Figure 1

a. Case 1: 1 year after surgery on the right side, no improvement has yet occurred. She was operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. The anterior deltoid was Grade3, the lateral deltoid Grade2, the posterior deltoid Grade0. Note the supination deformity of the forearm, the extension deformity at the wrist and biceps cocontraction on attempted active shoulder abduction. At this stage, with that degree of weak shoulder abduction, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will be of no avail. b. Case 1: 2 years after surgery. The anterior deltoid became Grade5, the lateral deltoid Grade4 and the posterior deltoid Grade2. The wrist extensors improved from Grade1 up to Grade3. Some degree of pronation has been regained at the forearm. At this stage, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will also be of no avail, because of extensive biceps cocontraction on attempted shoulder abduction. c. Case7: 4 years after surgery on the right side. She was also operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. In addition to improvement of the deltoid and wrist extensors, some shoulder external rotation has been regained as the infraspinatus became Grade3. Biceps cocontraction on attempted shoulder abduction improved. She may therefore benefit from secondary corrective procedures at the shoulder. In addition, a free functional gracilis transplantation has to be carried out to power the weak finger flexors.