Surgical technique guide for primary and secondary reconstruction in obstetric brachial plexus palsy — nerve grafting, nerve transfers, tendon transfers, humeral derotation osteotomy
High-yield overview
Primary nerve reconstruction and secondary reconstructive procedures for birth-related brachial plexus palsy | advanced
Surgical Imaging
The brachial plexus at root and trunk level — in obstetric palsy a neuroma-in-continuity at Erb point may be resected and grafted, or nerve transfers performed, to restore shoulder and elbow function.Credit: AI-generated medical illustration · OrthoVellum
Critical Decision Points and Danger Zones in OBPI Reconstruction
Timing — The 3-Month Rule
The trap: Waiting too long for spontaneous recovery beyond 6 months in a child with no biceps recovery misses the optimal surgical window for primary nerve reconstruction.
The fix: Perform serial monthly assessment of biceps (elbow flexion) and shoulder abduction from birth. If no antigravity biceps (MRC Grade 3 or better) by 3 months of age, refer for surgical opinion. Total plexus palsy with Horner's warrants exploration at 2-3 months without waiting.
Horner's Syndrome — Preganglionic Avulsion
What it means: Horner's syndrome (ptosis, miosis, anhidrosis, enophthalmos) in a newborn with total plexus palsy indicates preganglionic avulsion of C8 and T1 nerve roots from the spinal cord.
Why it matters: Preganglionic avulsions have essentially zero potential for spontaneous recovery. These children require early surgical exploration (by 2-3 months) and have a guarded prognosis for hand function even with optimal reconstruction.
Glenohumeral Dysplasia — The Silent Sequela
Pathogenesis: The persistent internal rotation/adduction contracture from unopposed subscapularis, latissimus dorsi, teres major, and pectoralis major leads to progressive posterior glenoid erosion, humeral head flattening, and fixed dislocation.
Clinical importance: May be silent on plain X-ray in the young child because the humeral head is not yet ossified. Requires MRI or arthrography to detect early. Grade III dysplasia or worse (greater than 5% posterior subluxation with glenoid deformity) may not correct with soft tissue releases alone and may require humeral osteotomy.
Pseudopalsy vs True Obstetric Palsy
The trap: A clavicle fracture, proximal humeral fracture, or shoulder dislocation sustained during delivery can produce a pseudo-paralysis that mimics OBPI.
The fix: Check the Moro (startle) reflex — if present, the child can move the limb involuntarily and true OBPI is less likely. Obtain plain radiographs of the clavicle and humerus in any newborn with suspected OBPI before making the diagnosis. If a fracture is present, the child usually recovers within 2-3 weeks.
Phrenic Nerve — Supraclavicular Danger
Location: The phrenic nerve arises from the C3, C4 and C5 anterior rami and runs on the anterior surface of the anterior scalene muscle, descending into the mediastinum to innervate the diaphragm.
Risk: In the supraclavicular approach to the brachial plexus, the phrenic nerve lies immediately deep to the prevertebral fascia and crosses the operative field. It can be stretched, compressed or divided during exposure of the upper trunk. Injury causes ipsilateral hemidiaphragm paralysis, which is usually well tolerated in infants but may cause respiratory distress in those with pre-existing pulmonary compromise.
Accessory Nerve — Donor Site Morbidity
Relevance: The spinal accessory nerve (cranial nerve XI) is the preferred donor for transfer to the suprascapular nerve to restore shoulder external rotation.
Donor morbidity: Harvest of the distal accessory nerve branch (innervating the middle and lower trapezius) may weaken shoulder shrug and scapular retraction. The proximal branch to the upper trapezius should be preserved. Test trapezius function preoperatively and counsel parents that some scapular winging or shoulder droop may occur post-operatively.
Mnemonic
B.I.C.E.P.SBICEPS — Assessment and Decision Making
Mnemonic
N.A.R.A.K.A.SNARAKAS — When to Operate
Surgical Indications for Primary Nerve Reconstruction
Absolute Indications
No antigravity biceps (MRC Grade less than 3) at 3 months of age — the most widely accepted criterion (Narakas, Gilbert)
Total plexus palsy (C5-T1) with Horner's syndrome — indicates preganglionic avulsion of C8-T1; negligible spontaneous recovery; operate at 2-3 months
Total plexus palsy without Horner's — explore at 3 months if no antigravity elbow flexion
Brachial plexus birth injury with complete flail limb and no recovery at 1 month — early exploration may be indicated
Relative Indications
Extended Erb's palsy (C5-7) with no biceps recovery at 4-6 months
Isolated C5-6 palsy with no biceps at 4-6 months but some shoulder recovery — observe to 6 months if progressive improvement
Recovery plateau before antigravity strength is achieved in key muscle groups
Contraindications
Absolute:
Active local infection at the surgical site
Uncorrected coagulopathy
Significant cardiopulmonary comorbidity precluding general anaesthesia
Relative:
Late presentation beyond 12-18 months of age (nerve grafting less effective; consider nerve transfers instead)
Family non-compliance with post-operative therapy programme
Indications for Secondary Reconstruction
Internal Rotation and Adduction Contracture (most common)
Subscapularis release — indicated for passive external rotation less than 20-30 degrees with the shoulder in adduction, in an ambulatory child aged 2-4 years
Modified L'Episcopo transfer (latissimus dorsi and teres major to rotator cuff) — indicated when passive external rotation is preserved but active external rotation is absent, in a child aged 3-8 years
Humeral derotation osteotomy — indicated for fixed internal rotation deformity with glenohumeral articular congruity (Waters Grade I-II), typically in children older than 4-5 years. Also indicated when soft tissue releases have failed to provide adequate external rotation
Elbow Flexion Deficit (less common)
Oberlin transfer (ulnar fascicle to biceps motor branch) — indicated for persistent elbow flexion weakness after failed primary reconstruction, or when primary nerve grafting was not possible
Steindler flexorplasty — transfer of the common flexor origin proximally on the humerus for residual elbow flexion weakness
Triceps-to-biceps transfer — indicated when the triceps is strong (MRC Grade 4+), the elbow flexors are absent, and other transfer options are not available
ComparisonTable — Erb's vs Total Plexus Palsy
Erb's Palsy (C5-6) vs Total Plexus Palsy (C5-T1)
Key Evidence
Evidence
Surgical repair of the brachial plexus in obstetric paralysis
Level III
Gilbert A, Tassin JL • Chirurgie
Clinical implication: Biceps recovery by 3 months is the key prognostic determinant; absence is a reliable indication for surgical exploration.
Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy
Level II
Waters PM • J Bone Joint Surg Am
Clinical implication: Confirms that the 3-month biceps criterion separates children who will do well with observation alone from those who benefit from nerve reconstruction.
Nerve transfer to biceps muscle using part of ulnar nerve for C5-C6 avulsion of the brachial plexus
Level IV
Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ • J Hand Surg Am
Clinical implication: The Oberlin transfer is now a standard technique for restoring elbow flexion in both obstetric and adult brachial plexus injuries.
The effect of derotational humeral osteotomy on global shoulder function in brachial plexus birth palsy
Level III
Waters PM, Bae DS • J Bone Joint Surg Am
Clinical implication: Humeral derotation osteotomy reliably improves shoulder position and function in children with fixed internal rotation contracture when the glenohumeral joint is congruent.
The early effects of tendon transfers and open capsulorrhaphy on glenohumeral deformity in brachial plexus birth palsy
Level III
Waters PM, Bae DS • J Bone Joint Surg Am
Clinical implication: Tendon transfer combined with subscapularis release improves shoulder external rotation and can partially reverse glenohumeral dysplasia when performed early, before age 4.
The brachial plexus is formed by the ventral (anterior) primary rami of C5, C6, C7, C8 and T1 spinal nerves. It extends from the cervical spine to the axilla and is divided into five structural levels: roots, trunks, divisions, cords, and terminal branches.
Cords are arranged around the axillary artery in the infraclavicular space
Terminal branches
Musculocutaneous, Axillary, Radial, Median, Ulnar
—
Final motor innervation to the upper limb
Clinical Relevance in OBPI
The upper trunk (C5-6) is the most commonly injured segment in birth palsy because of the greater angle of the C5-6 roots as they exit the spinal canal and the fixity of the lower trunk by the transverse cervical ligament
The C5 and C6 roots emerge between the anterior and middle scalene muscles at the level of the cricoid cartilage — the surface landmark is the intersection of the posterior border of the sternocleidomastoid with the external jugular vein (Erb's point)
Erb's point (Erb's supraclavicular point) is the point where the C5 and C6 roots unite to form the upper trunk, located approximately 2-3 cm above the clavicle at the posterior border of the sternocleidomastoid. Six nerves converge at this point: the suprascapular nerve, nerve to subclavius, and the anterior divisions of C5-6 (which form the lateral cord contribution) — it is the most common site of neuroma formation in OBPI
Relevant Surgical Anatomy for Nerve Transfers
Spinal Accessory Nerve (CN XI)
Emerges from the jugular foramen, descends obliquely through the posterior triangle of the neck
Runs superficial to the prevertebral fascia, deep to the trapezius and sternocleidomastoid
Divides into a proximal branch (to the upper trapezius) and a distal branch (to the middle and lower trapezius)
The distal branch is the preferred donor for transfer to the suprascapular nerve
It is identified approximately 2 cm above the clavicle at the anterior border of the trapezius
Suprascapular Nerve
Arises from the upper trunk (C5-6) at Erb's point
Passes laterally through the suprascapular notch (beneath the superior transverse scapular ligament) to supply the supraspinatus and infraspinatus muscles
In OBPI it is commonly affected because of its origin from the upper trunk
The nerve is identified during supraclavicular exploration as it leaves the upper trunk laterally
In the spinal-accessory-to-suprascapular transfer, the recipient suprascapular nerve is divided just distal to its takeoff from the upper trunk and coapted to the descending branch of the spinal accessory nerve
Oberlin Transfer — Ulnar Fascicle to Biceps Motor Branch
The musculocutaneous nerve arises from the lateral cord (C5-7) and pierces the coracobrachialis to run between the biceps and brachialis
The motor branch to the biceps arises from the musculocutaneous nerve approximately 5-8 cm distal to the acromion, entering the biceps muscle on its deep (medial) surface
The ulnar nerve lies adjacent to the brachial artery in the middle third of the arm and then passes posterior to the medial intermuscular septum
The transfer is performed through an incision in the medial arm; one or two fascicles of the ulnar nerve (about 10-15% of its cross-sectional area) are dissected free and transferred to the distal stump of the biceps motor branch
Fascicles supplying the flexor carpi ulnaris (FCU) are preferred as donors because FCU function is largely synergistic with hand grip and well compensated
Danger Zones in Surgical Dissection
Supraclavicular (Upper Trunk Exposure)
Phrenic nerve: lies on the anterior surface of the anterior scalene — must be identified and gently retracted medially before any scalene or scar dissection
