SCIENTIFIC ARTICLE

Factors Affecting Outcome of Triceps Motor Branch

Transfer for Isolated Axillary Nerve Injury
Joo-Yup Lee, MD, PhD, Michelle F. Kircher, Robert J. Spinner, MD, Allen T. Bishop, MD,
Alexander Y. Shin, MD

Purpose Triceps motor branch transfer has been used in upper brachial plexus injury and is
potentially effective for isolated axillary nerve injury in lieu of sural nerve grafting. We evaluated
the functional outcome of this procedure and determined factors that influenced the outcome.
Methods A retrospective chart review was performed of 21 patients (mean age, 38 y; range,
16 79 y) who underwent triceps motor branch transfer for the treatment of isolated axillary
nerve injury. Deltoid muscle strength was evaluated using the modified British Medical
Research Council grading at the last follow-up (mean, 21 mo; range, 12 41 mo). The
following variables were analyzed to determine whether they affected the outcome of the
nerve transfer: the age and sex of the patient, delay from injury to surgery, body mass index
(BMI), severity of trauma, and presence of rotator cuff lesions. The Spearman correlation
coefficient and multiple linear regression were performed for statistical analysis.
Results The average Medical Research Council grade of deltoid muscle strength was 3.5 1.1.
Deltoid muscle strength correlated with the age of the patient, delay from injury to surgery, and
BMI of the patient. Five patients failed to achieve more than M3 grade. Among them, 4 patients
were older than 50 years and 1 was treated 14 months after injury. In the multiple linear
regression model, the delay from injury to surgery, age of the patient, and BMI of the patient were
the important factors, in that order, that affected the outcome of this procedure.
Conclusions Isolated axillary nerve injury can be treated successfully with triceps motor
branch transfer. However, outstanding outcomes are not universal, with one fourth failing to
achieve M3 strength. The outcome of this procedure is affected by the delay from injury to
surgery and the age and BMI of the patient. (J Hand Surg 2012;37A:23502356. Copyright
2012 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV.
Key words Axillary nerve injury, factors affecting outcome, nerve transfer.

SOLATED AXILLARY NERVE injuries can occur after

From the Department of Orthopedic Surgery, St. Vincents Hospital, the Catholic University
of Korea, Seoul, Korea; the Brachial Plexus Clinic, and the Departments of Neurosurgery
and Orthopedic Surgery, Mayo Clinic, Rochester, MN.
Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic, Roch-
ester, MN.
Received for publication April 2, 2012; accepted in revised form July 27, 2012.
No benefits in any form have been received or will be received related directly or indirectly to
the subject of this article.
Corresponding author: Alexander Y. Shin, MD, Department of Orthopedic Surgery, Mayo Clinic,
200 First Street SW, Rochester, MN 55905; e-mail: shin.alexander@mayo.edu.
0363-5023/12/37A11-0022$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2012.07.030
I shoulder trauma or an iatrogenic event during
shoulder surgery13 resulting in severe dysfunction
of the shoulder. Although many of these injuries spon-
taneously recover within 3 to 4 months, some patients
will have persistent paralysis of the deltoid muscle that
requires surgical intervention.2,4
With advances in microsurgery, nerve grafting has
become the standard for repairing axillary nerve le-
sions.5 8 Satisfactory results have been reported in most
series, with useful strength of deltoid muscle obtained
in 73% to 88% of patients.5,79 It is well known that the
length of the nerve graft has a direct influence on

