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  1. G A Davis
  1. Consultant Neurosurgeon, Department of Neurosurgery, Austin and Repatriation Medical Centre, Burgundy Street, Heidelberg, Victoria 3084, Australia gadavis{at}

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    I congratulate the authors on a functionally good outcome in this case, but a few points on traumatic plexus injury require further comment.

    Injuries to the brachial plexus are best categorised as “in continuity” or “not in continuity” (or transections). A nerve can be transected sharply, as in a sharp knife injury, or, more commonly, there is blunt transection (such as a kick from a horse). Blunt transection results in nerve injury not only at the site of transection, but injury extends proximally and distally along the nerve for a variable distance, depending on the degree of associated “stretch” injury and contusion. Macroscopic and electrophysiological delineation of this extra length of injury takes a few weeks to occur. Therefore repair of a blunt transection should not be performed earlier than two weeks after such an injury. When immediate repair of associated injuries occurs, such as repair of the arterial injury described here, and a transected nerve is identified, the nerve ends should be sutured to the fascial layer to prevent nerve retraction, and repair delayed for two weeks. At the time of subsequent repair, the injury will be macroscopically apparent, and the nerve is cut back to healthy looking fascicles before suture or grafting. Although the graft appears to have taken in this case, the authors make no mention of the nerve gap, length of nerve cut back, or the graft length. As a general rule, results will not always be as successful as this if allowance is not made for the stretch injury proximal and distal to a blunt transection.

    The association with arterial injury is not uncommon in the setting of brachial plexus injuries, and consideration should always be given to performing angiography before the operation in all cases with haematoma formation, laceration, or gunshot wound. If needed, the services of a vascular surgeon can then be organised in advance. In the case presented, an angiogram should have been performed before surgery given the immediate onset haematoma.

    Finally, I must disagree with the authors' assertion in the discussion that a “complete nerve lesion” is suggestive of nerve rupture. To the contrary, most complete nerve injuries seen in the acute setting are neurapraxic (Sunderland grade I) and ultimately recover with conservative treatment. In the same paragraph, the authors state that cutaneous sensory loss in axillary nerve territory in the acute setting is also suggestive of nerve rupture. Again, I must stress that, in most cases, this is due to neurapraxia and not rupture (Sunderland grade V). Only careful clinical and electrophysiological follow up can differentiate a Sunderland I from higher grades of injury.

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