Long thoracic nerve: arises from C5-7 posterior to the plexus, runs on the serratus anterior — injury causes scapular winging
Transverse cervical artery and suprascapular artery: cross the operative field and can cause problematic bleeding if not controlled
Dorsal scapular nerve: arises from C5 and runs posteriorly to the rhomboids
Vertebral vessels: lie deep and medial at the C5-6 foramen level — dissection must stop lateral to the scalene tubercle
Infraclavicular and Axillary (Lower Trunk, Cords, Oberlin Transfer)
Axillary artery: the cords are arranged around the artery; the artery lies deep to the pectoralis minor and must be protected during dissection
Cephalic vein: lies in the deltopectoral groove and should be preserved
Medial cutaneous nerves of the arm and forearm: these small nerves run with the medial cord and can be inadvertently divided
Primary Nerve Reconstruction (Neuroma Excision and Grafting)
Positioning and Preparation
Patient position: Supine with a sandbag or roll under the ipsilateral shoulder and the head turned to the opposite side. The arm is draped free to allow intraoperative manipulation.
Anaesthesia: General anaesthesia without long-acting neuromuscular blockade (nerve stimulator is used for intraoperative nerve identification). The anaesthetist monitors for phrenic nerve stimulation — ventilation changes indicate proximity to the phrenic nerve.
Tourniquet: Not routinely required. Sural nerve graft harvest may be facilitated by a thigh tourniquet if simultaneous harvest by a second team is planned (inflated to 250 mmHg).
Supraclavicular Approach (Exposure of the Upper and Middle Trunks)
Incision: A transverse skin incision approximately 2 cm above and parallel to the clavicle, from the lateral border of the sternocleidomastoid to the anterior border of the trapezius. The incision is centred on the posterior border of the sternocleidomastoid (Erb's point).
Superficial dissection: Divide the platysma and the supraclavicular nerves (which cross the field). The external jugular vein is encountered and may be ligated or retracted. The sternocleidomastoid is retracted medially.
Deep dissection: Incise the prevertebral fascia to expose the supraclavicular fat pad. The omohyoid muscle crosses the field and may be divided or retracted. Identify the phrenic nerve on the anterior surface of the anterior scalene muscle — stimulate it to confirm (diaphragmatic contraction). Gently retract the phrenic nerve medially and protect it throughout the dissection.
Plexus exposure: The upper trunk (C5-6) is identified at Erb's point, at the junction of C5 and C6. The suprascapular nerve is seen arising from the upper trunk. The middle trunk (C7 contribution) is identified posterior and slightly inferior. The transverse cervical artery crosses the field and may require ligation.
Clinical Pearl
Technical Tip: 'I identify the phrenic nerve first, before any other dissection. I stimulate it to confirm its identity by watching for diaphragmatic contraction. I then pass a vessel loop around it and retract it gently medially. It is the single most important structure to protect because an iatrogenic phrenic palsy in an infant can cause respiratory difficulty. I find the upper trunk by tracing the phrenic nerve proximally to the C5 root — the upper trunk is immediately posterior and lateral to the phrenic at this level.'
Dangers at this step
Phrenic nerve injury — identify and protect before dividing any scalene fibres or scar tissue; use nerve stimulation to confirm
External jugular vein and transverse cervical artery — ligate rather than risk avulsion bleeding in a small infant
Supraclavicular nerves — division causes a small patch of anaesthesia over the shoulder; warn parents preoperatively
Lung apex — the pleura lies deep to the lower trunk; dissection at the C8-T1 level carries a risk of pneumothorax
Infraclavicular Extension (for Lower Trunk and Cord Exposure in Total Plexus Palsy)
If required, the incision extends laterally over the clavicle and curves into the deltopectoral groove. A clavicular osteotomy (usually avoided in infants) may be needed for complete exposure of the retroclavicular divisions and cords. Alternatively, the approach can be extended by releasing the pectoralis major insertion.
Neuroma Excision
Once the plexus is exposed, identify the neuroma — a fusiform or globular enlargement at the level of the upper trunk (or at the root-trunk junction) consisting of disorganised scar tissue, fibrosis, and tangled regenerating nerve fibres.
Incision of the epineurium longitudinally over the neuroma
Intraoperative nerve action potential (NAP) recording or direct nerve stimulation: if a NAP is conducted across the neuroma (indicating some regenerating axons), consider leaving the neuroma intact and performing an external neurolysis. If no NAP is conducted (non-conducting neuroma), the neuroma is resected.
