Traumatic brachial plexus lesions in the adult: indications and results.
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Adult↗
Biomedical subjects
J Y Alnot
Publications and source records attributed to J Y Alnot.
[Recent injuries of the nerves of the wrist and hand].
The advent of microsurgery has in the last few decades considerably improved the results of treatment of lesions of nerves in the wrist and the hand, both with regard to functional restoration of sensation and movement and to reduction of local irritant factors or those linked to cold injury. Peripheral nerves are frequently injured at the wrist and the hand by contusion, compression, straining or total or partial section. In the case of wrist, hand or finger wound, only well-directed, precise and systematic clinical examination can determine the neurological deficit. Surgery is always indicated. There are often associated complex lesions, and all injured elements must be completely repaired. The order of this repair is always the same: tendons, nerves, then vessels. Concerning nerves, therapy depends on the severity of the contusion and (or) the loss of substance. If the section is distinct, direct suture with physiological tension can be made. On the other hand, if there is contusion or loss of substance, direct suture cannot be performed since nonphysiological tension leads to endoneural ischaemia and fibrosis. Rather, the extremities should be brought closer together in order to avoid retraction and subsequent secondary sutures or short grafts should be made.
Hand↗
[The spinal accessory nerve (n. accessorius) I: anatomical study].
INTRODUCTION: In order to increase knowledge of the spinal accessory nerve concerning its situation, trajectory and terminal branches and also the connections with the cervical plexus, the authors report an anatomical study based on 11 dissections of the trapezius muscle mode of innervation and the connections between the accessory nerve, the sternocleidomastoid and trapezius muscles. DISCUSSION: The accessory nerve is a muscular nerve and supplies the main innervation to the trapezius muscle especially for the superior and middle sections. There is a clear participation of the cervical plexus either through the trapezius muscle by nerve anastomosis behind the trapezius or directly especially in the distal portion. CONCLUSION: This anatomical study allows a better understanding of the clinical aspects and the indications of nerve repairs.
Aged↗
[Traumatic lesions of the spinal accessory nerve. II: clinical study and results of a series of 25 cases].
INTRODUCTION: Trapezius muscle paralysis after accessory nerve injury was mostly seen after a so called minor surgery of the neck: 17 lesions among 25 appeared after the excision of a cervical cyst or a small benign tumor. This notion should be remembered because the prevention of this paralysis is easy. MATERIAL AND METHODS: In the established lesion, the repair is to be done as soon as possible. The authors report a retrospective study of 25 cases of traumatic accessory nerve injury, followed from 1983 and 1992. A nerve repair was done in 15 cases. It consisted in an average 5 centimeters graft in 10 cases, an intramuscular neurotization in 4 cases, a direct suture in 1 case, and a neurolysis in 6 cases. A palliative treatment was suggested in 4 cases. RESULTS: The mean follow up was 15 months (range 6 to 57 months) and 22 operated cases had more than a 1 year follow up. We observed 10 good results for 10 grafts, 1 good result after 1 direct suture; the 4 neurotisations has 3 good results and 1 average result; the 6 neurolysis had 1 very good, 4 good and 1 poor results and in one case there was no possibility of repair. DISCUSSION AND CONCLUSION: The authors underline the good results after nerve repair following a lesion near from the paralysed muscle and also the need for prevention.
Adolescent↗
[GUEPAR total trapeziometacarpal prosthesis in the treatment of arthritis of the thumb. 36 case reports].
The authors review a series of 36 total GUEPAR trapezometacarpal arthroplasties, performed between 1981 and 1990 in 32 patients, with a Dell stage III or IV carpometacarpal arthritis of the thumb (primary arthritis = 34 cases; secondary arthritis: 2 cases, 1 case of chondrocalcinosis, 1 case of osteochondromatosis). Scaphotrapezial arthritis present in 7 cases is not a contraindication to total arthroplasty. The mean follow-up period was 3 and a half years, with a range of 1 to 9 years. Functional results were considered to be good in 89%, without limitation of activity. X-ray study shows: 1) A radioclinical concordence in 64% of cases with good clinical and X-ray results, stable in the long term. 2) A radioclinical discordance in 22% of cases with good functional result but mobilisation of metacarpal stem. 3) Failure in 5 cases (14%) with unsealing and trapezial fracture. This radioclinical study yields two failure factors: preoperative destruction of trapezium in all the failures and these cases are now a contraindication to the prosthesis and inadaptation between stem arthroplasty and metacarpal cavity. This study supports total arthroplasty in trapezometacarpal arthritis of the thumb: III or IV Dell's stage, with preserved trapezium configuration.
