Traumatic Brachial Plexus Palsy Research Articles

Glenohumeral arthrodesis for late reconstruction of flail shoulder in patients with traumatic supraclavicular brachial plexus palsy.

Flail shoulder can occur following a brachial plexus injury and is characterized by painful subluxation of the glenohumeral joint and the inability to independently position the hand in space. The present study aimed to report the clinical outcomes following glenohumeral arthrodesis for late reconstruction of flail shoulder in patients with traumatic supraclavicular brachial plexus palsy. Seven patients were included in the present study and were followed-up for a mean of 98 months (range 27 months to 197 months). The mean age at the time of surgery was 48 years (range 28 years to 80 years) and the mean time to surgery from injury was 5 years (range 2.5 years to 8 years). Six patients achieved bony union with a mean time to fusion of 4.7 months (range 2 months to 8 months). Non-union occurred in one case. The mean Oxford Shoulder Score improved from 11 pre-operatively (range 4 to 16) to 27 postoperatively (range 16 to 40) (p = 0.016), and the mean Subjective Shoulder Value improved from 7 (range 0 to 15) pre-operatively to 45 (range 15 to 100) postoperatively (p = 0.029). In our series, glenohumeral arthrodesis was associated with few complications, and effectively reduced pain and improved functional outcome in this selected patient population.

Outcome following phrenic nerve transfer to musculocutaneous nerve in patients with traumatic brachial palsy: a qualitative systematic review.

The phrenic nerve can be transferred to the musculocutaneous nerve in patients with traumatic brachial plexus palsy in order to recover biceps strength, but the results are controversial. There is also a concern about pulmonary function after phrenic nerve transection. In this paper, we performed a qualitative systematic review, evaluating outcomes after this procedure. A systematic review of published studies was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Data were extracted from the selected papers and related to: publication, study design, outcome (biceps strength in accordance with BMRC and pulmonary function) and population. Study quality was assessed using the "strengthening the reporting of observational studies in epidemiology" (STROBE) standard or the CONSORT checklist, depending on the study design. Seven studies were selected for this systematic review after applying inclusion and exclusion criteria. One hundred twenty-four patients completed follow-up, and most of them were graded M3 or M4 (70.1%) for biceps strength at the final evaluation. Pulmonary function was analyzed in five studies. It was not possible to perform a statistical comparison between studies because the authors used different parameters for evaluation. Most of the patients exhibited a decrease in pulmonary function tests immediately after surgery, with recovery in the following months. Study quality was determined using STROBE in six articles, and the global score varied from 8 to 21. Phrenic nerve transfer to the musculocutaneous nerve can recover biceps strength ≥M3 (BMRC) in most patients with traumatic brachial plexus injury. Early postoperative findings revealed that the development of pulmonary symptoms is rare, but it cannot be concluded that the procedure is safe because there is no study evaluating pulmonary function in old age.

Direct cord implantation in brachial plexus avulsions: revised technique using a single stage combined anterior (first) posterior (second) approach and end-to-side side-to-side grafting neurorrhaphy

BackgroundThe superiority of a single stage combined anterior (first) posterior (second) approach and end-to-side side-to-side grafting neurorrhaphy in direct cord implantation was investigated as to providing adequate exposure to both the cervical cord and the brachial plexus, as to causing less tissue damage and as to being more extensible than current surgical approaches.MethodsThe front and back of the neck, the front and back of the chest up to the midline and the whole affected upper limb were sterilized while the patient was in the lateral position; the patient was next turned into the supine position, the plexus explored anteriorly and the grafts were placed; the patient was then turned again into the lateral position, and a posterior cervical laminectomy was done. The grafts were retrieved posteriorly and side grafted to the anterior cord. Using this approach, 5 patients suffering from complete traumatic brachial plexus palsy, 4 adults and 1 obstetric case were operated upon and followed up for 2 years. 2 were C5,6 ruptures and C7,8T1 avulsions. 3 were C5,6,7,8T1 avulsions. C5,6 ruptures were grafted and all avulsions were cord implanted.ResultsSurgery in complete avulsions led to Grade 4 improvement in shoulder abduction/flexion and elbow flexion. Cocontractions occurred between the lateral deltoid and biceps on active shoulder abduction. No cocontractions occurred after surgery in C5,6 ruptures and C7,8T1 avulsions, muscle power improvement extended into the forearm and hand; pain disappeared.Limitations includespontaneous recovery despite MRI appearance of avulsions, fallacies in determining intraoperative avulsions (wrong diagnosis, wrong level); small sample size; no controls rule out superiority of this technique versus other direct cord reimplantation techniques or other neurotization procedures; intra- and interobserver variability in testing muscle power and cocontractions.ConclusionThrough providing proper exposure to the brachial plexus and to the cervical cord, the single stage combined anterior (first) and posterior (second) approach might stimulate brachial plexus surgeons to go more for direct cord implantation. In this study, it allowed for placing side grafts along an extensive donor recipient area by end-to-side, side-to-side grafting neurorrhaphy and thus improved results.Level of evidenceLevel IV, prospective case series.

