Challenges and opportunities of early brachial plexus reconstruction in polytrauma: Case report and review of the literature

Challenges and opportunities of early brachial plexus reconstruction in polytrauma: Case report and review of the literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Challenges and opportunities of early brachial plexus reconstruction in polytrauma: Case report and review of the literature Martina Giacalone, Fabrizio Fiumedinisi, Richard Glaab, Regula Marti, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7131522/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Assessment and treatment of brachial plexus injury in polytrauma patients is often challenging due to concomitant injuries and the role of immediate exploration remains debated. We present the case of a 21-year-old male with an infraclavicular brachial plexus injury as well as a floating shoulder and axillary artery rupture, successfully treated with early multidisciplinary intervention. Vascular repair, bone stabilization, and nerve reconstruction using grafts and transfers led to significant functional recovery. Early exploration prevents degenerative changes, optimizing nerve regeneration and facilitating early rehabilitation. This case highlights the benefits of early intervention in complex brachial plexus injuries to improve outcomes and quality of life. Brachial plexus brachial plexus injury nerve grafting nerve transfer polytrauma Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Brachial plexus injury (BPI) is a severe condition causing long-term upper limb impairment, commonly affecting young males involved in high-speed motorcycle accidents [ 4 ]. In polytrauma cases, life-saving interventions often delay referral for BPI assessment [ 20 ]. However, early evaluation of BPI by a brachial plexus surgeon is crucial for an effective treatment as timely reconstruction significantly impacts the outcome of these devastating injuries. For closed in-continuity injuries, non-surgical conservative treatment is recommended to wait for spontaneous recovery [ 16 ]. In contrast, high-grade BPI, i.e. severe axonotmesis or neurotmesis, or open BPI should be explored and reconstructed as soon as possible. While the benefits of early exploration remain a subject of debate, delays in surgery are known to progressively diminish reconstructive outcomes due to declining regenerative capacity of motor nerve axons, loss of motor end-plates from denervation, and progressive muscle atrophy [ 7 , 8 , 14 ]. Surgical delay should therefore be avoided when spontaneous recovery appears unlikely. In this report, we present the case of a patient who sustained a polytrauma-related infraclavicular BPI associated with floating shoulder injury and axillary artery rupture. A multi-disciplinary approach included bone stabilization, vascular reconstruction as well as early brachial plexus reconstruction and multiple nerve transfers, resulting in satisfactory functional outcomes. CASE PRESENTATION A 21-year-old male was admitted to the emergency department following a high-velocity motorcycle accident. On admission the patient was conscious with patent airways but severe thoracic and abdominal pain. Absence of right radial pulse and complete absence of right upper limb motion were observed. Ultrasound showed right hemopneumothorax and diffuse abdominal bleeding, requiring chest tube drainage and immediate transfer to the operating room due to hemodynamic instability. Following stabilization, a polytrauma CT scan was performed showing a floating shoulder injury with a right clavicle, scapular neck as well as proximal humerus fracture and multiple rib fractures, associated with right axillary artery rupture ( Fig. 1a ). At day 0, a multi-disciplinary surgery was performed with arm revascularization using a polytetrafluorethylen (PTFE) bypass from the right common carotid to the radial artery. Additionally, forearm fasciotomies and a closed reduction of the humeral fracture with external fixation were done. Further clinical assessment of the right arm was complicated by a prolonged intubation. At postoperative day (POD) 10 only minimal flexion of the index and middle fingers with an otherwise paralyzed extremity could be observed. MRI of the spine and brachial plexus ruled out cervical root avulsions but was inconclusive regarding postganglionic nerve injury due to an extensive retroclavicular hematoma ( Fig. 1b ). Assuming high-grade postganglionic BPI, early exploration in a single-stage approach with vascular and bone repair was planned. At POD 11, the axillary artery was reconstructed using a reversed saphenous vein graft. Brachial plexus exploration confirmed neurotmesis at the infraclavicular level, including 7–8 cm defects of the ulnar and musculocutaneous nerve and distal avulsion of the