The Effect of Age and the Delay before Surgery on the Outcomes of Intercostal Nerve Transfers to the Musculocutaneous Nerve: A Retrospective Study of 232 Cases of Posttraumatic Total and Near-total Brachial Plexus Injuries.

Introduction Posttraumatic brachial plexus injuries are devastating, as the brain and spinal cord are disconnected from the upper limb. Restoration of elbow flexion has been widely recognized as the primary objective of nerve reconstruction. In the absence of utilizable (ruptured) root stumps in the neck, one has recourse only to nerve transfers. The direct transfer of intercostal nerves to the musculocutaneous nerve is one of the techniques that has been commonly employed over the past four decades. However, the outcomes of this procedure cited in the literature have varied considerably. The patient's age and the delay from the accident to surgery have been known to affect the results of nerve reconstruction operations. The authors present a study of the effect of these parameters on intercostal nerve transfers. Methods The data of 232 patients with total and near-total brachial plexus injuries treated by the senior author between April 1995 and December 2015 was examined. Intercostal nerve transfers were used for the restoration of biceps function in each of these patients. The outcomes were tabulated, and the correlation with the age and the delay before surgery was examined. Results The strength of the biceps regained was better in patients younger than 30 years old and those operated upon earlier than 6 months from the accident. The differences in outcomes were found to be statistically significant ( p = 0.001 for preoperative delay and p < 0.005 for the patient's age). Conclusion The results give clear proof of the significant effect of the age and preoperative delay on the outcomes of intercostal nerve transfers for restoration of biceps function. These findings can serve as pointers to help the surgeon in choosing the method of nerve reconstruction in a given case.

Living-donor nerve transplantation for global obstetric brachial plexus palsy.

The first reported case of live-donor nerve transplantation is presented, performed in an 8-month-old infant with global obstetric brachial plexus palsy (OBPP) and four root avulsions who had undergone prior sural nerve autografting at 3 months. Cross-chest C7 nerve transfer and temporary tacrolimus/prednisone immunosuppression were utilized. Acute rejection was prevented, with no observable complications from the immunosuppressive medications, ipsilateral deficits resulting from the use of the contralateral C7 root as a donor nerve, or untoward effects on growth and development occurring over a 2-year follow-up period. Although some return of sensory and motor responses on nerve conduction studies was documented, the failure to observe a clinically significant functional improvement in the affected limb directly attributable to the transplant may have been due to performing the procedure too late and/or inadequate follow-up. Results of additional cases performed earlier than in this patient with longer follow-up will need to be evaluated to determine whether the procedure proves to be a viable therapeutic option for treatment of global OBPP with four or five root avulsions.

Symptomatic progression of congenital ulnar nerve hypoplasia with brachial plexus anomaly.

Symptomatic progression of congenital ulnar nerve hypoplasia in association with an anomaly of the brachial plexus is uncommon. The authors present such a case involving an 11-year-old girl, who presented with a complaint of progressive numbness and hand weakness occurring in less than 6 months' time. Physical examination revealed limb hypoplasia, neurologic abnormalities, and a palpable hypoplastic ulnar nerve at the level of the cubital tunnel. An additional intraoperative finding was an anomalous brachial plexus. This combined case of congenital ulnar nerve hypoplasia, brachial plexus anomaly, and symptomatic progression, is discussed in the context of other literature.

Simultaneous three-flap reconstruction of extensive hand and finger degloving injury: case report.

Connecting the two areas of the hand and digits are the interdigital web spaces that serve as a transition zone and maintain a specific shape and architecture that facilitates the unique patterns of human prehension. In reconstructing a degloving injury that involves the fingers, hand, and interdigital webs, consideration must be given to the function of each of these three regions. The authors present a case report illustrating their management of an extensive degloving injury of the hand and fingers.