Treatment of injuries to the brachial plexus and upper extremity

Treatment of Injuries to the Brachial
Plexus and Upper Extremity
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The Nurses and attendants staff we provide for your healthy
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Patients with disabilities can do more with less
(depending upon the quality of their rehabilitation
treatment)
Rehabilitative Surgery
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Nerve Surgery
The
“Garage Door”
Analogy
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Nerve Surgery
 The “Garage Door” Analogy
 Outlet = spinal cord
 Wire = nerve
 Motor = muscle
 Chair = tendon
 Door = hand or foot
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is a process not an event
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Surgical Algorithm
Nerve Repair
Nerve Grafting
Neurotization
Tendon Transfer
Tenodesis
Joint Fusion
Splinting
Simplicity
Elegance
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Nerve Grafting
 Self transfer (i.e. Sural Nerve)
 Manufactured Nerve
 Processed Nerve
 Cadaver Transplant
 Living Related Transplant
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IN THE AREA OF THE PLEXUS
 NERVES
 BONES
 ARTERY
 VEIN
 LUNG
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BRACHIAL PLEXUS INJURIES
 BIRTH INJURY
 MOTOR VEHICLE ACCIDENTS
 MOTORCYCLES
 FALLS
 INDUSTRIAL ACCIDENTS
 SPORTS INJURIES
 TUMORS
 RADIATION
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BRACHIAL PLEXUS INJURIES
 4% OF ALL MOTORCYCLE ACCIDENTS
 19% ARE COMATOSE
 13% HAVE C-SPINE INJURIES
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THREE BASIC FACTORS
 PAIN
 SENSIBILITY
 MOTION
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OVERVIEW
 DIAGNOSIS
 WORK-UP
 NERVE STUDIES
 NERVE REPAIR
 POST-OP
 REHABILITATION
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DIAGNOSIS
 Often clouded by coma, etc
 Often clouded by orthopedic injuries
 Often ignored
 Often misinformed
 May be subtle
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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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WORK UP
 REPEAT EMG AT 6 MONTHS IF NO
IMPROVEMENT
 IF IMPROVEMENT REASSESS AT 9 MONTHS
 IF NO IMPROVEMENT OPERATE
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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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SURGERY
TEAM APPROACH
 SURGEONS
 CONSULTANTS
 NURSES
 THERAPISTS
 HOME CARE
 FAMILY
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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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POST-OP CARE
 UNDERLYING DISEASE
 MULTIPLE OPERATIONS
 PAIN RESISTANCE
 SEVERAL OPERATIVE SITES
 IMMOBILIZATION
 LONG PROCEDURES
 ANESTHESIA TIME
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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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Spinal Accessory Neurotization
Brachial Plexus Palsy
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BRACHIAL PLEXUS PALSY
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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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Nerve Transplant
 NO NEED TO PRIORITIZE
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Nerve Transplantation
 Allograft
 Abo Compatibility
 Prograf
 Wrist Monitoring
 Steroid Rescue
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 Who’s a candidate?
Injury about 1 year
Good health
Good support system
Massive injury
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 Who’s a good donor?
 Good health
 Abo match
 No communicable disease
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CADAVER
VS.
LIVING RELATED DONOR
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Spinal Cord Injury
Can we treat spinal cord injuries like bilateral
brachial plexus injuries?
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Spinal Cord Injury
Tetraplegic Hand Surgery
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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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Spinal Cord Paralysis
We can’t fix the problem but we can help to
RESTORE FUNCTION
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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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 Level of Injury
 Cranial nerves always spared
 Cervical plexus always spared
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 Prioritize Function
 Arm Abduction
 Triceps
 Bicep
 Wrist Extension
 Finger Extension/Flexion
 Individualize for Patient
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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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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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Stroke
Why can’t we treat a stroke patient like a brachial plexus
patient?
• Medical problems
• Spasm
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Spinal Cord Injury
Pressure Sores
 Can occur over any bony prominence
 Sacrum most common
 Scalp
 Ischium
 Hip
 Heels
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Spinal Cord Injury
Pressure Sores
 Prevention
 Prevention
 Prevention
 Prevention
 Prevention
 Prevention
 Prevention
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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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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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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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Spinal Cord Injury
Pressure Sores
 Neurotization for protective sensibility
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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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Complex Injuries:
“A Legal Perspective”
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This platform has been started by Parveen Kumar Chadha
with the vision that nobody should suffer the way he has
suffered because of lack and improper healthcare
facilities in India. We need lots of funds manpower etc. to
make this vision a reality please contact us. Join us as a
member for a noble cause.
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Treatment of injuries to the brachial plexus and upper extremity

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Treatment of injuries to the brachial plexus and upper extremity