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SUMMARY : Paralytic shoulder secondary to posttrau- .

lesions In cases where shoulder function has not been
matic peripheral nerve lesions in the adult. restored, palliative operations may be considered :
arthrodesis or, more often, derotation osteotomy of the
A critical review is presented of the indications for humerus which can be combined with transfer of the
nerve repair or transfer and for palliative operations teres major and latissimus dorsi.
in the management of paralytic shoulder following
traumatic neurological injuries in the adult. Different II. Retro- and infraclavicular lesions of the brachial
situations are considered : paralytic shoulder following plexus.
supraclavicular lesions of the brachial plexus, following
retro and infraclavicular lesions and following lesions
Twenty five percent of the lesions of the brachial plexus

to the terminal branches of the plexus (axillary , su- -

occur in the retro or infraclavicular region and involve
prascapular and musculocutaneous nerves) and finally the secondary trunks, most commonly the posterior
problems related to lesions of the accessory nerve and .
trunk Nerve repair should be performed early The .
the long thoracic nerve. shoulder may be affected owing to involvement of the
axillary nerve in cases of lesions of the posterior trunk,
I. Supraclavicular lesions of the brachial plexus. often associated with a lesion of the suprascapular
nerve Regarding the terminal branches (axillary, su -
In complete (C5 to Tl) lesions, the possibilities for prascapular and musculocutaneous nerves), spontane -
nerve repair or transfer are at best limited, and the ous recovery may be expected in a significant proportion
aim is to restore active flexion of the elbow. Palliative of cases but is often delayed (6-9 months), and the
opérations may be associated in order to stabilize the problem is to avoid unnecessary operations while not
shoulder. In case of a complete C5 to Tl root avulsion, unduly delaying surgical repair in cases where it is
amputation at the distal humerus may be considered
but is rarely performed combined with shoulder ar - .
indicated MRI may be useful to delineate those cases
where surgery is indicated : repair is usually performed
throdesis if the trapezius and serratus anterior muscles
are functioning. The shoulder may also be stabilized .
around 6 months following trauma Isolated lesions of
the axillary nerve may be repaired with good results
by a ligament plasty using the coracoacromial ligament . .
using a nerve graft The lesion may occur in combi -
In cases where the supraspinatus and long head of the nation with a lesion of the suprascapular nerve ; the
biceps have recovered, but where active external ro - latter may be interrupted at several levels. Proximal
tation is absent, function may be improved by dero - repair may be performed using a nerve graft ; distal
tation osteotomy of the humerus.
In partial C5,6 or C5,6,7 lesions, the indications for
nerve repair and transfer are wider, as well as the
indications for muscle transfers. In C5,6 lesions, a Service de Chirurgie Orthopédique et Traumatologique,
neurotization from the accessory nerve to the supras - Département de Chirurgie de la Main et du Membre Supé-
capular nerve gives 60% satisfactory results; this is also rieur, Centres Urgences Mains. Hôpital Bichat, 46 rue Henri
true following treatment of C5,6,7 lesions, whereas Huchard, F-75877 Paris cedex 18, France.
restoration of active elbow flexion is obtained in 100 % Correspondance et tirés à part : J. Y. Alnot.
Conférence donnée à la réunion de FAOLF, Louvain -la-
of cases in C5,6 lesions but only in 86% in C5,6,7
Neuve, mai 1998.

Acta Orthopædica Belgica, Vol. 65 - 1 - 1999


lesions are more difficult to repair and may require The indications for this surgery will be based on
intramuscular neurotization Lesions of the musculo - anatomopathological lesions, emphasizing that
cutaneous nerve may be repaired with good results using nerve surgery must always be done first, but that
a nerve graft Lesions of the axillary nerve may be seen secondarily or in parallel, palliative interventions
associated with lesions of the rotator cuff The treatment may be discussed.
varies according to the age and condition of the patient
Specific clinical pictures should be studied
and according to the condition of the cuff muscles and
according to the anatomic-pathological lesions and
tendons: in a young patient with avulsion of the
tendons from bone, cuff reinsertion is indicated ; in an
three main chapters can be individualized:
older patient, the cuff must be evaluated by MRI or - the paralytic shoulder as part of the lesions
arthroscan, and repair is indicated unless the cuff tear supraclavicular nerves of the brachial plexus,
is not amenable to surgery or there is fatty degeneration - the paralytic shoulder in the context of retro- and
of the muscles. infra-clavicular lesions of the brachial plexus and
Palliative surgery may be indicated in cases seen late especially of the truncal nerve lesions of the
or after failed attempts at nerve repair. In cases with terminal branches of the plexus, namely the axillary
isolated paralysis of the deltoid, transfer of the trapezius nerve, the supra-scapular nerve and the muscular-
to the proximal humerus or of the long head of the cutaneous nerve ,
triceps to the acromion may he performed depending - the paralytic shoulder in the context of isolated
on whether active elbow flexion is associated with ante - lesions of the nerves participating in the shoulder
or rétropulsion of the humerus In cases of deltoid
function, spinal nerve (trapezius) and Charles Bell's
paralysis with paralysis of the external rotators, one
of these transfers may be associated with transfer of nerve (large serrated)
the teres major and latissimus dorsi to the insertion The monograph on traumatic paralysis
of the infraspinatus. of the adult brachial plexus, J. Y. Alnot and
A. Narakas (7, 8) has gathered the opinion of many
III. Paralytic shoulder with isolated lesions of the authors and has reviewed the indications and the
results of this difficult surgery (11, 12, 26).
accessory or long thoracic nerves.
I. Paralytic shoulder in supraclavicular nerve injury
The accessory nerve is vulnerable and often incurs of the adult brachial plexus
iatrogenic lesions. Excellent results may be obtained The current evolution has been towards the repair
by direct suture or nerve graft. In cases seen late or of nerve damage and the goal is to restore the best
after failure of repair, palliative operations may be possible function knowing that the recovery of the
indicated, such as transfer of the levator scapulae or
bending of the elbow passes first, followed by the
rhomboid muscle. Paralysis of the serratus anterior due
function of the shoulder.
to lesion of the long thoracic nerve may occur following
forceful movements or overloading of the shoulder Without going back to the respective indications in
(haversack paralysis), in throwing sports or rugby. the C5-C6-C7-C8-T1 total paralysis or in the C5-
Spontaneous recovery often occurs but is usually slow C6 or C5-C6-C7 partial paralysis it is necessary to
(12-18 months). Palliative surgery may be considered recall several points concerning the shoulder as part
for cases seen late without recovery, with winging of of the overall plan nervous repair.
the scapula. Transfer of the pectoralis major or minor This nerve repair must be done every
has been advocated ; transfer of the latissimus dorsi whenever possible:
or teres major has also been advocated associated with - on the supra-scapular nerve and the nerve
scapulopexia, which is the author’s preferred treatment. axillary
Acta Orthopædica Belgica, Vol. 65 - 1 - 1999

