Nerve transfers in brachial plexus palsies.

It has been many years now since the introduction of nerve transfers for repair of traumatic brachial plexus lesions and more recently, we have seen its application in the field of obstetric brachial plexus palsy. These nerve transfers do not represent an alternative to anatomical repair by means of nerve grafting, but represent an additional possibility to increase the reconstructive options and improve the final results. This pushes the surgeon to decide: which function is to be restored by nerve grafting, which one by nerve transfer? What is the more reliable procedure? Does the age of the patient, the delay after the accident, or the type of accident influence this choice? If we add in the possibilities of palliative treatment, one can state that many therapeutic options are available today for brachial plexus reconstruction, and that no real consensus does exist. But some tendencies, some trends are apparent.

[Bizarre parosteal osteochondromatous proliferation (Nora's lesion). Two case reports]. / Prolifération ostéocartilagineuse parostéale bizarre ou tumeur de Nora. A propos de deux cas.

Bizarre parosteal osteochondromatous proliferation, or Nora's tumor, is an uncommon lesion, involving mostly tubular bones of hands and feet, arising from the cortical surface. It must be distinguishable from chondrosarcoma, parosteal osteosarcoma and florid reactive periostitis. It is a benign lesion, characterized by a proliferation of chondroid, bony and fibrous tissues. The authors report two cases involving the hand. The diagnosis can be made thanks to imaging techniques and confirmed by histological examination. The treatment is surgical, namely complete excision but there is a high rate of local relapse.

[Isolated traumatic serratus anterior muscle palsy]. / Paralysie isolée du muscle serratus antérieur d'origine traumatique.

PURPOSE OF THE STUDY: The serratus anterior, innervated by the long thoracic nerve, participates in shoulder abduction and elevation, stabilizing the scapula on the rib cage. Paralysis of the serratus anterior prohibits shoulder abduction and elevation beyond 90 degrees and elevation of the spinal border of the scapula. We report our experience with traumatic serratus anterior palsy. MATERIAL AND METHODS: Our series included 16 patients with traumatic unique injury to the long thoracic nerve. Mean age of the patients at the time of the accident was 27.6 years. Seven patients were not operated on due to total or partial spontaneous recovery. Scapulothoracic arthrodesis or scapulopexy was performed in nine patients. RESULTS: For the non-operated patients, mean elevation was 125 degrees at diagnosis and 145 degrees at five years follow-up with a Constant score of 85 and muscle force reaching 83% (12 kg shoulder abduction) of the healthy side. Outcome was rated very good in 4 patients, and good, fair and poor in one each. For the operated patients, elevation was 95 degrees preoperatively and 104 degrees at last follow-up. At four years follow-up mean values were: elevation 104 degrees, Constant score 75, muscle force 72% (9 kg shoulder abduction) of the healthy side. An infection required a revision procedure in one patient who recovered successfully. Outcome was rated very good in six patients and good in three. DISCUSSION: Several types of treatment have been proposed for serratus anterior palsy: non-operative care, muscle transfers mainly with pectoralis major flaps, and scapulothoracic arthrodesis. Most of the series on scapulothoracic arthrodesis have concerned fascioscapulohumeral dystrophy and cannot be compared with our patients. Data in the literature on muscle transfers, which could be considered as comparable with our trauma injuries, have demonstrated good results for shoulder motion but a limited effect on overall muscle force. In our series, scapulothoracic arthrodesis provided good results for muscle force, pain relief, and overall shoulder function, with shoulder motion being limited by the position of the arthrodesed scapula. We propose this type of treatment for serratus anterior palsy mainly for manual laborers.

Function of the upper limb after surgery for obstetric brachial plexus palsy.

We reviewed a consecutive series of 33 infants who underwent surgery for obstetric brachial plexus palsy at a mean age of 4.7 months. Of these, 13 with an upper palsy and 20 with a total palsy were treated by nerve reconstruction. Ten were treated by muscle transfer to the shoulder or elbow, and 16 by tendon transfer to the hand. The mean postoperative follow-up was 4 years 8 months. Ten of the 13 children (70%) with an upper palsy regained useful shoulder function and 11 (75%) useful elbow function. Of the 20 children with a total palsy, four (20%) regained useful shoulder function and seven (35%) useful elbow function. Most patients with a total palsy had satisfactory sensation of the hand, but only those with some preoperative hand movement regained satisfactory grasp. The ability to incorporate the palsied arm and hand into a co-ordinated movement pattern correlated with the sensation and prehension of the hand, but not with shoulder and elbow function.

Brachial plexus injuries in scapulothoracic dissociation.

The rare condition of scapulothoracic dissociation (STD) is characterized by a lateral displacement of the scapula from the thoracic cage following severe trauma to the scapular girdle. This study presents an analysis of five STDs. There were three supraclavicular brachial plexus palsies and two retro- and infraclavicular palsies. Recovery of elbow flexion was obtained in only two cases. Nerve damage dominates the prognosis and nerve recovery only rarely occurs. Nerve surgery should attempt to reestablish elbow flexion.