Nerve Transfers for Reconstruction of Traumatic Brachial Plexus Injury

Introduction: Neurolysis, nerve repair, or nerve grafting are options which are used for treatment of adult traumatic brachial plexus palsy. Because of the frequency of avulsion-type injuries, the lack of available nerve roots for grafting, and the extensive scarring at the injury site, these treatment options are frequently inadequate to restore function in the severely affected patient.In this situation nerve transfer is choice. Nerve transfer (neurotization) means redirection of an intact motor nerve from one muscle to the distal undamaged portion of a nerve. Aim: The purpose of this study was to assess the outcomes of different nerve transfers techniques in the restoration of shoulder and elbow functions in patients with brachial plexus injuries. Material and Methods: Between 2010-2013 a total of 16 patients with brachial plexus lesions underwent surgical exploration and reconstruction of the brachial plexus included transfer of the distal spinal accessory nerve into the suprascapular nerve for shoulder abduction and nerve transfer of a single motor fascicle from both ulnar and/ or median nerves or intercostal nerves directly to the biceps and brachialis branches of the musculocutaneous nerve for elbow flexion. The average age of patients was 22 years (16 and 40 years). The injury-surgery interval was between 3-4months. The follow-up period ranged from 5 to 20 months (average, 13 months). The clinical examination included testing of motor power in upper extremity muscles using the British Medical Research Council Grading System. Assessment included degree of shoulder abduction and recovery of elbow flexion. Results: Useful functional recovery for shoulder abduction was achieved in 15 patients; 75% had good results. The average shoulder abduction was 50 degrees. Good result for elbow flexion was 25% in intercostals nerves transfer and 57% for ulnar and/or median nerve transfer .No motor or sensory deficits related to the ulnar or median nerves were noted and all patients maintained good hand function. Conclusion: Nerve transfer techniques to restore shoulder and elbow function has good result for treatment of traumatic brachial plexus injury.it seems that use of ulnar or median nerve for transfer has much better result than intercostal nerve.

Robot-assisted surgery of the shoulder girdle and brachial plexus.

New developments in the surgery of the brachial plexus include the use of less invasive surgical approaches and more precise techniques. The theoretical advantages of the use of robotics versus endoscopy are the disappearance of physiological tremor, three-dimensional vision, high definition, magnification, and superior ergonomics. On a fresh cadaver, a dissection space was created and maintained by insufflation of CO2. The supraclavicular brachial plexus was dissected using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). A segment of the C5 nerve root was grafted robotically. A series of eight clinical cases of nerve damage around the shoulder girdle were operated on using the da Vinci robot. The ability to perform successful microneural repair was confirmed in both the authors' clinical and experimental studies, but the entire potential of robotically assisted microneural surgery was not realized during these initial cases because an open incision was still required. Robotic-assisted surgery of the shoulder girdle and brachial plexus is still in its early stages. It would be ideal to have even finer and more suitable instruments to apply fibrin glue or electrostimulation in nerve surgery. Nevertheless, the prospects of minimally invasive techniques would allow acute and subacute surgical approach of traumatic brachial plexus palsy safely, without significant and cicatricial morbidity.