2350 ASSH Published by Elsevier, Inc. All rights reserved.

 NERVE TRANSFER FOR AXILLARY NERVE INJURY
muscle recovery.10 Terzis et al11 reported that patients
with nerve grafts less than 6 cm in length regained
better shoulder abduction than patients with grafts lon-
ger than 7 cm after axillary nerve grafting. Because
many injuries of the axillary nerve occur near the quad-
rilateral space,12,13 nerve grafts at least 8 cm long are
frequently needed to bridge the gap, which may result
in less-than-optimal outcomes.
Triceps motor branch transfer to deltoid muscle, de-
scribed by Leechavengvongs et al,14 has been a widely
accepted treatment of deltoid paralysis in lesions of the
upper trunk.15,16 Compared with interposition nerve graft-
ing, the donor nerve is much closer to the target muscle,
which may result in better nerve recovery.17 Transfer of a
triceps motor branch to the anterior division of the axillary
nerve also can avoid wasteful regeneration of axons into
the functionally unrelated fascicles to the teres minor and
the superior lateral cutaneous nerve.14 Triceps motor
branch activity is synergistic to shoulder abduction and
external rotation, and this facilitates the postoperative re-
education of the deltoid.18 These advantages can poten-
tially be translated into the treatment of isolated axillary
nerve injury. Promising results were reported in a limited
case series.18
The purpose of this study was to present the func-
tional results of triceps motor branch transfer for iso-
lated axillary nerve injury in lieu of interposition nerve
grafting.
MATERIALS AND METHODS
After being approved by our institutional review board, a
retrospective chart review of all patients treated with tri-
ceps motor branch transfer for treatment of isolated axil-
lary nerve injuries between 2004 and 2009 was under-
taken. Inclusion criteria were the patients with isolated
axillary nerve injuries treated with triceps motor branch
transfer, age 16 years or older, and minimum follow-up of
12 months. Patients with upper brachial plexus injuries
who recovered spontaneously except for the axillary nerve
were included in this study. Recovery of the nerves was
determined by careful clinical examination and electro-
myography. We distinguished axillary nerve palsy and
suprascapular nerve palsy by using the active shoulder
extension test and the abduction in internal rotation test.19
Patients were excluded if the lesion was not caused by
trauma or if there were multiple nerve injuries in addition
to the axillary nerve that needed reconstruction. A total of
24 patients were eligible for study inclusion on initial data
trawl from the electronic patient database. Among them, 3
patients were lost to follow-up and were excluded from the
study. This left a final cohort of 21 patients, 19 (90%) of
whom were men. The average age of patients was 38 years
JHS Vol A, November
2351
(range, 1679 y). The mean follow-up was 21 months
(range, 1241 mo).
Indications for nerve surgery included injuries that
failed to show clinical or EMG evidence of deltoid
motor recovery more than 3 months after injury. Be-
cause early evidence of spontaneous recovery can take
longer in the deltoid than in some other muscles, such
as the biceps or triceps, patients were typically observed
for 4 to 6 months.6 After surgery, patients were fol-
lowed up at 3-month intervals. Serial clinical examina-
tions for deltoid muscle contraction were evaluated at
each of the visits. Deltoid strength was evaluated using
Medical Research Council (MRC) grading system. A
measurement of M4 or higher on the MRC scale was
graded as optimal, M3 as useful, and M2 or less as a
failure. The success of the procedure was defined by
achieving M3 or greater recovery of deltoid strength.
We did not include shoulder range of motion as an
outcome measure for 2 reasons: first, a normal range of
shoulder movement is possible with a completely par-
alyzed deltoid and, second, other lesions such as stiff-
ness of the glenohumeral joint may limit movement in
the presence of strong contraction of the deltoid.5 Time
to clinical recovery was determined by the first appre-
ciable contraction of the deltoid on physical examina-
tion.
Surgical procedure
The procedure was done according to the report by
Leechavengvongs et al.14 A longitudinal incision was
made on the posterior aspect of the arm from the acro-
mion to the mid-arm region. The deltoid was retracted
laterally. The axillary nerve was identified in the quad-
rilateral space. It was useful to identify and trace the
axillary sensory branch back toward the quadrilateral
space to help identify the main nerve. Typically, the
axillary nerve was dissected as far anterior as possible.
During this dissection, the injury to the axillary nerve
was often encountered. The axillary nerve was divided
as far anteriorly as possible and delivered posteriorly
out of the wound. The anterior division of the axillary
nerve was carefully divided from the posterior division
and selectively targeted. We left the posterior division
in continuity, which gives off a branch to the teres
minor, a shoulder adductor. This was the opposite func-
tion that we wanted to achieve. Next, the interval be-
tween the long and the lateral heads of the triceps was
exposed to identify the radial nerve and its branches to
the triceps. We typically selected the triceps long head
motor branch and confirmed its identity and function-
ality with a hand-held nerve stimulator. The chosen
triceps branch was mobilized distally and divided. If
2352 NERVE TRANSFER FOR AXILLARY NERVE INJURY
FIGURE 1: Schematic drawings of the triceps motor branch transfer to the axillary nerve. A The long head triceps motor branch.
B The anterior division of the axillary nerve.
needed, release of the teres major fascia was performed
to increase mobilization of the donor triceps branch.
Sufficient length of the triceps branch to reach the
anterior division of the axillary nerve was determined
before distally transecting this branch. Direct repair was
then accomplished without tension under an operating
microscope using 9-0 nylon sutures (Fig. 1). A tension-
free repair was obtained in all patients as verified by full
passive range of motion of the shoulder intraopera-
tively. All patients were immobilized for 3 weeks to
allow for soft tissue healing and maturation of the nerve
coaptation.
Statistical analysis
We analyzed the following variables to determine
whether they affected deltoid strength: the age and sex
of the patient, delay from injury to surgery, body mass
index (BMI) of the patient, severity of trauma, and the
presence of rotator cuff lesions. The Mann-Whitney U
test was used to compare deltoid strength between
groups, and the Spearman correlation coefficient ()
was used for correlation analysis. Multiple linear re-
gression analysis was also performed with correlated
factors. Significance was set at an alpha less than or
equal to 0.05.
JHS Vol A, November
RESULTS
Demographic data of the patients and final outcome are
listed in Table 1. Motorcycle or motor vehicle accidents
were the most common cause of isolated axillary nerve
injuries (15/21). Injuries from a fall or an athletic ac-
tivity were the second most common (5/21). One injury
occurred during surgery for proximal humerus fracture.
The most common associated lesion was glenohumeral
joint fracture-dislocations irrespective of velocity of
trauma (13/21). All fractures were treated prior to the
nerve transfers. All rotator cuff tears (6/21) occurred in
patients older than 40 years (range, 4272 y). Two
patients underwent rotator cuff repair concurrently.
Others received rotator cuff repair prior to the proce-
dure. Other associated lesions were brain injuries (3/21)
and clavicle fractures (2/21); all of these lesions oc-
curred after high-velocity trauma. There were no con-
comitant vascular injuries.
The average MRC grade of deltoid muscle strength
was 3.5 1.1. Sixteen of 21 patients obtained M3 or
greater recovery of deltoid muscle strength. Of the 16
patients, 6 patients regained M4, 6 regained M4, and
4 regained M3 deltoid strength. Although some muscle
bulk was recovered, asymmetry persisted in most of the
 NERVE TRANSFER FOR AXILLARY NERVE INJURY 2353