Morphometric study of the upper intercostal nerves: practical application for neurotizations in traumatic brachial plexus palsies.

UNLABELLED: The aim of the study was a morphometric evaluation of the intercostal nerves at different levels along their course in order to determine their adequacy in neurotizing the recipient nerves. The intercostal nerves were harvested from 5 cadavers. A biopsy of the nerve was obtained at 2 levels for each nerve in the parasternal region and at the level of the mid-axillary line. The musculocutaneous nerve was isolated at its origin from the lateral cord. Each harvested specimen was embedded in paraffin and sections were made using a microtome. These sections were then stained histochemically using HPS (Hematein, Phloxine, Safran). Real-time digitalisation of the video image under the microscope was performed. The sum of the different fascicular zones is the effective sensorimotor surface of the nerve at the level being studied. RESULTS: Direct suture of the upper three intercostal nerves to the musculocutaneous nerve is always possible upto the axillary fossa. The sixth intercostal nerve can be delivered upto this level in only 50% of cases without dissection of the musculocutaneous nerve upto its entry into the coracobrachialis. The musculocutaneous nerve presents a mean surface area of 2.64 mm2 while the nerve to the biceps has a mean surface area of 0.34 mm2 i.e. a ration of 1/8. The mean surface area of the intercostal nerves at the parasternal level is 0.23 mm2 while that at the axillary level is 0.34 mm2. Thus a loss of 33% in surface area occurs between the axillary and the parasternal levels. Our study confirms the insufficiency between the surface area of the intercostal nerves and the different nerve trunks to be neurotized. The relationship between the surface area of the musculocutaneous nerve and the three intercostal nerves is 26.72% with a minimum of 17.2%. If a fourth intercostal nerve is added, this ratio nerves appears to be a superior technique. We were able to deliver the sixth intercostal nerve for a direct suture to the musculocutaneous nerve in only half the cases.

Results of non-operative and operative treatment of humeral shaft fractures. A series of 104 cases.

The aim of this study was to examine the results of different modalities applied in the treatment of 104 fresh diaphyseal fractures of the adult humerus treated in the department between January 1994 and March 1997. These results were classified according to the criteria described by Stewart and Hundley. 32 patients (30.8%) were treated non-operatively using a sling and a moulded plaster splint. The type of treatment had to be changed in 12 of these patients due to 14 different complications that occurred during the course of non-operative treatment. Thus, 20 patients (62.5%) underwent non-operative treatment until fracture-union. The results in this group were: very good in 12 cases (60%), good in 5 cases (25%), fair in 3 cases (15%). 28 fractures were treated using plates and screws. 4 events (14%) occurred during in the post-operative period and, apart from 2 cases of non-union, the overall result in the 26 patients in whom the fracture united was: very good in 23 cases (88.5%) and good in 3 cases (11.5%). 22 patients (21.1%) underwent fixation using multiple flexible intramedullary wires via a supracondylar approach. Apart from one case of non-union, the final result in the 21 patients in whom the fracture united was: very good in 9 cases (42.8%), good in 9 cases (42.8%), fair in 2 cases (9.5%) and poor in 1 case (4.9%). 22 fractures were treated using an intramedullary Seidel nail. The final result in these patients was: very good in 11 cases (50%), good in 9 cases (41%) and poor in 2 cases (9%). The indications for treatment should be eclectic. Non-operative treatment remains the method of choice for undisplaced or minimally-displaced fractures or comminuted fractures with multiple parallel longitudinal fracture-lines over the middle-third, while surgical treatment is considered for displaced fractures and essentially depends upon the type and level of the fracture. Transverse and short oblique fractures are treated using a plate or a Seidel nail. Fractures with a third fragment require plate osteosynthesis. Multiple flexible intramedullary wires are used for segmental fractures or for diaphyseal fractures associated with fractures of the neck of the humerus. Comminuted fractures are realigned using an intramedullary Seidel nail or multiple flexible wires. As far as the site of fracture is concerned, those of the proximal and middle thirds of the humerus are well treated using an intramedullary nail or multiple wires or with a plate, while plating is most often the method of choice for fractures of the distal-third.

Extensor digiti minimi tendon "rerouting" transfer in permanent abduction of the little finger.

Permanent abduction of the little finger is a bothersome deformity which usually occurs in the context of sequelae of ulnar nerve palsy (Wartenberg's sign), but also in rheumatoid arthritis. The authors report an original technique for correction of this deformity. The extensor digiti minimi tendon is sectioned at its distal insertion and transferred in the wrist through the extensor retinaculum. The "rerouted" tendon is finally resutured distally on the radial aspect of the interosseous muscle. Side-to-side suture of the transferred tendon to the extensor digitorum tendon of the little finger further reinforces the solidity of the procedure. The distal insertion of the extensor digiti minimi tendon is consequently radialized. Its new direction eliminates the abduction component, and the tendon then behaves as an active adductor of the little finger. Five cases (2 cases of ulnar nerve palsy, 3 cases of rheumatoid arthritis) are reported with a mean follow-up of 19 months. All patients have complete active adduction of the little finger in extension, with a persistent capacity for abduction. The other correction techniques published in the literature are discussed.