Le développement des techniques de microchi-

rurgie nerveuse depuis ces 10 dernières années a
permis d’obtenir des résultats notables dans la
chirurgie des nerfs périphériques et du plexus
12 J. Y. ALNOT

- or, depending on the anatomo-pathological 1. In C5-C6-C7-C8-T1 total paralysis

lesions (3, 4, 9)
only on the suprascapular nerve a) The interest of nerve surgery is no longer to
It will not be necessary, however, to forget the defend, because on the one hand it allows to
restoration of the pectoralis major muscle which recover some active mobility of the upper limb
occurs after graft repair on the anterior part of and on the other hand it has an indisputable
the first primary trunk and which intervenes in effect on the pain by restoring certain afferences
the function of the shoulder. sen - sitive at the level of the upper limb.

The functional results are the result of muscle In 24% of cases, there is a root avulsion of all the
reinnervation and in the repairs of the single roots and only neurotization on the
supra-scapular nerve, the abduction antepulsion musculocutaneous nerve is possible. No nerve
is rarely greater than 40-50 degrees. repair surgery can be performed for the shoulder
and palliative procedures will be discussed later
The recovery of an active external rotation is after recovery of active elbow flexion.
very important to clear the arm of the thorax,
allowing a better positioning and a better In other cases where there are one or two
bending of the elbow. graftable roots C5 or C5-C6 (Figure 1), the
option is not to disperse the fibers and perform a
This flexion of the elbow is the first function to graft on the anterior part of the first primary
restore and it should be noted that it contributes trunk and if possible on the posterior part of the
to the stabilization of the shoulder by the long first primary trunk in the case of two roots
portion of the biceps.
transplantable. This graft on the posterior part
The assessment of shoulder function is difficult of the first primary trunk participates in the
in this context of radicular paralysis, but overall, resuscitation of the shoulder and it is also
it will be necessary to assess, on the one hand necessary to graft the suprascapular nerve by
the stabilization of the shoulder and on the other performing direct suture neurotization from the
hand, the recovery of certain active movements. terminal part of the spinal nerve.
Thus, we can say that we have obtained: The results in the literature and in our
- a good result, if the shoulder is stable, with an experience show that in 82% of cases a recovery
active mobility in external rotation of at least 30 of the active flexion of the M3 + -M4 elbow is
degrees and an active elevation in the frontal or obtained and in 60% of cases a recovery of the
sagittal plane of 40 degrees. external rotation abduction at the level of
- a fairly good result, if the shoulder is stable of the shoulder.
with active mobility in elevation in the frontal or The use of the terminal part of the spinal nerve
sagittal plane of at least 40 degrees, but without with respect to the branches going to the upper
or with very little active external rotation. and middle bundles of the trapezius does not
- a useful result, if the shoulder is only stabilized alter the function of this muscle, as several
without active mobility by differentiating, studies by Allieu, Alnot and Narakas have shown
however, the active stabilization by recovery of (7); on the other hand these results are better
the supraspinatus and infraspinal muscles at M2 than a suprascapular nerve transplant from C5.
or a stabilization occurring only actively when b) Palliative surgery
flexing the elbow with therefore lower
subluxation reduction by The first goal in the treatment of brachial plexus
palsy is to resuscitate the flexion of the elbow, but
the long portion of the biceps. A possible this elbow flexion can only be done properly if
stiffening should also be specified, the shoulder is stable with active external
rotation allowing
participating in passive stabilization.
- a failure, if the shoulder is not stabilized.

