Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 45:
Direct Surgery of Traumatic Lesions of the Brachial Plexus

These lesions have a better prognosis than those discussed previously because they are easier to repair. At this level, however, concomitant lesions are frequently observed. Before undertaking the repair of the cords and of the nerves that are frequently injured (musculocutaneous nerve and axillary nerve), it is necessary to check the integrity of the origin of the rotator muscles and to check the costoclavicular space, which might have been modified by a hypertrophic callus of clavicle or upper ribs. Finally, the time of repair of the plexus can be also a time to repair the subclavian artery.

Lesions are easy to identify after dissection of the cords and of the nerves. A frequent lesion is that of the axillary nerve, which is most often ruptured at the lateral aspect of the scapula, 2 cm distally from its origin on the posterior trunk. Repairing this lesion is done by dual approach. An anterior incision through the deltopectoral groove gives access to the posterior cord and to the proximal neuroma of the axillary nerve; a posterior incision is made vertically along the medial aspect of the posterior portion of the deltoid muscle (Figs. 45-16 through 45-18). The graft is first glued to the distal portion of the axillary nerve, then slipped through the foramen of Velpeau and glued to the proximal portion of the axillary nerve. This dual approach is minimally traumatic and uses grafts that are 5 to 7 cm shorter. In our series, useful results for the axillary nerve (between M3+ and M4) averaged 53% (Figs. 45-19 through 45-21).


Results are still better after grafting the musculocutaneous nerve, short grafts are used, and quick functional recovery is obtained (from 6 to 9 months). Conversely, repair of the medial cord yields unsatisfactory motor results. Satisfactory intrinsic hand function is rarely recovered. It is useful, however, to operate on these patients to obtain an acceptable trophic condition and protective sensitivity of the upper arm.



Early direct surgery of brachial plexus lesions helped bring comfort to patients. Before surgery, 79% of them had experienced pain. In 36%, the pain was described as permanent and 50% described paroxysmal episodes. These episodes were ill tolerated, had adverse behavioral consequences, and led to significant use of powerful analgesic medication.

next page...

  2002 © This page, and all contents, are Copyright by The Buncke Clinic