How to follow up patients with brachial plexus birth palsy in the long term: a survey of expert opinion.

There is no generally accepted diagnostic, treatment and follow-up algorithm for brachial plexus birth palsy in the current literature. This study evaluates the opinion of experts in the field of brachial plexus birth palsy surgery, to provide a follow-up guideline. A total of 35 experts attending an international meeting with a mean of 21.5 years (SD 10.1) of experience in the field filled out a questionnaire to evaluate the following: (1) the surgeons' background; (2) clinical follow-up; (3) radiological follow-up; and (4) International Classification of Functioning, Disability and Health (ICF) domains. A mean of 40 new brachial plexus birth palsy patients were seen per year by each expert, of which 36% needed surgery. In total, 27 experts scheduled a regular follow-up every year and the majority (83%) believed that standardized long-term clinical follow-up is necessary. However, standardized radiological follow-up is not necessary. Only 13 of 34 participants used patient-reported outcome measures to investigate ICF domains.Level of evidence: V.

Outcomes of humeral osteotomies versus soft-tissue procedures in secondary surgical procedures for neonatal brachial plexus palsy: a meta-analysis.

Secondary surgical procedures can be used in brachial plexus birth injury to correct shoulder movement imbalances. This study compares outcomes of the two secondary surgical procedure types: humeral osteotomies and soft tissue procedures. Outcome measures assessed included active and passive internal and external rotation, active and passive abduction and adduction, active and passive flexion and extension, percentage of the humeral head anterior to the middle glenoid fossa, glenoid version, and Mallet Score. Nineteen full-text articles were included in the analysis. Humeral osteotomies resulted in a loss of internal rotation postoperatively (-15.94°). Active internal rotation was not evaluated for soft tissue procedures. All other assessed outcomes were improved postoperatively for bony and soft tissue procedures. Bony procedures exhibited a greater degree of active external rotation postoperatively when compared to soft tissue procedures (+67° vs. +40°). Both bony and soft tissue procedures Improve shoulder function in children with neonatal brachial plexus palsy, however, soft tissue procedures showed greater consistency in outcomes. Level of Evidence: IV.

The Philadelphia Shriners Hospital Approach to Brachial Plexus Birth Injury.

The care of children with brachial plexus birth injuries (BPBI) is a complex multidisciplinary endeavor. At the Shriners Hospital for Children in Philadelphia, we have sought to elevate the quality of care delivered to patients through outcomes research and collaboration with colleagues around the world. Our approach to the management of this challenging pathology has evolved time and again. Here, we describe our current approach to patient assessment and operative management in patients with BPBI and its many sequelae.

Glenoid osteotomy with various tendon transfers for brachial plexus birth palsy: clinical outcomes.

BACKGROUND: Posterior shoulder dislocation is one of the disabling complications of brachial plexus birth injury (BPBI), and various treatment options including capsule and surrounding muscles release for open reduction, humeral derotational osteotomy, and tendon transfers have been recommended to manage it. In the present study, we aimed to determine the clinical outcome of open reduction with soft tissue release, tendon transfer, and glenoid osteotomy in patients with BPBI and posterior shoulder dislocation or subluxation. METHODS: From 2018 to 2020, 33 patients who underwent open reduction, glenoid osteotomy, and tendon transfer were included. The glenohumeral deformity was classified according to the Waters radiographic classification. Functional assessment was performed using the Mallet grading system before and at least 2 years after the surgery. RESULTS: The patients were monitored for 26.88 ± 5.47 months. Their average age was 27.5 ± 14 months. Significant improvement was seen in the overall Mallet score (from 13.5 to 18.91 points) and its segments including hand-to-mouth, hand-to-neck, global abduction, global external rotation, abduction range of motion (ROM), and external rotation ROM. Hand-to-back score and the presence of a Trumpet sign were significantly decreased in the postoperation phase (all P values < .001). The above-mentioned variables significantly changed for both infantile and noninfantile dislocations. CONCLUSION: Our study demonstrated that open reduction along with glenoid osteotomy improves retroversion, and muscle strengthening with different muscle transfers is an effective technique for BPBI.

