Restoration of abduction and exorotation is one of the goals in treating patients with severe brachial plexus (BP) injuries. The accessory to suprascapular nerve (XI-SS) transfer is used for this purpose when spinal roots are avulsed and proximal stumps are not available. In the present study we analyze the results obtained in a consecutive series of 22 patients with a BP traction/crush lesion treated with XI-SS transfer. The nerve transfer was part of an extended BP reconstruction with restoration of elbow flexion as the primary goal. Patients with neurotization of the axillary nerve were excluded. Our surgical intention was to perform direct XI-SS coaptation. The XI nerve was therefore transected as distally as necessary or technically possible. All patients were followed for at least two years postoperatively. The mean age at surgery was 24 years. The mean interval between trauma and operation was 127 days ± 62 (SD). Nine patients were shown to have avulsion C5-T1, and thirteen had rupture or avulsion C5, and avulsion C6 (C7). The force exerted by the supraspinatus and infraspinatus muscles was assessed according to the MRC scale. The glenohumeral abduction and exorotation angles and total (scapulothoracic and glenohumeral) range of movement was noted. Repeated postoperative needle EMG studies of the supraspinatus and infraspinatus muscles were performed in all patients. EMG signs of reinnervation in the supraspinatus muscle were found in 19 patients (86%) and of the infraspinatus muscle in 16 (72%). In 15 patients (68%) direct coaptation of XI to SS nerve was achieved. In this group, five patients (33%) attained supraspinatus muscle force of MRC grade ³ 3. In 4 patients (27%) glenohumeral abduction was 45° and total abduction range was 60°-90°. Three patients (20%) achieved infraspinatus MRC ³ 3. Glenohumeral exorotation was 45° in two patients and 70° in one. Only two patients (13%) had both supra- and infraspinatus MRC ³ 3. In seven patients (32%) a graft (mean length 4.8 centimeter ± 1.4 SD) was required to connect the XI to the SS nerve. In this group none of the muscles achieved MRC ³ 3. Six out of these seven patients had avulsion C5-T1. Although EMG signs of reinnervation were present in the vast majority of patients, restoration of useful shoulder function was limited; especially when grafts were needed to bridge the gap between the XI and SS nerve.