axillary nerve, not accessible from anteriorly. The median and radial nerve were in continuity. Medial antebrachial cutaneous and sural nerve cable grafts were used to reconstruct the biceps branch of the musculocutaneous nerve and the ulnar nerve, respectively ( Figs. 1c-d ). At POD 16, a triceps to axillary nerve transfer ( Somsak procedure ) [ 18 ] was done to reinnervate the deltoid ( Fig. 2a ). The patient was then sent to rehabilitation for 3 months, including intense occupational therapy with passive mobilization and compression as well as daily electrical stimulation of denervated muscle groups. To prevent intrinsic muscle loss in high ulnar nerve injury, a transfer of the opponens pollicis thenar branch to the deep branch of the ulnar nerve (DBUN) ( Bertelli transfer ) [ 18 ] and a transfer of the anterior interosseous nerve (AIN) to the deep ulnar nerve branch at the forearm were added 5 months after the initial injury ( Figs. 2b-c ). At 6 months follow-up, we observed an increasing restoration of shoulder abduction (MRC 4) and elbow flexion (MRC 4). Slow but progressive improvement of intrinsic hand muscle function was noted with restoration of 55% key pinch strength compared to contralateral healthy side, good restoration of thumb adduction, and weak fingers abduction/adduction movements at 18 months follow-up (Fig. 3 and Online Resource 1 and 2). The patient was able to return to his previous professional and recreational activities. DISCUSSION Postganglionic BPI in polytrauma patients is often characterized by varying degrees of severity and can be complicated by additional vascular injuries and fractures. Hence, time-consuming nerve exploration and reconstruction is guided by associated injuries [ 13 ]. While immediate exploration is indicated for penetrating injuries, the optimal approach to closed injuries remains controversial [ 2 ]. Monitoring for spontaneous recovery has been traditionally recommended, yielding good functional outcomes and avoiding unnecessary procedures in neurapraxia and low-grade axonotmesis [ 14 ]. However, when high-grade axonotmesis or neurotmesis are suspected, early repair is the only valid treatment [ 2 ]. Benefits and limitations of early BPI exploration have been discussed previously but there is no consensus for this complex problem in patients suffering from polytrauma [ 20 ]. We herein present a case of a young man with a severe BPI as part of a polytrauma. Early referral to our unit allowed for a prompt clinical and MRI evaluation, where we suspected a high-grade postganglionic injury. Early diagnosis and assessment of BPI in the context of polytrauma can be difficult due to multiple reasons. First, life-threatening injuries requiring immediate care often lead to delayed referrals. Although evaluation of BPI is desirable as soon as allowed by a patient’s conditions, there is a trend towards delayed referrals of severly injured patients, leading to suboptimal outcomes of BPI reconstruction [ 15 ]. Second, vascular injuries might complicate imaging-based evaluation of the brachial plexus due to fluid extravasation [ 19 ]. In line with this, MR imaging performed in our case allowed to rule out root avulsion but could not depict the intraclavicular plexus due to the presence of a diffuse hematoma. Finally, electrophysiological studies, even though routinely performed in the early posttraumatic period, are not helpful for the planning of early BPI exploration [ 3 ]. In our case, based on the clinical suspicion of a high-grade nerve injury, early interdisciplinary exploration was performed with the goal of one-staged vessel, bone as well as nerve reconstruction. From a technical perspective, early BPI exploration should only be planned by experienced brachial plexus surgeons since it requires demanding intraoperative decision-making, mastering multiple reconstructive strategies. For instance, evaluating in-continuity nerve injuries is challenging at this early stage, as persistent nerve conduction block and the absence of neuroma formation make the identification of higher-grade traction injuries difficult [ 5 , 6 ]. Despite these challenges, early BPI exploration comes along with important advantages. It allows for visualization of the nerve injuries in “fresh” tissues, preventing time-dependent degenerative effects on nerve and muscle tissues, which negatively affect reconstructive outcomes [ 11 ]. Furthermore, early exploration also facilitates nerve stump dissection and assessment in a physiological wound bed free of scars when compared to delayed surgery. From a biological point of view, the injured nerves are less retracted without intraneural fibrosis and do not have to be released from the perineural scar, which is commonly found in delayed exploration. These factors should lead to a more physiological