opinai at the bending of the elbow to be done without

rubbing against the thorax.
Cs C5

Ce Ce
Stabilization of the shoulder is ensured mainly
by 3 muscles, the supraspinatus, the deltoid and
s.s the long portion of the biceps; the active external
*¥ Ci

Ce ¥ Ce
rotation is ensured by the sub-spinous and the
small round..
r kf kf

R ?
0 * R
* Other elements come into play depending on the
associated lesions and sequelae of fractures or
Capsular retraction can stabilize passively
Fig. 1 a et 1 b
the shoulder emphasizing here that rehabilitation
This paralytic shoulder, whose function will always
be limited, must never seek to recover passive
mobility beyond 80 degrees of antepulsion and 30 to
Spinal Plexus cervical
40 degrees of external rotation. Palliative surgery at
the level of the shoulder finds its indications in the
failures of the nervous surgery, but also in
complement of this one and various situations can be
¥ Cs
- the upper limb has paralysis

Ce total and definitive .

S.S C7 This case, which often occurred before the advent of
Ce Cl
nerve surgery, is
* ¥
¥ currently frequent and it is a plexus
\ i complet avec avulsion radiculaire totale ne per-
K G. P ¥ \ i



Fig. 1 c Fig. 1 d

Fig 1: .
- 1 a and 1 b. - Total paralysis with C7-C8-T1 avulsion and putting no repair by graft from
possibility of grafts from C5-C6 depending on the size and
appearance of the roots associated with spinal neurotization
- - upper scapular. If this size and this aspect are the root and where the neurotizations have failed.
- satisfactory, it is possible to bridge the posterior The shoulder is paralytic without any active muscle
- of the first primary trunk. outside the trapezius and large serratus with obvious
- - l: total paralysis with C6-C7-C8-T1 avulsion and grafts instability.
- from C5 associated with spinal neurotization - The injured person has a dangling upper limb,
- upper scapular.
insensitive and annoying, and the weight of the
- - 1 d: total paralysis with avulsion of all the roots. The only
possibility is neurotization directly on the musculo- upper limb results in a lower subluxation of the
cutaneous. shoulder with functional discomfort and
pains in the scapular girdle.
The problem of the conservation of this limb arises,
but experience shows that very few wounded (0.5
to 1%) require an amputation which will then be
made in the lower third of the humerus, associated
with an arthrodesis of the 'shoulder.
It must be emphasized that this amputation will not
solve the problem of possible painful phenomena
and that the injured must be warned. In the
majority of cases, the injured person wishes to keep
his or her upper limb and the question is

Acta Orthopædica Belgica, Vol. 65 - 1 - 1999

14 J. Y. ALNOT

to know if the shoulder should be stabilized while Soejbjerg in 1988 (28) to treat lower shoulder
it dislocations with transposition of the acromial-
coracoid ligament acromial insertion on the
there is no bending of the elbow. trochin.
Of course, striving for spontaneous capsular The modification that we propose is the transfer of
retraction stabilization and a helical splint stage the coracoid insertion with the adjoining part of the
should be attempted. coracoid on the trochin which reduces the lower
If this splint is effective, stabilization of the subluxation and positions the shoulder in slight
shoulder by arthrodesis may be useful provided external rotation with a
that the large serrated muscle is present. benefit when flexing the elbow.
- paralytic upper limb with recovery
• the shoulder is stabilized by the recovery of
from elbow flexion to M3 + 4
supraspinatus muscle and long biceps with so
The problem of the shoulder will arise depending
on the recovery or not of certain periarticular an active antépulsion at 30 or 40 degrees.
muscles. Two scenarios arise depending on whether the
* the shoulder is paralytic without any muscle injured person has recovered an active external
rotation or not.
active outside the trapezium and the large
serrated, In cases where there is no active rotation, bending
of the elbow is done by scraping the chest and the
instability is evident with lower subluxation and arm must be released to allow better flexion.
the weight of the upper limb causes functional
discomfort and pain. The derotation osteotomy of the humerus is an
excellent intervention and greatly enhances the
Should stabilize the shoulder:
recovery of the elbow flexors.
* by arthrodesis, the position of which must be
It is necessary to derail 30 to 40 degrees, so that the
perfectly adjusted. elbow and forearm do not scrape the chest during
This arthrodesis should allow the movements of active bending movements while maintaining the
the scapulothoracic to proceed with their possibility of putting the arm on the chest and
maximum amplitude in the most useful area. abdomen.
The patient whose forearm and hand are In cases where there is active external rotation, no
additional indication is necessary.
The paralytic must be able to put his hand in his
pocket or put it on a table so as to hold an object 2. In C5-C6 and C5-C6-C7 paralysis
and he must be able to squeeze an object against The prognosis is dominated by the need to recover
the thorax, especially if the grand pectoralis has a useful elbow and shoulder to allow the best use
recovered. of the hand which is no longer, as in the previous
The ideal position, the scapula being in cases, paralyzed but normal or partially reached.
anatomical position, corresponds, in general, to a
position of the humerus at 20 degrees of flexion, (a) The indication of nerve repair must be given
30 degrees of abduction and 30 degrees of early (2, 10, 22) because it is very often root
internal rotation. lesions or primary trunks in the scalenic region
with possibilities for nerve repair and obtaining
The approach is superior with a longitudinal satisfactory functional results.
trans-deltoidal incision which gives an excellent
day on the articular cavity and the synthesis is Depending on the number of graftable roots,
then ensured by 3 screws or by a plate or by an level of breakage and appearance and size
external fixator and screws.
* by ligamentoplasty if the injured person wishes
maintain passive mobility in rotation.
A ligamentoplasty using the acro-ligament
mio-coracoid was described by Ovesen and

