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

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

3. Stiff hand Inappropriate physiotherapy

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

6.  prognosis

7. Prognosis

9.  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

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

11.  Sharp injury

12. Chest tube

14.  Bullet wound Clavicle osteotomy Junction of trunk and cords

15. Laceration

16. Nerve repair and graft

17. Laceration

18. Nerve graft

19.  Bullet injury

20.  velocity of gun shot

21.  Closed injury, (tractional injuries)

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

23.  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

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

25.  Pseudoaneurism

26.  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

27.  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

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

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

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

31.  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

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

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

34.  Gun shot injury

35. After neurolysis from scar tissue

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

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

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

41.  Motor cycle accident open wound

42. C5 C6 Vertebral foramen

43.  Accessory to superascapular

44.  Oberlin nerve transfer

45. Root avulsion

46.  Upper brachial

48. Pherenic nerve

49. Accessory Injured upper trunk Superascapular nerve

50. Oberlin nerve transfer Biceps m. Ulnar n. Anastamosis

51. Radial to axillary transfer

52. Axillary n (inverted) Radial n.

53. ICN 4 ICN 5 ICN 6 Musclocutaneus n

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

56.  Triceps to Biceps

59. Latismus dorsi m.

60. Latismus dorsi transfer to flexion elbow and extension finger

61. Deltoid paralysis

63.  Trapez to Deltoid

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

66.  Shoulder arthrodesis in BPI

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

68. Gracillis harvest Accessory n.

69. First stage of Doi procedure

70. Partial ulnar n. as a donor nerve

72.  Extra plexus donor

73. 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

75.  38 y male  Stab wound in axillary area  P/E:  Ulnar nerve complete paralysis with signs of posterior cord paralysis  Underwent vascular reconstruction immediately

76.  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?

77.  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

78.  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?

79.  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?

80.  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

81.  What is your treatment schedule?

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