PURPOSE:

Loss of biceps function is common in complete upper brachial plexus injury (C5- C6 root injuries) and in patients with musculocutaneous nerve injuries. Restoring elbow function is the most important goal in treatment of patients with upper brachial plexus injuries. Using a patient database from our brachial plexus and peripheral nerve center, we reviewed the results from single and double nerve transfers: multiple fascicles of the ulnar nerve to the musculocutaneous nerve branches to the biceps and brachialis muscles, or fascicles of the ulnar nerve to the branch to the biceps, and fascicles of the median nerve to the branch to the brachialis.

METHOD:

A retrospective review was performed on all patients with brachial plexus injuries from 2003 to 2007. We identified 8 surviving patients who had nerve transfers to restore elbow flexion. All surgeries were performed by the senior author (Edgerton).  Of the eight patients, 4 patients had C5 and C6 root avulsions, 2 patients had C5-C6-C7 palsies, and 2 patients had sustained infraclavicular injuries to the musculocutaneous nerve. The average age of the patients was 19 years. The average delay before surgery was 6.2 months. The average follow up was 29.4 months. Five patients had single transfer of one or more fascicles of the ulnar nerve to musculocutaneous nerve branches to the bicep and brachialis muscles, and four patients had double nerve transfer: fascicles of the ulnar nerve to the biceps branch, and fascicles of the median nerve to the brachialis branch.

RESULTS: Medical Research Council grade 4+/5 was restored in each of the 8 patients. Clinical evidence of reinnervation was noted at a mean of 8 months after surgery. There was no deficit in grip strength or sensation in patients with ulnar-to-musculocutaneous nerve transfer. One patient with transfer of a portion of the median nerve has long-standing sensibility changes in the hand. No difference in functional outcome was noted between single and double nerve transfer in restoring elbow flexion.

CONCLUSION:

Transfer of ulnar nerve fascicles to the musculocutaneous nerve branches to the biceps and brachialis muscle consistently results in early and good recovery of elbow flexion with no discernable deficit in patients with C5-C6 Brachial Plexus Palsy and musculocutaneous nerve injuries. We have abandoned concomitant use of the median nerve because one patient developed a troublesome sensibility deficit in the hand.