Chammas M, Meyer zu Reckendorf G, Allieu Y
Service de Chirurgie Orthopédique et Chirurgie de la Main, Hôpital Lapeyronie, CHU Montpellier.
Rev Chir Orthop Reparatrice Appar Mot. 1996;82(5):386-95.
In case of severe traction injuries of the supraclavicular brachial plexus in adult, the functional results of direct shoulder nerve repair are less predictable than those of the elbow. Furthermore, the surgical management of the remaining flail shoulder is still controversial. The post-operative results and the indication for shoulder arthrodesis are evaluated in this study.
Between October 1978 and January 1994, 18 gleno-humeral arthrodesis were performed on 18 patients for paralytic shoulder following brachial plexus injury. The average age at the time of operation was 25 years. A C5C6 lesion was present in 2 patients, a C5C6C7 lesion in 8 patients and a C5 to T1 lesion in the remaining 8 patients. Seven patients had a suprascapular nerve reinnervation failure. All these 18 patients recovered an active elbow flexion spontaneously or following direct nerve repair, tendon or free muscle transfer. The average delay between nerve repair and arthrodesis was 2 years and 4 months. For fixation, we always used internal fixation by screws, combined to an external fixator device in 10 cases.
16 patients were reviewed with an average follow-up of 6 years and 10 months (min. 6 months, max. 15 years and 8 months). Two types of complications occurred: 2 cases of gleno-humeral non-union requiring revision with bone-grafting, and 3 humeral fractures in the first 6 months after arthrodesis. The study of the arthrodesis position showed an average abduction of 25 degrees, an average flexion of 18 degrees, an average internal rotation of 22 degrees. The average motion values are 60 degrees of abduction and flexion, 14 degrees of extension, 0 degree of external rotation and 48 degrees of internal rotation. The range of motion depends closely on scapulo-thoracic muscles strength, especially the serratus anterior muscle. A flail hand primarily influences the subjective result. 14 of the 16 patients could easily reach their mouth. The average muscle shoulder strength, evaluated with the Isobex device, is 11 kg for flexion and abduction, 9 kg for adduction, 8 kg for internal rotation and 4 kg for external rotation.
Gleno-humeral arthrodesis is a reliable method for restoring shoulder function in case of brachial plexus sequellae lesion, giving more strength, but less external rotation than shoulder nerve repair.
在成人锁骨上臂丛神经严重牵拉伤的情况下，直接修复肩部神经的功能结果比修复肘部神经的结果更难预测。此外，对于剩余连枷肩的手术治疗仍存在争议。本研究评估了术后结果及肩关节融合术的适应证。
1978年10月至1994年1月，对18例臂丛神经损伤后出现麻痹性肩部的患者进行了18次盂肱关节融合术。手术时的平均年龄为25岁。2例患者存在C5C6损伤，8例患者存在C5C6C7损伤，其余8例患者存在C5至T1损伤。7例患者出现肩胛上神经再支配失败。所有这18例患者均自发或在直接神经修复、肌腱或游离肌肉转移后恢复了主动屈肘功能。神经修复与关节融合术之间的平均间隔时间为2年4个月。对于固定，我们总是采用螺钉内固定，10例患者联合使用外固定器装置。
对16例患者进行了复查，平均随访6年10个月（最短6个月，最长15年8个月）。发生了两种类型的并发症：2例盂肱关节不愈合，需要进行植骨翻修；3例在关节融合术后的前6个月内发生肱骨骨折。对关节融合位置的研究显示，平均外展25度，平均屈曲18度，平均内旋22度。平均活动度为外展和屈曲60度，伸展14度，外旋0度，内旋48度。活动范围密切取决于肩胛胸壁肌肉的力量，尤其是前锯肌。连枷手主要影响主观结果。16例患者中有14例能够轻松够到自己的嘴。使用Isobex装置评估的平均肩部肌肉力量为：屈曲和外展11千克，内收9千克，内旋8千克，外旋4千克。
盂肱关节融合术是恢复臂丛神经后遗症病变时肩部功能的可靠方法，能提供更大的力量，但与肩部神经修复相比，外旋功能较差。
