1. CASE #1 Edward Calkins, MD

2. 15-year old male High-speed motor vehicle rollover crash; unrestrained passenger No body cavity major organ injuries Limb injuries confined to right upper extremity

3. Case Review Severe arm-level injury

4. Injuries sustained Segmental injury to brachial artery with limb devascularization Open humerus fracture (Type 3C) Both-bones forearm fracture Degloving injury arm & forearm

5. Neurological function Absent median nerve function Absent radial nerve function (Absent elbow flexion; intact lateral antebrachial sensation)

6. Median nerve injury Long ( 8 cm) segmental nerve loss in brachium adjacent to injured brachial artery

7. Case #1 25 y/o R HD male, with R humerus fx, s/p MVA 2 months prior to EDX study – brachial a. repair PE – triceps 3/5, B-R 2-/5, ECRL 2-/5, FDP to middle, ring and little fingers 2/5, FDP –index 0/5 FPL 0/5, APB ?tr, impaired sensation median n Faren H. Williams, M.D., M.S.7

8. R Median motor response, s/p MVA Faren H. Williams, M.D., M.S.8

9. Left median motor Faren H. Williams, M.D., M.S.9

10. Right radial motor Faren H. Williams, M.D., M.S.10

11. Left Radial Motor Faren H. Williams, M.D., M.S.11

12. Motor NCS’s Right median motor –DL – 4.7 ms, ampli – 0.4 K with dispersed waveform Left median motor DL – 3.9 ms, amplitude 7.8 K Right radial motor DL – 3.3 ms, amplitude 0.5 K Left radial motor DL – 3.0 ms, amplitude 2.2 K Faren H. Williams, M.D., M.S.12

13. R Med-Radial Sensory Faren H. Williams, M.D., M.S.13

14. Right radial sensory- snuff box Faren H. Williams, M.D., M.S.14

15. Sensory NCS’s Right Median – No responses Right Radial – no response from thumb 4.2 ms peak latency, and 14 uV from snuff box Left Median – 2.4 ms peak latency, 68 uV ampl Left Radial (from thumb) -2.6 ms lat, 7.9 uV ampl from snuff box 3.2 peak latency, 40 uV ampli. Faren H. Williams, M.D., M.S.15

16. Needle EMG- Right Spontaneous activity –APB, EIP, Pronator Teres, Brachioradialis, ECRL –No MUAPs – in APB, and Pronator Teres –Radial innervated muscles – decreased recruitment Discrete recruitment in more distal muscles, all + MUAPs Faren H. Williams, M.D., M.S.16

17. Interpretation Median nerve injury - > 95% axonal loss, Motor & Sens 0 MUAPs in median innervated muscles Radial nerve injury – 75% axonal loss, motor –Reinnervation – proximal to distal Prognosis- median recovery guarded, radial fair Faren H. Williams, M.D., M.S.17

18. Treatment options Nerve autografting Nerve allografting Tendon transfers Selective nerve transfers

19. f/u EDX, 9 mos post-op Right radial motor ampl – 50% greater than ’12 Right median motor (s/p median n graft) –Amplitude 10x’s greater than Nov ‘12 Right median sensory – from thumb and index finger 3-5 uV amplitude –improved from no response in ‘12 Needle EMG – ongoing fibs/ positive waves R APB but with MUAPs with reduced/ discrete recruitment in median innervated muscles. Radial ones polyphasic Faren H. Williams, M.D., M.S.19

20. Median motor, s/p Nerve Repair Faren H. Williams, M.D., M.S.20

21. R radial motor, 9 mos post-op Faren H. Williams, M.D., M.S.21

22. Treatment & Recovery