Infraclavicular brachial plexus injuries (Level IV in Chuang's classification) have special characteristics, including high incidences of associated scapular fractures, glenohumeral dislocations, and vascular injuries. In addition, there are specific difficulties in surgical dissection and nerve repairs, especially if surgery is delayed (> 3 months). A total of 153 patients with Level IV brachial plexus injuries underwent surgery between 1987 and 2008 with 75 patients (average age 29 years) available for a minimum of 4 years follow-up. Accompanying fractures/dislocations were suffered by 48 (64) patients, and 17 (23) had associated vascular injuries. The most common nerves to be injured were the axillary and musculocutaneous nerves. Nerve grafts to the axillary, musculocutaneous, and radial nerves achieved impressive results, but less reliable outcomes were achieved with the median and ulnar nerves. Decompression and/or external neurolysis were also beneficial for nerve recovery. Some surgical tips are presented, and the use of the C-loop vascularized ulnar nerve graft and functioning muscle transfers are discussed.
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