Radiographic imaging modalities for perinatal brachial plexus palsy: a systematic review.

PURPOSE: Perinatal brachial plexus palsy (PBPP) has a wide spectrum of clinical symptoms that can range from incomplete paresis of the affected extremity to flaccid arm paralysis. Although there is a high rate of spontaneous recovery within the first two years of life, it remains challenging to determine which patients will benefit most from surgical intervention. The diagnostic and predictive use of various imaging modalities has been described in the literature, but there is little consensus on approach or algorithm. The anatomic, pathophysiological, and neurodevelopmental characteristics of the neonatal and infant patient population affected by PBPP necessitate thoughtful consideration prior to selecting an imaging modality. METHODS: A systematic review was conducted using six databases. Two reviewers independently screened articles published through October 2021. RESULTS: Literature search produced 10,329 publications, and 22 articles were included in the final analysis. These studies included 479 patients. Mean age at time of imaging ranged from 2.1 to 12.8 months and investigated imaging modalities included MRI (18 studies), ultrasound (4 studies), CT myelography (4 studies), and X-ray myelography (1 study). Imaging outcomes were compared against surgical findings (16 studies) or clinical examination (6 studies), and 87.5% of patients underwent surgery. CONCLUSION: This systematic review addresses the relative strengths and challenges of common radiologic imaging options. MRI is the most sensitive and specific for identifying preganglionic nerve injuries such as pseudomeningoceles and rootlet avulsion, the latter of which has the poorest prognosis in this patient population and often dictates the need for surgical intervention.

Musculoskeletal imaging in neonates: use of ultrasound.

High-resolution US is a practical, cost-effective modality to evaluate the musculoskeletal system in neonates. US can be performed portably in the neonatal intensive care unit so that the critically ill infant can be evaluated with minimal distress. Sonography is noninvasive and does not require sedation; typical questions that might require the use of MRI or CT in older children can be rapidly resolved with US. Dynamic imaging can be used in real time to stress joints and see how articular structures relate. Given the advantages of US within the neonatal population, it has been widely used to evaluate for neonatal fractures, congenital joint abnormalities, limb deficiencies as well as muscular and soft-tissue abnormalities.

Structures contributing to the shoulder contracture in brachial plexus birth palsy. An intraoperative biomechanical study.

Internal rotation contracture of the shoulder is a common sequel of the brachial plexus birth palsy. The purpose of this study is to describe the surgical method used in our centre and to measure the effect of sequentially releasing several anatomical structures that have been ascribed as the cause of the contracture. Twenty-four consecutive patients were operated on with an open release. We documented the increase in passive external rotation after each surgical step. We found small gains in passive external rotation when performing coracoidectomy and division of the upper part of the subscapularis tendon; 4° (95% confidence interval [CI] 2°-6° p < 0.01) and 6° (95% CI 4°-8° p < 0.01), respectively. A substantial gain in external rotation occurred when dividing the entire subscapularis tendon, 43° (95% CI 38°-48°, p < 0.01). Our findings indicate that a clinically relevant surgical release of the contracture requires lengthening of the entire subscapularis musculo-tendinous unit.Level of evidence: IV.

Single Versus Double Tendon Transfer to Improve Shoulder External Rotation During the Treatment of Brachial Plexus Birth Palsy.

