Treatment of injuries to the brachial plexus and upper extremity

1. Treatment of Injuries to the Brachial
Plexus and Upper Extremity
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3. Patients with disabilities can do more with less
(depending upon the quality of their rehabilitation
treatment)
Rehabilitative Surgery
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4. Nerve Surgery
The
“Garage Door”
Analogy
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5. Nerve Surgery
 The “Garage Door” Analogy
 Outlet = spinal cord
 Wire = nerve
 Motor = muscle
 Chair = tendon
 Door = hand or foot
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6. Rehabilitative Surgery
is a process not an event
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7. Rehabilitative Surgery
Surgical Algorithm
Nerve Repair
Nerve Grafting
Neurotization
Tendon Transfer
Tenodesis
Joint Fusion
Splinting
Simplicity
Elegance
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8. Nerve Grafting
 Self transfer (i.e. Sural Nerve)
 Manufactured Nerve
 Processed Nerve
 Cadaver Transplant
 Living Related Transplant
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10. IN THE AREA OF THE PLEXUS
 NERVES
 BONES
 ARTERY
 VEIN
 LUNG
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12. BRACHIAL PLEXUS INJURIES
 BIRTH INJURY
 MOTOR VEHICLE ACCIDENTS
 MOTORCYCLES
 FALLS
 INDUSTRIAL ACCIDENTS
 SPORTS INJURIES
 TUMORS
 RADIATION
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13. BRACHIAL PLEXUS INJURIES
 4% OF ALL MOTORCYCLE ACCIDENTS
 19% ARE COMATOSE
 13% HAVE C-SPINE INJURIES
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14. THREE BASIC FACTORS
 PAIN
 SENSIBILITY
 MOTION
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15. OVERVIEW
 DIAGNOSIS
 WORK-UP
 NERVE STUDIES
 NERVE REPAIR
 POST-OP
 REHABILITATION
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16. DIAGNOSIS
 Often clouded by coma, etc
 Often clouded by orthopedic injuries
 Often ignored
 Often misinformed
 May be subtle
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17. WORK UP
 PRELIMINARY WORK UP OF NERVE STUDIES
STARTS RIGHT AWAY
 FIRST EMG AT 6 WEEK TO 3 MONTHS
 CXR
 MRI
 CT MYELOGRAM
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18. WORK UP
 REPEAT EMG AT 6 MONTHS IF NO
IMPROVEMENT
 IF IMPROVEMENT REASSESS AT 9 MONTHS
 IF NO IMPROVEMENT OPERATE
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19. TIMING
 THE TEXTBOOKS ARE WRONG
 DO NOT WAIT A YEAR
 IF NOT IMPROVED BY 3 MONTHS, THEY WILL NOT
IMPROVE
 EMG AT 6-8 WEEKS
 REPAIR AT ABOUT 3 MONTHS
 ALLOWS FOR “SECOND SHOT” BEFORE ONE YEAR
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20. SURGERY
TEAM APPROACH
 SURGEONS
 CONSULTANTS
 NURSES
 THERAPISTS
 HOME CARE
 FAMILY
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21. RECOVERY
 WHEN NERVE REPAIR IS REQUIRED,
RECOVERY IS DELAYED
 1 - 2 MONTH LATENCY
 NERVE GROWTH
 1 mm/day
 1 inch/month
 LONGER DISTANCE, LONGER
RECOVERY TIME
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22. POST-OP CARE
 UNDERLYING DISEASE
 MULTIPLE OPERATIONS
 PAIN RESISTANCE
 SEVERAL OPERATIVE SITES
 IMMOBILIZATION
 LONG PROCEDURES
 ANESTHESIA TIME
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23. REHABILITATION
 IMMOBILIZATION
3 - 6 WEEKS POST-OP
 AGGRESSIVE REHAB
KEEP JOINTS SUPPLE
MAINTAIN STRENGTH
BUILD NEW STRENGTH
RELEARN MUSCLE MOVEMENT
BIOFEEDBACK
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24. Spinal Accessory Neurotization
Brachial Plexus Palsy
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25. BRACHIAL PLEXUS PALSY
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26. Nerve Transplants
 Its all about spare parts
 No need to prioritize
 Can’t go to home depot
 Cadaver
 Living related donor
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27. Nerve Transplant
 NO NEED TO PRIORITIZE
 NO NEED TO PRIORITIZE
 NO NEED TO PRIORITIZE
 NO NEED TO PRIORITIZE
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28. Nerve Transplantation
 Allograft
 Abo Compatibility
 Prograf
 Wrist Monitoring
 Steroid Rescue
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29. Nerve Transplantation
 Who’s a candidate?
