Research Article| Volume 65, ISSUE 5, P590-600, May 2012

Our experience with triceps nerve reconstruction in patients with brachial plexus injury

Published:December 14, 2011DOI:


      Although elbow extension is facilitated by gravity, triceps muscle provides elbow joint stability; in patients with brachial plexus injuries stable elbow is necessary for obtaining useful hand function. This study presents the senior author’s experience with triceps nerve reconstruction and the functional results in patients with brachial plexus injuries. Outcomes were analyzed in relation to denervation time, severity score, length of the interposition nerve graft and donor nerves used.
      One hundred and sixty two patients with brachial plexus injury had triceps nerve neurotization and elbow extension recovery between 1978 and 2006. The mean patient’s age was 25.45±9.90 years and the mean denervation time was 16.90±26.95 months. Two hundred and thirty two motor donors were used in 156 patients; 6 patients underwent neurolysis; 86 intercostal nerves were transferred in 41 patients. Interposition nerve grafts were used in 130 patients.
      Results were good or excellent in 31.65% of patients. The age of patients and the severity of the brachial plexus lesion are among the factors that significantly influenced functional results. Intraplexus motor donors are always preferable achieving better functional outcomes than extraplexus donors. Intercostal nerves and the posterior division of contralateral C7 proved preferred donors for elbow extension restoration in multiple avulsions.
      Although it is difficult to restore strong elbow extension, triceps nerve reconstruction is suggested in brachial plexus management, since it provides elbow stability. Satisfactory elbow extension strength was restored in young patients with high severity score.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Midha R.M.
        Epidemiology of brachial plexus injuries in a multitrauma population.
        Neurosurgery. 1997; 40: 1182-1189
        • Terzis J.K.
        • Papakonstantinou K.C.
        The surgical treatment of brachial plexus injuries in adults.
        Plast Reconstr Surg. 2005; 106: 1097-1122
        • Terzis J.K.
        • Kostopoulos V.
        The surgical treatment of brachial plexus injuries in adults.
        Plast Reconstr Surg. 2007; 119: 73e-92e
        • Naracas A.O.
        • Hentz V.
        Neurotization in brachial plexus injuries. Indication and results.
        Clin Orthop. 1988; 237: 43-56
        • Naracas O.A.
        Thoughts on neurotization or nerve transfers in irreparable nerve lesions.
        Clin Plast Surg. 1984; 11: 153-159
        • Giuffre L.J.
        • Kakar S.
        • Bishop A.
        • et al.
        Current concepts of the treatment of adult brachial plexus injuries.
        J Hand Surg Am. 2010; 35: 678-688
        • Terzis J.K.
        • Vekris M.D.
        • Soucacos P.N.
        Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis.
        Plast Reconstr Surg. 1999; 104: 1221-1240
        • Berger A.
        • Schaller E.
        • Mailander P.
        Brachial plexus injuries: an integrated treatment concept.
        Ann Plast Surg. 1991; 26: 70-76
        • Ruhmann O.
        • Schmolke S.
        • Gosse F.
        • et al.
        Transposition of local muscles to restore elbow flexion in brachial plexus palsy.
        Injury. 2002; 33: 597-609
        • Marshall R.W.
        • Williams D.H.
        • Birch R.
        • et al.
        Operations to restore elbow flexion after brachial plexus injuries.
        J Bone Joint Surg Br. 1988; 70: 577-582
        • Doi K.
        • Shigetomi M.
        • Kaneko K.
        • et al.
        Significant of elbow extension in reconstruction of prehension with reinervated free-muscle transfer following complete brachial plexus avulsion.
        Plast Reconstr Surg. 1997; 100: 364-372
        • Bertelli J.A.
        Lower trapezius muscle transfer for reconstruction of elbow extension in brachial plexus injuries.
        J Hand Surg. 2009; 34: 459-464
        • Goubier J.N.
        • Teboul F.
        Transfer of the intercostal nerves to the nerve of the long head of the triceps to recover elbow extension in brachial plexus palsy.
        Tech Hand Upper Extr Surg. 2007; 11: 139-141
        • Kai-Nan A.
        • Morrey B.F.
        Biomechanics of the elbow.
        in: Morrey B.F. Morrey B.F. The elbow and its disorders. 2nd ed. WB Saunders Company, 1993: 53-72
        • Morrey B.F.
        Anatomy of the elbow joint.
        in: Morrey B.F. The elbow and its disorders. 2nd ed. WB Saunders Company, 1993: 16-52
        • Zhang L.Q.
        • Nuber G.W.
        Moment distribution among human elbow extensor muscles during isometric and submaximal extension.
        J Biomech. 2000; 33: 145-154
        • Bertelli J.K.
