Reconstruction of Complete Palsies of the Adult Brachial Plexus by Root Grafting Using Long Grafts and Nerve Transfers to Target Nerves (original) (raw)
2007
Restoration of elbow flexion is the first goal in brachial plexus injuries. The current procedures using nerve grafts and nerve transfers authorize more extensive repairs, with different possible targets: shoulder, elbow extension, and hand. Elbow extension is important to stabilize the elbow without the contralateral hand and allows achieving a useful grasp. The transfer of the intercostal nerves to the nerve of the long head of the triceps may restore this function in brachial plexus palsies. Furthermore, in case of C5 to C7 palsy, this transfer spares the radial nerve and gives a chance to spontaneous triceps recovery by the reinnervation from C8 root. Moreover, in case of absence or insufficient (M0 to M2 according to Medical Research Council scoring) recovery of elbow flexion strength by nerve surgery, the reinnervated triceps can be transferred. We present the technique of intercostal nerve transfer to the long head of the triceps branch to restore elbow extension in brachial plexus palsy. Results concerning 10 patients are presented.
Injury, 2019
Elbow flexion is the first goal in upper partial brachial plexus palsy treatment. However, elbow extension is essential for daily living activities. To recover this function, one fascicle of ulnar nerve can be transferred to the branch of the long head of the triceps, but this procedure has been previously published in only two patients. The goal of our study is to assess a larger series of transfers of one fascicle of ulnar nerve to the branch of the long head of the triceps to help patients recover elbow extension. Ten male patients with C5, C6 and C7 brachial plexus injuries underwent operation. For shoulder recovery, we transferred the spinal accessory nerve and rhomboid nerve. For elbow flexion, one fascicle of median nerve was transferred to the nerve of the biceps. For elbow extension, we transferred one fascicle of ulnar nerve to the branch of the long head of the triceps. Tendon transfers were performed for wrist and finger extension. Nine patients recovered M4 elbow flexion and extension. One patient had M3 elbow extension and flexion. Average active shoulder elevation was 85 °and average active shoulder external rotation was 65 °All patients recovered finger and wrist extension. The classical techniques of grafts or phrenic or intercostal nerve transfers to recover elbow extension are not always reliable, according to the literature. Because the harvested ulnar nerve motor fascicle is close to the branch of the long head of the triceps, the recovery time for this procedure is shorter than that of other described nerve transfers. The isolated recovery of the reinnervated long head of the triceps muscle excludes spontaneous recovery occasionally noted in upper root plexus injuries. The transfer of one fascicle of ulnar nerve to the branch of the long head of the triceps is reliable for active elbow extension recovery in C5, C6 and C7 brachial plexus palsies.
Reanimation of elbow extension with intercostal nerves transfers in total brachial plexus palsies
Microsurgery, 2010
Background: Restoration of flexion in the elbow is the priority in the management of brachial plexus injuries. Current techniques of reconstructions, combining both nerve grafting and nerve transfer, allow more extensive repair, with additional targets: shoulder, elbow extension, hand. The transfer of intercostal nerves onto the nerve of the triceps long head is used to restore elbow extension. The aim of this retrospective study is to evaluate the results of this procedure, in total brachial plexus palsies with uninjured C5 and C6 roots. Methods: Eleven patients with total brachial plexus injury were reviewed 24 months in average after intercostal nerves transfer. The average age of the patients was twenty-nine years. The average time to surgery after occurrence of the injury was 5 months. Triceps re-innervation and strength of elbow extension were evaluated. Results: The averaged time required for triceps re-innervation after intercostal nerve transfer was 9 months. Seven patients achieved M4 elbow extension according to the Medical Research Council grading system. Two patients achieved M3 elbow extension. Two patients had poor results (M2 and M0). Discussion and conclusions: Transfer of intercostal nerves onto the nerve of the triceps long head is a reliable procedure for the restoration of elbow extension in total brachial plexus palsy.
