Early exploration is not necessary in open injuries caused by low velocity bullets, unless the adjacent vessels or internal organs are injured and require urgent treatment. In these cases, the patient’s condition is usually not conducive to extensive brachial plexus nerve repair or nerve grafting. The injury and its extent should be observed and documented. These injuries often result in nerve disuse or disruption of continuity. Leffert stresses the importance of regular review and establishing a schedule for recovery of nerve function. After 3 to 4 weeks of nerve damage, another EMG should be performed to determine the extent of muscle innervation loss. This should be followed by periodic reviews every 4 to 6 weeks. If an appropriately timed examination confirms that there is no sign of nerve recovery or that recovery has ceased, nerve exploration and suturing, nerve grafting, or nerve release may be beneficial. It is difficult to determine the timing of exploration, but an observation period of 4 to 6 weeks after injury is acceptable.Bonney found that in high-velocity bullet wounds that injure the entire brachial plexus, severe spastic pain and Horner’s syndrome are signs of a poor prognosis.Kline reported experience in treating 141 brachial plexus nerve injuries from civilian gunshot wounds and found that only 6 of 90 surgical patients had complete nerve dissection; 98 patients with nerve grafts and 53 of 26 patients with direct sutures, and 18 of 26 patients with direct sutures recovered motor function to grade 3 or better. Patients with superior trunk, lateral bundle, and posterior bundle injuries had the best results. The order of brachial plexus injury repair is as follows: (1) restoration of flexion of elbow function; (2) restoration of shoulder abduction function; (3) restoration of forearm and medial hand sensation. Depending on the degree of injury, different surgical methods can be chosen, including one-stage nerve suturing, nerve release, nerve grafting and nerve transposition. Intraoperative stimulation and recording of the injured nerve is required. If the nerve has an action potential, nerve release alone is sufficient. If there is a complete loss of nerve integrity or if no action potential can be recorded via the damaged portion of the nerve, excision and nerve grafting are required. For upper brachial plexus nerve root avulsions without a proximal section receiving a nerve graft, intercostal nerve transposition to the musculocutaneous nerve may be considered to restore elbow flexion. After brachial plexus nerve repair and reconstruction, 12 to 18 months are required to determine the degree of nerve regeneration. If the recovery is considered unsatisfactory, peripheral reconstruction should be considered. Periprosthetic tendon transfers that can be considered include the transposition of the trapezius in place of the deltoid to improve abduction as described by Saha and the transposition of the latissimus dorsi to improve external rotation as described by L’Episcopo. If there is mobility in the scapulothoracic wall joint, shoulder fusion is beneficial to improve elbow flexion by preventing involuntary internal rotation of the shoulder joint. The shoulder joint should be fused in an abducted 20 to 30° position, as most patients rely heavily on the upper arm? trunk to complete the grip. Procedures to restore elbow flexion include latissimus dorsi, pectoralis major, triceps, sternocleidomastoid, and flexor? Marshall et al. reviewed 50 patients who underwent tendon transposition and found that latissimus dorsi and triceps transposition were the most reliable. Even with loss of hand function, restoration of flexion function in the elbow joint is beneficial to the patient. Amputations are rarely performed. If the patient decides that the nonfunctional upper extremity is a liability and useless, then amputation with a prosthesis may be helpful. yeoman and Seddon found that the use of a prosthesis was not ideal unless the injury was no more than 2 years old and the patient preferred to have a prosthesis. Amputation should never be performed for pain relief. (1) Surgical technique Depending on the site of injury, the brachial plexus may be revealed from above or below the clavicle. If a nerve suture is required above or near the clavicle, the clavicle may need to be severed. However, the nerve graft can be performed posteriorly without amputating the clavicle. The approach described here is used to expose the entire brachial plexus, and each section can be used separately to expose a portion of the brachial plexus. We do not recommend it because the transverse incision cannot be