nerve revascularization and reduced gap lengths and, ultimately, to superior motor and sensory outcomes [ 16 ]. In the present case, a sequence of nerve grafts and transfers was used to address the functional loss. While nerve grafting can still be considered the gold standard to reconstruct postganglionic brachial plexus injuries, nerve transfers yield at least non-inferior outcomes, providing several advantages with expansion of the reconstructive armamentarium [ 9 ]. The musculocutaneous and ulnar nerve were reconstructed using nerve grafting, while a Somsak nerve transfer was performed for deltoid reinnervation. Of note, after proximal ulnar nerve cable graft reconstructions, restoration of intrinsic hand function cannot be expected in adults [ 10 ]. Consequently, we addressed this problem with additional distal nerve transfers, i.e. the Bertelli and AIN to deep motor branch of ulnar nerve transfers, which have shown promising outcomes in literature [ 10 ]. One year following reconstruction, the reconstructive strategy resulted in restoration of elbow flexion, shoulder abduction, satisfactory grip, pinch strength, and thumb adduction as well as weak finger abduction and adduction. Finally, early exploration and reconstruction of brachial plexus injuries in polytrauma patients can also enhance the quality of life following these injuries by facilitating effective rehabilitation and promoting faster return to daily activities. Pain often hinders rehabilitation and timely reconstructive surgery might reduce the central exposure to posttraumatic neuropathic pain, possibly leading to lower rates and intensity of pain syndromes. [ 1 , 12 , 17 ]. CONCLUSION This article discussed the challenges and opportunities of early exploration and reconstruction of BPI in a polytrauma case. We are convinced that prompt multidisciplinary evaluation and nerve reconstruction can significantly enhance functional recovery, mitigating degenerative changes and facilitating early rehabilitation. Considered the striking technical and functional advantanges, early surgical exploration and reconstruction should be considered to enhance outcomes and improve patients’ quality of life, particularly when dealing with BPI in polytrauma patients. Integrating proximal nerve grafts and distal nerve transfers allows for individually tailored reconstructions, preventing devastating sequelae such as complete loss of intrinsic hand function. Abbreviations BPI Brachial plexus injury PTFE polytetrafluorethylene POD postoperative day DBUN deep branch of the ulnar nerve AIN anterior interosseous nerve MRC Medical Research Council Declarations COMPLIANCE WITH ETHICAL STANDARDS Funding : No funding was received for this research. Conflict of Interest : All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Ethical approval : This article does not require ethical approval. Consent to publish : Patients signed informed consent regarding publishing their data and photographs. References Birch R (2015) Timing of surgical reconstruction for closed traumatic injury to the supraclavicular brachial plexus. J hand Surg Eur volume 40(6):562–567. https://doi.org/10.1177/1753193414539865 Burge P, Rushworth G, Watson N (1985) Patterns of injury to the terminal branches of the brachial plexus. The place for early exploration. J Bone Joint Surg Br Vol 67(4):630–634. https://doi.org/10.1302/0301-620X.67B4.4030864 Chen YC, Lian Z, Lin YN, Wang XJ, Yao GF (2018) Injury to the axillary artery and brachial plexus caused by a closed floating shoulder injury: A case report. World J Clin cases 6(15):1029–1035. https://doi.org/10.12998/wjcc.v6.i15.1029 Faglioni W, Jr, Siqueira MG, Martins RS, Heise CO, Foroni L (2014) The epidemiology of adult traumatic brachial plexus lesions in a large metropolis. Acta Neurochir 156(5):1025–1028. https://doi.org/10.1007/s00701-013-1948-x Frueh, F. S., Labèr, R., Schiller, A., Guidi, M., Besmens, I. S., Calcagni, M., &Giovanoli, P. (2021). Die intraoperative Faszikel-topografische Elektromyografie in der peripheren Nervenchirurgie – Übersichtsarbeit und Fallbeispiele [The use of intraoperative fascicle-topographic electromyography in peripheral nerve surgery: review of the literature and clinical experience]. Handchirurgie, Mikrochirurgie, plastische Chirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse : Organ der V… , 53 (6), 526–533. https://doi.org/10.1055/a-1492-2802 Frueh FS, Ho M, Schiller A, Ducommun P, Manoliu A, Andreisek G, Calcagni M, Giovanoli P (2017) Magnetic Resonance Neurographic and Clinical Long-Term Results After Oberlin's Transfer for Adult Brachial Plexus Injuries. Ann Plast Surg 78(1):67–72. https://doi.org/10.1097/SAP.0000000000000924 Fu SY, Gordon T (1995) Contributing factors to poor functional recovery after delayed nerve repair: prolonged axotomy. 