Contralateral lower trapezius transfer for restoration of shoulder external rotation in traumatic brachial plexus palsy: a preliminary report and literature review

The importance of external rotation of the shoulder is well accepted. Patients with inadequate recovery of shoulder function after nerve transfers for a brachial plexus injury have difficulty in using their reconstructed limb. The options for secondary procedures to improve shoulder function are often limited, especially if the spinal accessory nerve has been used earlier for nerve transfer or as a donor nerve for a free functioning muscle transfer. We have used the contralateral lower trapezius transfer to the infraspinatus in three cases, to restore shoulder external rotation. All patients had significant improvement in shoulder external rotation (mean 97°; range 80°-110°) and improved disability of the arm, shoulder and hand scores. The rotation occurred mainly at the glenohumeral joint, and was independent of the donor side. All patients were greatly satisfied with the outcome. Contralateral lower trapezius transfer appears to help in overall improvement of shoulder function by stabilizing the scapula. The results have remained stable after mean follow-up of 58 months (range 12-86). No donor site deficit was seen in any patient.

Spinal to accessory nerve transfer in traumatic brachial plexus palsy: is body mass index a predictor of outcome?

Several factors that affect functional recovery after surgery in severe brachial plexus lesions have been identified, i.e., time to surgery and presence of root avulsions. The body mass index (BMI) of the patient could be one of these possible factors. The objective of the present paper is to systematically study the relationship between BMI and the outcome of abduction following spinal accessory to suprascapular nerve transfer. We retrospectively studied 18 cases that followed these inclusion criteria: (1) Male patients with a spinal accessory to suprascapular nerve transfer as the only procedure for shoulder function reanimation; (2) at least C5-C6 root avulsion; (3) interval between trauma and surgery less than 12 months; (4) follow-up was at least 2 years; (5) no concomitant injury of the shoulder girdle. Pearson correlation analysis and linear regression was performed for BMI versus shoulder abduction. The mean range of post-operative abduction obtained across the entire series was 49.7° (SD ± 30.2). Statistical evaluation revealed a significant, negative moderately strong correlation between BMI and post-operative range of shoulder abduction (r = -0.48, p = 0.04). Upon simple linear regression, time to surgery (p = 0.04) was the only statistically significant predictor of abduction range negatively correlated. Analysis of this series suggests that a high BMI of patients undergoing brachial plexus surgery is a negative predictor of outcome, albeit less important than others like time from trauma to surgery. Nevertheless, the BMI of patients should be taken into consideration when planning surgical strategies for reconstruction.

Current Procedure of Double Free Muscle Transfer for Traumatic Total Brachial Plexus Palsy.

We describe the current procedure of not only double free muscle transfer but also supplemental techniques including nerve transfer for shoulder and elbow reconstruction and secondary surgery for the wrist and fingers to improve prehensile function following traumatic total brachial plexus palsy1-4. Coronal and transverse MRIs and intraoperative electrical stimulation are useful for nerve-root evaluation. If the nerve gap is <10 cm, use the sural nerve as an interpositional graft; if the nerve gap is >15 cm, use a vascularized ulnar or radial nerve graft from the ipsilateral forearm; if the ipsilateral nerve roots are not available, explore the contralateral plexus. Prepare the recipient site, harvest the gracilis muscle, and transfer the muscle graft. Repair the long-head branches of the triceps brachii muscle of the radial nerve by using the third and fourth intercostal nerves, and the median nerve by using the sensory branch of the the second and third intercostal nerves; then transfer the second free muscle. Immobilize the upper limb for eight weeks, and start early passive mobilization at one week. Secondary procedures include wrist fusion, correction of intrinsic minus deformity, etc. From 2002 to 2008, thirty-six patients underwent reconstruction with the double free muscle technique to treat a total brachial plexus palsy5. IndicationsContraindicationsPitfalls & Challenges.

