Working Diagnosis:
Diffuse brachial plexus injury.

Treatment:
At 13 weeks post-injury, surgical exploration with electrodiagnostic testing revealed nerve root avulsions at C6,C7, and C8 as well as damage to the C5 nerve root. Using a sural nerve graft, the damaged portion of the C5 nerve root to the axillary nerve and suprascapular nerve was repaired. Intercostal motor nerve transfer of the 4th, 5th, and 6th intercostal nerves to the motor branches of the musculocutaneous nerve innervating the brachialis and biceps muscles. Sensory intercostal neurotization with transfer of the 4th, 5th, and 6th intercostal nerve to the median nerve was performed. The spinal accessory nerve was transferred to the triceps. At 24 weeks a tendon transfer surgery was performed to help regain limited wrist and finger extension.

Outcome:
The athlete was unable to return to football activities. He regained limited function of his right upper extremity, partial shoulder abduction and flexion and partial elbow flexion and extension. A tendon transfer surgery did restore some limited wrist and finger extension. Sensation to the palmar aspect of the hand improved.

Editor's Comments:
Restoration of function in these brachial plexus injuries is often incomplete. Due to the extensive nature of the nerve root damage, partial paralysis, atrophy and minimal use of the lumbricals of the hand is in the literature. Timing of the surgery is usually after 12 weeks of no improvement, and surgical exploration usually demonstrates more extensive nerve root damage than imaging details.

References:
Vasileios, IS, et al. "Treatment options for brachial plexus injuries", ISRN Orthopedics.Volume 2014 (2014), Article ID 314137.

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