Nerve Root Grafting and Distal Nerve Transfers for C5-C6 Brachial Plexus Injuries
The Journal of Hand Surgery, 2010
Purpose To investigate the results of distal nerve transfer, with and without nerve root grafting, in C5-C6 palsy of the brachial plexus. Methods We prospectively studied 37 young adults with C5-C6 brachial plexus palsy who underwent surgical repair an average of 6.3 months after trauma. In 7 patients, no nerve roots were available for grafting, so reconstruction was achieved by transferring the accessory nerve to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps branches to the axillary nerve (a triple nerve transfer). In 24 patients, C5 nerve root grafting to the anterior division of the upper trunk was combined with triple nerve transfer. In 6 patients, the C5ϩC6 nerve roots were grafted to the anterior and posterior divisions of the upper trunk, the accessory nerve was transferred to the suprascapular nerve, and ulnar nerve fascicles were connected to the biceps motor branch. The range of shoulder abduction/ external rotation recovery and elbow flexion strength were evaluated between 24 and 26 months after surgery. Results Both full abduction and full external rotation of the shoulder were restored in one of the 7 patients in the C5 and C6 nerve root avulsion group, in 14 of 21 patients who received C5 nerve root grafting, and in 2 of 6 patients in the C5ϩC6 nerve root graft group. The average percentages of elbow flexion strength recovery, relative to the normal, contralateral side, were 27%, 43%, and 59% for the C5-C6 nerve root avulsion, C5 nerve root graft, and C5ϩC6 nerve root graft groups, respectively. Conclusions We repaired C5-C6 brachial plexus palsies using a combination of strategies depending on the site of root injury (ie, intradural vs extradural). Patients with injuries that were able to be reconstructed with both root grafting and nerve transfers had the best function. These results suggest that the combined use of nerve transfers and root grafting may enhance outcomes in the reconstruction of C5-C6 injuries of the brachial plexus.
Nerve reconstruction: A cohort study of 93 cases of global brachial plexus palsy
Indian Journal of Orthopaedics, 2011
Introduction: Brachial plexus injury leading to flail upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgeries may preclude reinnervation of the paralysed muscles. Currently for such injuries nerve transfers are the preferred procedures. We here present a series of 93 cases of global brachial plexus palsy treated with nerve transfers. Materials and Methods: Ninety-three cases of global palsies out of 384 cases of brachial plexus injury operated by the senior surgeon (AB) were selected. Age varied from 4 to 51 years with 63 patients in 20 to 40 age group and all patients having a minimum follow up of at least 1 year post surgery ranging up to 130 months. The delay before surgery ranged from 15 days to 16 months (mean 3.2 months). The aim of the surgery was to restore the elbow flexion, shoulder abduction, triceps function and wrist and finger flexion in that order of priority. The major nerve transfers used were spinal accessory to suprascapular nerve, intercostal to musculocutaneous nerve and pectoral nerves, contralateral C7 to median and radial nerves. Nerve stumps were used whenever available (30 patients). Results: Recovery of ≥ grade 3 power was noted in biceps in 73% (68/93) of patients, shoulder abduction in 89% (43/49), pectoralis major in 100% (8/8). Recovery of grade 2 triceps power was seen in 80% (12/16) patients with nerve transfer to radial nerve. Derotation osteotomies of humerus (n=13) and wrist fusion (n=14) were the most common secondary procedures performed to facilitate alignment and movements of the affected limb. Better results were noted in 59 cases where direct nerve transfers were done (without nerve graft). Conclusion: Acceptable function (restoration of biceps power ≥3) can be obtained in more than two thirds (73%) of these global brachial plexus injuries by using the principles of early exploration and nerve transfer with rehabilitation.
Nerve Transfer to the Triceps After Brachial Plexus Injury: Report of Four Cases
The Journal of Hand Surgery, 2011
These case reports review the clinical outcomes of 4 patients who underwent nerve transfer to a triceps motor branch of the radial nerve. Mean follow-up was 26 Ϯ 15 months. Two patients had a transfer using an ulnar nerve fascicle to the flexor carpi ulnaris muscle, yielding a motor recovery of grade M5 elbow extension strength in one case and M4ϩ in the other. In 1 patient, a thoracodorsal nerve branch was used as the donor; this patient recovered M4 strength. One patient had a transfer using a radial nerve fascicle to the extensor carpi radialis longus muscle and recovered M5 strength. These outcomes indicate that expendable fascicles of the ulnar, thoracodorsal, and radial nerves are viable donors in the surgical reconstruction of elbow extension.
