Brachial plexus injuries. Management and results.

At the time of accident the brachial plexus can be repaired primarily if there is a clean transection. In case of a clavicular fracture and/or of a severe bleeding by rupture of the subclavian artery, the hematoma has to be evacuated to avoid compression of the brachial plexus. For the same reason, the fracture should be stabilized as soon as possible and the artery repaired. The reconstruction of the brachial plexus is performed as a secondary procedure. In case of a closed injury all efforts should be directed to clarify the diagnosis and to exclude cases with good chances of spontaneous recovery. The remaining cases are subject to direct repair. According to the amount of damage, external or internal neurolysis, neurorrhaphy, nerve grafting, or neurotization by nerve transfer is performed. Direct surgery is followed by a period of intensive physiotherapy. Social and psychologic care are extremely important. Patients should start to work as soon as possible. If they are not able to resume their original profession, they have to be prepared for another job that they can perform with one arm and one hand. The whole treatment is planned and supervised by the surgeon. After a sufficiently long period, usually one-and-a half years following direct repair, the amount of functional return is analyzed. Decisions are made to perform adequate palliative surgery, in order to make maximum use of the returned function.