Kamrani R. Sh. M.D. 3 rd annual POTA congress March 2008

 Introduction  Multiple trauma patient  Young active male with long standing problem

Stiff hand Inappropriate physiotherapy

 Introduction  Multiple trauma patient  Young active male with long standing problem  Realistic outcomes  Prognostic factors  After injury  After treatment

 prognosis

Prognosis

 Introduction  Multiple trauma patient  Young active male with long standing problem  Realistic outcomes  Prognostic factors  After injury  After treatment  Socioeconomic aspect of the treatment  Psychological aspects of the treatment

 Open wounds  Sharp injury  Bullet injury  Closed injuries

 Sharp injury

Chest tube

 Bullet wound Clavicle osteotomy Junction of trunk and cords

Laceration

Nerve repair and graft

Laceration

Nerve graft

 Bullet injury

 velocity of gun shot

 Closed injury, (tractional injuries)

 Early exploration  Underobservation  Decision for the time of delay exploration  Decision for the type of the treatment  Late recostruction Straight on Brachial plexus

 Closed injury, (tractional injuries)  Early exploration  Underobservation  Decision for the time of delay exploration  Decision for the type of the treatment  Late recostruction Peripheral reconstruction

 Closed injury, (tractional injuries)  Early exploration vascular reconstruction

 Pseudoaneurism

 Closed injury, (tractional injuries)  Early exploration  Underobservation First 6-12 weeks Stabilization of the patient Stabilization of the injury Evaluation of the improvement After 2-3 months No improvement; exploration Progressive improve; wait & watch Non-anatomic recovery; explor. Based on severity

 Closed injury, (tractional injuries)  Early exploration  Underobservation  Decision for the time of delay exploration  No recovery  After 6-12 weeks ( based on the severity of the trauma )  Progressive improvement  Wait for further improvement  Non-anatomic recovery  Exploration before 9-12 months

 Closed injury, (tractional injuries)  Early exploration  Underobservation  Decision for the time of delay exploration  Decision for the type of the treatment

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps Straight on Brachial Plexus Peripheral reconstruction

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps Straight on Brachial Plexus Early exploration Delay exploration Peripheral reconstruction Late reconstruction Danger of more damage Failure is obvious

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps

 Gun shot injury

After neurolysis from scar tissue

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps

 Motor cycle accident open wound

C5 C6 Vertebral foramen

 Accessory to superascapular

 Oberlin nerve transfer

Root avulsion

 Upper brachial

Pherenic nerve

Accessory Injured upper trunk Superascapular nerve

Oberlin nerve transfer Biceps m. Ulnar n. Anastamosis

Radial to axillary transfer

Axillary n (inverted) Radial n.

ICN 4 ICN 5 ICN 6 Musclocutaneus n

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps

 Triceps to Biceps

Latismus dorsi m.

Latismus dorsi transfer to flexion elbow and extension finger

Deltoid paralysis

 Trapez to Deltoid

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps

 Shoulder arthrodesis in BPI

 Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps

Gracillis harvest Accessory n.

First stage of Doi procedure

Partial ulnar n. as a donor nerve

 Extra plexus donor

Brachial plexus injury Open sharp injuryShot gun Tractional injury Immediate explorationunder observation Exploration No improvement in 2-3 m Explor. In 12 m. Non-anatomic improvement Peripheral reanimation > 12m. Gradual improvement Low energy High energy

 38 y male  Stab wound in axillary area  P/E:  Ulnar nerve complete paralysis with signs of posterior cord paralysis  Underwent vascular reconstruction immediately

 Exploration note is a complete ulnar nerve laceration from medial cord, 90% laceration of the posterior cord  What did you do ; when you called on emergency room? when you were consulted the day after ER operation?

 23 y man victim of falling from height  Whole brachial plexus injury at the presentation, with only wek movement of the index finger  Without concomitant vascular or skeletal injury

 The patient was followed;  One month, return of normal finger and wrist flexion, normal hand intrinsic, flail shoulder and elbow  Three months, elbow flexion 2/5, flail shoulder EMG/NCV shows a combination of root aqnd cord injuruy  Five months, elbow flexion is 4+/5, flail shoulder, no active elbow, wrist, and finger extension  What is your strategy?

 A 20 y old man victim of motorcycle accident  Presented with whole brachial plexus injury  No recovery of the limb after two months  EMG/NCV and MRI show C5-T1 root avulsion more probably avulsion  What is your next step?

 22 y male suffered from automobile accident 12 months ago  A case of 5-6 injury  Delay of the the treatment because of one month of coma and ICU admission and post head trauma rehabilitation  There is no sign of upper motor neuron sequale in the paralytic hand  Stiff elbow with heterotopic ossification in the ipsilateral elbow

 What is your treatment schedule?

 A 25 y male  Traffic accident 3 months ago  Clinical finding and electrodiagnostic study reveal C8-T1 injury  What is your treatment strategy?