Outcome of Surgical Reconstruction After Traumatic Total Brachial Plexus Palsy

Double free muscle transfer for the treatment of traumatic total brachial plexus injury provides useful prehensile function. We studied the outcome of this muscle transfer procedure, including the changes in disability and quality-of-life scores. Thirty-six patients with traumatic total brachial plexus injury who underwent double free muscle transfer for reconstruction from 2002 to 2008 and had a minimum follow-up of twenty-four months after the second free muscle transfer were studied. All were evaluated preoperatively and postoperatively with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) questionnaires. A separate questionnaire was used to determine job status, pain, use of the reconstructed hand, and satisfaction with the procedure. The mean patient age was twenty-nine years (range, sixteen to forty-nine years), and the mean duration of follow-up was thirty-six months (range, twenty-four to seventy-nine months). The mean active range of motion was 23° (range, 0° to 80°) for shoulder flexion, 31° (range, 0° to 90°) for shoulder abduction, -18° (range, -80° to 40°) for shoulder external rotation, 62° (range, 0° to 130°) for the shoulder rotation arc, 119° (range, 90° to 150°) for elbow flexion, and -33° (range, -60° to -20°) for elbow extension. The power of elbow flexion was M4 in twenty-five patients and M3 in eleven. Twenty-three patients had triceps nerve reconstruction; extension was M0 in two of these patients, M1 in seven, M2 in ten, and M3 in four. Total active motion of the fingers was 46° (range, 0° to 98°), with a mean hook grip strength of 4 kg (range, 0 to 12 kg). Wilcoxon tests revealed significant improvements in the DASH score and the SF-36 physical functioning, role physical, and physical component summary scores. The majority of patients worked but had changed their type of work, used the reconstructed hand in activities of daily living that required both hands, and were satisfied with the procedure. Double free muscle transfer yielded satisfactory function and allowed use of the reconstructed hand in activities that required both hands. The improvement in the DASH score was greater than that in the SF-36 score.

Current Procedure of Double Free Muscle Transfer for Traumatic Total Brachial Plexus Palsy

Current Procedure of Double Free Muscle Transfer for Traumatic Total Brachial Plexus Palsy

Free Gracilis Transfer Reinnervated by the Nerve to the Supinator for the Reconstruction of Finger and Thumb Extension in Longstanding C7-T1 Brachial Plexus Root Avulsion

To report the clinical results of a free gracilis muscle transfer to finger and thumb extensors reinnervated by supinator muscle motor branches in patients with longstanding C7-T1 root avulsion. Between January 2010 and January 2011, 3 young adult patients with traumatic C7-T1 brachial plexus palsies had gracilis transfer to the thumb and finger extensors at a mean of 38 months after injury. The muscle flap was connected to radial vessels and comitant veins and to nerve branches supplying the supinator muscle. All patients had recovery of active thumb and finger extension, scoring M3 and M4 on the Medical Research Council scale, respectively, at a mean of 12 months after surgery. Reconstruction of finger and thumb extension in lower-type brachial plexus injuries is a challenging problem that is most commonly addressed with an extensor tenodesis technique, which depends on wrist flexion. Free gracilis transfer innervated by nerve branches to the supinator provided the restoration of thumb and finger extension independent of wrist flexion. For those patients with lower brachial root injury more than a year old, transfer of a free functional gracilis muscle is an alternative for the reconstruction of thumb and finger extension. Therapeutic IV.

Recovery of Shoulder Function in Traumatic Brachial Plexus Palsy After Nerve Repair

Recovery of Shoulder Function in Traumatic Brachial Plexus Palsy After Nerve Repair

The Importance of Shoulder External Rotation in Activities of Daily Living: Improving Outcomes in Traumatic Brachial Plexus Palsy

To define the importance of shoulder external rotation in activities of daily living in normal individuals to better understand how restoration of shoulder external rotation in traumatic brachial plexus palsy could improve patient function. Thirty-one normal individuals performed 12 common activities of daily living (ADLs) wearing a custom shoulder orthosis designed to selectively limit shoulder external rotation to 3 different settings, ranging from 0° (most restrictive) to 90° (least restrictive) of external rotation. Outcomes were measured with a visual analog scale of perceived difficulty in accomplishing the ADLs with each orthosis setting and the Disabilities of the Arm, Shoulder, and Hand questionnaire administered after each set of 12 ADLs was completed. Subjects perceived increasing difficulty during all ADLs tested and registered higher disability scores with increasing restriction of shoulder external rotation. The ADLs requiring motions predominantly above the waist exhibited more marked and earlier changes in visual analog scale scores with increasing shoulder external rotation restriction. Traditionally, surgeons have pursued restoration of shoulder abduction and forward elevation in secondary reconstruction of traumatic brachial plexus injuries. Recently, the concept of preferentially restoring shoulder external rotation has been proposed, without clear evidence in the literature of the role of shoulder external rotation in ADLs. Our results support the notion that restoring shoulder external rotation in the treatment of traumatic brachial plexus palsy patients might improve outcomes by decreasing patient disability and increasing the ability to perform ADLs.

