Case Study: Surgical, Prosthetic, and Therapeutic Considerations for a Patient with Ipsilateral Brachial Plexus Injury and Transradial Amputation

Brachial plexus injured patients are difficult at best to treat from an orthotic or prosthetic perspective. Often times these patients present with multiple problems resulting from a flail arm presentation which may include distal “hanging” weight, lack of supporting musculature, chronic subluxation of the glenohumeral joint, scapular instability, and chronic pain [1]. Advancements in surgical management of brachial plexus injuries have resulted in greater return of functional capacity in the affected arm. Timing of reconstruction is critical as delays in surgical intervention can preclude options for successful direct repair or neurotization [2]. Delayed or late presentations, typically 3-12 months after the initial injury, can result in the need for free functioning muscle transfers for reliable elbow flexion [2]. A free functioning gracilis muscle transfer with corresponding anterior division of the obturator nerve has been described as a commonly used muscle transfer in brachial plexus reconstruction due to its proximally based muscle neurovascular pedicle and its long length [2]. The reestablishment of elbow flexion to position the hand in space should be the first priority to any reconstruction surgery. The second most important priority is stabilization of the shoulder complex [4].