Motor nerve transfers for restoration of upper arm function in adult brachial plexus injuries
2022
Introduction: Nerve transfers are the only surgical option for reconstruction of directly irreparable injuries of the brachial plexus. In the recent years, there has been a trend toward the increased use of nerve transfers, with the introduction of new methods and novel indications. Patients with total brachial plexus palsy generally have poor outcomes due to the limited number of donor nerves. On the contrary, patients with partial injuries involving the C5, C6, and sometimes C7 spinal nerves have favorable outcomes in a large majority of cases. In both situations, restoration of elbow flexion and shoulder functions are the main priorities. The purpose of this review article to characterize the advantages, problems and controversies of nerve transfers. Methods: PubMed/Medline database was searched for English-language original research and series of adult patients who received nerve transfers for functional restoration of the upper arm, performed within one year after injury and with minimum follow-up of one year. Literature search for outcome analysis was limited to articles published after 1990, amounting to 45 systematic reviews / meta-analyses of the most common nerve transfers (intercostal, spinal accessory, fascicular, and collateral branches of the brachial plexus). Analysis of clinical outcomes was based on Medical Research Council (MRC) grading system for muscle strength, and grades M3 or more were considered as useful functional recovery. Results: A total of 70 articles were included. Generally, intraplexal nerve transfers resulted in a higher rate and better quality of recovery compared to extraspinal transfers. Grades M3 or higher were obtained in 72% of the intercostal and 73% of the spinal accessory nerve transfers for restoration of elbow flexion, and in 56% vs. 98% of transfers for restoration of shoulder function. Among intraplexal nerve transfers, elbow flexion was restored in 84% to 91% of the medial pectoral, 100% of the thoracodorsal, and 94% to 100% of the single or double fascicular nerve transfers. Shoulder function was restored in 81,8% of the medial pectoral, 86% to 93% of the thoracodorsal, and 100% of the triceps branch nerve transfers. Dual nerve transfer (simultaneous reinnervation of the suprascapular and axillary nerves), resulted in 100% rate of recovery. Conclusion: Double fascicular transfer for restoration of elbow flexion and dual nerve transfer for restoration of shoulder function resulted in the most favorable results relative to other transfers, especially regarding quality of recovery. Medial pectoral and thoracodorsal nerve transfers were reasonable alternatives for restoration of both functions.
Nerve Transfers for Restoring Elbow Flexion in Brachial Plexus Palsy
Brachial Plexus Injury [Working Title], 2021
Nerve transfers (NT) consist in sectioning a donor nerve and connecting it to the distal stump of a recipient unrepairable nerve. For elbow flexion restoration in brachial plexus palsy (BPP) we used different NT: 1) GF motor Ulnar Nerve to Biceps nerve (Oberlin technique), 2) Double fascicular median/ulnar to biceps/brachialis nerve transfer (Mackinnon), 3) InterCostal Nerves (ICN) to MCN (+/− nerve graft), 4) Medial Pectoral Nerve (MPN) to MCN, 5) ThoracoDorsal Nerve (TDN) to MCN, 6) Spinal Accessory Nerve (SAN) to MCN transfer, 7) Phrenic Nerve (PhN) to MCN, 8) Cervical Plexus C3-C4 to MCN and 9) Contralateral C7 (CC7). I want to present my personal experience using the phrenic nerve (PhN), the intercostal nerves (ICN) and Oberlin’s technique. The aim of this retrospective study is to evaluate the results of this procedure in BPP. NT is an important goal in BPP. ICN transfer into the nerve of biceps for elbow flexion recovery is a reliable procedure in BPP. ICN transfer for tricep...
Journal of Neurosurgery, 2021
OBJECTIVENerve transfers are commonly used in treating complete injuries of the brachial plexus, but donor nerves are limited and preferentially directed toward the recovery of elbow flexion and shoulder abduction. The aims of this study were to characterize the anatomical parameters for identifying the nerve to the levator scapulae muscle (LSN) in brachial plexus surgery, to evaluate the feasibility of transferring this branch to the suprascapular nerve (SSN) or lateral pectoral nerve (LPN), and to present the results from a surgical series.METHODSSupra- and infraclavicular exposure of the brachial plexus was performed on 20 fresh human cadavers in order to measure different anatomical parameters for identification of the LSN. Next, an anatomical and histomorphometric evaluation of the feasibility of transferring this branch to the SSN and LPN was made. Lastly, the effectiveness of the LSN-LPN transfer was evaluated among 10 patients by quantifying their arm adduction strength.RESU...
