Isolated and combined lesions of the axillary nerve. A review of 146 cases.

We have assessed the final strength of the deltoid in 121 patients who had repair of isolated or combined lesions of the axillary (circumflex) nerve and were available for statistical analysis. Successful or useful results were achieved in 85% after grafting of isolated lesions. The strength was statistically better when patients had grafting of the axillary nerve within 5.3 months from the time of injury. The dramatic decrease in the rate of success seen with longer delays suggests that surgery should be undertaken within three months of injury. A statistically significant downward trend of the rate of success was noted with increasing age. The force and level of injury to the shoulder play an important role in the type, combination and level of nerve damage and the incidence of associated rotator-cuff, vascular and other injuries to the upper limb. Management of isolated and combined lesions of the axillary nerve after injury to the shoulder needs to be thorough and systematic.

Restoration of hand function after brachial plexus injury.

Brachial plexus injuries effect hand function in different ways. Deficits may resemble those of a radial nerve palsy or those of an associated, high medioulnar paralysis. Analysis shows that active extension of the wrist is paramount in all procedures to gain quality results.

The endoscopic diagnosis and possible treatment of nerve root avulsions in the management of brachial plexus injuries.

The spinal cord, dorsal rootlets, and ventral rootlets at the cervical level were visualized by endoscopy in ten goats. It is currently possible to visualize and document avulsed rootlets. With refinement in techniques and instruments, it will be possible to perform repairs, transfers or implantation of avulsed rootlets in the brachial plexus.

Silastic implants of the scaphoid and lunate. A long-term clinical study with a mean follow-up of 13 years.

39 implant replacement arthroplasties were reviewed with a mean follow-up of 13 years. The study includes nine cases of partial replacement of the proximal pole of the scaphoid, 16 cases of total replacement of the scaphoid and 14 cases of replacement of the lunate. In 33 cases the conventional silicone elastomer (CSE) was used and in six the high performance elastomer (HP). Subjective, clinical and radiological evaluations gave different results. Respectively the results were excellent in 41, 23 and 5%, satisfactory in 41, 49 and 39% and poor in 18, 28 and 56% of the cases. Lytic lesions in carpal and/or pericarpal bones were present in all except two cases. Study of the X-rays chronologically revealed that they increased in number and size. Six cases had their implant removed. All had histologically proven silicone synovitis. A major secondary operation has been performed or is foreseen in all cases except one. We do not recommend implant replacement arthroplasty for the scaphoid or the lunate bone.

Lesions found when operating traction injuries of the brachial plexus.

Traumatic traction injuries occurring mostly during road traffic accidents frequently cause severe lesions of the brachial plexus. 108 patients with such lesions were surgically explored in the last 5 years by one surgeon. By contrast, 101 patients with other lesions to the brachial plexus or various injuries to neighbouring nerves were operated on during the same period. Among the former, root avulsions were found in 73 patients, 33 presenting with 4 or all roots avulsed. In 14 of these patients the subclavian artery was ruptured. Out of 17 patients with infraclavicular distal plexus lesions 7 presented with a rupture of the axillary artery. The severity of the lesions to nerves and vessels in the shoulder girdle region seems to have increased over the past 10 years. The different injury patterns seen at operation are presented.

Muscle transpositions in the shoulder and upper arm for sequelae of brachial plexus palsy.

Permanent deficiency in abduction and external rotation of the arm seen after brachial plexus injury may be corrected by a levator scapulae transposition onto the supraspinatus, while the teres major, associated or not with latissimus dorsi, is transferred onto the infraspinatus muscle. Transposed in a bipolar manner, the latissimus may compensate the deltoid muscle. Associated measures have to be carried out in children with deformities caused by obstetrical palsy. A paralysed serratus anterior is best compensated by a transfer of the pectoralis major together with pectoralis minor muscle.

Operative management of lesions of the axillary nerve, isolated or combined with other nerve lesions.

Sixty-six surgically treated lesions of the axillary nerve were reviewed and 57 were followed up over 1 year. Patients were divided into 4 groups: isolated axillary nerve lesions (n = 23), axillary and suprascapular nerve lesions (n = 15), axillary and infraclavicular nerve/plexus lesions (n = 26), and axillary nerve lesions and lower root avulsions (n = 2). Of 34 patients operated upon within 6 months after the trauma, 24 (71%) recovered a force of M4 or M5. Of 17 patients operated upon within 1 year, 10 (59%) had M4 or M5. Of 6 patients operated upon after 1 year, only one had M4. Good shoulder function was only regained when the spinati muscles had recovered good force.

[Carpal tunnel syndrome]. / Le syndrome du tunnel carpien.

The carpal tunnel syndrome is very frequent. The authors insist on some points of surgical technique. The results of a Swiss study on the problem of the recurrent carpal tunnel syndrome are described (96 cases); the etiology of the recurrency, the surgical technique and the results after operative revision are analysed.

