Figure 6.

A 13-year-old female suffered a right brachial plexus palsy following a high-velocity motorcycle accident. Preoperative appearance of the right upper extremity (a). She underwent primary brachial plexus reconstruction at 8 months postinjury. Exploration of the brachial plexus revealed C5 and C6 roots rupture and C7–T1 root avulsion. Reconstruction involved use of ipsilateral vascularized ulnar nerve graft for neurotization of MC, axillary, median, and radial nerves from C6 root and placement of banked nerves from C5, cervical motors, and T4 for future free muscles. She recovered good elbow flexion, but shoulder abduction and elbow extension were weak. She underwent a double free muscle transfer of gracilis for elbow extension and adductor longus for shoulder abduction at 3 years postinjury. Neurotizations were from cervical motors. The patient is shown 5 years after the double muscle transfer with excellent elbow extension (b) and shoulder abduction from the double muscle (c) and powerful elbow flexion from the C6–vascularized ulnar–MC neurotization (d).