Background: Tendon transfers are commonly performed in patients with brachial plexus birth palsy (BPBP) to improve function. Transferring 2 tendons in patients with C5-7 injury has the potential complication of loss of midline function. The purpose of this study was to investigate whether a single tendon transfer (1TT) as opposed to the traditional double tendon transfer (2TT) resulted in any differences in functional outcomes in patients with C5-7 BPBP. Methods: A retrospective review of all patients with C5-7 BPBP who underwent tendon transfers to improve shoulder external rotation over a 5-year period was performed at 2 institutions. Outcomes were assessed using the modified Mallet (MM) classification scores. Results: Twenty-two C5-7 patients had complete records of preoperative and postoperative MM scores, including 11 sex-matched patients in both the 1TT and 2TT groups. When comparing preoperative and postoperative MM categories, there were significant improvements in both the 1TT and 2TT groups for global abduction (P < .05 and P < .01, respectively) and external rotation (P < .00001 for both). Modified Mallet (MM) hand to neck scores were significantly improved in the 2TT group (P < .05) but not in the 1TT group (P = .053). Internal rotation scores significantly decreased in both groups (P < .001). Both groups demonstrated significant increases in total scores from the preoperative MM scores (P < .01). Conclusion: The 1TT and 2TT procedures result in substantial gains in upper extremity functions for patients with C5-7 BPBP as measured by the MM score, specifically within the global abduction and external rotation subcategories. However, a significant loss occurs in internal rotation for both groups.

Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy.

Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.

How brachial plexus birth palsy affects motor development and upper extremity skill quality?

PURPOSE: This study aimed to investigate the gross motor functions including head control, midline crossing, and rolling, and the relationship between these developmental skills and upper extremity skill quality in children with neonatal brachial plexus palsy (NBPP). METHODS: A total of 106 children with NBPP, aged 10-18 months, were included in this study. Injury severity was determined with the Narakas Classification. The gross motor function measurement lying and rolling sub-scale was used to evaluate gross motor functions including head control, midline crossing, and rolling, while the Quality of Upper Extremity Skills Test was applied to assess the upper extremity skill quality. The assessments were performed only once during routine physiotherapy controls. RESULTS: As the severity of injury increased, developmental skill capacity decreased and upper extremity skill quality deteriorated (ps = 0.0001). There was a strong positive correlation between these developmental skills and upper extremity skill quality (ps = 0.0001). CONCLUSION: Developmental skills are affected by NBPP. Rehabilitation programs aimed at increasing the quality of upper extremity skills should be included in neurodevelopmental treatment approaches.

Upper limb kinematics after Latissimus Dorsi transfer in children with brachial plexus birth palsy.

BACKGROUND: Brachial plexus birth palsy remains a frequent condition and one of its treatments is to transfer the Latissimus Dorsi tendon to the infraspinatus muscle. The aim of this study was to analyse, for the first time, the three-dimensional kinematic effects of this operation on the upper limb joints during the five Mallet tasks and their correlation with clinical parameters. METHODS: Kinematic analysis was performed using an electromagnetic device. An Index of Improvement taking into account the angle in preop and postop, the reproducibility and the angle of a control group was developed. Three groups of patients were analysed: sixteen patients (mean: 10,5 years) for the reproducibility, thirty children (mean: 9,5 years) for the control group and ten patients (mean: 8 years 7 months) who were operated. FINDINGS: The humerothoracic and glenohumeral external rotations improved during the external rotation, the neck and the abduction tasks and worsened during the spine task. The glenohumeral external rotation worsened during the mouth task. The Humerothoracic abduction improved during the abduction and the neck tasks. The elbow flexion improved for the neck task. Differences were observed between patients and correlations were obtained between the Index of Improvement and clinical parameters. INTERPRETATION: Using kinematics allows to better analyse the evolution of joint angles after the latissimus dorsi transfer. The Index of Improvement allows to quickly analyse the effect of the operation for each angle and each patient. This effect depends on clinical parameters.

Conjoint muscle transfer and subscapularis slide in brachial plexus birth palsy: Clinical outcomes in shoulder functions.

