Complete Brachial Plexus Injury

Complete Brachial Plexus Injuries result from a complete transection of the C5, C6, C7, C8, and T1 nerve roots in the neck. This leads to weakness, numbness, or the complete loss of movement in the affected shoulder, arm, forearm, and hand. In cases of Complete BPI, the limb is entirely nonfunctional, rendering the patient unable to lift the affected shoulder, elbow, and hand, as well as making it impossible to grasp objects or perceive sensations in that limb.

One of the major challenges in treating Brachial Plexus Injuries is delayed presentation due to limited awareness about these injuries. Often, patients seek medical attention late after the injury has occurred. This emphasizes the importance of consulting plastic surgeons specialized in Brachial Plexus surgery for the management of such cases. Dr. Amit Agarwal specializes in this field with over 14 years of expertise, making him well-equipped to handle all aspects of treatment.

In Brachial Plexus injuries, the adage “sooner the treatment, better the outcome” holds true. Surgery involves exploring, repairing, and transferring nerves. If no recovery is observed within 3 months of the accident, nerve transfer surgery is performed as early as possible. Although surgery can still be considered for injuries occurring within 9 months to 1 year of the accident, the chances of recovery diminish compared to surgeries performed within the first 3 months.

Attempting nerve transfer surgery after 1 year of the accident is associated with significantly reduced chances of success. There is insufficient time left for nerve regeneration. Consequently, specific targeted muscle and tendon transfers become the preferred option instead of nerve transfer surgery in cases of Complete BPI beyond 1 year of the accident.

When a patient presents more than one year after the accident, and no surgery has been performed during that time, or no recovery has been observed after the initial nerve repair, targeted muscle and tendon transfers are carried out. These procedures aim to achieve acceptable movements in the shoulder, elbow, wrist, and finger joints.

After one year of the accident, specific investigations like MR Neurography and NCV studies are not typically performed. However, a thorough examination of the brachial plexus, muscle movements, sensory return, history of previous surgeries, fracture assessments, and evaluations of the patient’s vocational abilities are essential before proceeding with reconstruction.

In complete Brachial Plexus injuries, even with dedicated effort and physiotherapy, the maximum expected result is as follows:

• Abduction: The patient can lift their arm away from the body up to 90 degrees.
• Elbow Flexion: The patient can bend the elbow toward the body.
• Mild Grip in Hand: Just enough strength to hold objects and use the paralyzed hand for support.

For late presentations of Complete Brachial Plexus Injuries, targeted muscle and tendon transfers are the primary surgical approach. These procedures are also recommended when initial nerve repair surgeries fail to yield any response even after one and a half years.

FFMT surgery is the primary procedure recommended for restoring elbow flexion, which is a major goal in the reconstruction of complete Brachial Plexus injuries. This surgery involves harvesting a muscle from the thigh and transferring it to the paralyzed arm to replicate the action of the biceps muscle, restoring elbow flexion.

In some cases, even after nerve repair surgery, the results for elbow function might be disappointing. Therefore, FFMT, in addition to nerve surgery, should be considered in late cases presenting after one year of the injury.

The surgery involves the following steps:

• Admission of the patient one day before the surgery.
• Routine pre-operative investigations and pre-anesthetic checkups.
• Surgery under General Anesthesia with informed written consent.
• Exploration of the arm and forearm for donor nerve and vessels, followed by creating a tunnel for muscle insertion.
• Harvesting the gracilis muscle from the thigh, along with its vessels and nerve.
• Transferring the muscle/flap to the paralyzed arm and suturing.
• Microscopic anastomosis of vessels and nerve.

• Continuous monitoring of the free flap after surgery.
• Observation of the patient for about 10-12 days after surgery before discharge.
• Frequent dressing changes.
• Follow-up appointments at weekly intervals.
• Initiation of physiotherapy and TENS therapy after 1-1.5 months.
• Monthly follow-up initially for stability, followed by visits every 3-6 months.
• Elbow flexion may begin to reappear between 6 to 9 months post-surgery, with complete recovery taking approximately one to one and a half years.

Wrist joint fusion is a surgical procedure that stabilizes the wrist in a completely paralyzed hand. This procedure places the wrist in a stable functional position, allowing subsequent muscle or tendon transfers to enhance finger function and increase grip strength. It can also improve movement and power in the elbow.

• Admission of the patient one day before surgery.
• Routine pre-operative investigations and pre-anesthetic checkups.
• Surgery with an incision on the back of the hand and distal forearm.
• Exposing the wrist joint and fusing it using a dynamic compression plate.

• Observation of the patient for about 2 days after surgery, followed by splinting.
• Dressing changes and suture removal after 2 weeks.
• Splinting for about 4-6 weeks post-surgery.
• Physiotherapy to maintain distal joint flexibility.

In this procedure, a muscle is harvested from the thigh and transferred to the paralyzed forearm to replicate the action of the finger flexor muscles, restoring finger movement.

This surgery is often performed after wrist stabilization. The patient should be able to extend their wrist and/or fingers after the primary FFMT surgery for elbow flexion and wrist extension. This provides functional restoration of the hand after a complete BPI.

The time period for finger flexion to appear is typically between 6 to 9 months, with complete recovery taking about one to one and a half years.

Trapezius transfer is a surgical procedure used to partially restore the outward movement of the shoulder joint (abduction) in cases of complete Brachial Plexus injuries.

In patients seen after a year of the accident, FFMT is the first surgery performed to restore elbow flexion. Surgery to restore shoulder joint movement can be considered in the second stage but is ideally done as a final-stage procedure.

The trapezius muscle is a large upper back muscle. It is usually spared because of its innervation by the spinal accessory nerve in addition to contributions from C3 and C4 neck nerves. Additionally, it often increases in bulk after deltoid muscle paralysis, making trapezius transfer the most common tendon transfer for shoulder abduction movement in adult brachial palsy.

• Admission of the patient one day before the surgery.
• Routine pre-operative investigations and pre-anesthetic checkups.
• Confirmation of muscle strength.
• Making a horizontal incision over the shoulder region.
• Dissection, mobilization, and fixation of the trapezius muscle to the bone in the arm.

• Observation of the patient for about 3-4 days after surgery, followed by splinting.
• Dressing changes and suture removal after 2 weeks.
• Initiation of physiotherapy after about one month, once the scars have matured.
• Follow-up appointments every month initially for recovery, and later every 3-6 months.

If less than one year has passed since the accident, nerve repair or transfers are advised for Complete Brachial Plexus Injuries (C5678T1) .