Transfer of the Accessory Nerve to the Suprascapular Nerve in Brachial Plexus Reconstruction
The Journal of Hand Surgery, 2007
Purpose: Transfer of the accessory nerve to the suprascapular nerve is a common procedure, performed to reestablish shoulder motion in patients with brachial plexus palsy. We propose dissecting both nerves via a distal oblique supraclavicular incision, which can be prolonged up to the scapular notch. The results of the transfer to the suprascapular nerve are compared with those of the combined repair of the suprascapular and axillary nerves. Methods: Thirty men between the ages of 18 and 37 years with brachial plexus trauma had reparative surgery within 3 to 10 months of their injuries. In partial injuries with a normal triceps, a triceps motor branch transfer to the axillary nerve was performed. The suprascapular and accessory nerves were dissected via an oblique incision, extending from the point at which the plexus crosses the clavicle to the anterior border of the trapezius muscle. In 10 patients with fractures or dislocations of the clavicle, the trapezius muscle was partially elevated to expose the suprascapular nerve at the suprascapular notch. Results: In all cases, transfer of the accessory to the suprascapular nerve was performed without the need for nerve grafts. A double lesion of the suprascapular nerve was identified in 1 patient with clavicular dislocation. In those with total palsy, the average improvement in range of abduction was 45°, but none of the patients with total palsy recovered any active external rotation. Patients with upper-type injury recovered an average of 105°of abduction and external rotation. If only patients with C5-C6 injuries were considered, the range of abduction and external rotation increased to 122°and 118°, respectively. Conclusions: Use of the accessory nerve for transfer to the suprascapular nerve ensured adequate return of shoulder function, especially when combined with a triceps motor branch transfer to the axillary nerve. The supraclavicular exposure proposed here for the suprascapular and accessory nerves is advantageous and can be extended easily to explore the suprascapular nerve at the scapular notch. (J Hand Surg 2007;32A:989 -998.
Techniques in Hand & Upper Extremity Surgery, 2007
In C5, C6, or C5-to-C7 root injuries, many surgical procedures have been proposed to restore active elbow flexion. Nerve grafts or nerve transfers are the main techniques being carried out. The transfer of ulnar nerve fascicles to the biceps branch of the musculocutaneous nerve is currently proposed to restore active elbow flexion. Recovery of biceps muscle function is generally sufficient to obtain elbow flexion. However, the strength of elbow flexion is sometimes weak because the brachialis muscle is not reinnervated. Therefore, the transfer of 1 fascicle of the median nerve to the brachialis branch of the musculocutaneous nerve may be proposed to improve strength of the elbow flexion. We describe the technique of this double transfer to restore elbow flexion. The results concerning 5 patients are presented.
Plastic and Reconstructive Surgery, 2012
In extended upper-type lesions of the brachial plexus, nerve transfers and root grafting have improved the results of shoulder and elbow reconstruction. However, wrist extension reconstruction has received little attention. Methods: In 20 cadaveric upper limbs, we dissected the anterior interosseous nerve and extensor carpi radialis brevis motor branch. Four patients with upper-type lesions of the brachial plexus with paralysis of wrist and finger extension were operated on within 10 months of trauma and followed up for 12 months after surgery. The terminal division of the anterior interosseous nerve, which innervates the pronator quadratus muscle, was transferred to the extensor carpi radialis brevis, and the distal stump was connected to a motor fascicle of the median nerve (n ϭ 2) or to the distal branch of the flexor superficialis of the index finger (n ϭ 2). Results: The anterior interosseous nerve and extensor carpi radialis brevis had similar diameters (roughly 1 mm). The number of myelinated fibers in the nerve averaged 670, whereas the number in the extensor carpi radialis brevis averaged 183. The length of the nerve was approximately 80 mm, allowing for direct transfer to the extensor carpi radialis brevis with redundant length. At last evaluation, pronation scored M4 according to the Medical Research Council grading system. All patients recovered active wrist extension, scoring M4 with full, independent motor control. Conclusion: In C5 to C8 root injuries of the brachial plexus, transfer of the motor branch of the pronator quadratus to the extensor carpi radialis brevis can restore active wrist extension, and pronation is preserved. (Plast.
Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery
Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, ± C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n = 43), or a fascicle of the median nerve (group B, n = 16) or a combination of both (group C, n = 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar + median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). T...
Restoration of shoulder function with nerve transfers in traumatic brachial plexus palsy patients
Microsurgery, 2006
Shoulder stabilization is of utmost importance in upper extremity reanimation following paralysis from devastating injuries. Although secondary procedures such as tendon and muscle transfers have been used, they never achieve a functional recovery comparable to that following successful reinnervation of the supraspinatus, deltoid, teres minor, and infraspinatus muscles. Early restoration of suprascapular and axillary nerve function through timely brachial plexus reconstruction offers a good opportunity to restore shoulder-joint stability, adequate shoulder abduction, and external rotation function. Overall, in our series, 79% of patients achieved good and excellent shoulder abduction (muscle grade, þ3 or more), and 55% of patients achieved good or excellent shoulder external rotation after reinnervation of the suprascapular nerve. The best results were seen when direct neurotization of the suprascapular nerve from the distal spinal accessory nerve or neurotization by the C5 root was carried out. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction and external rotation function.
Surgical outcomes following nerve transfers in upper brachial plexus injuries
Indian Journal of Plastic Surgery, 2009
Background: Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury. Materials and Methods: We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors-radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient). Results: Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50-170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).