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J Plast Reconstr aesthetic surgery: JPRAS 75(2):703–710. https://doi.org/10.1016/j.bjps.2021.09.072 Jivan S, Kumar N, Wiberg M, Kay S (2009) The influence of pre-surgical delay on functional outcome after reconstruction of brachial plexus injuries. J Plast Reconstr aesthetic surgery: JPRAS 62(4):472–479. https://doi.org/10.1016/j.bjps.2007.11.027 Kato N, Htut M, Taggart M, Carlstedt T, Birch R (2006) The effects of operative delay on the relief of neuropathic pain after injury to the brachial plexus: a review of 148 cases. J Bone Joint Surg Br Vol 88(6):756–759. https://doi.org/10.1302/0301-620X.88B6.16995 Lam WL, Fufa D, Chang NJ, Chuang DC (2015) Management of infraclavicular (Chuang Level IV) brachial plexus injuries: A single surgeon experience with 75 cases. J hand Surg Eur volume 40(6):573–582. https://doi.org/10.1177/1753193414553753 Martin E, Senders JT, DiRisio AC, Smith TR, Broekman MLD (2018) Timing of surgery in traumatic brachial plexus injury: a systematic review. J Neurosurg 130(4):1333–1345. https://doi.org/10.3171/2018.1.JNS172068 Morris BE, Teven CM, Noland SS (2022) Early Referral in Brachial Plexus Injury: An Ethical Obligation. Plast Reconstr Surg Glob Open 10(5):e4294. https://doi.org/10.1097/GOX.0000000000004294 Pondaag W, van Driest FY, Groen JL, Malessy MJA (2019) Early nerve repair in traumatic brachial plexus injuries in adults: treatment algorithm and first experiences. J Neurosurg 130(1):172–178. https://doi.org/10.3171/2017.7.JNS17365 Rasulić L, Savić A, Živković B, Vitošević F, Mićović M, Baščarević V, Puzović V, Novaković N, Lepić M, Samardžić M, Mandić-Rajčević S (2017) Outcome after brachial plexus injury surgery and impact on quality of life. Acta Neurochir 159(7):1257–1264. https://doi.org/10.1007/s00701-017-3205-1 Rinker B (2015) Nerve Transfers in the Upper Extremity: A Practical User's Guide. Ann Plast Surg 74(Suppl 4):S222–S228. https://doi.org/10.1097/SAP.0000000000000373 Szaro P, Geijer M, Ciszek B, McGrath A (2022) Magnetic resonance imaging of the brachial plexus. Part 2: Traumatic injuries. Eur J Radiol open 9:100397. https://doi.org/10.1016/j.ejro.2022.100397 Zhang D, Dyer GSM, Garg R (2021) Delayed Referral for Adult Traumatic Brachial Plexus Injuries. J Hand Surg 46(10):929e1–929e7. https://doi.org/10.1016/j.jhsa.2021.01.026 Additional Declarations No competing interests reported. Supplementary Files Onlineresource1.mp4 Online Resource 1 Postoperative follow-up evaluation at 18 months from brachial plexus reconstruction. Onlineresource2.mp4 Online Resource 2 Postoperative follow-up 12 months after transfer of the opponens pollicis thenar branch to the terminal division of the deep branch of the ulnar nerve and anterior interosseous nerve to the deep ulnar nerve branch. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7131522","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":492545948,"identity":"b1402c9b-52ad-4e25-b613-f34260380fda","order_by":0,"name":"Martina Giacalone","email":"","orcid":"","institution":"Kantonsspital Aarau","correspondingAuthor":false,"prefix":"","firstName":"Martina","middleName":"","lastName":"Giacalone","suffix":""},{"id":492545949,"identity":"e9aea6c8-a6b1-474e-b9a3-cf98b6833afc","order_by":1,"name":"Fabrizio Fiumedinisi","email":"","orcid":"","institution":"Kantonsspital Aarau","correspondingAuthor":false,"prefix":"","firstName":"Fabrizio","middleName":"","lastName":"Fiumedinisi","suffix":""},{"id":492545950,"identity":"6aa4305e-2270-46dc-8d38-f532285a0d3c","order_by":2,"name":"Richard Glaab","email":"","orcid":"","institution":"Kantonsspital Aarau","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Glaab","suffix":""},{"id":492545953,"identity":"a4f1a3c3-65da-416b-ba41-9b7ffbb37357","order_by":3,"name":"Regula Marti","email":"","orcid":"","institution":"Kantonsspital Aarau","correspondingAuthor":false,"prefix":"","firstName":"Regula","middleName":"","lastName":"Marti","suffix":""},{"id":492545954,"identity":"58141e49-4a08-4890-90cf-06c2d1492c49","order_by":4,"name":"Jan A. 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In polytrauma cases, life-saving interventions often delay referral for BPI assessment [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, early evaluation of BPI by a brachial plexus surgeon is crucial for an effective treatment as timely reconstruction significantly impacts the outcome of these devastating injuries. For closed in-continuity injuries, non-surgical conservative treatment is recommended to wait for spontaneous recovery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In contrast, high-grade BPI, i.e. severe axonotmesis or neurotmesis, or open BPI should be explored and reconstructed as soon as possible. While the benefits of early exploration remain a subject of debate, delays in surgery are known to progressively diminish reconstructive outcomes due to declining regenerative capacity of motor nerve axons, loss of motor end-plates from denervation, and progressive muscle atrophy [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Surgical delay should therefore be avoided when spontaneous recovery appears unlikely.