extended, which limits exposure. The patient is placed supine with a sandbag on the back. The sterilization sheet covers the cervical and upper thoracic extremities and both lower extremities, the latter should also be sterilized for nerve graft extraction. Starting 5 cm above the clavicle, an incision is made along the posterior border of the sternocleidomastoid muscle, which is then extended along the superior border of the clavicle to the upper part of the deltoid pectoralis major gap. Continue distally along the deltoid pectoralis major muscle gap. After crossing the anterior axillary crease, the “Z” shape turns to the axilla. The cut is made posteriorly in the direction of the dermatome of the axilla to the midpoint of the medial upper arm, and then parallel to the neurovascular bundle distally. Above the clavicle, the subcutaneous tissue and the broad jugular muscle are incised. The external jugular vein is ligated, and the scapulolingual muscle is distracted or severed to expose the deep fascia. The subclavian vein is rarely seen because it is a few centimeters below this area. A transverse dissection of the deep fascia is made to remove the exposed loose connective tissue. The clavicular head of the sternocleidomastoid muscle is retracted or severed to expose the medial anterior oblique muscle. The transverse cervical artery, which crosses the anterior oblique muscle superficial to the phrenic nerve, is usually cut and ligated. The phrenic nerve is passed through this muscle from the outside to the inside and is found and then retracted medially. At this point, all branches of the brachial plexus can be seen, which pass deeper from the lateral border of the anterior oblique muscle to form the superior, middle, and inferior trunks of the brachial plexus. To more fully visualize the branches, the anterior oblique muscle is transected so that the subclavian artery below the point of dissection and the branches of the brachial plexus above the point of dissection can be seen. To see or free the deep surface of the clavicle or the portion of the brachial plexus beneath it, continue to separate deeper at the junction of the external and external 1/3 of the clavicle. The deltoid and pectoralis major gaps are identified according to the cephalic vein, and the fascia is cut distally. The pectoralis major tendon is cut 1 cm proximal to the humeral stop, traction is applied medially, the sternoclavicular fascia is identified and incised longitudinally. The pectoralis minor tendon is then severed, marked with a suture and retracted. After exposing the clavicle from top to bottom, the broken end is separated with a wire saw (or partially excised if needed). Before the clavicle is osteotomized, a plate can be shaped to its contour and used as a template for pre-drilling to facilitate clavicle alignment after nerve reconstruction. The clavicle should be amputated only when absolutely necessary and after the tissue below and above the clavicle has been separated. The subclavian muscle is cut and the cephalic vein is ligated. The deep fascia of the upper arm and the deep fascia surrounding the neurovascular bundle are dissected longitudinally to expose the entire brachial plexus. The relationship between the various parts of the brachial plexus and their relationship to the vasculature is described in detail in standard anatomy books and will not be discussed in detail here. However, some parts require special emphasis. When separating from the proximal to the distal upper arm, the medial cutaneous nerve of the forearm is often found first across the thick axillary vein, which should not be mistaken for the ulnar nerve. The ulnar nerve is nearby and can be seen by freeing and tugging the axillary vein laterally. The axillary artery can be seen by pulling the axillary vein medially. Medial traction on the axillary artery fully exposes the median nerve lateral to the neurovascular bundle, while lateral traction on the axillary artery, axillary vein, and ulnar nerve easily locates the radial nerve, which is located just posterior to the other structures of the neurovascular bundle. Tracing the axillary artery proximally reveals the medial bundle with branches of the lateral bundle forming the median nerve where this artery is located just posterior to it. Proximal to this location, posterior to the pectoralis minor tendon, the axillary artery separates the medial and lateral bundles and lies directly anterior to the posterior bundle. It is good to keep in mind the variation in the point where the musculocutaneous nerve emanates from the lateral bundle: usually on the deep side of the pectoralis minor