Brachial Plexus Injury and Repair--Symposium: Experience With the

Free Vascularized Ulnar Nerve Graft in Repair of Supraclavicular Lesions of the Brachial Plexus. Birch-Rolfe. Dunkerton-Mark. Bonney-George. Jamieson-A-M. Clinical Orthopaedics and Related Research. 1988 Dec. 237. pp 96-104. The treatment consisted of a free vascularized ulnar nerve graft in 63 patients with lesions of the supraclavicular brachial plexus. Since 1978, the outcome in 42 patients with a minimum follow-up period of 30 months was certainly better than with an avascular segment of ulnar nerve. Clear proof of hopeless prognosis for recovery along the course of the ulnar nerve is essential before using this graft. The early operations used the ulnar artery and accompanying veins as the pedicle for the graft; later a technique using collateral vessels in the arm has been favored. Although functional elbow flexion has been regained in the majority of patients, recovery of function into the hand has been disappointing. Although it cannot be proved that results are better than when conventional sural nerve grafts are performed, the authors believe that this is the case. The vascularized ulnar nerve graft (VNG) is indicated in more severe injuries of the brachial plexus, where preganglionic injury to the eighth cervical and first thoracic nerves is proven, where the gap between nerve stumps is long, and when the presence of two or three proximal stumps allows the opportunity for extensive repair. In ten adults recovery into the flexors of the *wrist* and of the digits has reached Grade 3 power but function is restricted to the crudest hook grasp. Sensory return sufficient for recognition of harmful stimuli and temperature change has occurred in ten adults. Hypersensitivity has not been a problem in this series, unlike experience following repair of the median or ulnar nerve injured more distally. All of these patients experienced pain, often to very severe degrees, and in four patients pain remained a dominating problem at the time of review. On the whole pain is worst in those in whom no recovery occurs, but a successful graft is no guarantee of pain relief.