Acta Orthopædica Belgica, Vol 65 - 1 - 1999

from the root to the operating microscope, it will be
necessary to make a choice in the elements to be The therapeutic plan must be global by not
repaired and to associate therein depending on the dissociating nerve surgery and the possibility of
cases of the complementary neurotisations or the palliative surgery.
muscular transfers innervated by the intact roots In C5-C6 paralysis, nerve surgery or muscular
(figure 2). transfer allowed to recover in 100% of the cases
the bending of the elbow.
At the shoulder level, spinal neuroti-
supra-scapular allowed to obtain a good or very
good result in 60% of the cases, contrary to
C5-suprascapular grafts that gave only 25%
good or very good results.-

Cs .
In C5-C6-C7 paralysis, flexion of
/ Ce
elbow was recovered only in 86% of cases by this
n nerve surgery or muscle transfer and at the
X s s houlder neurotization surgery
C8 y,
of the suprascapular nerve gives identical results.

MC M n C5-C6 paralysis. The shoulder is a real
problem in these
Partial ralysies with however 60% of results

satisfactory by neurotization.
Fig. 2 a Fig. 2 b
In other cases, it will be necessary to move towards
palliative interventions:
- - arthrodesis whose indications are enough

- rare,
% Cs
+ Transfert - - Or derotation osteotomy that can be associated
% flexion coude

SS . with a muscle transfer using the large round and

C7 Û7
% the latissimus dorsal when they are present.
Ca /

R S' R

The technique described by L'Episcopo in
1939(24) consists in transferring both the tendon of
thelarge round and dorsal large postero-
Fig. 2 c Fig. 2 d external,but this technique often only limits the
internal rotation and acts only by tenodesis effect.
Fig. 2 : That's why we associate itat a derotation osteotomy of
20 to 30 degreesand fixing the muscles on the insertion
of the under -
- 2a and 2b: C5-C6 paralysis with possibility of - 2d: C5-C6 paralysis with avulsion of these two roots.
grafting into Elbow flexion is restored by muscle transfer
depending on the size and appearance of the roots. associated with neurotization of the spinal nerve on
If this size and appearance are satisfactory, it is the superior scapular nerve.
to bridge the posterior part of the first primary trunk.
- 2 c: C5-C6 paralysis with a single graftable root
and graft on the anterior part of the first primary
trunk associated with neurotization of the spinal
nerve on the superior scapular nerve.
thorny.a) treatment in C5-C6 and C5-C6-C7
paralysis must therefore combine nerve surgery
and palliative surgery with results, in theseems,
very satisfactory on the bending of the elbow.The
shoulder poses, on the other hand, a real problem
and it is necessary, by multiple neurotizations and
palliative interventions, to recover the best
possible function.

Acta Orthopædica Belgica, Vol. 6 5 - 1 -

16 J. Y. ALNOT

IL The paralytic shoulder in the context of axillary nerve. They noted that, depending on the
retro- and infra-clavicular lesions of the trauma, the anatomo-pathological lesions could
brachial plexus and in the context of truncular range from grade 2 to grade 5 of Sun.
nerve lesions of the terminal branches, axillary derland and that in many cases was occurring
nerve, supra-scapular nerve and musculo-
spontaneous recovery.
cutaneous nerve
Other authors [Coene and Narakas (19), Petrucci et
A. THE PARALYTIC SHOULDER IN THE al (29), Sedel (32)] have subsequently reported
their experience; Alnot and Liverneaux (6) have, in
FRAMEWORK a recent article, reviewed this problem.
The whole diagnostic problem can be summed up
LESIONS in two pitfalls to be avoided: to disregard a rupture
or to disregard a spontaneous recovery.
If, in traumatic palsy of the brachial plexus, To ignore a break is not unusual since in about
75% of the pathological lesions are root lesions 11% of cases, the wounded have a shoulder of
by supraclavicular lesions, 25% are retro- and almost normal mobility apart from a decrease in
infra-clavicular lesions (1).
Trauma is diverse and nerve damage is often This is the result of the particular physiology of the
muscles of the cuff and explains the relative
associated with osteoarticular lesions of the frequency of the lack of knowledge or the delay in
scapular girdle. diagnosis, but does not justify any surgical
As for the nerve lesions, they sit at the level of abstention.
the secondary trunks behind and behind the Indeed, in addition to the loss of strength, the risk
clavicle and pose difficult diagnostic and of rupture by overworking of the muscles of the
therapeutic problems. legitimate headdress in these young subjects, the
nerve repair within a period of 6 to 9 months.
Secondary posterior trunk involvement is the
most common (50% of cases) with all degrees of Ignorance of spontaneous recovery
severity. pulled to unnecessary surgery. In
These lesions of the posterior lateral trunk are Indeed, especially in dislocations of the shoulder,
associated in 30% of cases with lesions of the spontaneous recovery occurs in 75 to 80% of
antero-external secondary trunk. cases, sometimes late and electromyography is
As for the lesions of the anterolateral secondary essential studying the three bundles of the deltoid,
specifying that recovery begins with the posterior
trunk, they are much rarer, exceptionally beam.
isolated and exist in the total lesions with However 6 to 9 months is a long time and it would
rupture of all the trunks. be desirable to operate sooner and current studies
Nerve repair must be done early and will with MRI can, perhaps, allow by showing a
depend on the anatomic-pathological lesions. neuroma of interruption, to decide in a faster time.
Indeed, if the procedure is more than one year after
With regard to the shoulder, the lesions are the initial accident, the chances of recovering after
those of the axillary nerve in the context of the nerve transplantation, a force at M5 without
posterior trunk lesion very often associated with muscular fatigability are less, but on the other
hand, the reduction of the operating delay risks
lesion of the suprascapular nerve. 'lead to abusive surgical explorations on nerves
Palliative surgery will only be considered that can spontaneously recover between 6 to 9
secondarily depending on the case. months, which is why most statistics mention
interventions around the 6th month.

