Peripheral Nerve Regeneration A Follow-Up Study of 3,656 World War II Injuries (1957) / Chapter Skim
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Recovery Following Injury to the Brachial Plexus
Recovery Following Injury to the Brachial Plexus
Pages 389-408
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From page 389... ...
In addition, an initial total paralysis of the arm was so universally reported, except in 3 stab wounds, that a classification of cases according to nerve elements suffering major damage was achieved by arbitrarily considering an element uninvolved when it gave evidence of good motor and sensory function by 2 months after injury. Accordingly, the data on spontaneous recovery in this series can be expected to be less favorable than often reported, because all examples of very early recovery have been discarded from the analysis.
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From page 390... ...
One satisfactory recovery occurred in a lysis case in which distal muscles began to function in the third month, and proximal muscles began 4 months after injury.
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From page 391... ...
Three additional cases had posterior cord and medial cord damage. The latter by itself prevented the recovery of a useful hand so that it is of only academic interest that 2 posterior cord sutures resulted in good elbow and wrist extensor function.
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From page 392... ...
The preservation of median sensation (through lateral cord) and of fair median forearm muscles avails little in the face of this total loss of intrinsic hand muscle action.
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From page 393... ...
The 6 good cases were all characterized by early recovery of some intrinsic hand muscle function as evidence of relatively intact medial cord function. In 1 case a suture of the lateral cord gave the usual good return in biceps with increasing strength in median flexors and improvement in median sensation (never totally lost)
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From page 395... ...
In lateral cord sutures considerable flexion could be provided by the unaffected brachioradialis when a "useful recovery" indicated the observation of a strong contraction of the biceps as a major contribution to elbow flexion. Triceps and finger extensors offered fewer problems in isolated innervation -- action against gravity plus resistance was considered useful.
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From page 396... ...
Table 226. -- Motor and Sensory Recovery Attributable to Suture of a Component of the Brachial Plexus Recovery Specific motor or sensory involvement Total cases Useful Lowgrade None Number Percent Median sensation 19 34 20 30 35 31 61 32 16 36 37 37 3 6 16 18 55 80 46 13 21 0 6 6 0 0 3 9 1 2 10 5 11 2 3 6 3 3 13 19 8 4 9 22 37 30 12 28 34 34 Ulnar sensation 11 24 16 4 13 0 1 2 0 0 Triceps Wrist extensors Wrist flexors Finger extensors Median finger flexors Ulnar finger flexors Median intrinsic hand muscles Ulnar intrinsic hand muscles The results of suture might have been better had it been accomplished earlier after injury. However, there is a sufficient number of relatively early sutures (38 by 4 months)
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From page 397... ...
While in most Table 227. -- Motor and Sensory Recovery Occurring Spontaneously or After Lysis Following Brachial Plexus Injury * Total cases Recovery Specific motor or sensory involvement Useful Lowgrade None Number Percent Median sensation 47 44 35 52 37 38 27 40 28 48 45 44 23 20 23 41 28 12 7 8 2 13 5 5 49 45 66 79 76 31 26 20 7 27 11 11 11 10 5 3 4 10 4 7 2 18 10 9 13 Ulnar sensation 14 7 8 5 16 16 25 24 17 30 30 Shoulder abductors .
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From page 398... ...
Much shorter time intervals obtain for the first evidences of recovery in the distal muscles, if such recovery is to progress to useful function. In none of these cases with useful recovery to finger flexors and extensors or to hand muscles was action in these muscles delayed beyond 3 months after injury.
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From page 399... ...
in a review of 63 cases, has made observations similar to ours; he concludes that, while proximal motor recovery can begin as late as 6 months and progress to good strength, distal muscles not working by 2 months will never regain useful function. A review of the management of the present series shows that no time limitation for recovery was generally accepted.
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From page 400... ...
It is an area of indispensable function whose absence can largely negate the value of proximal motor function achieved spontaneously or by suture. The proximal muscles can, paradoxically, follow a slower schedule of recovery than distal muscles and progress to useful function because here the slow-going process of axonal regrowth can be effective.
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From page 401... ...
have gone so far as to imply that lysis is important even with partial nerve function because "subsequent extensive scar tissue formation tends to impair to various degrees many originally uninjured portions of the plexus and gives rise to disseminated and incomplete motor and sensory disturbances." Certainly this external scarring can be so dense as to make the surgeon believe he must be performing a useful function in liberating the encased nerve. However, the absence of one well-documented case where there has been a clear regression of function, without further external trauma or growth of an aneurysm, forces the conclusion that peripheral nerve function does not deteriorate from progressive scarring, logical as this idea might seem.
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From page 402... ...
. Suture of the following elements carries a high expectation of useful innervation: upper trunk or either of its roots for supraspinatus, deltoid, and biceps; lateral cord for biceps and a partial contribution to median forearm flexors; posterior cord for deltoid, triceps, and, with luck, wrist extensors.
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From page 403... ...
Surprisingly, in 5 instances the posterior cord was affected. In 2, where the medial cord was intact, posterior cord suture permitted useful recovery with the assistance of tendon transfers.
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From page 404... ...
(b) If paralysis involves those distal muscles which will be uninfluenced by surgery, and proximal muscles whose isolated recovery will contribute little, surgery can be deferred for 3 months to determine whether distal recovery, even with tendon transfers, is consistent with hand function.
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From page 405... ...
In 10 pure medial cord lesions and in 5 multiple lesions, the residual deficit was total loss of intrinsic hand muscle function in the face of good sensation and working forearm muscles. However, too few of these forearm muscles were considered sufficiently strong to provide both opposition of thumb and stabilization of curled fingers to oppose the thumb.
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From page 406... ...
In particular, the less frequent recovery of shoulder abduction in comparison with elbow flexion appears not to depend upon any less frequent motor recovery. Rather, restricted shoulder joint movement coupled with overstretching of paralyzed muscles appears to account for this difference in results, presumably remediable by greater attention to shoulder mobility and splinting in abduction.
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From page 407... ...
2. The major disability in brachial plexus lesions occurs when its lower roots or medial cord elements are involved with loss of hand function.
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From page 408... ...
4. When such deficits are incomplete, yet disabling, tendon transfers, sometimes in combination with joint fusions, may permit useful function.
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