Adult↗
[Epiphysio-diaphyseal unicondylar reduction osteotomy for the treatment of clinodactyly due to proximal interphalangeal joint malunion].
Epiphysio-diaphyseal unicondylar reduction osteotomy is a simple technique for correcting clinodactyly due to intra articular proximal interphalangeal joint mal-union, with preservation of pre-operative joint mobility. This technique is based on equilibration of the articular surfaces. By means of a conservative approach, a strong osteosynthesis allows immediate rehabilitation. In the two cases presented here, there was realignment of the overall finger axis and preservation of the pre-operative range of movement.
Adolescent↗
[The plexal hand (involvement of the hand in traumatic lesions of the brachial plexus in adults)].
After spontaneous recovery following brachial plexus injuries, or after nerve regeneration following nervous surgery on traumatic brachial plexus, there usually is a variable residual distal deficit involving the hand and wrist. This deficit is defined by both a functional approach, and its anatomical nervous correspondence, in order to predict which motor muscles will be available for palliative surgery, and to establish the most reasonable therapeutic plan. Total palsy of the hand will only be mentioned, whereas three main presentations of the "plexic hand" are of a greater surgical interest and will be detailed: the "wrist drop", due to C5 C6 +/- C7 supra-clavicular lesions, the hand presenting with a deficit of digit flexion, pinch and intrinsic functions, due to C8 T1 +/- C7 supra-clavicular lesions, non-standardized deficits due to infra- and retro-clavicular lesions, whose therapeutic indications and prognosis are closer to more classical trunk palsies. The review of 44 "plexic hands" after distal palliative surgery indicates the need to modify the fundamental rules of tendinous transfer surgery, and suggests new principles properly adapted to the surgery of plexic hand palsies.
Adult↗
[Fresh sections of the flexor tendons of the fingers and thumb. New therapeutic trends. Apropos of a clinical series of 77 tendon lesions].
In flexor tendon surgery, the main concern of hand surgeons in the last two decades has been to find an effective and reproducible means to avoid post-operative adhesions. For most authors, these adhesions were responsible for the bad results. Since 1960, a constant progress has been achieved with the progress in operative procedures and the better understanding of tendon healing process. Post-operative rehabilitation, especially Kleinert's and Duran's active and passive methods, have radically transformed the prognosis of fresh tendon lesions. In spite of all this progress, zone II tendon injuries are still a difficult problem. In this clinical study, we wanted to introduce two new orientations in order to improve the overall results, the use of human fibrin sealant instead of the epitendinous running suture and an improvement of Duran's technique, developed by the Bichat rehabilitation team since 1987. Seventy-seven tendon lesions treated according to our technique (55 fingers and 22 thumbs) between 1987 and 1991, were reviewed. All the lesions studied were in zone II and T II. The mean follow-up is 14.4 months. The evaluation is based on the International Federation of Hand Surgery score for fingers, and the Tubiana score for thumbs. 74% of fingers and 86% of thumbs were scored as good and excellent.
Adult↗
[Therapeutic possibilities of arthroscopy in chronic painful wrists. Apropos of 27 cases with 55 arthroscopies].
55 arthroscopies of radio- and midcarpal joints of the wrist were performed for chronic wrist pain with a difficult diagnosis and/or treatment. None of the patients suffered a deterioration and no complications were observed. The results were analysed according to Jackson's and Abe's criteria. In the overall series, arthroscopy was considered to be beneficial for the diagnosis in 80% of cases and for treatment in 49% of cases. Wrist arthroscopy was beneficial in 100% of cases for exact evaluation of the lesions of osteoarthritic wrists or wrists with intracarpal disorganisation and guided the subsequent therapeutic indications. Only 41% of cases obtained a therapeutic benefit from arthroscopy, which nevertheless constituted a useful alternative to surgical operations with a long postoperative course, allowing rapid return to work. Arthroscopy was beneficial for the diagnosis in 66% of chronic painful wrists in which the standard radiological and dynamic assessment was normal, by identifying the anatomical lesions. Arthroscopy was not beneficial in 34% of cases, corresponding to patients with no precise clinical symptoms. Arthroscopy was beneficial for treatment in 54% of cases, with complete cure in the majority of cases.