Alnot, Jolly and Valenti (13) reported

first major round of graft repair

Acta Orthopædica Belgica, Vol. 65 - 1 - 1999


- in the isolated lesions of the axillary nerve, with - if it is a relatively young patient who has bone
rupture in the region of Velpeau's square hole, the disinsertion of the muscles of the cap, the indication
surgical procedure by two ways first, one delto- of reintegration is formal.
pectoral and the other posterior to the posterior - if it is an older patient, over the age of fifty, an
edge of the deltoid allows to realize a nerve
transplant and to obtain good (M4) or very good arthro-scanner or an MRI can assess the condition of
(M5) results in more than 65% of cases and a 22% the muscles of the cap and the importance of the
average result (M3). rupture . If this rupture is reinsertion, with muscles in
- - In axillary nerve lesions associated with stages O or I (Bernageau (17), we proceed to a
suprascapular nerve lesions, the shoulder is reinsertion then we follow the evolution of the axillary
paralytic and the repair of both nerves is desirable. nerve.If the rupture is not re-insertable with muscles
- The difficulties sit on the supra-scapular nerve at stages 3 or 4 (amount of fat greater than or equal to
which can be broken at different stages either in
the coracoid notch, or more distally at the level of the amount of muscle) there is no indication to
its terminal branches. intervene on the muscles of the cap if the patient did
- A third approach is necessary and the possible not present disorders before the accident and it is
graft repair in proximal fractures becomes more hoped to recover the state previous, either by
random during distal tearing and in some cases spontaneous recovery of the nerve
intramuscular neurotization is required. axillary, or by subsequent nerve graft.
- - the associated rupture of the musculocutaneous
nerve does not pose, in general, no repair problem
with very satisfactory results by nerve graft. A. PALLIATIVE SURGERY
- - finally, lesion of the axillary nerve may be
associated with The lesions of the axillary nerve should not be ignored
- not to other nerve damage but especially in young subjects and the nerve surgery is
- to rotator cuff lesions. the treatment of choice facilitated by the oligo-
- These lesions greatly aggravate the prognosis, first fascicular structure of the nerve, by its constitution
because they occur in older patients whose nerve predominant in motor fibers and by the proximity of
recovery potential is weakened and then because
they add to the paralysis of the deltoid muscle an the effectors.
attack of other muscles of the shoulder. However, there are some failures or patients seen late
- The association with a rupture either existing or for which a palliative surgery is indicated.
concomitant of the supraspinous muscle which is In the case where the only deltoid is paralyzed, two
then ineffective results in a poor functional result. muscular transfers can be proposed, either the transfer
- Our attitude towards an associated headdress break of the trapezium on the upper end
- to axillary nerve injury depends on the condition
of the humerus according to Bateman (15, 16), that is
- of the rotator cuff.
- In general, these are valid patients who do not the trans-
- feeling no trouble before the accident. Filling the long portion of the triceps according to
- Two scenarios then arise depending on the age Sloaman.
- of The indications depend on the surgeons' preferences,
the patient:
but in our experience, we must judge according to the
existence or not of an active retropulsion of the
humerus during the flexion of the elbow.
If the bending of the elbow is done with some
Active antepulsion, Bateman's trapezium transfer
seems to be a good indication (14, 23).
Léo Mayer (25) described the main intervention
vines and the technique has been modified by Lange