tendon, but it can also emanate more distally. Sometimes multiple branches emanate from the lateral bundle to form this nerve. The point of emanation of the axillary nerve in the posterior fascicle is usually slightly closer than the point of emanation of the musculocutaneous nerve from the lateral fascicle and then turns posteriorly through the quadrilateral foramen. (2) Methods for closure of nerve defects Extensive defects in the proximal portions of the roots, trunk, and femur of the brachial plexus and its lateral aspect are difficult to close because it can give off numerous branches that limit freeing, and these branches include the suprascapular, anterior thoracic, subscapular, and axillary nerves. Currently, in brachial plexus nerve reconstruction, taking one or both peroneal nerves for interfascicular grafting is the most commonly used method. This allows early movement of the patient due to minimal tension in the repair. If an interfascicular nerve graft is performed, a Velpeau bandage is applied postoperatively to brake the wound. Active pendulum-like movement of the affected limb begins after 4 weeks, and mild abduction begins after 6 weeks. Significant functional recovery may take 3 to 5 years. Physical therapy should be performed during this period to prevent joint and muscle contractures. Vocational rehabilitation is equally important, and it is inconclusive whether electrical stimulation is beneficial for loss of neuromuscularity. (3) Long-term follow-up As with all peripheral nerve injuries, there are many factors that can influence the outcome after a brachial plexus injury. Thus, it is difficult to substantiate multiple assertions regarding the prognosis of different brachial plexus injuries. Some brachial plexus injuries, usually those that are closed, can be expected to have a better outcome with non-surgical treatment. 13 patients with brachial plexus injuries were found by Barnes to have no electromyographic signs of degeneration at 3 weeks, with rapid and complete recovery. 33 patients with upper brachial plexus injuries had spontaneous recovery of significant function in the shoulder, elbow, and wrist muscles in 22 cases. 26 patients with lower brachial plexus injuries had some proximal muscle function in 18 cases. Brooks found satisfactory spontaneous recovery in C5 and C6 nerve root or superior trunk injuries, fair recovery in posterior lateral bundle injuries, and poor recovery in C8 and T1 or medial bundle injuries. In the experience of Leffert and Seddon, the prognosis for subclavian brachial plexus injuries is quite good. They found that such injuries are usually associated with closed fractures or dislocations of the shoulder joint. Almost all 14 patients obtained normal muscle strength of the proximal hand muscles. The intrinsic hand muscles innervated by the median and ulnar nerves partially regained muscle strength and restored useful sensory function. Of the 92 subclavian injuries of the brachial plexus studied later, Seddon found almost normal recovery in 42 cases and partial recovery in 31. Narakas reported 248 patients with less severe injuries or early signs of recovery, with an excellent rate of 98.4%. 17 cases were considered for surgical treatment, but surgery was abandoned because of early recovery, with an excellent rate of 86.7%. Until recently, surgical treatment of brachial plexus injuries remained pessimistic, except in isolated cases. The results of surgical treatment of some similar brachial plexus injuries that occurred in World War II were reported in the 1956 monograph Peripheral Nerve Regeneration by Woodhall and Beebe of the Veterans Administration. Brooks reported the results of surgical exploration in 54 of 170 open brachial plexus injuries treated at the British Center for the Treatment of Peripheral Nerve Injuries in World War II. 11 nerve sutures were performed, but only the upper trunk injury recovered satisfactorily. In the past, nerve grafting for brachial plexus injuries was of little significance. In 1947, Seddon reported three cases of brachial plexus nerve strain with autologous nerve cable grafting and incomplete recovery in one case. 1955, Brooks reported incomplete functional recovery in three of six patients with nerve grafting. 