Postoperative Monitoring in Free Muscle Transfers for Reconstruction in Brachial Plexus Injuries

Free gracilis transfers are done for reanimation of the upper limb in traumatic total brachial plexus palsy. Because of buried nature of the free muscle and monitoring skin flap in the axillary or infraclavicular region, it is always a tricky situation for continuous and repeated monitoring to assess vascular status. Critical ischemia times vary between the muscle and monitoring skin flap because of which signs of ischemic changes in the monitoring skin flap are always delayed with respect to the muscle. We describe a novel method that uses the principle of evoked potentials from the muscle to assess the vascular status of the free muscle and detects vascular compromise early before the skin changes are apparent.

Transfer of Triceps Motor Branches of the Radial Nerve to the Axillary Nerve with or without other Nerve Transfers Provides Antigravity Shoulder Abduction in Pediatric Brachial Plexus Injury

Restoration of shoulder abduction following injury to the brachial plexus is sometimes difficult to achieve in obstetrical brachial plexus palsy and traumatic brachial plexus palsy. Nerve transfers are a recognized treatment option for patients with traumatic brachial plexus injuries [5]. To maximize shoulder function, notably shoulder abduction and external rotation, simultaneous reconstruction of the suprascapular and axillary nerves is often advocated [6, 7]. Nerve transfers permit faster reinnervation of muscle than traditional nerve grafting because the nerve repair can be performed much closer to the neuromuscular junction [9]. Application of nerve transfers in the obstetric brachial plexus palsy-affected population is gaining acceptance and is increasingly practiced along with or in lieu of neuroma resection with autologous nerve grafting [2]. While the triceps branch of the radial nerve to the axillary nerve transfer has been described in the adult patient population, there is a paucity of reports of its effectiveness in restoring shoulder abduction in children. In this report, consecutive cases of triceps to axillary nerve transfer in children performed by a single surgeon are reviewed. These nerve transfers were performed for patients with obstetrical brachial plexus palsy and also for traumatic injuries.

Early post operative results after repair of traumatic brachial plexus palsy

Treatment options for traumatic brachial plexus injuries include nerve grafting, or neurotization. The type of lesion and the reconstructive procedures affect functional results and postoperative pain relief. A total number of twenty five patients suffering from post-traumatic brachial plexus injury were included in the study. The patients underwent exploration and primary repair of the affected plexus, based on case by case policy. Spinal accessory nerve transfer to suprascapular nerve procedure regained 78.95% of functional muscle power, 10.50% of non functional muscle power and only 10.5 % of non innervated muscle. The Oberlin procedure regained 83.33% with elbow flexion muscle power, 16.67% with non functional muscle power. Intercostal nerve transfer to musculocutaneous nerve regained 62.5% with functional muscle power, 25% with non functional muscle power and only 12.5 % with non innervated muscle. The shoulder, elbow and wrist extension functions were significantly improved early post-operatively. In addition, the post-operative improvement of shoulder, elbow and wrist extension functions had significant negative correlations with the pre-operative elapsed time, and accompanied by a significant positive correlation with post-operative follow up period. Early intervention for traumatic brachial plexus palsy is recommended to get good results with pain relief.

Comparison of Nerve Transfers and Nerve Grafting for Traumatic Upper Plexus Palsy: A Systematic Review and Analysis

