Enhancing hand motor recovery in neonatal total brachial plexus palsy with a novel surgical approach

Neonatal total brachial plexus palsy (NBPP) is one of the most challenging birth injuries, especially if it is associated with hand palsy and sensory loss. Current techniques offer limited success for both extrinsic and intrinsic hand muscles recovery, especially for the latter. We present an innovative combined surgical method designed to reinnervate the hand in complete palsies: (1) the ulnar nerve of the affected limb, which is insensate and nonfunctional, is harvested as an autologous graft and used to connect the contralateral C7 root to the medial (motor) trunk contribution to the median nerve; (2) at the wrist level, two distal nerve transfers, one motor from the anterior interosseous nerve (AIN) to the motor branch of the ulnar nerve, and one sensory, from the palmar cutaneous branch of the median to the sensory part of the ulnar, are performed. This approach leaves two entire sural nerve grafts and the eventual intact ipsilateral roots for reconstructing the upper and middle parts of the injured plexus when necessary, while at the same time assures a healthy donor and an adequate graft for hand reanimation, a priority in severe injuries. By combining proximal reconstruction with distal nerve transfers, this innovative strategy provides a promising new pathway for functional hand recovery in neonatal total brachial plexus palsy.