Axillary and Partial Radial Nerve Reconstruction with Thoracodorsal and FCU Branch Nerve Transfers: Technique and Outcome
Anthony Thanh Vu, MD
University of Cincinnati Medical Center, Cincinnati, OH
Introduction: Traumatic brachial plexus injuries can be devastating with regard to functional outcomes and quality of life.Primary repair with or without nerve grafting has been described but has been met with mixed results, particularly in the older patient population.Current treatment options include nerve transfers, tendon transfers, or a combination of both, depending on the type and location of injury.We describe a patient with an unusual injury pattern consisting of incomplete posterior cord palsy involving the entire axillary nerve and the triceps branch of the radial nerve and his subsequent treatment and outcome.
Methods: A 38-year old male presented to our clinic after a tree fell on him from behind, striking his left posterior shoulder and neck. An EMG performed at three months post-injury revealed mononeuropathies of the axillary nerve and to the triceps branch of the radial nerve. X-rays did not reveal any fractures in the shoulder girdle. MRI of the cervical spine was normal.On exam, he had complete loss of triceps function (0/5), inability to abduct his shoulder greater than 30 degrees (thought to be due to teres major rather than deltoid function), and no sensation in the territory of the axillary nerve.At 5 months post-injury, we performed a FCU branch of the ulnar nerve transfer to the triceps branch of the radial nerve. Given that his triceps was unable to function as a donor for the axillary nerve, a posterior branch of the thoracodorsal nerve transfer to the axillary nerve was performed with a sural nerve graft.
Results: There were no donor site complications. Primary coaptation was achieved with the FCU to triceps branch nerve transfer. A 15cm sural nerve graft was needed for the thoracodorsal to axillary nerve transfer. At his most recent follow up 11 months post-surgery, he demonstrated 5/5 strength in his triceps and deltoid with ability to raise his arm completely above his head.
Conclusion: Traumatic incomplete posterior cord palsy involving the entire axillary nerve and the triceps branch of the radial nerve has yet to be described in the literature.The most common treatment for an isolated axillary nerve palsy is to perform a triceps branch transfer, however, given this patient’s injury pattern, this was not feasible. Using the thoracodorsal nerve to neurotize the axillary nerve and an FCU branch of the ulnar nerve to neurotize the triceps nerve is a good option for this injury pattern.
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