LOW VELOCITY GUN SHOT WOUNDS OF THE BRACHIAL PLEXUS B.C. VRETTOS, S. ROCHKIND and R.S. BOOME From the Department of Orthopaedic Surgery, University of Cape Town, Groote Sehuur Hospital, Cape Town, South Africa 28 patients with low velocity gunshot wounds of the brachial plexus were treated at Groote Schuur Hospital from 1980 to 1991. Delayed exploration of the brachial plexus (up to 7 months after injury) was performed in nine (30%) of the patients. The other 19 patients did not have exploration of the plexus; most of these patients showed signs of recovery within 2 to 4 weeks of injury. Injury to the subclavian or axillary artery occurred in nine (30%) of the cases. The average length of follow-up of the patients was 19 months (range 2-90 months). Of the 19 patients treated non-operatively, 15 (79%) had an excellent or good result and four (21%) a fair result. The indications for surgery were the absence of improvement within 3 months of injury or persistent pain. Surgery was indicated for significant pain in five of the nine patients; post- operatively two had complete relief of pain, two improvement in the pain and one no improvement. Of the nine surgically treated patients, three (33%) had a good result, two (22%) a fair result and four (45%) a poor result. The potential for recovery was not dependent on the severity of the injury at presentation or the presence of vascular injury but on the appearance of signs of recovery within 4 weeks of injury. Journal of Hand Surgery (British and European Volume, 1995) 20B." 2:212--214 Experience of the five peripheral nerve centres during the 2nd World War showed that the surgical treatment of gun shot wounds (GSWs) of the brachial plexus is "rarely profitable or justifiable" (Brooks, 1949; Nulsen and Slade, 1956). Seddon (1972) and Sunderland (1978) suggested that many lesions recover without surgical treatment and the results of surgery are often unsatisfac- tory. On the other hand, two cases treated surgically with success were reported (Binns and Wynn Parry, 1970; Hudson and Dommisse, 1977) and attempts at surgical treatment of GSWs of the brachial plexus have continued (Narakas, 1977; Leffert, 1985). Surgery has been undertaken to relieve pain, and Brooks (1949) reported one patient with complete relief of pain following neurolysis. Kline (1989) reported three out of five patients having improvement in pain after neurolysis. Controversies surrounding surgical treatment of GSWs of the brachial plexus were addressed by Kline and Judice (1983) and Kline (1989). From their extens- ive 18 years of experience with GSWs of the brachial plexus they concluded that the indications for surgery should include patients with severe or complete loss that had persisted for 2 months or more in the distribution of one or more elements, and those experiencing severe pain. Our series supports their view. MATERIAL AND METHODS The patients' injuries were classified according to the nerve roots involved. They were further classified by severity. Complete injuries had total loss of function, incomplete injuries had partial loss of motor function or complete loss of motor function but some sensory sparing, and in mixed injuries where there was complete loss in some roots and incomplete in the others. Tables 1 and 2 show the distribution of lesions in the non- operatively and operatively treated patients respectively. Surgical exploration was performed in those patients who showed no signs of improvement within 3 months of injury or in whom pain was significant. In those cases with a complete injury, the digital deep pressure test was useful in determining whether continuity existed in the nerve (Dunkerton and Boome, 1988). The digital deep pressure test was performed in those patients with no apparent sensation in a digit. The technique consists of compressing the patient's nail firmly between the examiner's thumb and index fingers whereupon the digit is pulled out sharply. This severely compresses the pulp of the tip and, if nerve continuity Table 1--Patterns and severity of injury at presentation in the patients treated non-operatively Pattern Severity Complete Incomplete Mixed 30 patients with GSWs of the brachial plexus were C5-T1 treated at Groote Schuur Hospital over a 12-year period, c5-c7 Two patients were excluded due to inadequate records, c5-c6 24 were male and four female, and their ages at presen- C6-T1 tation ranged from 16 to 60 years (average 29 years). C7-Yl The left side was involved in 14 patients and the right C8-T1 in 14. 1 2 2 1 1 - 1 2 - 2 1 - 1 1 - 1 3 - (7) (10) (2) 212