TABLE 1. Demographic Data and the Final Outcome of the Patients

Delay From First
Injury to Clinical Last
Age/ Injury Associated Surgery Recovery Follow-Up MRC Shoulder
Number Sex Type Lesions (mo) (mo) (mo) BMI Grade Abduction

1 46/M Motorcycle GH fracture-dislocation 4 6 37 24.9 4.5 110

2 39/M Motor vehicle Head injury, 4 7 24 27.4 4.5 120
acromioclavicular injury
3 39/M Motorcycle GH fracture-dislocation, 7 5 14 23.6 4 160
clavicle fracture
4 42/M Motorcycle GH dislocation, RC tear 8 6 33 22.8 4.5 90
5 46/F Motor vehicle Acromial-coracoid fracture, 10 8 17 24.2 3 160
RC tear
6 22/M Sport injury GH dislocation 12 6 13 21.4 4 170
7 19/M Pedestrian Distal radius fracture 6 7 12 21.1 4 160
8 65/M Fall GH dislocation, RC tear 8 8 15 43.1 2 40
9 21/M Sport injury GH dislocation 14 7 35 22.4 2 120
10 32/M Motor vehicle None 6 5 23 30 4 150
11 16/M Motorcycle GH fracture-dislocation 7 6 41 24.5 4.5 170
12 42/F Motorcycle GH fracture-dislocation 6 6 22 43.1 3 70
13 21/M Motorcycle GH dislocation 7 7 13 21 4 160
14 19/M Motorcycle Brain injury 5 6 13 24.2 4.5 170
15 24/M Motorcycle Brain injury 9 6 24 29.1 3 130
16 38/M Snowmobile GH dislocation 7 6 21 27.7 4 140
17 72/M Fall GH fracture dislocation, RC 6 7 22 31.9 2 20
tear
18 56/M Fall GH dislocation and RC tear 9 11 19 29.5 2 40
19 79/M Iatrogenic Proximal humerus fracture 9 10 19 28.1 2 50
20 47/M Motor vehicle GH dislocation and RC tear 7 5 16 31.3 3 100
21 16/M Motorcycle None 8 6 12 19.3 4.5 170