Resection: Excise the neuroma back to healthy-appearing fascicular tissue on both the proximal and distal ends. The resection is complete when the cut surface shows a healthy fascicular pattern on microscopic examination — a pouting, granular appearance with visible fascicular bundles. A gap of 2-4 cm is typical after complete resection.
Frozen section: In selected cases, frozen section histology can confirm the absence of scar tissue at the resection margins.
Clinical Pearl
Technical Tip: 'I resect the neuroma progressively in 1-2 mm slices under the microscope, starting from the centre and moving proximally until I see a healthy fascicular pattern — discrete bundles of neural tissue surrounded by loose epineurium, not scar. The distal resection is similarly done until healthy fascicles are visible. The gap after resection determines whether I can do a direct repair (rare in OBPI — the gap is almost always too long) or need sural nerve grafts. In total plexus palsy, I may have to resect both the upper trunk neuroma and the lower trunk neuroma separately.'
Sural Nerve Graft Harvest
The sural nerve is the preferred donor nerve graft in OBPI
Position: Supine, hip externally rotated, knee flexed. Tourniquet optional.
Landmark: The sural nerve runs with the short saphenous vein, posterior to the lateral malleolus, then ascends in the midline of the calf between the two heads of the gastrocnemius
Harvest: A transverse incision posterior to the lateral malleolus identifies the nerve. A nerve stripper or a series of short transverse incisions (2 cm each) is used to harvest 15-25 cm of nerve
The nerve is preserved in saline-moistened gauze until grafting
Alternatives: The medial antebrachial cutaneous nerve (from the medial cord, if already exposed in the plexus dissection and non-functional) or a vascularised ulnar nerve graft (rarely used)
Graft Coaptation
Reverse the sural nerve graft (so that the smaller distal branches are proximal and the larger main trunk is distal — this maximises the number of fascicles that can be coapted)
Coapt the grafts using 8-0 or 9-0 nylon microsutures through the epineurium, typically 2-4 sutures per coaptation
Fibrin glue is applied around the coaptation to seal the repair and reduce suture load
Graft arrangement: Proximal coaptation to the proximal C5 and C6 root stumps (and C7 if available), distal coaptation to the corresponding distal trunks or divisions — typically 3-5 cable grafts are required
Tension-free: The grafts should be cut to the exact length needed without tension. If tension is present, additional graft length is required
The wound is closed in layers over a drain (optional), with absorbable sutures in the subcutaneous tissue and skin
Nerve Transfers
Spinal Accessory (CN XI) to Suprascapular Nerve Transfer
Indication: To restore shoulder external rotation (and to a lesser degree abduction) in OBPI with persistent deficit after primary recovery or as part of primary reconstruction.
Approach: Through the same supraclavicular incision described above, extended posteriorly.
Step 1: Identify the spinal accessory nerve at the anterior border of the trapezius, approximately 2 cm above the clavicle. Use a nerve stimulator — trapezius contraction confirms the nerve. Follow it distally to identify its division into proximal and distal branches. The distal branch (to the middle and lower trapezius) is selected as the donor.
Step 2: Identify the suprascapular nerve as it arises from the upper trunk at Erb's point. Trace it laterally towards the suprascapular notch. Divide it as distally as possible to maximise the number of motor axons reaching the target.
Step 3: Divide the distal spinal accessory branch distally and transpose it to the suprascapular nerve stump. Coapt with 9-0 nylon microsutures and fibrin glue.
Expected outcome: Active shoulder external rotation recovers over 6-12 months. Shoulder abduction improves secondarily.
Clinical Pearl
Technical Tip: 'I stimulate the spinal accessory nerve proximally to confirm trapezius contraction, then trace it distally. I preserve at least one branch to the upper trapezius to minimise shoulder shrug weakness. The distal branch is divided as far distally as possible to gain length for a tension-free coaptation to the suprascapular nerve. I aim for direct coaptation without an interposition graft. Post-operatively, the child will usually recover some trapezius function through the preserved proximal branch.'
Oberlin Transfer (Ulnar Nerve Fascicle to Biceps Motor Branch)
Indication: To restore elbow flexion in C5-6 or C5-7 palsy where the biceps motor branch is intact but receiving no input, or after failed primary reconstruction. Also used as a primary transfer in older children presenting beyond the window for nerve grafting.
Approach: The medial arm approach.
Step 1: With the arm abducted and externally rotated, make a longitudinal incision along the medial border of the biceps, centred at the junction of the middle and distal thirds of the arm (approximately 5-8 cm distal to the acromion).
Step 2: Identify the musculocutaneous nerve as it emerges from between the biceps and brachialis. Stimulate to confirm biceps contraction. Trace the motor branch to the biceps — it enters the biceps muscle on its deep (medial) surface.
Step 3: Identify the ulnar nerve adjacent to the brachial artery (medial to it) at this level. Gently dissect the ulnar nerve free from its surrounding connective tissue. Using the nerve stimulator, map the individual fascicles of the ulnar nerve.
Step 4: Select one or two fascicles that produce strong flexor carpi ulnaris (FCU) or hypothenar muscle contraction on stimulation, representing approximately 10-15% of the ulnar nerve cross-sectional area. Avoid fascicles that produce intrinsic hand function (first dorsal interosseous, abductor digiti minimi).