Acta Orthopædica Beigica, Vol. 65 - 1 - 1999

18 J. Y. ALNOT

III- Paralytic shoulder in the context of

and Bateman in 1954 with fixation of the acromial isolated lesions of nerves participating in the
insertion and the outer quarter of the clavicle, as function of
low as possible on the humerus.
For our part, we use a longitudinal skin incision, a shoulder: spinal nerve (trapezius) and nerve
booklet opening on the deltoid and a fixation of Charles Bell (large serrated)
the anterior part only of the acromion on the
trochiter in its external part, then closing of the A. THE SPINAL NERVE
deltoid which will also be fixed to the trapezium
. The superficial situation of the accessory spinal
The postoperative immobilization is provided by a nerve (nerve accessorius) makes it particularly
thoraco-brachial for 4 to 6 weeks, followed by vulnerable in any traumatic neck injury, but
reeducation. the most frequent causes of this branch are
iatrogenic during ganglion dissection, exeresis
When there is a retropulsion of the humerus and of benign tumors or simple ganglion biopsies.
therefore of the shoulder during the flexion of
the elbow, it seems logical to us to use the These lesions pose medico-legal problems
transfer of the long triceps described by
Sloaman in 1916. and surgeons need to pay attention
The skin incision is longitudinal along the posterior very particular to the surgical approach of this
border of the deltoid paralyzed and extended up region even for a simple ganglionic biopsy (1).
and forward to the tip of the acromion. The long
triceps is approached in the space between teres Depending on the level of neck damage, there is
minor and teres major respecting the nerve
always a paralysis of the trapezius muscle and
radial and its branches. sometimes
The large calf tendon, surrounded by thick muscle
fibers, is cut flush with the glide of the scapula sternocleidomastoid.
and after release, the tendon can be brought into Osgard found, like us, that all
contact with the acromion, either directly or by
passing it on. under the posterior head of the patients have difficulty in dressing with a heavy
deltoid and it will be fixed at the place where
the middle chief of the deltoid is inserted by shoulder within hours of the procedure.
trans-osseous points. In the following days, scapular pain occurs with
This fixation and the postoperative immobilization frequent irradiation of the ooplatum and / or
will be done with the abduction shoulder at 90 arm.
degrees, the elbow in extension.
After a month or two, the picture becomes typical
The results of these two palliative procedures make it with the falling shoulder, atrophy of the
possible to improve the function of the shoulder trapezius, the detachment of the scapula and
with an abduction-antepul- sion which, the lack of abduction beyond 90 degrees.
however, does not exceed 90 degrees.
Registry repair is particularly
When the paralysis of the deltoid is accompanied by
paralysis of the external rotators, we must effective on this muscular nerve with a lesion close
associate with the transfer of the trapezius or the to the effector [Osgard and Eskensen, Sedel
long portion of the triceps, a transfer of the and Abois (13), Alnot and Aboujaoudé (2)] and
tendons of the big round and the latissimus dorsi
to the insertion of the sub- thorny. all these authors report, either by direct
suture, or especially by nerve graft of excellent
If the shoulder is stiff, with impossible passive results. Some cases are failures or are seen
external rotation, it is typically the indication of late, no longer allowing for nerve surgery, and
a derotation osteotomy. the possibility of palliative intervention such as
the transfer of the angular scapula
the technique recommended by Bigliani (3).
This procedure consists in removing the anchor
from its insertion on the superior-internal edge
of the scapula and transferring it to the

Acta Orthopædica Belgica, Vol. 65 - 1 - 1999


In the same way, the insertions of the rhomboid of regressive but with a long delay, a year or
the small upper and posterior serratus are 18 months because of the length of the nerve.
tightened so as to avoid the tilting of the scapula There is no mention of nerve exploration at an early
with, according to the authors, acceptable results stage, and it is difficult to form an opinion on this
by decreasing the fall of the scapula and by subject, and no one at this time can say what are the
improving the abduction of the shoulder. indications for neurolysis or repair of this nerve
A. THE PARALYSIS OF CHARLES BELL'S except for iatrogenic lesions, especially during
NERVE ganglion dissection or costoclavicular parade
(NERF OF THE LARGE DENTELÉ) surgery (12, 18).
Nevertheless, a certain number of patients do not
The involvement of Charles Bell's nerve with recover and are seen a year or a year and a half after
paralysis of the large serrated muscle is a rare
the onset of paralysis. Palliative surgery is indicated
pathology and the pathogenic hypotheses have not
in view of functional disorders with shoulder blade
been proven.
detachment during antepulsion movements,
The nerve of Charles Bell which is perpendicular
to the roots of the brachial plexus is, as a rule, not limitation of mobility and decrease
reached in the lesion mechanisms of the of strength associated with pain in the effort (6).
paraplegia of the brachial plexus, but on the other Muscle transplants are intended to get as close as
hand, it is sensitive to the lowering movements of possible to the normal physiology of the large
the megnon. shoulder, thwarted antepulsion or serrated muscle, but in practice, the active character
exaggerated retropulsion. of the transplant is quickly lost by the effect of
All movements that brutally reproduce lowering passive tenodesis, by functional deficiency of the
the stump of the shoulder or carrying heavy loads transfer of a muscle. in an already unbalanced
on the shoulder (paralysis of the knapsack) or shoulder or because of the problems of the insertion
pulling downwards by heavy loads carried at of the transfer, its direction and its moment of
arm's length are likely to damage this nerve. action.
Certain repetitive and daily actions can cause The transfer of the pectoralis major was proposed,
nerve damage and several publications concern by diverting one of its bundles extended by a graft
the sportsman (9) with a risk in sports that require directly on the large dentate, like Tubby (15) or on
armament thrown by a retropulsion followed by a the spinal edge of the scapula. In 1987, Iceton and
rapid antepultion, such as tennis, javelin, weight, Harris (42) reported 15
thrusts on the shoulder, like rugby. cases treated by the transfer of the sternal portion of
Multiple physiopathogenic hypotheses have been the pectoralis major extended by a strip of fascia
developed and, alongside inflammatory and viral
lata and fixed in transosseous level of the tip of the
theories, the traumatic or microtraumatic theory is
scapula with, overall, satisfactory results in 9 cases.
that which is retained with a truncular lesion of
the nerve by elongation (4, 7, 8,
The transfer of the small breastplate was described
16). by Chavez in 1951 and the entire distal insertion of
Charles Bell's nerve can not support more than the muscle is diverted to the lower angle of the
10% of its length of rest and two lesions are scapula. Vastamaki in 1984 reported 6 cases with 5
particularly suspected, on the one hand, between good results (17).
the scalene muscles and on the other hand, at the The transfer of the dorsal dorsal reported by Dikson
level of the and Lange and the transfer of the large round
the 2nd coast pass. described by Hass are part of mixed interventions
Anyway, it's very often about lesions because very often they are associated with
types I or II of Sunderland, usually scapulopexy.
Scapulopexy (5, 14) is the most
Acta Orthopædica Belgica, Vol. 65 - 1 - 1999
20 J. Y. ALNOT

