gms | German Medical Science

Objectives/Interrogation: Severe upper and total obstetric brachial plexus lesions must be explored and reconstructed within the first months of life. The frequently encountered non conducting neuroma in continuity are routinely excised and grafted by sural interposition fascicles. In specific cases, when the gap is around 1 cm and the mobilisation of the distal plexus is achievable, a direct coaptation of both the proximal and distal nerve stumps after histographic control is feasible - we present those cases among our patient series.

Methods: We performed direct intraplexic coaptations in 22 children between 2013 and 2016, involving 10 combined upper and middle trunk, 12 upper trunk (1 partial rupture).

All patients were followed clinically and video documented.

Results and Conclusions: We observed good functional improvement in all cases, comparable to autologous grafts. Six months after surgery, active elbow flexion ranged between 60 and 90 degrees and active abduction was 75°, improving to 90° after 12 months and 124° after 18 months.

In upper lesions treated by direct coaptation of the upper trunk, an additional spinal to suprascapular nerve transfer improves passive and active shoulder lateral rotation.

In selected cases with short gap after neuroma resection, the direct stump coaptation is feasible and appealing. Suture tension is reduced by special 6/0 sutures and a more adducted- elbow flexed limb position and immobilisation. Clear advantages are the missing need for sural nerve harvest and the coaptation of thick, fiber rich nerve stumps of good regenerative capacity. Potential drawbacks are the risk of suture rupture and intraneural fibrosis; also do we observe some more coactivation. So far our clinical results are promising and feared complications are rare.