Adolescent↗
[Epicondylalgia, diagnosis and treatment A review of a series of 31 surgically treated cases].
Thirty-one of lateral elbow pain have been reviewed, with an average follow-up of 32.4 months after surgery. The necessity of an adequate surgical procedure for each cause is confirmed. The etiology are: epicondylitis, posterior interosseous nerve entrapment and humero-radial articular pathology. We tried to define a correspondence between etiology and clinical examination. For type I (pain by palpation on lateral epicondyle = tendinitis) and for type II (isolated pain on the head of the radius = nerve entrapment) the correlation is good with operative findings. In contrary there is a correspondence in type III (regional pain with irradiation) only for 50% of the cases. Specific surgical technique is employed for each supposed cause. The results at follow-up are good for 87% of the patients (27 cases) and failed in two. These two cases can be explained: by multiple surgery, psychologic context and inadaptation of the work for full activity. The value electrophysiological examination before operation is examined.
Adult↗
[Chronic ulnar nerve compression syndrome at the elbow. Apropos of 74 cases].
Seventy-four patients were operated at Bichat hospital for chronic ulnar nerve entrapment at the elbow between 1982 and 1988. For 62 of them, the etiology of the compression was idiopathic and these cases were treated by neurolysis only or, if the nerve was unstable, by neurolysis associated with medial epicondylectomy. For 12 of them, the etiology of the compression was post-traumatic and these cases were treated by anterior subcutaneous transposition of the nerve using a fat sling. The average follow-up is 28 months and the results take into account the clinical preoperative grading according Mac Gowan's classification: grade I subjective symptoms combined with hypoesthesia in ulnar fingers grade II: weakness and wasting of the interossei combined with subjective symptoms, grade III: marked weakness and wasting of the interossei, adductor pollicis, and hypothenar muscles combined with anesthesia in ulnar fingers. The 62 idiopathic compressions treated by neurolysis only or, if the nerve was unstable, by neurolysis associated with medial epicondylectomy showed 51 very good and good results. The 12 post-traumatic compressions treated by anterior subcutaneous transposition of the nerve using a fat sling showed 9 very good and good results. The authors stress the importance of their approach which takes account of the clinical preoperative grading and the etiology of the compression in order to apply correct surgical treatment.
Elbow↗
[Chronic, post-traumatic scaphoid-lunate instability treated by scaphoid-lunate arthrodesis].
The authors after a review of certain elements of the physiology and pathophysiology of the scapho-lunate couple, report a series of 10 patients presenting a post-traumatic scapho-lunate instability stabilized by scapho-lunate bone graft in order to obtain scapho-lunate arthrodesis. The bone fusion was obtained 5 times out of 10, 3 times complete and 2 times by an incomplete bony bridge. In 5 cases, bone fusion was not evident, a fibrous non-union probably occurred which maintained the correction. Nevertheless, the overall results were considered good in 9 out of 10 cases with only one poor result. The outcome with a mean follow-up of 4 years did not show any arthritic changes. The authors consider that scapho-lunate stabilization with an interposed bone graft is a good method which can ensure good stabilization and good clinical results.
Adult↗
[Resection of the proximal carpal bones in the sequelae of scaphoid fractures].
Proximal row carpectomy has precise indications in cases of severe sequelae of scaphoid fractures. This procedure may be indicated either as first-line treatment in a case of advanced pseudarthrosis with osteoarthritis, particularly radio-scaphoid, or secondarily after scaphoid pseudarthrosis has been unsuccessfully treated by other methods. It is essential to make sure that the head of the capitatum and the radial surface of the lunate bone have a satisfactory appearance on plain X-rays, MRI and occasionally arthroscopy. The overall results of this operation which retains wrist movements and which also preserves a good grip strength are very encouraging, as demonstrated by the series of 48 cases of sequelae of scAphoid fractures treated by this technique.
Activities of Daily Living↗
[Apropos of ... ulnar translocation of the carpus after surgery of the rheumatoid wrist. Review of 54 cases].
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Arthritis, Rheumatoid↗
[Total paralysis of the brachial plexus caused by supra-clavicular lesions].