BMI, body mass index; GH, glenohumeral; MRC, Medical Research Council; RC, rotator cuff.

patients. No patient had M5 results. Five patients failed
to achieve useful recovery. Clinical motor recovery was
apparent on average 6.7 months after surgery (range,
511 mo). No patient had clinically detectable triceps
muscle weakness in manual muscle strength testing.
Deltoid strength negatively correlated with delay
from injury to surgery (Spearman .533, P
.013) (Fig. 2). There tended to be an advantage in
obtaining increased deltoid strength in patients who
underwent early nerve transfer. Although we attempted
to operate within 6 months of injury, some patients
were referred long after injury, and thus, the preopera-
tive interval varied between 4 and 14 months with a
mean of 8 months. The success rate was 86% (6/7) and
the average MRC grade of deltoid muscle strength was
3.8 1.0 when the patients were treated within 6
months after injury. These results were not significantly
better than those with more than 6 months delay (10/
14, 3.3 1.0, P .28). However, the average deltoid
strength was decreased dramatically if the treatment
was delayed for 9 months or more (3/6, 2.7 0.8, P
.02). The 1 patient whose treatment occurred 12 months
after injury did not regain useful recovery of deltoid
strength.
Deltoid strength correlated with the age of the patient
(Spearman .585, P .005) (Fig. 3). There was
a significant downward trend in the proportion of grade
M3 or more results with increasing age. The success
rate in patients 39 years or younger was 92% (11/12),
and the average MRC grade of deltoid strength was
3.9 0.7, which was significantly better than those in
patients between 40 and 49 years (5/9, 2.9 1.0, P
.04). No patients older than 50 years of age regained
useful recovery of deltoid strength.

