A common secondary brachial plexus surgery coined the “mod quad” consists of a series of procedures in one surgery aimed to improve shoulder abduction, external rotation, and elbow and hand function. The outpatient operation involves an incision in the armpit, neurolysis (removal of scar tissue surrounding nerves) to improve conduction of damaged nerves, moving the latissimus muscle (and sometimes the teres major muscle) insertion from being an internal rotator to becoming an external rotator, releasing or weakening tight muscles that cause internal rotation, and intraoperative nerve stimulation to check viability and conduction of other nerves. Patients are placed in a splint for two weeks and then aggressive physical therapy is started. Depending on the severity of injury, other procedures can be added, such as nerve grafts, in preparation for future procedures.
As the patient grows, functional deficits become more apparent or problematic. Again, with careful examination and EMG evaluation, the overall rate of progress is accessed in order to decide if surgery is the right option. If surgery is needed, these issues are dealt with by a series of surgeries that in essence follow the Robin Hood principle-take from the rich and give to the poor. Muscles and tendons are rerouted to provide additional strength in areas of weak function. There are a multitude of combinations and variations of tendon transfers that can be performed. In addition, loosened joint capsules are tightened, and tendon length can be adjusted.
As children go through puberty and growth spurts, their function usually decreases as their bodies change, and physical therapy routines must be adjusted. If significant residual deformity still exists, bone and joint positions can be addressed. Although joint fusions and osteotomies are reserved for the severe injuries, these procedures can be of significant benefit in limb positioning and function.