Free Muscle Transfer in Posttraumatic Plexopathies: Part III. The Hand

Background: In lower root avulsion plexopathies, free muscle transfers for hand reanimation provide the only hope for the paralyzed hand, as the outcomes of hand functional restoration after primary brachial plexus reconstruction are uniformly poor. The purpose of this study was to analyze the outcomes of free gracilis muscle transfers for hand reanimation in severe brachial plexus injuries in relation to the respective motor donors. Methods: Since 1981, 71 free gracilis muscles have been transplanted for hand reanimation. Thirty-eight were for finger flexion and 33 were for finger extension. Neurotizations included motor donors such as intercostal nerves (n = 29), contralateral C7 root (n = 28), spinal accessory nerve (n = 7), or upper roots of the ipsilateral plexus (n = 5). Results: Preoperative and postoperative muscle grading and range of motion were found to be significantly different. The strongest motor donor for finger extension was the distal spinal accessory. The medial antebrachial cutaneous nerve as a conduit nerve carrying motor axons yielded worse results than other motor donors. Intercostals were useful for finger flexion and the contralateral C7 root was useful for finger extension. Scar formation in the volar wrist area was frequently a problem. Conclusions: After securing the stability and function of the proximal joints of the upper limb, attention should be shifted to the hand, and in compliant patients with supple finger joints, hand reanimation should be attempted. It is only through these efforts that the future of the paralytic limb can be upgraded to a useful assist extremity. (Plast. Reconstr. Surg. 124: 1225, 2009.)