JHS Vol A, November

2354 NERVE TRANSFER FOR AXILLARY NERVE INJURY
FIGURE 2: The relationship between deltoid strength and
delay from injury to surgery (linear regression; .533,
P .013).
FIGURE 3: The relationship between deltoid strength and age
of the patient (linear regression; .585, P .005).
Deltoid strength also correlated with BMI of the
patient (Spearman .511, P .018) (Fig. 4).
Severity of trauma, sex of the patient, and presence of
rotator cuff lesions were not correlated with deltoid
muscle strength (P .072, P .400, P .193).
DISCUSSION
Shoulder weakness secondary to axillary nerve injury
can be devastating. Traditionally, isolated lesions of the
axillary nerve with no evidence of recovery have been
treated with neurolysis and/or interposition nerve graft-
ing. Although useful recoveries of deltoid strength have
been reported,5,79 there are several factors that inter-
fere with optimal outcome. Lengthy grafts are fre-
quently needed to bridge the gap owing to the anatomic
location of the injury. Scarring at the zone of injury is
JHS Vol A, November
FIGURE 4: The relationship between deltoid strength and body
mass index (BMI) of the patient (linear regression;
.511, P .018).
usually profound if fractures and/or dislocations of the
glenohumeral joint are combined.20 22 Nerve transfers
are advantageous in that they bypass the zone of injury,
obviate the need for an interposition nerve graft, and
theoretically decrease the time to regeneration because
the repair is close to the motor end plate.
This study demonstrated that the isolated axillary
nerve injury can be treated successfully with triceps
motor branch transfer. This procedure has been widely
used in upper brachial plexus injury15,16 and, as shown,
is effective for the treatment of isolated axillary nerve
injury. There is a paucity of literature on the manage-
ment of isolated axillary nerve lesions with triceps
motor branch transfer. Bertelli et al18 presented clinical
results of triceps motor branch transfer through an ax-
illary approach. They treated 3 men with a mean age of
23 years (range, 19 27). Time between the injury and
the surgery was 8 months, 9 months, and 10 months in
the 3 patients. Eighteen months after surgery, all pa-
tients had M4 deltoid strength and no triceps weakness.
In the present study, the delay from injury to surgery
was the most important factor affecting the final deltoid
strength. There is a consensus that late surgery results in
worse clinical outcome after interposition nerve graft-
ing. Bonnard et al5 demonstrated that a delay of 6
months resulted in a decrease in the number of success-
ful outcomes. Terzis et al11 reported that patients with a
denervation time of less than 4 months had improved
shoulder function after nerve grafting. One of the main
factors responsible for the poor results produced by late
repair is the progressive degeneration of the motor end
plate.23 Because the donor nerve is much closer to the
target muscle, better motor recovery can be expected
after delayed repair with a nerve transfer procedure.
 NERVE TRANSFER FOR AXILLARY NERVE INJURY
Excellent results were reported after average delay of 9
months in the Bertelli et al series.18 In our study, we
found that the average deltoid strength was decreased
dramatically if the treatment was delayed for more than
9 months. No patient whose treatment was delayed 12
months after injury regained useful recovery of deltoid
muscle strength. The advantage of faster nerve reinner-
vation after nerve transfer on the outcome of delayed
repair might be minimal, if any.
It has been well known that the patients age is one
of the contributing factors on the outcome of nerve
grafting procedure. Wehbe et al24 stated that the out-
come seemed to be better in patients younger than 25
years compared with older patients. Bonnard et al5
demonstrated that there was a downward trend in the
proportion of grade M4 or M5 results with increasing
age. We also found the deltoid strength correlated with
the age of the patient. The success rate in patients 39
years or younger was 92%, which was significantly
better than those in patients 40 years and older. The
average MRC grade of deltoid strength of our study was
3.5 1.1, which is generally worse than that of the
Bertelli et al study. The patients in our study were
significantly older (38 y; range, 16 79 y; P .004)
than those in the Bertelli et al study (23 y; range, 19 27
y). We believe this contributed to the worse results.
We identified the BMI as one of the factors affecting
the deltoid strength. Because patients with higher BMI
do not necessarily have larger deltoid muscles, they
need more deltoid strength to elevate their heavier arms.
The severity of trauma is thought to be an important
factor affecting the outcome of nerve repair.23,25 This
was not the case in our study. Actually, younger pa-
tients had motorcycle or motor vehicle accidents more
often, and they recovered better than older patients.
Although most of the injuries in older patients were
caused by a fall, their outcome was generally worse.
Because the most common associated lesion was gle-
nohumeral joint fracture-dislocations irrespective of the
cause of trauma, we can postulate that the age of the
patient had more influence on the final outcome. A
majority of the patients in this series had severe trauma
resulting in their axillary nerve injury. In patients with
less severe trauma, we would recommend observation
with serial examination and electrodiagnostic studies
for up to 6 months. With no clinical or electrodiagnostic
evidence of reinnervation, we would recommend oper-
ative intervention at 6 months. Determination of the
optimal procedure depends on concomitant injuries as
well as time from injury and patient/surgeon prefer-
ences. We would recommend interposition nerve graft-
JHS Vol A, November
2355
ing in situations in which the axillary nerve lesion is
identified early ( 6 mo).
The presence of rotator cuff lesion did not have a
statistically significant effect on the outcome. Small to
medium-sized rotator cuff tears do not hamper shoulder
abduction strength.26 However, it is important to differ-
entiate isolated axillary nerve injury with combined
injury of the suprascapular nerve and/or rotator cuff. If
the suprascapular nerve and rotator cuff are intact, nor-
mal range of shoulder movement can be observed in
spite of the isolated axillary nerve injury.27 Measure-
ment of the scapulohumeral angle may be helpful to
identify a lesion of the suprascapular nerve and/or ro-
tator cuff.3
This study has several limitations. Its retrospective
nature inherently weakened the analysis power. A min-
imum of 12 months follow-up may not be adequate to
determine ultimate long-term recovery. Despite its wide
acceptance, manual muscle strength testing and MRC
grading is a subjective measure. Another limitation is
that a comparative group of isolated axillary nerve
injuries treated with interposition grafting was not avail-
able. These limitations notwithstanding, our study dem-
onstrated that isolated axillary nerve injury can be
treated successfully with triceps motor branch transfer,
although no patients older than 50 years of age or
whose treatment was delayed 12 months after injury
regained useful recovery of deltoid strength. Among
factors affecting outcome of this procedure, the delay
from injury to surgery is the only factor that can be
controlled to some extent by surgeon.
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