Review Question - QID 4647

The infant has pre-ganglionic obstetric brachial plexus palsies. Neurotization (nerve transfer) using expendable motor fascicles from the median and ulnar nerves to biceps and brachialis branches of the musculocutaneous nerve is indicated.

Signs of pre-ganglionic lesions (root avulsion) include winged scapula (long thoracic nerve), absent rhomboid (dorsal scapular nerve), rotator cuff (suprascapular nerve) and latissimus dorsi (thoracodorsal nerve) function, Horner's syndrome (sympathetic chain) and elevated hemidiaphragm (phrenic nerve). Reconstruction for pre-ganglionic lesions is performed at 3 months or less.

Sedain et al. reviewed the outcomes of late Oberlin transfer (FCU fascicles from the ulnar nerve to the biceps branch of the musculocutaneous nerve) in brachial plexus injury. All 9 patients operated on after 1 year had >=2/5 biceps power, and 7 had >=3/5 power.

Toussaint et al. reviewed double fascicular nerve transfer (described above) and conclude that it is effective in restoring elbow flexion.

Mackinnon et al. first described double fascicular transfer in 6 patients. Advantages of nerve transfers include: (1) shifting a high proximal nerve injury to a more distal level of nerve injury, reducing time to muscle reinnervation, (2) restoration of sensibility if sensory nerves are transferred, (3) avoidance of dissection in scarred muscle beds, and (4) dissection in uninjured tissue planes. Four patients achieved MRC grade 4+, and 2 patients achieved grade 4.

Oberlin et al. described the transfer which now bears his name. 10% of the ulnar nerve is sutured to the motor nerve to the biceps for C5-6 root avulsion brachial plexus injury. They found there was no impairment of hand function. Of 4 patients, 3 recovered MRC grade 4 biceps function, and 1 had MRC grade 3.

Figure A shows a child with "waiter's tip" posturing (shoulder adduction, internal rotation, elbow extension, wrist and digit flexion). Illustration A shows double fascicular neurotization from ulnar/median donor fascicles. Illustration B shows the Oberlin transfer.

Video V is a surgical video of a Double Fascicular Transfer: Median Fascicle to Biceps Branch and Ulnar Fascicle to Brachialis Branch Nerve Transfers by Dr. Susan Mackinnon.

Incorrect Answers:
Answer 1: Abduction exercises and splinting are appropriate in the 1st month. If signs of PRE-GANGLIONIC lesions, are present, or if there is no sign of reinnervation at 3 months of age, nerve transfers are indicated.
Answer 2: This is indicated for POST-GANGLIONIC lesions.
Answer 3: Following neuroma resection, sural nerve grafting is necessary to bridge the gap and provide tension free repair. Direct repair is not indicated. Again, this is indicated for POST-GANGLIONIC lesions.
Answer 5: Latissimus transfer to the rotator cuff is indicated as a secondary procedure to address abduction and external rotation deficits. It is not indicated as first-line management in this case.