachial plexus palsy failing to recover spontaneously by 3 to 6 months Contraindications
• Absolute: life-threatening associated injuries precluding prolonged anaesthesia; complete motor endplate degeneration beyond 18 to 24 months with no viable targets; patient refusal or inability to comply with rehabilitation.
• Relative: isolated neurapraxia expected to recover (serial EMG shows improving conduction); poor donor nerve availability or comorbidities increasing surgical risk. The one decision that matters — match the operation to the lesion. Every reconstruction begins with exposure and intraoperative confirmation of avulsion versus rupture; what you then do depends on what you find:

Consent for realistic partial recovery, donor morbidity (sural sensory loss, spinal accessory shoulder droop, possible ulnar weakness), the likelihood of multiple procedures, and a 12 to 24 month rehabilitation timeline. Setup. Supine, head turned away from the operative side, arm abducted 30 to 45 degrees on an arm board. Prep and drape the entire arm, neck, chest and both legs for sural harvest. General endotracheal anaesthesia with muscle relaxant used only for induction — no paralytics during the nerve-stimulation phase — and intraoperative nerve monitoring set up. Loupe magnification (3.5x) or operating microscope, bipolar cautery, nerve stimulator, vessel loops and microsurgical instruments.

The goal is to expose the plexus (supraclavicularly, infraclavicularly, or both), differentiate avulsion from rupture by intraoperative stimulation, and reconstruct following a fixed priority ladder: shoulder stability and external rotation first, then elbow flexion, then hand function. The exposure is laid out in full as the opening steps of the sequence below. Reconstructive priorities

1. Shoulder stability and external rotation — spinal accessory to suprascapular.
2. Elbow flexion — Oberlin or double fascicular transfer.
3. Shoulder abduction — axillary nerve grafting or transfer if donors available.
4. Hand sensation and basic grasp — intercostal or contralateral C7 transfers.
5. Wrist and finger extension — if donors remain.

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Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 | 0 to 6 weeks | Abduction sling or brace | Gentle passive ROM of elbow, wrist and hand from day 1; no active shoulder or elbow loading; wound, oedema and scar care from 2 weeks | | 2 | 6 weeks to 6 months | Removable as transfers heal | Active-assisted ROM; electrical stimulation of target muscles once reinnervation is detected; strengthening from MRC grade 3; clinical and EMG review every 3 months | | 3 | 6 to 24 months | Support as needed | Task-specific training for shoulder stability, elbow flexion and hand function; consider secondary tendon transfers or arthrodesis once recovery plateaus | Expected outcomes

• Elbow flexion MRC grade 3 or better: 80 to 95 percent with an Oberlin transfer within 6 months.
• Shoulder abduction greater than 30 degrees: 60 to 75 percent with a spinal accessory to suprascapular transfer.
• Intercostal transfers: useful elbow flexion in 60 to 75 percent but with higher donor morbidity.
• Sural nerve grafting of ruptures: shoulder and elbow function restored in 60 to 80 percent when gaps are short and the repair tension-free.
• Useful hand function: 30 to 50 percent with multiple transfers; many patients achieve only protective sensation.
• Overall: 60 to 70 percent report meaningful functional improvement despite incomplete recovery. Complications

Critical danger structures and exam traps

Epidemiology. Traumatic brachial plexus injuries are high-energy traction injuries, classically sustained by young men in motorcycle crashes; closed traction dominates, with a smaller proportion of sharp or penetrating lacerations. The injury pattern ranges from a single root or trunk to complete pan-plexus avulsion, and the prognosis is driven by whether the lesion is pre- or post-ganglionic. Surgical anatomy. Supraclavicularly, the upper trunk (C5-C6 union) lies superficial in the posterior triangle; the middle trunk (C7) and lower trunk (C8-T1) sit progressively deeper and closer to the subclavian vessels. The dorsal scapular nerve (C5) and long thoracic nerve (C5-C7) arise proximally, so their denervation on EMG confirms a preganglionic injury. Infraclavicularly, the divisions lie behind the clavicle and the cords surround the axillary artery in the deltopectoral groove — the lateral cord gives the musculocutaneous and lateral pectoral nerves, the posterior cord the axillary and radial nerves, and the medial cord the ulnar, medial pectoral and medial cutaneous nerves of arm and forearm. Classification — avulsion versus rupture. The single most important distinction, because it determines whether grafting is even possible:

Key evidence. Early exploration (less than 3 months) for a closed injury risks operating on neurapraxia that would recover, while exploration beyond 6 to 9 months yields poorer regeneration as motor endplates fibrose. The strategy follows the lesion type: postganglionic ruptures have a graftable proximal stump and are reconstructed with tension-free sural cable grafts, whereas preganglionic avulsions have no proximal stump and require nerve transfers. The spinal accessory to suprascapular and Oberlin ulnar fascicle transfers are the workhorse procedures with the strongest evidence; intercostal and contralateral C7 transfers extend the donor pool for pan-plexus avulsions.