From 1983 to 1987, 50 adult patients who suffered total palsy of brachial plexus were operated on. The average follow up was 39 months. They suffered severe supra-clavicular lesions of all the roots. All the roots damaged in the scalenic area were grafted, the avulsed ones were not. One root was grafted in 23 patients, two roots in 9 patients, three roots in 5 patients, four roots in 1 patient. No root was grafted in 12 patients. An active flexion of the elbow (over M3+, M4) was recovered in 39 patients (76 per cent). An active adduction of the shoulder (m. pectoralis major) was recovered in 24 patients (48 per cent), and an active abduction (supraspinatus or deltoid) in 13 patients (26 per cent). Twenty seven patients had severe pain before surgery. After grafting, pain decreased in 17 (62 per cent. At follow-up, 31 of the 50 patients had no pain or mild pain. These results justify for the authors nerve repair in total palsy of brachial plexus by supra-clavicular lesions.
Adolescent↗
[Synovectomy in the realignment-stabilization of the rheumatoid wrist. Apropos of a series of 104 cases with average follow-up of 5 years].
The authors studied a series of 104 rheumatoid wrists, stages II, III or IV according modified Larsen's grading, treated between 1980-1988 by synovectomy realignment stabilization. The mean follow-up period was 5 years. The operation presents different steps which have an additive effect and must be associated in order long term clinical and radiological stability. They associated: extensor tendons and articular synovectomy stabilization of the distal radio ulnar complex by Sauve-Kapandji's operation, tendon transfert: the extensor carpis radialis longus is transferred on the extensor carpi radialis brevis the extensor carpi ulnaris is relocated with posterior annular dorsal ligament plasty. Results concerning relief of pain were very clear because the patients presented either complete relief of pain (73%) or only intermittent occasional pain. The overall active range of motion is nearly the same, when compared pre- and post-operative ratings. In general the patients who presented good pre-operative mobility usually improved them and the others preserved them. Larsen's radiological grading was modified by the authors to include instability's criteria in frontal and sagittal plane. Carpal height remained stable (75% less than or equal to 1 mm), ulnar deviation has never overreached 3 mm, radial deviation was not modified in 50% of cases. They found only 4 wrists presenting a stage II radiological grading with an evolution to the stage III and 12 of the stage III grading became stage IV. The instable type of the stage IV was stabilized by a surgical radiolunate arthrodesis. The stabilized type was nearly not modified. The different steps of operation (articular and tenosynovectomy, carpus stabilization and realignment with stabilization by stabilization of the radio ulnar complex joint using Sauve-Kapandji operation, tendons transfers and dorsal retinacular plasty) have an additive effect in achieving relief of pain with preservation of the pre-existing mobility. The stabilization of the radio ulnar complex by the Sauve-Kapandji operation constitutes a new approach in rheumatoid arthritis published by the author in 1985 and in our opinion appears to be simple and is very efficient in stabilizing wrist immediately, thus allowing early rehabilitation of these patients. Long term stability is affirmed by clinical and roentgenologic follow-up and globally a painless wrist, a preservation of the pre-operative motion and a stabilization in frontal and sagittal plane is obtained.
Adult↗
[Carpal tunnel syndrome. Etiology, physiopathology, diagnosis, principles of treatment].
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Carpal Tunnel Syndrome↗
[Surgical repair of the axillary nerve. Apropos of 37 cases].
The authors have reviewed the results of the operative repair of 37 injuries of the axillary nerve. In 25 patients only the axillary nerve was injured, in 8 the suprascapular nerve was also damaged and in a further 4 the musculocutaneous nerve had also sustained injury. There was an associated anterior dislocation of the shoulder in 10 patients and a fracture was present in 8. Eleven patients out of 25 had a nearly normal range of abduction in spite of paralysis of the deltoid muscle, and this accounted for delay in diagnosis. Operation was undertaken 8 months after injury using a combined anterior and posterior approach. In 34 patients disruption of the nerve had occurred in relation to the quadrilateral space. In 32 cases nerve grafts were employed, in 2 direct suture and 1 underwent neurolysis. The results were good or very good in 23 out of the 25 direct repairs of isolated axillary lesions, and in all 4 patients with associated injury to the musculocutaneous nerve. Only 4 good results were obtained in the 8 patients who also had injuries to the suprascapular nerve. The results suggest that repair should be carried out early at between 3 and 6 months. E.M.G. studies are necessary before operation for proper assessment of nerve recovery.
Adolescent↗