traumatic paralysis C5-C6 and C5-C6-C7 by

practiced and this is the one we recommend if, supraclavicular lesions. Brachial plexus palsy, Monograph
during the initial clinical examination, the of the French Society of Surgery
hand held shoulder blade against the thorax the hand. French Scientific Expansion, Paris, 2nd
clearly improves the mobility and function of
the shoulder, which the patient can perfectly Edition, 1995, 21, 188-196.
see for himself. 1. Alnot J. Y, Daunois O., Oberlin, Bleton R. Total palsy
of the brachial plexus by supraclavicular lesions. Rev.
The attachment of the scapula to the costal Chir. Orthop., 1992, 78, 495-504.
grill is done at the spinal edge of the scapula
using nylon thread or wire interposing bone 2. Alnot J. Y, Daunois O., Oberlin C., Bleton R. Total
grafts between the ribs and the scapula so as to palsy of brachial plexus by supra-clavicular lesions. J.
obtain an arthrodesis scapulothoracic.
Orthop. Surg., 1993, 7, 1, 58-66.
The immobilization on a thoraco-brachialis
abduction, without any antépulsion for 2 to 3 3. Alnot J. Y. The paralytic shoulder, Brachial plexus
months, followed by reeducation, allows a palsy. Monograph of the French Society of Surgery of the
Hand. French Scientific Expansion,
stability of the scapula during the movements
of the scapulo-humeral and a very clear Paris, 2nd ed., 1995, 21, 228-231.
improvement of the function . 4. Alnot J. Y., Liverneaux R H., Silberman O. Lesions of
CONCLUSION the axillary nerve. Rev. Chir. Orthop., 1996, 82, 579-589.
5. Alnot J. Y., Narakas A. Paralysis of the brachial plexus,
Monograph of the French Society of Surgery of the Hand.
In the context of posttraumatic peripheral French Scientific Expansion, Paris, 2nd Ed., 1995, 21, 1-
nerve lesions, the shoulder poses problems of 297.
clinical diagnosis and therapeutic indication. 6. Alnot J. Y, Narakas A. Traumatic brachial plexus
If there is no difficulty in recognizing a totally injuries, Monograph of the French Society of Hand
paralyzed shoulder, it is not the same when Surgery. French Scientific Expansion, Paris, 1996, 1-279.
only one muscle is affected and it is necessary
to 7. Alnot J. Y Traumatic paralysis of the brachial plexus.
Diagnostic and therapeutic problems. Paralysis of the
brachial plexus. Monograph of the French Society
then analyze in a precise way the various
functions of Hand Surgery, Scientific Expansion Fra-
scapulohumeral and scapulo- French, Paris, 2nd Ed., 1995, 21, 99-116.

thoracic. 8. Alnot J. Y, Rostoucher R, Oberlin C. Traumatic C5-C6

and C5-C6-C7 traumatic palsies of the adult brachial
The current evolution has been towards nerve plexus by supraclavicular lesions, Rev. Chir Orthop, 1999,
in press.
surgery as a function of anatomo-pathological
lesions, emphasizing that this nerve surgery 9. Alnot J. Y. Traumatic brachial plexus palsy in adults.
must always be done first and secondarily, and In: Tubiana R., The Hand. W Saunders Company, 1988,
/ or at the same time vol. III, 607-644.
10. Alnot J. Y. Traumatic paralysis of the brachial plexus
palliatives can be discussed, namely, ar-
preoperative problems and therapeutic indications. Micro-
throdesis, ligamentoplasty, muscle transfer and reconstruction of nerve injuries. W. Saunders Company,
Philadelphia, 1987, 325-347.
Derotation osteotomy of the humerus.
11. Alnot J. Y, Valenti P. H. Surgical repair of the nerve
axillary. Int. Orthopedics (SICOT) 1991, 15, 7-11.
BIBLIOGRAPHY 12. Aziz W., Singer R. M., Volff T. W. Transfer of the
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16. Chammas M., Allieu Y., Meyer Zu Reckendorf. The
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du plexus brachial. Monographie de la Société Française 33. Brientini J.M., Vichard P. H. Isolated paralysis of the
de Chirurgie de la Main. Expansion Scientifique Fran- large serrated muscle. Memoirs of the Academy, Masson,
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6. L’Episcopo J. B. Restoration of mucle balance in 4L Gregg J. R., Labosky D. Serratus anterior paralysis in
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traumatiques du nerf spinal accessoire. Rev. Chir. Or-
thop., 1994, 80, 297-304. ResumeJ. Y ALNOT. Paralytic shoulder secondary to
35. Bigliani L. U., Perez Sanz J. R., Wolff I. N. post-traumatic peripheral nerve injuries in the adult.A
Treatment critical review of the indicias for nerve repair, the transfer
of trapezius paralysis. J. Bone Joint Surg., 1990, 72,
701- 704. and palliative operations in the policy of the paralytic
shoulders after traumatic neurological injuries in the adult.
Different situations are considered: paralyticActa
Orthopædica Belgica, Vol. 65 - 1 - 1999
22 J. Y. ALNOT

