Traumatic brachial plexus palsy in the adult. Retro- and infraclavicular lesions.

The author reviewed 420 adults treated with surgery for traumatic palsy of the brachial plexus. The results of 105 patients (25%) who suffered plexus injury behind or beyond the clavicula are presented. In 69 patients, lesions affected secondary trunks and in the other 36 affected terminal branches. Simultaneous fractures or vascular injuries were not uncommon and often influenced overall prognosis. Decision criteria for nerve grafting or neurolysis are presented. Surgery is generally performed three weeks to six months after injury. Most patients present extensive damage due to traction lesions. Although secondary sutures can be performed on some injuries, nerve grafting is usually necessary. Such a procedure depends on the length of the gap and the quality of surrounding tissues. Among distal lesions a distinction must be made between (a) injuries located close to effectors on axillary, suprascapular, musculocutaneous, or radial nerves where good recovery can be expected in 70% to 80% of grafted patients and (b) injuries involving lateral or medial cords or the median or ulnar nerves far from effectors, where results are less satisfactory. Sixty percent of such patients recovered wrist flexion but no intrinsic muscle function in the hand. Reinnervation nevertheless generally provided a protection sensibility particularly in the area controlled by the median nerve. Multiple injuries may occur, mainly posterior cord lesions combined with lesions of the musculocutaneous, median, or ulnar nerves. The overall prognosis of infra- or retroclavicular plexus injuries is nevertheless better than that of supraclavicular lesions.