BACKGROUND: Shoulder deformity and inadequate shoulder function in brachial plexus birth palsy (BPBP) occur due to imbalance between the shoulder abductors, external rotators, adductors and internal rotators. This is due to cross innervation of the regenerating axons and subsequent target muscle innervation. These lead to internal rotation deformity along with glenohumeral dysplasia. Conjoint muscle transfer in the form of latissimus dorsi and teres major muscle combined with release and slide of subscapularis muscle improves shoulder functions. This study aims to evaluate the outcomes of shoulder function after a simultaneous conjoint muscle transfer and subscapularis slide in the management of BPBP. METHODS: 18 children with BPBP, who presented with shoulder deformity and inadequate shoulder functions, underwent conjoint muscle transfer along with subscapularis muscle slide. At 18 months, shoulder functions were assessed preoperatively and postoperatively using Mallet score system and range of motions. Statistical analysis was performed to ascertain if the outcomes were statistically significant. RESULTS: Mean age was 4.64 years with a mean preoperative Mallet score of 10.89 ± 1.60 and mean postoperative Mallet score of 16.22 ± 1.86. At 18 months, mean gain in shoulder abduction at 18 months was 57.22 ± 16.11° with external rotation of 26.66 ± 7.67°. All children showed improvement in shoulder functions. There was no correlation between the clinical outcomes and age of the child. CONCLUSION: This procedure was effective in improving shoulder functions in a cohort of patients. The long-term effect of this procedure, however, remains to be evaluated by further follow-up and with similar such studies.

Outcomes of Late Microsurgical Nerve Reconstruction for Brachial Plexus Birth Injury.

PURPOSE: Microsurgical nerve reconstruction has been advocated between 3 and 9 months of life in select patients with brachial plexus birth injury (BPBI), yet some patients undergo indicated surgery after this time frame. Outcomes in these older patients remain poorly characterized. We analyzed outcomes of nerve reconstruction performed after 9 months of age and hypothesized that (1) Active Movement Scale (AMS) scores improve after surgery, and (2) there are no differences in AMS scores between patients undergoing nerve transfers versus those undergoing nerve grafting. METHODS: From 2000 to 2014, 750 patients at 6 U.S. centers were prospectively enrolled in a multicenter database. We included patients treated with nerve reconstruction after 9 months of age with minimum 12 months' follow-up. Patients were evaluated using AMS scores. To focus on the results of microsurgery, only outcomes prior to secondary surgery were analyzed. We analyzed baseline variables using bivariate statistics and change in AMS scores over time and across treatment groups using linear mixed models. RESULTS: We identified 32 patients (63% female) with median follow-up of 29.8 months. Median age at microsurgery was 11.2 months. Twenty-five (78%) had an upper trunk injury. Compared with before surgery, total AMS scores improved modestly at 1 year and 2 or more years follow-up. At 1 year follow-up, AMS scores improved for shoulder function (abduction, external rotation) and elbow flexion. Between-group comparisons found no differences in total AMS scores or AMS subscales between graft and transfer groups at 1 year or 2 or more years after surgery, so we cannot recommend one strategy over the other based on our findings. CONCLUSIONS: Overall, nerve reconstruction in patients with BPBI after 9 months of age resulted in improved function over time. There was no difference in outcomes between nerve transfer and nerve graft groups and 1 or 2 or more years follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Role of Early Referral and Surgical Intervention in Brachial Plexus Birth Palsy: Awareness Among Obstetricians and Pediatricians in a Teaching Hospital.

A cross-sectional study was conducted using a validated and standardized questionnaire answered by willing pediatricians and obstetricians at our university teaching hospitals. Nearly two thirds of the pediatricians (62.8%) and three fourths of the obstetricians (73.6%) continued to accept the terminology of obstetric brachial plexus birth palsy which is a misnomer; 32.6% of pediatricians felt that they were unaware of the current trends in its management. Parental reluctance (23.5%) and inadequate knowledge in current approaches among surgeons and pediatricians (41.2%) were suggested as chief causes for the delay in their adequate referral and management using surgical exploration, nerve grafting, and nerve transfer. The delayed presentations of birth brachial plexus injuries with missed opportunity for optimum treatment can be partly attributed to inadequate information available on definitive guidelines in its management among the stakeholders including parents, primary care physicians, and surgeons.

Prevalence and predisposing factors of brachial plexus birth palsy in a regional hospital in Ghana: a five year retrospective study.