post trauma. Isolated lesions of the axillary nerve can be

shoulder after supraclavicular lesions of the plexus repaired with a nervous system. This injury can be
brachialis, after retro- and infraclavicular lesions, after combined with injuries of the suprascapular. The latter
lesions of the end branches of the plexus (n.axillaris, n. can even be interrupted at different levels. A proximal
suprascapularis and n. musculocutaneus) and then after recovery with a nerve can be performed. More distal
the lesions of the n. accessorius and the n. thoracicus injuries are already more difficult to repair and can be
longus. require cular neurotonization. Injuries of the muscu-
1. Supraclavicular injuries. With complete (C5 to Tl) locutaneus can be repaired with a nervous system, with
injuries, the possibilities for nerve recovery and / or good results. Injuries of the n. axillaries can also be
transfer are limited and the ultimate goal is to achieve combined with injuries from the rotator cuff. Treatment
an active flexion of the elbow. Palliative operations varies depending on the age, general condition of the
may be added to stabilize the shoulder. With full C5 to patient and condition of the cuff muscles and tendons. In
Tl root emulsion, the a young patient with
amputation of the distal humerus are contemplated but avulsion of the tendons a cuff reincidence is indicated.
this is rarely performed. It should be combined with In the older patient, the cuff can be evaluated with an
shoulder arthrodesis when the trapezius and serratus MRI or an artro-CT and the recovery is indicated when
anterior muscles function. The shoulder can also be the cuff muscles are relatively well-preserved. If these
stabilized with one show a fat degeneration, surgery is contraindicated.
ligament plastic, use the coraco-acro- Palliative surgery can be
mial ligaments in case when the supraspinatus and the employed in these cases where the nerve recovery has
biceps have been recuperated, but when active external failed. In cases with isolated paralysis of the deltoid,
rotation is absent a derotation osteotomy can transfer from the trapezius to the proximal humerus or
from the long head of the triceps to the acromion can be
of the humerus. For particle C5-6 or C5-6-C7 lesions, performed. This is determined by the active elbow
the indications for nerve recovery and transfer are flexion depending on the anti-or retropulsion of the
broader, as are the indications for muscle transfers. In humerus. In cases of deltoid paralysis with paralysis of
C5-6 lesions, a neurotomization of the the exorotators
accessorius nerve to the suprascapular nerve to give one of previous transfers is associated with transfer of
60% satisfactory results. This is also the case for the the teres maior and latissimus dorsi to the insertion of
treatment of C5 to C7 lesions. When the active flexion the infraspinatus.
of the elbow is up to 100%
1. Paralytic shoulder due to isolated injuries of the n.
recovered in C5-6 injuries, this was only 86% accessorius or the thoracicus longus. Pine tree.
the C5-6-7 lesions. In cases where the shoulder accessorius is vulnerable and often suffers from
function could not be restored, palliative procedures iatrogenic injuries. Excellent results can be achieved by
are indicated: arthrodesis or more frequent derotation direct suture or nervous. In late cases or after failure of
osteotomy of the humerus with a transfer of the teres nerve recovery, palliative procedures are indicated, such
maior and latissimus dorsi. as a transfer of the levator scapulae or m rhomboidus.
2. Retro and inferoclavicular lesions of the plexus
of the serratus anterior due to a thoracic injury to the
brachialis. longus often occurs in the case of strong movements
29% of the lesions of the plexus occur in this zone and such as rugby or shoulder overload (backpack paralysis).
affect the secondary strains, most frequently the This is sometimes also seen in throwing sports.
posterior truncus. A nerve recovery must occur Spontaneous recovery happens often but slowly (12 to
quickly. The shoulder can be affected by an injury of 18 months). Palliative surgery can be used in cases
the axillary nerve often in combination with an injury where a wing of the scapula is too tedious. Transfer
of the suprascapularis. With regard to the end branches from the pectoralis maior or minor
of the plexus (axillaris, suprascapularis and
musculocutaneus), a spontaneous recovery can be have been proposed. Transfer of the latissimus dorsi or
expected but often delayed (6 to 9 months). It comes teres maior are also associated with a scapulopexy. The
down to avoiding redundant procedures while an latter is the preferential treatment of the author.
urgent surgical recovery may be appropriate. MRI can
make sense to distinguish these cases. The recovery
surgery usually takes place around the sixth month

Acta Orthopædica Belgica, Vol. 65 - 1 - 1999