Step 5: Divide the selected fascicle(s) distally and transpose them to the divided distal stump of the biceps motor branch. Coapt with 9-0 nylon microsutures (2-3 sutures) and fibrin glue. The repair should be tension-free with the elbow in 30-60 degrees of flexion.
Clinical Pearl
Technical Tip: 'I spend time mapping the ulnar nerve fascicles with the nerve stimulator. I look for fascicles that produce strong wrist flexion (FCU) with minimal intrinsic hand function — these are the safest to harvest. I harvest no more than 15% of the cross-sectional area of the ulnar nerve. I do the coaptation with the elbow slightly flexed so there is no tension when the arm is extended. The biceps motor branch is divided as proximally as possible to give the transferred ulnar fascicle the shortest distance to the motor end plate.'
Dangers at this step
Harvesting too many ulnar nerve fascicles (greater than 20% of cross-sectional area) risks permanent ulnar nerve deficit — limit to 10-15%
Dividing the wrong fascicle — always stimulate to confirm FCU or hypothenar function before cutting
Tension at the coaptation site — ensure the repair is loose with the arm extended; if tight, dissect the ulnar fascicle more proximally
Injury to the brachial artery — the ulnar nerve lies adjacent to the artery; a vessel loop around both structures before dissection improves safety
Secondary Reconstructive Procedures
Subscapularis Release
Indication: Internal rotation contracture with passive external rotation less than 20-30 degrees with the shoulder in adduction, in a child aged 2-4 years.
Technique Options:
Open subscapularis release through an anterior axillary approach:
Incision: A transverse or oblique incision in the anterior axillary fold
Identify the pectoralis major tendon and retract it medially
Identify the subscapularis tendon on the anterior surface of the glenohumeral joint
Divide the subscapularis tendon completely from its humeral insertion, preserving the underlying anterior capsule if possible
Alternatively, perform a fractional lengthening of the subscapularis by dividing its tendon in a Z-plasty fashion
Confirm external rotation range to at least 40-50 degrees after release
Arthroscopic subscapularis release: In older children with less severe contractures, an arthroscopic release of the subscapularis tendon and capsule can be performed.
Modified L'Episcopo Transfer (Latissimus Dorsi and Teres Major to Rotator Cuff)
Indication: Absent or weak active external rotation with preserved passive external rotation (after subscapularis release if indicated), typically in children aged 3-8 years.
Contraindication: Active infraspinatus of MRC Grade 4 or greater — the transfer may overcorrect if the external rotators are already partially functional.
Technique:
Position: Lateral decubitus or semi-beach-chair with the arm draped free
Incision: A posterior approach — an oblique incision along the posterior axillary fold, or a curved incision centred over the posterolateral shoulder
Identification: Identify the latissimus dorsi tendon (anterior, larger, inserts on the floor of the intertubercular groove) and the teres major tendon (posterior, smaller, inserts on the medial lip of the intertubercular groove). They are identified at their common insertion on the proximal humerus
Release: The tendons are detached from the humerus with a small periosteal sleeve. The latissimus dorsi is mobilised proximally to gain length. The teres major is similarly freed from surrounding adhesions. The radial nerve is protected posterior to the humerus during deep dissection
Tendon transfer: The freed tendons are passed posteriorly (subcutaneously or through the interval between the deltoid and the long head of triceps) and anchored to the rotator cuff at the greater tuberosity — either through bone tunnels or with suture anchors
Tension: The arm is held in 90 degrees of abduction and 90 degrees of external rotation while the transfer is tied. The goal is to provide a tenodesis effect that is activated when the shoulder is abducted
Closure: The wound is closed in layers over a drain. The arm is immobilised in 60-90 degrees of abduction and 90 degrees of external rotation in a shoulder spica or custom brace
Post-operative: The brace is worn for 4-6 weeks, followed by gradual weaning and physiotherapy. Active external rotation typically improves over 3-6 months.
Humeral Derotation Osteotomy
Indication: Fixed internal rotation deformity in a child over 4-5 years of age with a congruent glenohumeral joint (Waters Grade I-II) where soft tissue procedures have failed or are insufficient. Also indicated for older children with fixed rotational deformity and joint congruity.
Technique:
Position: Supine with the arm draped free
Approach: An anterolateral or lateral approach to the proximal humeral shaft
Osteotomy: A transverse osteotomy is made at the level of the deltoid insertion. The humerus is derotated externally by 30-45 degrees (or until the forearm is in neutral rotation with the arm at the side)
Fixation: A 4- or 6-hole dynamic compression plate (DCP) or locking plate is applied. The osteotomy is compressed and fixed
Closure: Standard wound closure over a drain. The arm is placed in a collar and cuff or sling
Post-operative: Sling for 4-6 weeks. X-rays at 2 weeks and 6 weeks confirm union. Physiotherapy begins when healing is evident.
Complications in OBPI Reconstruction — Recognition, Prevention, Management
Immobilisation: The arm is immobilised in a collar and cuff or a soft sling for 3-4 weeks to protect the nerve coaptations. The head and neck are immobilised with a soft cervical collar for the first week if the repair was under tension.
