Recovery of Hand Function Following Nerve Grafting and Transfer in Obstetric Brachial Plexus Lesions

Obstetric brachial plexus lesions (OBPL) are the result of traction during delivery. Hand function is impaired in approximately 15% of patients. In these infants, usually a lesion comprising the entire brachial plexus exists. When spontaneous recovery fails, surgical repair of the brachial plexus is commonly performed. Extensive data from the results of nerve repair aiming at restoration of shoulder and biceps functions are available. However, communication concerning outcomes of hand function after nerve repair is limited.

The authors presented their surgical strategy in 35 patients with flail arm, who were operated on during a period of 10 years. The mean patient age at surgery was 5 months. Neurotization of C8, T1, inferior trunk, or middle trunk was performed aimed at restoration of functions innervated by the median and/or ulnar nerves. Eighteen patients had sufficient follow-up (mean: 50 months) for final analysis. The Raimondi score was used to evaluate hand function.

Patients were divided into three groups: 13 (Group 1) had complete discontinuity of the C7, C8, and T1 outflow; Group 2 (n = 3) consisted of patients in whom C8 and/or T1 had been left in place during surgery, because of shortage of nerve grafts or limited availability of proximal outlets. In two patients (Group 3) treated in the early phase of clinical experience, no attempt was made to restore hand function. In Group 1, 9/13 (69%) gained a Raimondi score of 3 or more, as well as 1/3 patients in Group 2. Both patients in Group 3 did not gain any hand function.

The objective of surgical treatment in OBPL patients with flail arm should be the ability to use the affected hand to assist in bimanual activity (Raimondi score > 3). In those cases in which reanimation of the hand could be fully dependent on surgical reconstruction, 69% of patients in the presented series obtained a useful hand. The authors conclude that reanimation of hand function is possible in OBPL infants and that this should be the first goal of nerve repair in OBPL patients with flail arm. The optimal technique of reconstruction is not yet clear and cannot be deduced from this series. The authors' surgical philosophy was discussed in the presentation.