The Journal of Hand Surgery, 2004
Purpose: In C5 and C6 brachial plexus avulsion lesions, elbow flexion, shoulder abduction, and external rotation are the functions that need to be restored. Because the proximal stumps are not available for grafting, surgical repair is based on nerve transfers. The purpose of this study was to describe and report the results of the use of multiple nerve transfers in the reconstruction of these avulsion injuries. Methods: Ten patients had multiple nerve transfers: cranial nerve XI to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps long or lateral head motor branch to the axillary nerve. Triceps branch transfer was performed through a posterior arm incision. Results: Two years after surgery, all the patients had recovered full elbow flexion; 7 scored M4 and 3 scored M3ϩ according to Medical Research Council scoring. All the patients had recovered active abduction and external rotation. Abduction recovery averaged 92°(range, 65°-120°) and external rotation, measured from full internal rotation, averaged 93°(range, 80°-120°). Shoulder abduction strength was graded M4 in 3 patients and M3 in the remaining 7 patients. Shoulder external rotation strength was graded M4 in 2 patients, M3 in 5 patients, and M2 in 3 patients. No donor site deficits were observed. Conclusions: The proposed nerve transfers constitute a valid strategy in C5-C6 avulsion injury reconstruction.
Acta Neurochirurgica, 2011
Background Elbow flexion and shoulder abduction are the primary goals in brachial plexus surgery; however, reinnervation of the triceps is also an objective to be considered, as restoration of elbow extension improves the stabilization of the elbow and can provide a more powerful grasp. This study aims to demonstrate the author's experience with restoration of elbow extension function in cases of brachial plexus surgery in adults. Methods Records of 25 patients sustaining traumatic brachial plexus injuries who were treated surgically with reinnervation of the triceps were reviewed. Nine techniques were employed, including posterior cord reconstruction and nerve transfers using donors such as the ipsilateral C7 root, phrenic nerve, medial pectoral nerve, intercostal nerves, the spinal accessory nerve, and a motor fascicle of the ulnar nerve. The targeted structure was the radial nerve or the branch to the long head of the triceps. Findings Twenty-one subjects (83%) obtained triceps reinnervation, and good results (M3 or better) were observed in 19 cases (76%). M4 grade was noted in 36% of the cases, M3 grade in 40%, M2 grade in 8%, M1 grade in 8%, and M0 grade in 8% of the patients. The best outcomes were observed in the cases presenting a C5 to C7 palsy and those in which the nerve to the triceps was chosen as the transfer target. Conclusions Reinnervation of the triceps can be achieved in most patients if adequate donor and recipient nerves are carefully selected based on an individual case-specific decision.
Journal of neurosurgery, 2009
In C7-T1 palsies of the brachial plexus, shoulder and elbow function is preserved, but finger motion is absent. Finger flexion has been reconstructed using tendon or nerve transfers. Finger extension has been restored ineffectively by attaching the extensor tendons to the distal side of the dorsal radius (that is, tenodesis). In these types of nerve palsy, supinator muscle function is preserved because innervation stems from the C-6 root. In the present study, the authors investigated the anatomy and the feasibility of transferring the supinator motor branches to the posterior interosseous nerve. Sacrifice of the supinator motor branches does not abolish supination because biceps muscle function is preserved in lower-type injuries of the brachial plexus.
Nerve Transfers for Restoration of Elbow Flexion following Adult Brachial Plexus Injury
2017
Restoration of elbow flexion is a fundamental functional requirement following adult brachial plexus injury. Nerve transfer offers advantages over grafting and has shown better motor recovery. Contemporary literature regarding elbow flexion reconstruction is reviewed and compared. Intraplexal expendable nerve donors for C5, C6, C7 injuries allow nerve regeneration closer to the end organ and hence improved outcomes. A strategic approach using intraplexal donors for elbow restoration allows reservation of extraplexal donors for transfer to reconstruct shoulder function.
Thoracodorsal nerve transfer for triceps reinnervation in partial brachial plexus injuries
Microsurgery, 2015
Purpose: To report the clinical outcomes of thoracodorsal nerve (TDN) transfers to the triceps motor branches for elbow extension restoration in patients with partial brachial plexus injuries (BPI). Methods: Eight male patients of mean age 23 years and suffering from a partial BPI underwent direct coaptation of the TDN to the nerve of the upper medial and long heads of the triceps, an average 6 months after their accident. Results: Seven patients achieved M4 elbow extension strength and one patient M3, according to the BMRC scale, after a mean follow-up of 21 months. Discussion: Direct TDN transfer might be a valid surgical procedure for the restoration of elbow extension in patients with partial BPI. V