Double free-muscle transfer to restore prehension following complete brachial plexus avulsion

Restoration of finger flexion and extension as well as elbow flexion and extension with a double free-muscle and multiple nerve transfers following complete avulsion of the brachial plexus (nerve roots C5 to T1) is reported. The procedure combines (1) free-muscle transfer with reinnervation by the spinal accessory nerve to achieve elbow flexion and finger extension, (2) free-muscle transfer with reinnervation by the fifth and sixth intercostal nerves to restore finger flexion, (3) third and fourth intercostal motor nerve transfer to the triceps brachi to extend and stabilize the elbow, (4) nerve transfer of the supraclavicular nerve or nerve transfer of the sensory rami of the intercostal nerves to the median nerve to restore hand sensibility, and (5) glenohumeral arthrodesis. Seven of 10 patients recovered elbow function and finger flexion and extension. Five patients reported use of their hand in activities of daily living.