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?