kamrani r. sh. m.d. 3 rd annual pota congress march 2008
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Kamrani R. Sh. M.D.3rd 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 woundClavicle osteotomy
Junction of trunk and cords
Laceration
Nerve repair and graft
Laceration
Nerve graft
Bullet injury
velocity of gun shot
Closed injury, (tractional injuries)
Closed injury, (tractional injuries)
Early exploration Underobservation Decision for the time of delay exploration Decision for the type of the treatment
Late recostruction
Straig
ht o
n Bra
chia
l ple
xus
Closed injury, (tractional injuries)
Early exploration Underobservation Decision for the time of delay exploration Decision for the type of the treatment
Late recostructionPeripheral reconstruction
Closed injury, (tractional injuries)
Early exploration vascular reconstruction
Pseudoaneurism
Closed injury, (tractional injuries)
Early exploration Underobservation
First 6-12 weeksStabilization of the patientStabilization of the injuryEvaluation of the improvement
After 2-3 monthsNo improvement; explorationProgressive improve; wait & watchNon-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 explorationDelay 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
C5C6
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 transferto 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 injury Shot gun Tractional injury
Immediate exploration under 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 shoulderEMG/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?
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