Dressing: Sterile, non-adherent dressing over the supraclavicular wound. A separate dressing over the sural nerve harvest site.
Analgesia: Paracetamol and NSAIDs; opioids sparingly. Neuropathic pain (from nerve manipulation) is rare in infants but may require gabapentin if present.
Monitoring: Neurological examination daily for 48 hours — document active movement of shoulder, elbow, wrist, and hand. Chest X-ray to exclude pneumothorax or haemidiaphragm elevation.
Passive ROM: Gentle passive range of motion exercises of the shoulder, elbow, and hand begin at post-operative day 1, but the shoulder is kept in neutral rotation and adduction for the first 3-4 weeks.
Rehabilitation Phase (Week 4 to Month 6)
Sling removal: After 3-4 weeks, the immobilisation is weaned. Passive range of motion exercises are escalated.
Therapy: Formal physiotherapy 2-3 times per week focusing on passive stretching (especially external rotation and abduction) and maintaining joint mobility
Electromyography (EMG): First signs of reinnervation are typically seen on EMG at 4-8 months post-operatively
Parental education: Parents perform daily passive ROM exercises. Splinting of the wrist (if wrist extension is absent) to prevent flexion contracture
Late Follow-up (Month 6-24)
Serial clinical examinations every 3-6 months documenting motor recovery using the Active Movement Scale (AMS) or Medical Research Council (MRC) grading
Reinnervation of biceps is usually seen first (6-12 months), followed by shoulder abductors (6-12 months), then forearm and hand muscles (12-24 months)
Recovery plateaus by 18-24 months post-operatively — at this point a decision is made regarding the need for secondary reconstruction
Immobilisation: 3-4 weeks of elbow immobilisation in 60-90 degrees of flexion after Oberlin transfer; shoulder immobilisation in 30-45 degrees of abduction after SAN-to-SSN transfer
Therapy: Gradual weaning of immobilisation over weeks 4-6; passive ROM initially, active-assisted then active exercises as reinnervation occurs
Recovery timeline: Oberlin transfer — first biceps contraction at 3-6 months; functional elbow flexion (MRC Grade 3 or better) by 6-12 months. SAN-to-SSN — first external rotation at 6-12 months post-operatively
EMG: Confirms reinnervation at 3-6 months for Oberlin, 4-8 months for SAN-to-SSN
Immobilisation: Arm in an abduction-external rotation splint for 4-6 weeks
Therapy: Passive and active-assisted external rotation exercises after splint removal; active internal rotation is typically regained spontaneously
After Modified L'Episcopo Transfer
Immobilisation: Shoulder spica or abduction brace at 60-90 degrees abduction and 90 degrees external rotation for 4-6 weeks
Therapy:
Weeks 4-6: Splint removed; gentle passive external rotation and abduction
Weeks 6-12: Active-assisted range of motion in abduction and external rotation; no active internal rotation or adduction against resistance for 12 weeks
Weeks 12+: Progressive strengthening; the child learns to use the transfer by activating the latissimus dorsi and teres major (now external rotators) through abduction and external rotation
Expected outcome: Gain of 30-60 degrees of active external rotation is typical
After Humeral Derotation Osteotomy
Immobilisation: Sling or collar and cuff for 4-6 weeks until early union evident on X-ray
Therapy: Passive range of motion of the shoulder and elbow from day 1 (protected); active motion begins at 6 weeks
Outcome: The osteotomy corrects the resting posture of the limb, positioning the hand in a more functional position. Active external rotation may improve but the primary benefit is cosmetic and functional positioning
Long-term Surveillance
All children with OBPI require annual follow-up until skeletal maturity, regardless of the initial treatment.
Birth to 6 months
Assessment
Monthly motor examination (AMS / Toronto scale), passive ROM, X-ray clavicle/humerus at presentation
Monitor for growth-related changes, limb length discrepancy, late glenohumeral degeneration
Mature skeleton
Discharge with advice on vocational implications
Functional outcome is stable
Outcomes
After Primary Nerve Reconstruction
C5-6 (Erb's) palsy: 80-90% achieve functional shoulder abduction (greater than 90 degrees) and elbow flexion (MRC Grade 3 or better). External rotation is the most commonly incomplete recovery.
Total plexus palsy without Horner's: Approximately 60-70% achieve functional elbow flexion. Hand function is variable — protective sensation and gross grip are often achieved but intrinsic hand function is rarely normal.
Total plexus palsy with Horner's: The most challenging group. Less than 40% achieve useful hand function. Shoulder and elbow outcomes are also worse. Parents should be counselled realistically about the guarded prognosis.
After Secondary Reconstruction
Subscapularis release: Gains 30-50 degrees of passive external rotation. Results are best when performed before age 3 and before glenohumeral dysplasia becomes fixed.
Modified L'Episcopo transfer: 70-80% of patients achieve active external rotation greater than 30 degrees. Outcome is best when the transfer is combined with subscapularis release and performed before age 6.
Humeral derotation osteotomy: Reliably improves limb position and function. Approximately 30-45 degrees of external rotation correction is achieved. Patient satisfaction is high for cosmetic and functional improvement.
