neurotization involves the repair of a distal denervated nerve element using a proximal foreign nerve as the neuron and axon donor to reinnervate the distal target4 ) . direct nerve - to - nerve transfers can provide a closer nerve source to the target muscle , thereby enhancing the quality and rate of recovery7 ) . traumatic brachial plexus palsy is usually caused by traction across long segments of the trunks , divisions , or cords and may be segmental in nature8 ) . brachial plexus palsy remains one of the most challenging traumatic peripheral nerves injuries to treat . treatment options including neurolysis , nerve grafting , or neurotization have become important in restoring function in patients with irreparable preganglionic lesions5 ) . tuttle12 ) published the first report on neurotization in an attempt to restore injured plexus function and narakas6 ) published a review of the historical precedents and the anatomical basis and rationale for nerve transfers in brachial plexus surgery . some of the more common neurotization sources include the spinal accessory nerve , the phrenic nerve , the medial pectoral nerves , and intercostal nerves . in a c5-c6 injury , brandt and mackinnon1 ) used a closer nerve source to restore musculocutaneous function . branches of the medial pectoral nerves were transferred directly to the musculocutaneous nerve , promoting good recovery of function7 ) . we describe a 4-year - old patient with a brachial plexus injury who received neurotization from two medial pectoral nerves to the musculocutaneous nerve . a 4-year - old right - hand - dominant boy sustained a fracture of the left scapula in a car accident . he was treated conservatively . after the accident , he presented with motor weakness of his left upper extremity . motor assessment was based on the motor classification m0-m5 in the mallet and medical research council ( mrc ) muscle grading system . the patient underwent magnetic resonance imaging ( mri ) , which revealed a lateral pseudomeningocele arising from the left c4 - 5 intervertebral foramen ( fig . left musculocutaneous nerve and axillary nerve motor conduction studies revealed low compound motor action potential ( cmap ) amplitudes . on a needle emg , positive sharp waves and fibrillation potentials were noted in the left deltoid , biceps brachii , and brachioradialis muscles . the patient was admitted to rehabilitation medicine and treated . however , marked neurological dysfunction in the left upper extremity was still noted . six months after trauma , under general anesthesia with the patient in the supine position , the brachial plexus was explored through infraclavicular and supraclavicular incisions . for supraclavicular exposure the incision extended from the level of the angle of the mandible and followed the posterior border of the sternocleidomastoid muscle to the clavicle . the brachial plexus was observed between the scalenus anterior and scalenus medius muscle , and the phrenic nerve was found on the anterior surface of the scalenus anterior muscle . dissection proceeded medially by cutting both scalenus muscles to fully expose the plexus and the roots . the incision for the infraclavicular exposure began at the distal third of the clavicle and moved inferiorly into the deltopectoral groove . dissection proceeded along the groove between deltoid muscle and pectoralis major muscle from clavicle to axilla . neurotization from the musculocutaneous nerve to two medial pectoral nerves was performed with nylon 8 - 0 ( fig . , the shoulder was immobilized in adduction and internal rotation and the elbow in flexion . physical therapy and electrostimulation started 2 weeks postoperatively . at a 3-month postoperative visit , evidence of reinnervation of the elbow flexors the incidence and severity of brachial plexus injury have been increasing worldwide mainly due to an escalating number of motorcycle accidents . these injuries are often devastating , and can lead to significant long - term functional disability13 ) . patients with traction brachial plexus lesions are generally observed for spontaneous recovery for several months . those who do not demonstrate clinical or electrical recovery by 3 to 6 months after trauma should undergo operative intervention5 ) . nerve transfer by reinnervating the most functionally important nerves using intact neighboring nerves has become widely accepted since the 1963 study by sedden10 ) . . a critical number of motor axons must regenerate and reinnervate the motor end plate to provide adequate muscle power2 ) . surgical management of patients with severe brachial plexus injuries involves first determining preoperatively whether most or all the nerve roots are truly avulsed3 ) . the second goal is to perform nerve repair , which in severe cases ( i.e. , those with avulsion ) involves appropriate nerve transfers to reanimate the extremity11 ) . intraoperative electrical tests and operative findings are used in concert with the preoperative clinical , electromyography , and imaging findings to determine the extent of the injury and the presence of nerve root avulsion and to guide determination of the most suitable nerve reconstructive procedure4 ) . left brachial plexopathy was confirmed through neurophysiological tests , including ( electromyography and nerve conduction velocity tests ) . in c5 root avulsion injuries , loss of abduction and external rotation at the shoulder and flexion in the elbow are the main functional deficits . the goal in the management of upper ( c5 - 6 ) nerve root paralysis is complete repair . when the upper roots are avulsed from the spinal cord , the only repair option is neurotization using a nerve transfer4 ) . the musculocutaneous nerve , one of the terminal branches of the brachial plexus , arises principally from the fifth and sixth cervical nerves . the pectoralis major muscle has dual input from the medial and lateral pectoral nerves , arising from the medial and lateral cords , respectively4 ) . brandt and mackinnon1 ) directed the medial pectorals to the musculocutaneous nerve , with the additional innovation of turning the lateral antebrachial cutaneous nerve ( the cutaneous derivative of the musculocutaneous nerve ) into the biceps muscle to avoid loss of motor axons in the cutaneous distribution . however , samardzic9 ) noted that medial pectoral nerve transfers were associated with significantly improved outcomes in elbow flexion as compared with intercostal and accessory nerve transfers . the proximity of a normal medial pectoral motor nerve to the musculocutaneous recipient provides a theoretical advantage for early recovery ; the present case demonstrated that after total avulsion injury of the brachial plexus , an upper limb could be restored through neurotization from the musculocutaneous nerve to the medial pectoral nerves . one must isolate the function of the biceps and pectoralis major muscle to allow an object to be held within the arm and thorax without concomitant elbow flexion . postoperative rehabilitation is an essential final step and usually requires 2 to 3 years . to maximize function following neurotization , the rehabilitation program must include motor re - education to initiate recruitment of the weak reinnervated muscles and establish new motor patterns and cortical mapping . neurotization is an effective treatment option for the restoration of elbow and shoulder function in brachial plexus injuries . early intervention and postoperative rehabilitation allow for the recovery of shoulder and elbow function in most patients . we have shown that neurotization from the medial pectoral nerves to musculocutaneous nerve can be used successfully to restore elbow flexion in patients with brachial plexus injuries .
traumatic brachial plexus injuries can be devastating , causing partial to total denervation of the muscles of the upper extremities . surgical reconstruction can restore motor and/or sensory function following nerve injuries . 
 direct nerve - to - nerve transfers can provide a closer nerve source to the target muscle , thereby enhancing the quality and rate of recovery . 
 restoration of elbow flexion is the primary goal for patients with brachial plexus injuries . a 4-year - old right - hand - dominant male sustained a fracture of the left scapula in a car accident . 
 he was treated conservatively . after the accident , he presented with motor weakness of the left upper extremity . 
 shoulder abduction was grade 3 and elbow flexor was grade 0 . 
 hand function was intact . 
 nerve conduction studies and an electromyogram were performed , which revealed left lateral and posterior cord brachial plexopathy with axonotmesis . 
 he was admitted to rehabilitation medicine and treated . however , marked neurological dysfunction in the left upper extremity was still observed . 
 six months after trauma , under general anesthesia with the patient in the supine position , the brachial plexus was explored through infraclavicular and supraclavicular incisions . 
 each terminal branch was confirmed by electrophysiology . 
 avulsion of the c5 roots and absence of usable stump proximally were confirmed intraoperatively . under a microscope , 
 neurotization from the musculocutaneous nerve to two medial pectoral nerves was performed with nylon 8 - 0 . physical treatment and 
 electrostimulation started 2 weeks postoperatively . at a 3-month postoperative visit , evidence of reinnervation of the elbow flexors 
 was observed . at his last follow - up , 2 years following trauma 
 , the patient had recovered medical research council ( mrc ) grade 4 + elbow flexors . 
 we propose that neurotization from medial pectoral nerves to musculocutaneous nerve can be used successfully to restore elbow flexion in patients with brachial plexus injuries .