Priorities of Treatment and Rationale in Adult Brachial Plexus Injuries

In most adult brachial plexus injuries, a high-energy mechanism results in extensive longitudinal axonotmetic damage, frequently with multiple nerve root avulsions. Resources for restoring function are limited by the resulting absence of most or all proximal plexal nerves. When extradural injury permits nerve grafting, limited autogenous sources of nerve graft often prove insufficient. Delay in surgical management, slow rates of nerve regeneration, and long distances required for axon growth to reach a target muscle often prevent a successful outcome. These factors require prioritization of desired functions to make best use of limited available resources. Best options for restoring elbow, shoulder, and grasp function are discussed based upon pattern of injury, with an analysis of published results to aid the reader in evaluation and treatment of these complex and challenging injuries.