\u003c/p\u003e\u003cp\u003eIn this report, we present the case of a patient who sustained a polytrauma-related infraclavicular BPI associated with floating shoulder injury and axillary artery rupture. A multi-disciplinary approach included bone stabilization, vascular reconstruction as well as early brachial plexus reconstruction and multiple nerve transfers, resulting in satisfactory functional outcomes.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 21-year-old male was admitted to the emergency department following a high-velocity motorcycle accident. On admission the patient was conscious with patent airways but severe thoracic and abdominal pain. Absence of right radial pulse and complete absence of right upper limb motion were observed. Ultrasound showed right hemopneumothorax and diffuse abdominal bleeding, requiring chest tube drainage and immediate transfer to the operating room due to hemodynamic instability. Following stabilization, a polytrauma CT scan was performed showing a floating shoulder injury with a right clavicle, scapular neck as well as proximal humerus fracture and multiple rib fractures, associated with right axillary artery rupture (\u003cb\u003eFig.\u0026nbsp;1a\u003c/b\u003e). At day 0, a multi-disciplinary surgery was performed with arm revascularization using a polytetrafluorethylen (PTFE) bypass from the right common carotid to the radial artery. Additionally, forearm fasciotomies and a closed reduction of the humeral fracture with external fixation were done. Further clinical assessment of the right arm was complicated by a prolonged intubation. At postoperative day (POD) 10 only minimal flexion of the index and middle fingers with an otherwise paralyzed extremity could be observed. MRI of the spine and brachial plexus ruled out cervical root avulsions but was inconclusive regarding postganglionic nerve injury due to an extensive retroclavicular hematoma (\u003cb\u003eFig.\u0026nbsp;1b\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eAssuming high-grade postganglionic BPI, early exploration in a single-stage approach with vascular and bone repair was planned. At POD 11, the axillary artery was reconstructed using a reversed saphenous vein graft. Brachial plexus exploration confirmed neurotmesis at the infraclavicular level, including 7–8 cm defects of the ulnar and musculocutaneous nerve and distal avulsion of the axillary nerve, not accessible from anteriorly. The median and radial nerve were in continuity. Medial antebrachial cutaneous and sural nerve cable grafts were used to reconstruct the biceps branch of the musculocutaneous nerve and the ulnar nerve, respectively (\u003cb\u003eFigs.\u0026nbsp;1c-d\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eAt POD 16, a triceps to axillary nerve transfer (\u003cem\u003eSomsak procedure\u003c/em\u003e) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] was done to reinnervate the deltoid (\u003cb\u003eFig.\u0026nbsp;2a\u003c/b\u003e). The patient was then sent to rehabilitation for 3 months, including intense occupational therapy with passive mobilization and compression as well as daily electrical stimulation of denervated muscle groups. To prevent intrinsic muscle loss in high ulnar nerve injury, a transfer of the opponens pollicis thenar branch to the deep branch of the ulnar nerve (DBUN) (\u003cem\u003eBertelli transfer\u003c/em\u003e) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and a transfer of the anterior interosseous nerve (AIN) to the deep ulnar nerve branch at the forearm were added 5 months after the initial injury (\u003cb\u003eFigs.\u0026nbsp;2b-c\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eAt 6 months follow-up, we observed an increasing restoration of shoulder abduction (MRC 4) and elbow flexion (MRC 4). Slow but progressive improvement of intrinsic hand muscle function was noted with restoration of 55% key pinch strength compared to contralateral healthy side, good restoration of thumb adduction, and weak fingers abduction/adduction movements at 18 months follow-up (Fig. 3 and Online Resource 1 and 2). The patient was able to return to his previous professional and recreational activities.