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
Viva scenarioAdvanced
Clinical prompt
“A 3-month-old infant presents with a total brachial plexus palsy (C5-T1) after a difficult vaginal delivery. There is Horner's syndrome on the affected side, a flail upper limb with no active movement, and asymmetric Moro reflex. What is your assessment and management plan?”
Practical approach
This infant has a total obstetric brachial plexus palsy with Horner's syndrome — the most severe form of birth-related brachial plexus injury. The presence of Horner's indicates preganglionic avulsion of the C8 and T1 nerve roots from the spinal cord. These injuries have essentially no potential for spontaneous recovery and require early surgical intervention.\n\n**Assessment**: I would first confirm the diagnosis by obtaining plain radiographs of the clavicle and humerus to exclude fracture (pseudopalsy). The asymmetric Moro reflex supports a true neurological injury rather than a fracture. I would also perform a baseline chest X-ray to assess diaphragmatic position (the phrenic nerve may have been injured concurrently). An MRI of the cervical spine and brachial plexus (with contrast if possible) can demonstrate pseudomeningoceles, which are indirect signs of preganglionic avulsion, although MRI in a 3-month-old is technically challenging and may require sedation. I document the neurological examination using the Active Movement Scale (AMS) for all upper limb joints — every joint from shoulder to digits.\n\n**Indications for surgery**: This child meets absolute criteria for early surgical exploration — total plexus palsy with Horner's. I would plan surgery at 2-3 months of age (this child is already at 3 months).\n\n**Operative plan**: The goal is to explore the entire brachial plexus through a supraclavicular incision, with infraclavicular extension if needed. I expect to find neuromas at both the upper trunk (C5-6) and the lower trunk (C8-T1) levels, and possibly preganglionic avulsion of C8-T1 (which would be confirmed by the absence of a proximal stump or the presence of dorsal root ganglion tissue). The surgical strategy would be:\n\n1. Neuroma excision of the upper trunk, with sural nerve grafting from proximal C5 and C6 roots to the distal upper trunk and divisions\n2. For the lower trunk (C8-T1), if there is a postganglionic rupture, sural nerve grafting is performed. If there is a preganglionic avulsion (no proximal stump), nerve transfers are required — intercostal nerve transfers or the contralateral C7 transfer are options, though they have limited outcomes\n3. I would also consider performing a spinal-accessory-to-suprascapular nerve transfer in the same sitting to reliably restore shoulder external rotation\n\n**Prognosis**: I would counsel the parents honestly — the prognosis for useful hand function is guarded (less than 40% achieve functional hand). Shoulder and elbow function can be improved but rarely return to normal. The child will require long-term follow-up to skeletal maturity for contracture management, glenohumeral dysplasia surveillance, and possible secondary procedures.\n\n**Post-operative plan**: Three to four weeks of immobilisation, passive ROM exercises starting day 1, serial neurological examinations, and EMG at 4-6 months to detect reinnervation.
Viva scenarioStandard
Clinical prompt
“A 3-year-old child presents with a persistent internal rotation and adduction contracture of the right shoulder following an obstetric brachial plexus palsy (Erb's type) that was managed non-operatively. The parents are concerned about the arm hanging in internal rotation when the child walks. How do you assess and manage this?”
Practical approach
This child has the most common residuum after obstetric brachial plexus palsy — an internal rotation and adduction contracture of the shoulder. The deformity results from muscle imbalance: the internal rotators (subscapularis, pectoralis major, latissimus dorsi, teres major) are unopposed or overactive because the external rotators (infraspinatus, teres minor) are weak or paralysed from the original C5-6 injury.\n\n**Assessment**: I perform a structured clinical assessment.\n\n1. **History**: Age of the child, hand dominance, functional limitations (difficulty reaching overhead, touching the opposite shoulder, perineal care, sports participation), previous treatment (physiotherapy, splinting, any prior surgery).\n\n2. **Examination**:\n - Passive external rotation — measure with the arm at the side (adduction) and in 90 degrees of abduction. If passive external rotation is less than 20-30 degrees in adduction, a subscapularis contracture is present.\n - Active external rotation — ask the child to bring the hand to the mouth and then reach overhead. Active external rotation lag is the functional deficit.\n - Shoulder abduction — active and passive range.\n - Mallet score — a standardised scoring system for global shoulder function in OBPI. The child is scored on shoulder abduction, external rotation, hand-to-mouth, hand-to-neck, and internal rotation. A score of 15 is normal; less than 12 indicates significant functional impairment.\n - Glenohumeral joint stability — posterior stress test (load and shift) for posterior subluxation.\n\n3. **Imaging**:\n - Plain X-ray of the shoulder (AP and axillary lateral) — assess glenohumeral alignment, humeral head shape. In the 3-year-old, the humeral head is ossifying and the X-ray can show posterior subluxation.\n - MRI of the shoulder (or CT arthrogram) — essential for assessing glenohumeral dysplasia grade (Waters classification). Grade I (normal) to Grade V (fixed dislocation with severe glenoid deformity). This determines whether soft tissue reconstruction alone will suffice or whether humeral osteotomy is required.\n\n**Management decision based on imaging**:\n\n- **Waters Grade I-II (congruent joint, less than 5% posterior subluxation)**: Soft tissue reconstruction is appropriate. I would perform a subscapularis release (open or arthroscopic) combined with a modified L'Episcopo transfer (latissimus dorsi and teres major to the rotator cuff). This addresses both the contracture (release) and the active external rotation deficit (transfer).\n\n- **Waters Grade III or worse (greater than 5% posterior subluxation with glenoid deformity)**: Soft tissue reconstruction alone may not be sufficient. If the joint is still reducible, I would perform the subscapularis release and L'Episcopo transfer, but counsel the parents that the outcome may be limited. If the joint is fixed and dislocated, a humeral derotation osteotomy is more reliable.\n\n- **Fixed deformity with congruent joint (Waters I-II) in an older child (5+ years)**: Humeral derotation osteotomy is a good option.\n\n**Prognosis**: With appropriate reconstruction, the child can expect improved limb positioning, up to 30-50 degrees of active external rotation gain, and better functional use of the limb for overhead activities.