[Fractures of the clavicle and secondary lesions of the brachial plexus]. / Fractures de la clavicule et lésions secondaires du plexus brachial.

The fractures of the clavicle are fundamentally minor and usually will heal by simple immobilization. When the trauma is severe, the fracture may cause a lesion of the subclavicular neuro-vascular bundle. However, if the lesion is limited it may appear clinically only a few days after the accident. In other cases, whether the clavicular fracture heals or not, the bone lesion may produce a hypertrophic callus. This phenomenon will cause a narrowing of the costo-clavicular outlet and a compression of the neurovascular bundle which will provoke a real TOS. The authors present 16 cases of clavicular fractures, two of which having had early neurovascular complications and the 14 others a late phenomenon of costo-clavicular syndrome. The pathogenesis of the lesions, the principles of treatment and the results are discussed.

[Microsurgical emergencies with the exception of reimplantations]. / L'urgence microchirurgicale à l'exclusion des réimplantations.

Although reimplantations are very well defined operations, the indications for emergency free flaps and the management of nerve injuries are much less so. Using several examples, the authors define the conditions in which a free flap is justified and the most useful procedures for nerve repair. An emergency free flap should constitute the best solution, with a reasonable chance of success, without compromising other possibilities of reconstruction in the event of failure. The authors present the three situations observed in the case of nerve lesions: clean nerve sections, nerve defects, cases with an unclear diagnosis and cases in which the conditions are unsuitable for immediate permanent repair.

Late lesions of the brachial plexus after fracture of the clavicle.

Fractures of the clavicle, particularly those which are markedly displaced, may, in rare instances cause injury to the subclavian vessels and the brachial plexus which manifest progressively days or weeks after the initial trauma. More often than not, however, a costo-clavicular compression syndrome appears months or years after the clavicular fracture as a result of constriction by scar which invests the neuro-vascular bundle, by a secondary aneurysm or by hypertrophic callus. The authors report 16 such cases, one of which was treated conservatively, thirteen treated by surgical intervention while two cases are awaiting operation. These patients represent just over 1% of brachial plexus lesions seen over a period of twenty years in two surgical centres. Operative treatment consists of reduction of the clavicular deformity, possibly first rib resection, liberation of the plexus and correction of a vascular lesion as required. The outcome is usually good.

The role of thoracic outlet syndrome in the double crush syndrome.

The association between thoracic outlet syndrome (TOS) and carpal tunnel syndrome (CTS) (40 cases), ulnar neuropathy (UN) (19 cases) and radial tunnel syndrome (29 cases) is investigated. The possibility of a double crush syndrome is considered with reference to the difficulties in diagnosis. It is demonstrated that in approximately half of all cases the proximal neuropathy precedes the distal one. Despite the fact that surgical treatment of the thoracic outlet syndrome appears to improve the distal neuropathy it is still difficult to decide, in a given case, which decompression takes priority with the exception of carpal tunnel release which is generally to be performed first. The historical background and theoretical basis of the management of double crush syndrome is outlined and arguments for and against the association of the various neuropathies are presented.

[Pancoast's tumor: multi-disciplinary treatment and combined cervico-thoracic approach]. / Tumeur de Pancoast: traitement pluridisciplinaire et abord chirurgical cervico-thoracique combiné.

Five patients were treated from May 1987 to April 1988 in CHUV, Lausanne, for a superior sulcus tumor (3 epidermoid, 2 undifferentiated carcinomas). Treatment consisted of preoperative radiotherapy (3000 cGy)-surgery-postoperative radiotherapy (1500-2500 cGy). Two patients died from metastases. Only one patient presented with a local recurrence. Surgical resection was carried out by combined cervical and thoracic exposure. The cervical approach allows separation of the tumor from the subclavian artery, brachial plexus and vertebrae. Then, by thoracotomy, the superior lobe with tumor and thoracic wall is removed. Technical aspects of the procedure are described.

Neurotization in brachial plexus injuries. Indication and results.

In neurotization or nerve transfer, a healthy but less valuable nerve or its proximal stump is transferred in order to reinnervate a more important sensory or motor territory that has lost its innervation through irreparable damage to its nerve. In brachial plexus injuries, extraplexal nerves such as the spinal accessory nerve, rami of the cervical plexus, or intercostal nerves are transferred onto trunks, cords, or individual nerves or else segments of the brachial plexus that maintain continuity with the spinal cord may be coapted to trunks or cords the surgeon wishes to innervate. This method is particularly indicated in root avulsion injuries that occur frequently following traction trauma to the brachial plexus. The authors convey their experience with neurotization using the long thoracic nerve in seven cases, the accessory nerve in 30 cases, intercostal nerves in 66 cases, and various nerve transfers within the plexus in 31 cases. Results of other authors are also reported. With these methods, it is possible to obtain good elbow flexion in more than one-half of patients; however, only limited shoulder function and no useful finger function are obtained.