Most patients don’t fall into neat management strategies, but there are several case patterns that can occur.

If your patient falls into one of these injury patterns, and the timing of presentation is appropriate to allow intervention, you might consider using the following as an example.

However, nothing can substitute for direct patient observation, a consideration of the exact biopsychosocial situation and the shared decision making with the patient/friends and family and the treating physician.

Overall strategies for management of more classic injury patterns–further details are provided in the Surgical Options and Case Studies sections.

For example, for the following injury patterns, consider the following treatment options:

Upper plexus injury – loss of elbow flexion:

  • Double fascicular nerve transfer (from median and ulnar nerves to biceps and brachialis nerve branches)
  • Transfer of triceps, latissimus or pectoralis nerve branches to the elbow flexors; Steindler flexorplasty, long nerve grafts

Upper plexus injury – loss of shoulder function:

  • Spinal accessory nerve to suprascapular nerve and triceps to deltoid nerve branch transfers
  • Shoulder fusion, Saha procedure, long nerve grafts

Lower plexus injury – loss of pronation

  • Brachialis or extensor carpi radialis brevis (if C7 is spared) to pronator nerve branch transfer
  • Biceps, brachioradialis or brachialis muscle rerouting

Lower plexus injury – loss of thumb and index finger flexion

  • Supinator branch to anterior interosseous nerve transfer
  • Brachialis branch to anterior interosseous nerve transfer
  • Tendon transfers (brachioradialis to flexor pollicis longus and extensor carpi radialis longus to index flexor digitorum profundus)

Axillary nerve injury

  • Triceps,  medial pectoral or thoracodorsal nerve to axillary nerve transfer
  • Shoulder fusion, long nerve grafts

Radial nerve injury

  • Median (flexor carpi radialis, flexor digitorum superficialis branches) to radial (extensor carpi radialis brevis and posterior interosseous nerve branches) nerve transfers
  • Tendon transfers (pronator teres to extensor carpi radialis brevis, palmaris longus to extensor pollicis longus, and flexor carpi ulnaris, flexor carpi radialis or flexor digitorum superficialis to extensor digitorum communis)

Loss of median innervated pronation

  • extensor carpi radialis brevis to pronator teres branch
  • Biceps, brachialis or brachialis muscle rerouting

Loss of median innervated thumb and finger flexion

  • Supinator or brachialis to anterior interosseous nerve branch (combine w/ tenodesis of long to ring/small flexors)
  • Tendon transfers (brachioradialis or extensor carpi radialis longus to flexor pollicis longus and side to side tenodesis with ulnar flexor digitorum profundus or extensor carpi radialis longus to index/long  flexor digitorum profundus)

Isolated AIN injury

  • flexor digitorum superficialis to anterior interosseous nerve branch
  • brachioradialis to flexor pollicis longus tendon transfer and flexor digitorum profundus tenodesis, fusion of interphalangeal joint of thumb

Distal median nerve injury

  • AIN to median motor branch
  • Opponensplasty

Distal ulnar nerve injury

  • anterior interosseous nerve to ulnar nerve deep motor branch
  • Static and dynamic claw hand correction procedures