Injury about 1 year
Good health
Good support system
Massive injury
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30. Nerve Transplantation
 Who’s a good donor?
 Good health
 Abo match
 No communicable disease
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31. Nerve Transplantation
CADAVER
VS.
LIVING RELATED DONOR
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32. Spinal Cord Injury
Can we treat spinal cord injuries like bilateral
brachial plexus injuries?
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33. Spinal Cord Injury
Tetraplegic Hand Surgery
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34. Spinal Cord Injury
Hand Surgery
 Minimize Spasticity
 Maximize passive range of motion
 Maximize active range of motion
 Tendon Lengthening
 Joint Stabilization/Joint Fusion
 Splinting Static/Dynamic
 Tendon Transfer/ Tenodesis Effect
 Neurotization
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35. Spinal Cord Paralysis
We can’t fix the problem but we can help to
RESTORE FUNCTION
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36. Spinal Cord Injury
 Need for Functioning Donors
 Nerve donors above the lesion
 Muscle donors for tendon transfers
 Free muscle donors
 Sacrifice contra lateral side?
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37. Spinal Cord Paralysis
 Level of Injury
 Cranial nerves always spared
 Cervical plexus always spared
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38. Spinal Cord Paralysis
 Prioritize Function
 Arm Abduction
 Triceps
 Bicep
 Wrist Extension
 Finger Extension/Flexion
 Individualize for Patient
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39. Spinal Cord Injury
Timing
 Need to let injury evolve
 Need to maximize therapy
 Need to maintain existing function
 Motor end plates do not degrade
 Spasm must be balanced
 Can take advantage of two-stage procedures
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40. Spinal Cord Injury
 Trapezius to Deltoid Transfer
 Neurotization from spinal accessory nerve
 Nerve to levator scapulae
 Nerve to sternocleidomastoid
 Latissmmus to bicep
 Latissimus to triceps
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41. Stroke
Why can’t we treat a stroke patient like a brachial plexus
patient?
• Medical problems
• Spasm
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42. Spinal Cord Injury
Pressure Sores
 Can occur over any bony prominence
 Sacrum most common
 Scalp
 Ischium
 Hip
 Heels
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43. Spinal Cord Injury
Pressure Sores
 Prevention
 Prevention
 Prevention
 Prevention
 Prevention
 Prevention
 Prevention
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44. Spinal Cord Injury
Pressure Sores
 Any pressure above capillary perfusion pressure is to high
 Only a Clinitron works to heal a wound
 Other mattresses may work to help prevent
 Floating the pressure point is best
 Extra padding is bad
 Prevention is HARD work
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45. Spinal Cord Injury
Treatment of Pressure Sores
 Grading scale has no value
 Maximize inflow
 Maximize protoplasm
 Remove “bacteria food”
 Means of debridement is not of great importance
 Re-educate patient
 The VAC does not debride
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46. Spinal Cord Injury
Pressure Sore Treatment
 High recurrence rate
 Maximize everything
 Quality of soft tissue coverage
 Bed trial
 Social support
 Prognosis
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47. Spinal Cord Injury
Pressure Sores
 Prevention
 Prevention
 Prevention
 Prevention
 Prevention
 Prevention
 Prevention
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48. Spinal Cord Injury
Pressure Sores
 Neurotization for protective sensibility
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49. Spinal Cord Injury
Summary
 We do not have a cure
 We have treatments to deal with complications
 We have cutting edge methods to maximize function and
impact lives
 Education is our greatest hurdle
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51. Complex Injuries:
“A Legal Perspective”
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