[Retrosternal luxation of the clavicle. Apropos of 4 cases surgically treated using a temporary screwed anterior plate and review of the literature]. / Les luxations rétro-sternales de la clavicule. A propos de quatre cas traités chirurgicalement par plaque antérieure vissée provisoire et revue de la littérature.

The authors report 4 new cases of retrosternal dislocation of the clavicle operated by capsular and ligament restoration, and temporary stabilization by anterior plating. The 4 patients were men with a mean age of 17.5 years. The lesion was caused by a sports injury (football, rugby) in 3 out of 4 cases and was related to an indirect mechanism. Clinical examination allowed the diagnosis, was related to based on painful palpation of a dip over the joint, supported by radiology and computed tomography. CT did not reveal the epiphyseal separation present in two cases. Complications were frequent: 1 case of tracheal compression, 2 cases of temporary paresthesia of the upper limb, 2 cases of venous compression with one case of subclavian and medial jugularis venous thrombosis, 1 hemopneumothorax. Surgical reduction was performed in all 4 cases after 2 failures of attempted orthopedic treatment under general anesthesia. All patients recovered a full range of movement, a painless shoulder and no recurrence has been observed. All complications resolved after reduction. Venous thrombosis responded favourably after 6 months of anticoagulant therapy. One plate breakage was observed with no clinical implications. On the basis of an extensive review of the literature, the authors discuss the epidemiology, pathology and the importance of associated injuries, which are frequent and sometimes serious, justifying urgent reduction. Computed tomography is the most useful radiologic modality, both for diagnosis and for investigation of complications. Orthopedic treatment must be attempted first (especially in children) according to a well systematized technique. One third of attempts fail, and cases of delayed diagnosis and serious vascular complications, then require surgical treatment. The costoclavicular ligament is repaired either by Burrows's ligamentoplasty or by bone suture; the clavicle is stabilized by bone suture or by anterior plating. The authors do not advocate either joint fixation by Kirschner wire, or resection of the medial end of the clavicle.

[Ulnar nerve fascicle transfer onto to the biceps muscle nerve in C5-C6 or C5-C6-C7 avulsions of the brachial plexus. Eighteen cases]. / Transferts de fascicules du nerf ulnaire sur le nerf du muscle biceps dans les avulsions C5-C6 ou C5-C6-C7 du plexus brachial. A propos de dix huit cas.

The authors report 18 cases of transfer of several ulnar nerve fascicles onto the biceps muscle nerve, performed between 1990 and 1997. The patients were between the ages of 17 and 41 years, and presented C5-C6 paralysis in 8 cases and C5-C6-C7 paralysis in 10 cases. The operation was tempted between 4 months and 6 years (m = 17 months) after the initial accident. In the 8 cases of C5-C6 paralysis reviewed, 7 patients recovered elbow flexion and only one required an additional Steindler transfer. In the 9 cases of C5-C6-C7 paralysis reviewed, 4 patients recovered elbow flexion after nerve surgery alone, while 4 patients only obtained elbow flexion after a complementary Steindler transfer. Two of these 4 patients were operated very late (27 and 75 months). Finally, a single 40-year-old patient, operated 28 months after the accident, was considered to be a complete failure. Overall, ulnar biceps nerve transfer appears to be indicated in C5-C6 avulsion, during the months following the initial accident. Flexion against gravity is then regularly obtained in less than 6 months, without any objective or subjective sequelae of the hand.

Distal insertions of abductor pollicis longus muscle and arthritis of the first carpometacarpal joint in 104 dissections.

The different types of distal insertions of the tendons of the abductor pollicis longus muscle (APL) were studied in 104 cadaveric hands, and the appearance of the rhizarthrosis in the level of the basal joint of the thumb, as well, in a try to detect possible anatomical relationships. From the anatomical point of view, it was evident that the insertions of the APL muscle are usually multiple (95%), that the insertion to the base of the first metacarpal is constantly present, accompanied in 70% of the cases with an insertion to the trapezium. Finally, the accessory tendon to the thenar eminence was proved to be extremely frequent (42%). Rhizarthrosis has been found in 97% of the dissections. The lateral compartment of the joint surface appeared to be the most frequently affected with arthritis (71%) and probably the starting point of the lesion. But no correlation has been recorded between severe arthritis and any type of distal insertion of abductor pollicis longus muscle. Early tenotomy of some tendons, in order to prevent arthritis of the first CMC joint, cannot be recommended from this study.