INTRODUCTION: Brachial plexus birth injury is one of the challenges associated with maternal delivery, with varying prevalence between countries. Brachial plexus birth injury poses negative health implications to children and also has socio-economic implications on families and the community as a whole. To treat brachial plexus birth injury, a multi-disciplinary treatment approach is recommended. Brachial plexus birth palsy (BPBP) is categorised into two-upper plexus injury (Erb's palsy) and lower plexus injury (Klumpke's palsy). These categories present with various degrees of injuries, with less severe injuries responding well to treatment and in most instances may resolve on their own, but serious and complicated injuries will require a multi-disciplinary treatment approach to treat and/or manage. Effective treatment and management depends on adequate knowledge of the disease condition. These include the risk factors and prevalence of brachial plexus birth palsy within a particular population at a specific period in time. The aim of this study was to determine the risk factors and the prevalence of a hospital based brachial plexus birth palsy within a five-year period (2013-2017). METHODS: A five-year retrospective study design was used. The study involved selection of all clients' diagnosed with brachial plexus birth palsy, where their gender, birth weight, complications at birth, type of brachial plexus suffered, mothers' diabetes status, mother's age, birth attendant, side of affectation, presentation at birth and mode of delivery were recorded. RESULTS: The prevalence rate of brachial plexus birth palsy was 14.7% out of a total of three hundred and twenty (320) cases reviewed over the study period in the Volta Regional Hospital. Erb's palsy was found to be the modal type of BPBP in this population (93.6%). CONCLUSION: There is the need to provide a nationwide education on the risk factors that predispose babies to brachial plexus birth palsy. There is also the need for frequent antenatal visit by pregnant women; this will help in the provision of best antenatal history, diagnostic investigation in determining the birth weight and safe mode of delivery.

Development of the glenohumeral joint after subscapular release and open relocation in children with brachial plexus birth palsy: long-term results in 61 patients.

BACKGROUND: We present the long-term results of remodeling of the glenohumeral joint after open subscapularis elongation and relocation of the humeral head in patients with an internal rotation contracture and joint incongruity due to brachial plexus birth palsy. METHODS: In this before-and-after study, 61 patients who underwent open subscapularis elongation and reduction of the glenohumeral joint were evaluated with respect to joint remodeling, with a mean follow-up period of 10.2 years (range, 7-16 years). The mean age at operation was 3.2 years (range, 8 months to 15 years). Measurements of the percentage of the humeral head anterior to the midscapular line (PHHA), glenoid version, and diameter of the humeral head were recorded using magnetic resonance imaging, comparing the affected joints preoperatively vs. postoperatively (n = 31) and comparing the operated vs. unaffected sides postoperatively (n = 61). RESULTS: The mean increase in PHHA was 27.6 percentage points (95% confidence interval, 22.4-32.7 percentage points; P < .01), from 13.2% to 40.8%. The glenoid retroversion changed by 14.8° (95% confidence interval, 11.1°-18.4°; P < .01), from 25.4° to 10.6°, approaching a normal value. All patients, even those older than 5 years, showed a clear benefit from surgery. CONCLUSIONS: Our study confirms that open subscapularis lengthening with joint repositioning, up to the age of 5 years, gives consistent remodeling of incongruent shoulders with surprisingly small differences between the operated and unaffected shoulders at long-term follow-up. The findings indicate that open reduction is useful also in adolescents and challenges the notion that older children should be treated with derotational humeral osteotomy.

The Association of Clavicle Fracture With Brachial Plexus Birth Palsy.

