Between 1993 and 1998, 32 male patients with brachial plexus injuries were surgically treated. Eighteen interfascicular grafting and 71 extraplexal neurotization procedures were performed separately or in combination. Donor nerves were the intercostals, spinal accessory, phrenic, contralateral C7, and cervical plexus, in order of frequency. Patients were followed for a minimum of 24 (average, 35) months. Biceps function was best following grafting the musculocutaneous nerve itself, or neurotization with the phrenic nerve (100 percent grade 4), followed by neurotization with the intercostals (89.5 percent grade 3 or more) and last, grafting the C5 root or upper trunk (grade 3 in one of three patients). Phrenic to suprascapular neurotization produced the best results of shoulder abduction (40 to 90 degrees), followed by combined neurotization of the spinal accessory to suprascapular and phrenic to axillary (20 to 90 degrees). Sensory recovery over the lateral forearm and palm varied from S2 to S3+, according to the method of reconstruction.

Metacarpal hand refers to the hand that has lost its prehensile ability through amputation of all fingers with or without amputation of the thumb. Functional restoration can be achieved by a wide variety of microvascular toe transfer techniques. When deciding which procedure should be used, careful consideration must be given to the level of amputation of the fingers as well as the functional status of the remaining thumb. In this article we propose a classification for the various patterns of the metacarpal hand along with guidelines for selection of the proper toe transfer procedure.

We conclude that the technique offers the possibility of salvaging limbs that are, otherwise, nonreconstructable. It is useful for young patients. When the flap is long, it can function as a nutrient flap for the distal limb even though the pedicle has been divided. It is a backup procedure in an urgent situation of re-exploration in which reestablishment of circulation should take place as soon as possible.