Brachial plexus injuries, in all their severity and complexity, have been extensively studied. Although brachial plexus injuries are associated with serious and often definitive sequelae, many concepts have changed since the 1950s, when this pathological condition began to be treated more aggressively. Looking back over the last 20 years, it can be seen that the entire approach, from diagnosis to treatment, has changed significantly. Some concepts have become better established, while others have been introduced; thus, it can be said that currently, something can always be offered in terms of functional recovery, regardless of the degree of injury. Advances in microsurgical techniques have enabled improved results after neurolysis and have made it possible to perform neurotization, which has undoubtedly become the greatest differential in treating brachial plexus injuries. Improvements in imaging devices and electrical studies have allowed quick decisions that are reflected in better surgical outcomes. In this review, we intend to show the many developments in brachial plexus surgery that have significantly changed the results and have provided hope to the victims of this serious injury.

OBJETIVO: Avaliar ganho de força e amplitude de movimento do cotovelo após cirurgia de Steindler Modificada em pacientes com lesão do tronco superior do plexo braquial. MÉTODO: Foram acompanhados de 1998 a 2007 onze pacientes com lesão traumática fechada do tronco superior do plexo braquial. Todos apresentavam evolução de pelo menos 1 ano da lesão e grau de força de flexão do cotovelo que variou de M1 a M3. Os pacientes foram submetidos à cirurgia de Steindler modificada e seguidos por período mínimo de 6 meses. Realizadas avaliações pré e pós-operatórias do ganho de força muscular, amplitude de movimento do cotovelo e pontuação conforme escala DASH. RESULTADOS: Dos onze pacientes analisados, nove (82%) atingiram nível de força igual ou maior a M3 (MRC). Dois (18%) chegaram ao nível de força M2(MRC). Observamos que os pacientes apresentaram ganho médio de amplitude de movimento do cotovelo pós-operatória de 43,45 graus. A média de flexão do cotovelo pós-operatória foi de 88 graus. Houve melhora da função do cotovelo demonstrada na Escala DASH em 81% dos pacientes do estudo. CONCLUSÃO: A cirurgia de Steindler Modificada mostrou-se eficaz no tratamento dos pacientes com lesão de tronco superior de plexo braquial, com ganho estatisticamente significativo de amplitude de movimento. Em todos os casos algum grau de ganho de força e amplitude de flexão do cotovelo, sendo tanto maior quanto maior a força muscular inicial. Nível de Evidência: Nível II, ensaio clínico prospective.

OBJECTIVE: To evaluate the gain in strength and range of motion after modified Steindler surgery of the elbow in patients with lesions of the upper trunk of the brachial plexus. METHOD: From 1998 to 2007, eleven patients with traumatic closed upper trunk lesion of the brachial plexus were studied. All the patients had development of at least 1 year of injury and degree of strength of elbow flexion ranging from M1 to M3. The patients underwent Steindler surgery with at least 6 months of follow-up. Pre- and post-operative assessments were carried out to determine gain in muscle strength, range of motion of the elbow, and DASH scale score. RESULTS: Of the eleven patients studied, nine (82%) achieved a level of strength equal to or greater than M3 (MRC) with good functional recovery. Two (18%) reached strength level M2 (MRC). We observed that the patients had an average postoperative gain in range of motion of the elbow of 43.45 degrees. The average elbow flexion after surgery was 88 degrees. There was an improvement in elbow function, as demonstrated in the DASH Scale, in 81% of the patients studied. CONCLUSION: Modified Steindler surgery was effective in the treatment of patients with injuries of the upper trunk of the brachial plexus, with statistically significant gains in range of motion. In all the cases studied, there was some degree of gain in strength and range of elbow flexion, the gain being correlated with the initial muscle strength. Level of Evidence: Level II, prospective clinical trial.

OBJETIVO: As tenólises dos tendões flexores na zona 2 são procedimentos difíceis e um verdadeiro desafio na cirurgia da mão. Com o objetivo de comparar os resultados obtidos entre as tenólises com despertar intraoperatório, realizadas sob anestesia locorregional (grupo 1), daqueles obtidos com as tenólises convencionais, realizadas sob anestesia geral ou bloqueio total do plexo braquial (grupo 2), os autores realizam um estudo prospectivo e controlado. MÉTODOS: Foram avaliados 22 pacientes com 39 dedos portadores de lesão de tendão flexor na zona 2 que evoluíram para aderências. Todos os pacientes foram operados após três meses e antes de um ano da sutura tendinosa primária. Todos apresentavam limitação da movimentação ativa sem melhora com a reabilitação. Os grupos 1 e 2 mostraram-se homogêneos em relação à idade dos pacientes, sexo, comprometimento pré-operatório e ausência de lesões ou patologias associadas. Todos os pacientes foram avaliados de acordo com a movimentação ativa (TAMs) no período pré-operatório e com seis meses de pós-operatório. RESULTADOS: A análise estatística dos dados obtidos nos grupos 1 e 2 demonstra que as tenólises realizadas pelas duas técnicas proporcionam bons resultados. Ao comparar os resultados da movimentação ativa total após seis meses da tenólise, observa-se que os pacientes do grupo 1, tratados pela técnica do despertar intraoperatório, apresentavam melhores resultados. CONCLUSÕES: As tenólises dos flexores na zona 2 proporcionam bons resultados em termos de ganho de amplitude articular. A técnica de despertar intraoperatório com anestesia locorregional proporciona resultados mais satisfatórios que a técnica convencional.

OBJECTIVE: Flexor tendon tenolysis on zone 2 is a difficult and really challenging for hand surgery. With the objective of comparing the results obtained between tenolyses with intraoperative awakening, performed with locoregional anesthesia (group 1), from those obtained with traditional tenolysis performed under general anesthesia or total blockage of the brachial plexus (group 2), the authors conducted a prospective and controlled study. METHODS: 22 patients with 39 fingers with flexor tendon injuries on zone 2 evolving to adherences were assessed. All patients were operated after three months and before one year of the primary tendinous suture. All patients showed limited active motion not improved by rehabilitation. Groups 1 and 2 showed to be homogenous concerning patients' age and gender, preoperative compromising, and absence of associated injuries or pathologies. All patients were assessed according to active motion (TAMs) both preoperatively and at 6 months postoperatively. RESULTS: The statistical analysis of data obtained for groups 1 and 2 shows that the tenolysis performed with both techniques produce good results. By comparing the results for total active motion after six months of the tenolysis, group 1 patients (treated by the intraoperative awakening technique) were found to present better outcomes. CONCLUSIONS: Flexor tenolysis on zone 2 provide good results in terms of joint range of motion. The intraoperative awakening technique with locoregional anesthesia provides improved outcomes when compared to the traditional technique.