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003ePostganglionic BPI in polytrauma patients is often characterized by varying degrees of severity and can be complicated by additional vascular injuries and fractures. Hence, time-consuming nerve exploration and reconstruction is guided by associated injuries [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. While immediate exploration is indicated for penetrating injuries, the optimal approach to closed injuries remains controversial [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Monitoring for spontaneous recovery has been traditionally recommended, yielding good functional outcomes and avoiding unnecessary procedures in neurapraxia and low-grade axonotmesis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, when high-grade axonotmesis or neurotmesis are suspected, early repair is the only valid treatment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Benefits and limitations of early BPI exploration have been discussed previously but there is no consensus for this complex problem in patients suffering from polytrauma [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe herein present a case of a young man with a severe BPI as part of a polytrauma. Early referral to our unit allowed for a prompt clinical and MRI evaluation, where we suspected a high-grade postganglionic injury. Early diagnosis and assessment of BPI in the context of polytrauma can be difficult due to multiple reasons. First, life-threatening injuries requiring immediate care often lead to delayed referrals. Although evaluation of BPI is desirable as soon as allowed by a patient\u0026rsquo;s conditions, there is a trend towards delayed referrals of severly injured patients, leading to suboptimal outcomes of BPI reconstruction [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Second, vascular injuries might complicate imaging-based evaluation of the brachial plexus due to fluid extravasation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In line with this, MR imaging performed in our case allowed to rule out root avulsion but could not depict the intraclavicular plexus due to the presence of a diffuse hematoma. Finally, electrophysiological studies, even though routinely performed in the early posttraumatic period, are not helpful for the planning of early BPI exploration [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In our case, based on the clinical suspicion of a high-grade nerve injury, early interdisciplinary exploration was performed with the goal of one-staged vessel, bone as well as nerve reconstruction.\u003c/p\u003e\u003cp\u003eFrom a technical perspective, early BPI exploration should only be planned by experienced brachial plexus surgeons since it requires demanding intraoperative decision-making, mastering multiple reconstructive strategies. For instance, evaluating in-continuity nerve injuries is challenging at this early stage, as persistent nerve conduction block and the absence of neuroma formation make the identification of higher-grade traction injuries difficult [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite these challenges, early BPI exploration comes along with important advantages. It allows for visualization of the nerve injuries in \u0026ldquo;fresh\u0026rdquo; tissues, preventing time-dependent degenerative effects on nerve and muscle tissues, which negatively affect reconstructive outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, early exploration also facilitates nerve stump dissection and assessment in a physiological wound bed free of scars when compared to delayed surgery. From a biological point of view, the injured nerves are less retracted without intraneural fibrosis and do not have to be released from the perineural scar, which is commonly found in delayed exploration. These factors should lead to a more physiological nerve revascularization and reduced gap lengths and, ultimately, to superior motor and sensory outcomes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the present case, a sequence of nerve grafts and transfers was used to address the functional loss. While nerve grafting can still be considered the gold standard to reconstruct postganglionic brachial plexus injuries, nerve transfers yield at least non-inferior outcomes, providing several advantages with expansion of the reconstructive armamentarium [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The musculocutaneous and ulnar nerve were reconstructed using nerve grafting, while a Somsak nerve transfer was performed for deltoid reinnervation. Of note, after proximal ulnar nerve cable graft reconstructions, restoration of intrinsic hand function cannot be expected in adults [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Consequently, we addressed this problem with additional distal nerve transfers, i.e. the Bertelli and AIN to deep motor branch of ulnar nerve transfers, which have shown promising outcomes in literature [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. One year following reconstruction, the reconstructive strategy resulted in restoration of elbow flexion, shoulder abduction, satisfactory grip, pinch strength, and thumb adduction as well as weak finger abduction and adduction.