        • Santos M.A.
        • Kechele P.R.
        • et al.
        Triceps motor nerve branches as a donor or received in nerve transfers.
        Neurosurgery. 2007; 61: 333-339
        • Stanescu S.
        • Post J.
        • Ebraheim A.
        • et al.
        Surgical anatomy of the radial nerve in the arm: practical considerations of the branching patterns to the triceps branchii.
        Orthopedics. 1996; 19: 311-315
        • Liberson W.T.
        • Terzis J.K.
        Contribution of clinical neurophysiology and rehabilitation medicine to the management of brachial plexus palsy.
        in: Terzis J.K. Micro reconstruction of nerve injures. Saunders, Philadelphia1987: 555-567
        • Hovnanian P.A.
        Latissimus dorsi transplantation for loss of flexion or extension at the elbow. A preliminary report on technic.
        Ann Surg. 1956; 143: 493-499
        • Ozkan T.
        • Okumus A.
        • Aydin A.
        • et al.
        Brachioradialis transposition for elbow extension in obstetrical brachial plexus palsy.
        Tech Hand Up Extreem Surg. 2005; 9: 60-65
        • Soucacos P.N.
        • Vekris M.D.
        • Zoubos A.B.
        • et al.
        Secondary reanimation procedures in late obstetrical brachial plexus patients.
        Microsurgery. 2006; 26: 343-351
        • Lieber R.L.
        • Friden J.
        • Hobbs T.
        • et al.
        Analysis of posterior deltoid function one year after surgical restoration of elbow extension.
        J Hand Surg Am. 2003; 28: 288-293
        • Mulcahey M.J.
        • Lutz C.
        • Kozin H.S.
        • et al.
        Prospective evaluation of biceps to triceps and deltoid to triceps for elbow extension in tetraplegia.
        J Hand Surg Am. 2003; 28: 964-971
        • Zheng X.M.
        • Xu D.W.
        • Qiu Q.Y.
        • et al.
        Phrenic nerve transfer for elbow flexion and intercostals nerve transfer for elbow extension.
        J Hand Surg Am. 2010; 35: 1304-1309
        • Bertelli J.A.
        • Ghizoni M.F.
        Reconstruction of complete palsies of the adult brachial plexus by root grafting using long grafts and nerve transfers to target nerves.
        J Hand Surg Am. 2010; 35: 1640-1646
        • Bertelli J.A.
        • Ghizoni M.F.
        Results of grafting the anterior and posterior divisions of the upper trunk in complete palsies of the brachial plexus.
        J Hand Surg Am. 2008; 33: 1821-1826
        • Ochiai N.
        • Nagano A.
        • Sugioka H.
        • et al.
        Nerve grafting in brachial plexus injuries. Results of free grafts in 90 patients.
        J Bone Joint Surg Br. 1996; 78: 754-758
        • Bentolila V.
        • Nizard R.
        • Bizot P.
        • et al.
        Complete traumatic brachial plexus palsy.
        J Bone Joint Surg Br. 1999; 81: 20-28
        • Sedel L.
        The results of surgical repair of brachial plexus injuries.
        J Bone Joint Surg Br. 1982; 64: 54-66
        • Samii A.
        • Carvalho A.G.
        • Samii M.
        Brachial plexus injury: factors affecting functional outcome in spinal accessory nerve transfer for the restoration of elbow flexion.
        J Neurosurgery. 2003; 98: 307-312
        • Terzis J.K.
        • Kostopoulos V.
        Vascularized ulnar nerve graft: 151 reconstruction for posttraumatic brachial plexus palsy.
        Plast Reconstr Surg. 2009; 123: 1276-1291
        • Gu Y.D.
        • Zhang G.M.
        • Chen D.S.
        • et al.
        Cervical nerve root transfer from contralateral normal side for treatment of brachial plexus root avulsions.
        Chin Med J (Eng). 1991; 104: 208-211
        • Terzis J.K.
        • Kokkalis Z.
        Selective contralateral c7 transfer in posttraumatic brachial plexus injuries: a report on 56 cases.
        Plast Reconstr Surg. 2009; 123: 927-938
        • Mcguiness C.N.
        • Kay S.P.
        The prespinal route in contralateral C7 nerve root transfer for brachial plexus avulsion injuries.
        J Hand Surg Br. 2002; 27: 159-160
        • Xu L.
        • Gu Y.
        • Xu J.
        • et al.
        Contralateral C7 transfer via the prespinal and retropharyngeal route repair brachial plexus root avulsion: a preliminary report.
        Neurosurgery. 2008; 63: 553-558
        • Gu Y.
        • Xu J.
        • Chen L.
        • et al.
        Long-term functional results of contralateral c7 transfer.
        J Reconstr Microsurg. 1998; 14: 57-59
        • Kawai H.
        • Kawabata H.
        • Masada K.
        • et al.
        Nerve repairs for traumatic brachial plexus palsy with root avulsion.
        Clin Orthopaed Relat Res. 1988; 237: 75-86
        • Doi K.
        • Muramatsu K.
        • Hattori Y.
        • et al.
        Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus.
        J Bone Joint Surg Am. 2000; 82: 650-666