In treating patients with brachial plexus injury, there are no comparative data on the outcomes of nerve grafts or nerve transfers for isolated upper trunk or C5-C6-C7 root injuries. The purpose of our study was to compare, with systematic review, the outcomes for modern intraplexal nerve transfers for shoulder and elbow function with autogenous nerve grafting for upper brachial plexus traumatic injuries. PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies in which patients had surgery for traumatic upper brachial plexus palsy within one year of injury and with a minimum follow-up of twelve months. Strength and shoulder and elbow motion were assessed as outcome measures. The Fisher exact test and Mann-Whitney U test were used to compare outcomes, with an alpha level of 0.05. Thirty-one studies met the inclusion criteria. Two hundred and forty-seven (83%) and 286 (96%) of 299 patients with nerve transfers achieved elbow flexion strength of grade M4 or greater and M3 or greater, respectively, compared with thirty-two (56%) and forty-seven (82%) of fifty-seven patients with nerve grafts (p < 0.05). Forty (74%) of fifty-four patients with dual nerve transfers for shoulder function had shoulder abduction strength of grade M4 or greater compared with twenty (35%) of fifty-seven patients with nerve transfer to a single nerve and thirteen (46%) of twenty-eight patients with nerve grafts (p < 0.05). The average shoulder abduction and external rotation was 122° (range, 45° to 170°) and 108° (range, 60° to 140°) after dual nerve transfers and 50° (range, 0° to 100°) and 45° (range, 0° to 140°) in patients with nerve transfers to a single nerve. In patients with demonstrated complete traumatic upper brachial plexus injuries of C5-C6, the pooled international data strongly favors dual nerve transfer over traditional nerve grafting for restoration of improved shoulder and elbow function. These data may be helpful to surgeons considering intraoperative options, particularly in cases in which the native nerve root or trunk may appear less than optimal, or when long nerve grafts are contemplated.

Shoulder arthrodesis with plate fixation

The aim of this study was to evaluate the long-term outcome of shoulder arthrodesis with plate fixation and primary autogenous grafting in terms of pain, functional status and arthrodesis position. The study included 8 patients (7 males and 1 female; mean age: 39.3 years; range: 22 to 68 years) who underwent arthrodesis with plate fixation and primary autogenous grafting. Mean follow-up period was 66.6 (range: 47 to 96) months. Five cases had traumatic brachial plexus palsy, 2 polio sequela and 1 sequela of an operated proximal humerus fracture due to a falling injury. One of the traumatic palsy cases was accompanied with a humerus shaft fracture. Arthrodesis was performed in all cases according to AO principles with plate fixation and primary autogenous grafting. Five of the paralytic patients also underwent Steindler flexorplasty. Follow-up assessments included monthly radiologic control for union, the visual analog scale (VAS) for pain and the Oxford shoulder score (OSS) for functional status. Radiological fusion was seen in all cases in an average of 16 (range: 12 to 18) weeks, and arthrodesis was stable at physical examination. The accompanying humerus shaft fracture was also fixed with plate. One patient with traumatic palsy experienced a humerus fracture distal to the arthrodesis plate at the 8th postoperative month. An additional traumatic palsy case had flexion deformity at the wrist in the second year of follow-up and a wrist arthrodesis with dorsal plate was performed. One patient (12.5%) had a donor site infection on the tenth day after surgery. The target positions of 30° of abduction, 30° of forward flexion, and 30° of internal rotation were achieved with an average deviation of 7°. Mean active abduction was 68.1° (range: 55° to 90°), flexion was 67.5° (range: 60° to 85°), and internal rotation was at the level of trochanter major. The mean OSS was 35.9 (range: 32 to 40), and the mean VAS score was 2.9 (range: 1 to 7). Our findings show that AO reconstruction plate and primary autogenous bone grafting is a safe and effective arthrodesis method that can also be used as a salvage procedure.

Pediatric Traumatic and Obstetrical Brachial Plexus Palsy: Triceps to Axillary Nerve Transfers to Restore Shoulder Abduction

Plastic and Reconstructive Surgery: October 2010 - Volume 126 - Issue - p 91 doi: 10.1097/01.prs.0000388815.66047.70

Nerve transfers in children with traumatic partial brachial plexus injuries

Brachial plexus trauma is a rare condition in children except for obstetrical lesions, for which nerve grafting is generally proposed. Two children (9 and 12 years old) with C5 and C6 traumatic brachial plexus avulsion lesions are presented, where elbow flexion and shoulder abduction and external rotation were the functions to be restored. Nerve transfers have been performed. Shoulder abduction was restored by an accessory-to-suprascapular nerve transfer in one patient, while the triceps long head motor branch was transferred to the axillary nerve in both patients. Fascicles of the ulnar and median nerve were transferred respectively to the biceps muscle nerve and the brachialis motor branch. At 11 months follow-up, the elbow flexion scored M4 and the shoulder abduction recovered in both patients. No complications were observed. Nerve transfers currently used in adult patients may be applied in children with traumatic partial brachial plexus palsies.