Palliative Surgery in Brachial Plexus Palsies

Palliative surgery is sometimes necessary after failure of nerve repair to improve the function of the upper extremity but it can also be indicated at the same time with the nerve surgery.

Palliative surgery must be individualized for each patient and depends on the degree of recovery gained after nerve repair. Intensive rehabilitation to obtain complete passive motion of the joints is essential after brachial plexus injuries. Patient's motivation and ability to cooperate is very important. Restoration of shoulder's stability and elbow's flexion are prerequisites for good hand positioning. The ultimate goal is the restoration of the most basic functions of the hand: pinch and grip.

1. Different procedures can be used to stabilize and to improve the function of the shoulder:

• Ligament plasty reduces the inferior subluxation of the humeral head and provides slight external rotation of the arm.

• Arthrodesis of the shoulder is recommended by some authors in cases of deltoid, supraspinatous and infraspinatous paralysis. Ideal positioning is difficult and nonunion is a frequent complication. However, strength is improved after arthrodesis and nerve repair procedures can be focused on the reconstruction of the function of the elbow and hand. The procedure is contraindicated in serratus anterior paralysis.

• In cases of isolated deltoid paralysis, transfer of the trapezius onto the humerus (Bateman's procedure) provides 30° of abduction.

• Derotation osteotomy of the humeral shaft is the last solution to avoid abnormal positioning of the forearm during elbow flexion due to the lack of external rotation.

2. Numerous procedures have been used to restore elbow flexion depending on the nerve lesion:

• In C5, C6 palsies a triceps to biceps transfer (Bunnel 1951) is preferable. Pectoralis minor (Le Coeur 1953) or flexor-pronator (Steindler 1918) transfers can be also used.

• In C5, C6, C7 palsies, a flexor-pronator advancement is preferable. The strength of the transfer can be improved with an associated arthrodesis of the wrist.

• In total palsies a triceps to biceps or a latissimus dorsi transfer can be used.

3. Palliative surgery for restoration of basic functions of the hand (extension of the wrist, flexion of the fingers, adduction flexion of the thumb and extension of the MP joints), depend on the nerve lesions:

• In the cases that C5, C6, C7 are involved and C8, T1 are spared, conditions analogous to high radial palsies, Tubiana's technique can be used:

- Pronator teres (PT) transfer to extensor carpi radialis brevis (ECRB)

- Flexor carpi ulnaris (FCU) to extensor digitorum communis (EDC) and to extensor pollicis longus (EPL)

- Palmaris longus (PL) to abductor pollicis longus (APL) and extensor pollicis brevis (EPB)

• In the cases that C8, T1 are involved (with or without the C7) and C5, C6 are spared, finger flexion can be obtained through transfer of extensor carpi radialis brevis or through tenodesis of flexor digitorum profondus and pinch grip can be obtained through brachioradialis to flexor pollicis longus transfer.

• In cases of total palsies, tenodesis and arthrodesis procedures allow functional positioning of the fingers and the thumb.

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