Viva scenarioAdvanced
Clinical prompt
“A 15-month-old infant presents with a persistent C5-6 (Erb's) palsy. The parents report the child had some recovery of elbow flexion around 4 months but then plateaued. The child now has MRC Grade 2 biceps, MRC Grade 2 shoulder abduction, and no active external rotation. What is your surgical approach?”
Practical approach
This child has an established C5-6 palsy with incomplete recovery — the biceps never reached antigravity (MRC Grade 3 or better) and has plateaued. At 15 months, the child is beyond the optimal window for primary nerve grafting (3-9 months). However, it is not too late for reconstruction. The surgical approach at this age favours nerve transfers over neuroma excision and nerve grafting, because the distance from the proximal nerve stump to the target muscle is too great for reliable regeneration by grafting in a 15-month-old.\n\n**Assessment**: I would first confirm the C5-6 deficit pattern clinically — affected shoulder abduction (deltoid, supraspinatus), external rotation (infraspinatus), and elbow flexion (biceps, brachialis). I would document passive range of motion, looking for developing contractures. I would obtain an MRI of the brachial plexus and cervical spine to assess for neuroma, pseudomeningoceles (suggesting preganglionic avulsion), and root integrity.\n\n**Surgical plan**:\n\n1. **Nerve transfers** are the primary strategy:\n - **Oberlin transfer (ulnar nerve fascicle to biceps motor branch)**: To restore elbow flexion. This is the most reliable transfer for biceps reinnervation and works well even at 15 months because the distance from the coaptation site to the biceps motor end plate is short (3-5 cm).\n - **Spinal accessory to suprascapular nerve transfer (SAN-to-SSN)**: To restore shoulder external rotation. The SAN is identified in the posterior triangle and transferred to the suprascapular nerve at Erb's point.\n - If deltoid function is also absent, a **triceps-to-axillary nerve transfer** (using a branch of the triceps motor nerve) can be considered to restore shoulder abduction, though this is more technically demanding.\n\n2. **Neuroma resection with grafting** is not my primary choice at 15 months because the regeneration distance from proximal root to target muscles (25-30 cm for hand intrinsics, 10-15 cm for shoulder girdle) is too great for reliable recovery at this age. However, if intraoperative findings show a favourable neuroma with healthy proximal and distal stumps within 5-6 cm, nerve grafting remains an option.\n\n3. **Secondary reconstruction** will likely be needed later (after age 2-4) for any residual contractures or deficits.\n\n**Expected outcomes**: Oberlin transfer restores active elbow flexion (MRC Grade 3 or better) in approximately 80-90% of patients by 6-12 months post-operatively. SAN-to-SSN transfer restores active external rotation in approximately 70-80%.\n\n**Post-operative**: Immobilisation for 3-4 weeks (elbow flexed for Oberlin, shoulder in neutral or slight abduction for SAN-to-SSN). Passive ROM from day 1. The first signs of reinnervation are expected at 3-6 months after transfer.
Exam day cheat sheet
Obstetric Brachial Plexus Palsy — Reconstruction: Exam Day Summary
References
Evidence
Surgical repair of the brachial plexus in obstetric paralysis
Level III
Gilbert A, Tassin JL • Chirurgie
Clinical implication: The 3-month biceps rule remains the single most important clinical tool for selecting surgical candidates.
Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy
Level II
Waters PM • J Bone Joint Surg Am
Clinical implication: Confirms that observation is appropriate for early biceps recovery, while surgery improves outcomes for those who fail to recover.
The effect of derotational humeral osteotomy on global shoulder function in brachial plexus birth palsy
Level III
Waters PM, Bae DS • J Bone Joint Surg Am
Clinical implication: Humeral derotation osteotomy reliably improves shoulder position and function in children with fixed internal rotation contracture when the glenohumeral joint is congruent.
The early effects of tendon transfers and open capsulorrhaphy on glenohumeral deformity in brachial plexus birth palsy
Level III
Waters PM, Bae DS • J Bone Joint Surg Am
Clinical implication: Tendon transfer combined with subscapularis release improves shoulder external rotation and can partially reverse glenohumeral dysplasia when performed early, before age 4.