PURPOSE: Shoulder dystocia is the strongest known risk factor for brachial plexus birth palsy (BPBP). Fractures of the clavicle are known to occur in the setting of shoulder dystocia. It remains unknown whether a clavicle fracture that occurs during a birth delivery with shoulder dystocia increases the risk of BPBP or, alternatively, is protective. The purpose of this study was to use a large, national database to determine whether a clavicle fracture in the setting of shoulder dystocia is associated with an increased or decreased risk of BPBP. MATERIALS AND METHODS: The 1997 to 2012 Kids' Inpatient Database (KID) was analyzed for this study. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify newborns diagnosed with shoulder dystocia and BPBP as well as a concurrent fracture of the clavicle. Newborns with shoulder dystocia were stratified into 2 groups: dystocia without a clavicle fracture and dystocia with a clavicle fracture. Multivariable logistic regression was used to quantify the risk for BPBP among shoulder dystocia subgroups. RESULTS: The dataset included 5,564,628 sample births extrapolated to 23,385,597 population births over the 16-year study period. A BPBP occurred at a rate of 1.2 per 1,000 births. Shoulder dystocia complicated 18.8% of births with a BPBP. A total of 7.84% of newborns with a BPBP also sustained a clavicle fracture. Births with shoulder dystocia and a clavicle fracture incurred BPBP at a rate similar to that for newborns with shoulder dystocia and no fracture (9.82% vs 11.77%). Shoulder dystocia without a concurrent clavicle fracture was an independent risk factor for BPBP (odds ratio, 112.1; 95% confidence interval, 103.5-121.4). Those with shoulder dystocia and clavicle fracture had a risk for BPBP comparable with those with shoulder dystocia but no fracture (odds ratio, 126.7 vs 112.1). CONCLUSIONS: This population-level investigation suggests that, among newborns with shoulder dystocia, clavicle fracture is not associated with a significant change in the risk of BPBP. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Surgical Technique and Anatomical Considerations for the Modified L'Episcopo Tendon Transfer.

BACKGROUND: Birth brachial plexus injury usually affects the upper trunks of the brachial plexus and can cause substantial loss of active shoulder external rotation and abduction. Due to the unbalanced rotational forces acting at the glenohumeral joint, the natural history of the condition involves progressive glenohumeral joint dysplasia with associated upper limb dysfunction. Surgical reconstruction methods have been described previously by Sever and L'Episcopo, and modified by Hoffer and Roper to release the adduction contracture and to restore external rotation and shoulder abduction. METHODS: The authors describe their preferred technique for contracture release and tendon transfer to improve external rotation and shoulder abduction. Pertinent anatomy and highlights of surgical exposure are reviewed. RESULTS: The senior author has utilized this technique with consistent clinical outcomes to improve shoulder function for patients with persisting nerve palsy associated with birth brachial plexus injury. A review of the literature supports utilization of this technique. CONCLUSIONS: Transfer of the latissimus dorsi and teres major to the posterior rotator cuff for reanimation of shoulder abduction and external rotation deficits associated with birth brachial plexus injury is a safe and reliable technique. Careful patient selection and attention to surgical detail are critical for optimal outcomes.

Assessment of Current Epidemiology and Risk Factors Surrounding Brachial Plexus Birth Palsy.

PURPOSE: Brachial plexus birth palsy (BPBP) is common; however, the current incidence is unknown and more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known risk factors, and evaluate hypotonia as a new risk factor, as well as estimate the length of stay (LOS) and direct costs of children with an associated BPBP injury. METHODS: Data from the 1997 to 2012 Kids' Inpatient Database data sets were evaluated to identify patients with a BPBP injury and various risk factors. Evaluation of LOS data and direct costs was also performed. Multivariable logistic regression analysis was utilized to assess the association of BPBP with its known and previously undescribed risk factors. RESULTS: The incidence of BPBP has steadily decreased from 1997 to 2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number 1 risk factor for the development of a BPBP injury. Hypotonia is a newly recognized risk factor for the development of BPBP. Fifty-five percent of infants with BPBP have no known perinatal risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury and the hospital stay direct costs are approximately 40% higher. CONCLUSIONS: The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the most common risk factor for sustaining a BPBP injury. Children with a BPBP injury have longer LOSs and hospital direct costs compared with children without a BPBP injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The Anterior Approach for Transfer of Radial Nerve Triceps Fascicles to the Axillary Nerve.

Nerve transfers are an increasingly popular method for surgical treatment of nerve injuries. One of the most popular of these is the transfer of radial nerve triceps fascicles to the axillary nerve. The most common approach for this transfer is the posterior approach, which gives excellent access to both nerves but is not easy to combine with other nerve transfers. We describe here an alternative, the anterior approach, that offers safe access to both radial and axillary nerves and has the added advantage of compatibility with approaches for other common nerve transfers.