Groote Schuur Hospital is a major tertiary care hospital situated on the southernmost tip of Africa, serving the whole of the Cape Province up to 800 miles northeast and northwest of Cape Town. In 1980, the Hand Clinic at Groote Schuur Hospital, which had been in existence for 10 years, extended its scope to formal care of brachial plexus injuries. Narakas's 1978 paper was used to plan the repair of traction lesions' and Gilbert's paper of 1980 contributed to the obstetric palsy repair concept. ' In 1980 and 1981, 127 brachial plexus injuries were seen at the Hand Clinic (Table 1) and an already busy clinic with insufficient operating time for all hand trauma was now further burdened by the brachial plexus surgery. Prior to 1980 no real management plan for brachial plexus injuries existed, and only stab injury repairs (end-to-end) were attempted. Obstetric injuries were treated conservatively and only tendon transfers done later. The new brachial plexus clinic adopted the management plan of Narakas for all traction injuries and that of Gilbert for all obstetric traction injuries. The immediate load of cases flooded the available theatre time and, although further theatre time was soon allocated, modification of the management plan had to be made.
It was noted that adult traction injuries from rural areas often presented after 3-4 months with a clear history of significant improvement in the first few weeks after the injury. Surgery was planned as soon as possible, ruptured nerves were grafted, and partially functioning nerves were neurolysed. Dramatic improvements were sometimes seen after extensive neurolysis, with recovery occurring within weeks in injuries of 4-6 months' standing. This encouraged us to delay surgery rather than operate in the first weeks after injury, and decompressed the waiting list somewhat; occasionally a patient would recover sufficiently so as not to require surgery. Similarly, because only one surgeon (R.S.B.) was available, the extensive number of supraclav-icular3 stab injuries also presented a logistic problem. The principle of primary exploration and nerve graft of all stab From the Hand Clinic, Groote