1973 Lusskin et al. reported the results of exploration of 20 cases of traumatic brachial plexus injury, 19 cases had varying degrees of paralysis. In the 2 patients with autologous nerve grafts, there was significant restoration of innervation to the proximal muscles. They recommended autologous nerve grafting if the break was in the distal portion or if the stump was long enough after removal of a nonconducting neuroma. in 1977 Millesi reported that in 54 patients with injuries to different components of the brachial plexus, muscle strength was restored to grade III or higher in 38 (70%) cases using autologous intertrabecular grafts. in 1984 he further reported 134 patients with complete injuries to the brachial plexus using nerve treatment such as nerve release, nerve graft or nerve transposition. Narakas used the same nerve graft technique to treat 164 patients with brachial plexus strains, with an excellent rate of 61%. He concluded that repair of brachial plexus nerve injuries with nerve grafting is expected to restore function in the following locations: (1) bundle injuries in the superior trunk, middle trunk, or inferior and posterior to the clavicle; (2) nerves leaving the beginning of the brachial plexus; (3) rupture of any two roots of C5, C6, and C7 outside the intervertebral foramen without more than one tear, and without C8, T1, and median and ulnar nerve injuries; (4) partial injuries of the upper brachial plexus without root avulsions In 1983, Kline and Judice reported their experience with surgical treatment of 171 cases of brachial plexus injury. only 43 of 89 nerve grafts achieved acceptable results. In 1990, Kanaya et al. reported that in 38 patients with brachial plexus injury who underwent nerve grafting, 44% and 65% of shoulder and elbow muscle strength was restored to grade III or higher, respectively. in 1999, Terzis et al. reported the results of 204 cases of brachial plexus reconstruction. The excellent rate of superior scapular nerve reconstruction was 75%, deltoid reconstruction was 40%, biceps reconstruction was 48%, and triceps reconstruction was 30%. In some cases, especially in sharp cut injuries, nerve suturing may be preferred. Usually C5 and C6 nerve root injuries, superior trunk injuries, and injuries to the lateral bundle in the vicinity of the emitting musculocutaneous nerve may be treated with some degree of success by nerve suturing, while other parts of the brachial plexus are not as effective. functional recovery of the intrinsic hand muscles after repair of C8 and T1 nerve root injuries is rare. This does not mean, however, that other parts of the brachial plexus in children or young people cannot regain useful function after early surgical treatment. kline emphasizes that sharps cuts to the brachial plexus are best repaired in one stage. 14 of 18 patients regained good motor function after one stage repair. 37 patients with delayed repair recovered only 50% and usually required nerve grafting. Some brachial plexus injuries are amenable to nerve release, especially if the nerve component is found to be intact on exploration and has conduction function after electrical stimulation. In patients who undergo nerve release alone, it is difficult to determine whether the recovery of nerve function is due to surgery or to purely spontaneous recovery. The results of this treatment vary widely. lusskin et al. reported 17 cases of significant improvement in 13 cases after nerve release. They concluded that nerve release is beneficial if scarring is present around the brachial plexus; they found rapid recovery in some patients. narakas reported excellent results in 47.6% of 21 patients treated with nerve release and poorer results in 52.4%. Experience with nerve transposition after nerve root avulsion injury is well documented; in 1989 Nagano et al. reported 179 cases of transposition of the intercostal nerve to the musculocutaneous nerve without nerve grafting. In 1988, Narakas and Hentz reported experience with nerve transposition for brachial plexus injuries. 50% of patients recovered elbow flexion, but limited restoration of shoulder function and no useful finger function. This technique is not commonly used, but the results reported in the literature suggest that it is an effective method for treating some nerve root avulsion injuries, especially when only one function needs to be restored. Donor nerves include the phrenic nerve, the paramedian nerve, the intercostal nerve, the deep motor branch of the cervical nerve, the hypoglossal nerve, and the contralateral cervical 7 nerve root. in 1994, Oberlin reported a successful case of transferring an intact segment of the ulnar nerve into the musculocutaneous nerve to reconstruct elbow flexion. mackinnon et al. reported six cases of transferable motor nerve bundles from the median and ulnar nerves into the Mackinnon et al. reported six cases of transferable motor nerve bundles from the median and ulnar nerves into the musculocutaneous nerve, and all six cases achieved satisfactory elbow flexion.