\u003c/p\u003e\u003cp\u003eFinally, early exploration and reconstruction of brachial plexus injuries in polytrauma patients can also enhance the quality of life following these injuries by facilitating effective rehabilitation and promoting faster return to daily activities. Pain often hinders rehabilitation and timely reconstructive surgery might reduce the central exposure to posttraumatic neuropathic pain, possibly leading to lower rates and intensity of pain syndromes. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis article discussed the challenges and opportunities of early exploration and reconstruction of BPI in a polytrauma case. We are convinced that prompt multidisciplinary evaluation and nerve reconstruction can significantly enhance functional recovery, mitigating degenerative changes and facilitating early rehabilitation. Considered the striking technical and functional advantanges, early surgical exploration and reconstruction should be considered to enhance outcomes and improve patients\u0026rsquo; quality of life, particularly when dealing with BPI in polytrauma patients. Integrating proximal nerve grafts and distal nerve transfers allows for individually tailored reconstructions, preventing devastating sequelae such as complete loss of intrinsic hand function.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBPI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBrachial plexus injury\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePTFE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epolytetrafluorethylene\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePOD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epostoperative day\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDBUN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edeep branch of the ulnar nerve\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAIN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eanterior interosseous nerve\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedical Research Council\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCOMPLIANCE WITH ETHICAL STANDARDS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No funding was received for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e: All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers\u0026rsquo; bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e: This article does not require ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e:\u0026nbsp;Patients signed informed consent regarding publishing their data and photographs.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBirch R (2015) Timing of surgical reconstruction for closed traumatic injury to the supraclavicular brachial plexus. 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J Hand Surg 46(10):929e1\u0026ndash;929e7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jhsa.2021.01.026\u003c/span\u003e\u003cspan address=\"10.1016/j.jhsa.2021.01.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Brachial plexus, brachial plexus injury, nerve grafting, nerve transfer, polytrauma","lastPublishedDoi":"10.21203/rs.3.rs-7131522/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7131522/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAssessment and treatment of brachial plexus injury in polytrauma patients is often challenging due to concomitant injuries and the role of immediate exploration remains debated. We present the case of a 21-year-old male with an infraclavicular brachial plexus injury as well as a floating shoulder and axillary artery rupture, successfully treated with early multidisciplinary intervention. Vascular repair, bone stabilization, and nerve reconstruction using grafts and transfers led to significant functional recovery. Early exploration prevents degenerative changes, optimizing nerve regeneration and facilitating early rehabilitation. This case highlights the benefits of early intervention in complex brachial plexus injuries to improve outcomes and quality of life.\u003c/p\u003e","manuscriptTitle":"Challenges and opportunities of early brachial plexus reconstruction in polytrauma: Case report and review of the literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 10:24:08","doi":"10.21203/rs.3.rs-7131522/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"56265409-ab56-4023-846c-e208345fca01","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-14T20:08:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-31 10:24:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7131522","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7131522","identity":"rs-7131522","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}