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Treatment of Injuries to the Brachial Plexus and Upper Extremity

Treatment of Injuries to the Brachial Plexus and Upper Extremity. Andrew I. Elkwood , MD, FACS Plastic & Reconstructive Surgery Director, The Center for Treatment of Paralysis and Reconstructive Nerve Surgery. Rehabilitative Surgery.

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Treatment of Injuries to the Brachial Plexus and Upper Extremity

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  1. Treatment of Injuries to the Brachial Plexus and Upper Extremity Andrew I. Elkwood, MD, FACS Plastic & Reconstructive Surgery Director, The Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  2. Rehabilitative Surgery Patients with disabilities can do more with less (depending upon the quality of their rehabilitation treatment) Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  3. Nerve Surgery The “Garage Door” Analogy Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  4. Nerve Surgery • The “Garage Door” Analogy • Outlet = spinal cord • Wire = nerve • Motor = muscle • Chair = tendon • Door = hand or foot Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  5. Rehabilitative Surgery is a process not an event Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  6. Rehabilitative SurgerySurgical Algorithm Nerve Repair Nerve Grafting Neurotization Tendon Transfer Tenodesis Joint Fusion Splinting Elegance Simplicity Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  7. Nerve Grafting • Self transfer (i.e. Sural Nerve) • Manufactured Nerve • Processed Nerve • Cadaver Transplant • Living Related Transplant Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  8. IN THE AREA OF THE PLEXUS • NERVES • BONES • ARTERY • VEIN • LUNG Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  9. Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  10. BRACHIAL PLEXUS INJURIES • BIRTH INJURY • MOTOR VEHICLE ACCIDENTS • MOTORCYCLES • FALLS • INDUSTRIAL ACCIDENTS • SPORTS INJURIES • TUMORS • RADIATION Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  11. BRACHIAL PLEXUS INJURIES • 4% OF ALL MOTORCYCLE ACCIDENTS • 19% ARE COMATOSE • 13% HAVE C-SPINE INJURIES Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  12. THREE BASIC FACTORS • PAIN • SENSIBILITY • MOTION Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  13. OVERVIEW • DIAGNOSIS • WORK-UP • NERVE STUDIES • NERVE REPAIR • POST-OP • REHABILITATION Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  14. DIAGNOSIS • Often clouded by coma, etc • Often clouded by orthopedic injuries • Often ignored • Often misinformed • May be subtle Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  15. WORK UP • PRELIMINARY WORK UP OF NERVE STUDIES STARTS RIGHT AWAY • FIRST EMG AT 6 WEEK TO 3 MONTHS • CXR • MRI • CT MYELOGRAM Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  16. WORK UP • REPEAT EMG AT 6 MONTHS IF NO IMPROVEMENT • IF IMPROVEMENT REASSESS AT 9 MONTHS • IF NO IMPROVEMENT OPERATE Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  17. 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 Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  18. SURGERYTEAM APPROACH • SURGEONS • CONSULTANTS • NURSES • THERAPISTS • HOME CARE • FAMILY Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  19. 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 Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  20. POST-OP CARE • UNDERLYING DISEASE • MULTIPLE OPERATIONS • PAIN RESISTANCE • SEVERAL OPERATIVE SITES • IMMOBILIZATION • LONG PROCEDURES • ANESTHESIA TIME Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  21. REHABILITATION • IMMOBILIZATION • 3 - 6 WEEKS POST-OP • AGGRESSIVE REHAB • KEEP JOINTS SUPPLE • MAINTAIN STRENGTH • BUILD NEW STRENGTH • RELEARN MUSCLE MOVEMENT • BIOFEEDBACK Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  22. Spinal Accessory Neurotization Brachial Plexus Palsy Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  23. BRACHIAL PLEXUS PALSY Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  24. Nerve Transplants • Its all about spare parts • No need to prioritize • Can’t go to home depot • Cadaver • Living related donor Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  25. Nerve Transplant • NO NEED TO PRIORITIZE • NO NEED TO PRIORITIZE • NO NEED TO PRIORITIZE • NO NEED TO PRIORITIZE Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  26. Nerve Transplantation • Allograft • Abo Compatibility • Prograf • Wrist Monitoring • Steroid Rescue Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  27. Nerve Transplantation • Who’s a candidate? • Injury about 1 year • Good health • Good support system • Massive injury Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  28. Nerve Transplantation • Who’s a good donor? • Good health • Abo match • No communicable disease Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  29. Nerve Transplantation CADAVER VS. LIVING RELATED DONOR Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  30. Spinal Cord Injury Can we treat spinal cord injuries like bilateral brachial plexus injuries? Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  31. Spinal Cord Injury Tetraplegic Hand Surgery Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  32. Spinal Cord InjuryHand 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 Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  33. Spinal Cord Paralysis We can’t fix the problem but we can help to RESTORE FUNCTION Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  34. Spinal Cord Injury • Need for Functioning Donors • Nerve donors above the lesion • Muscle donors for tendon transfers • Free muscle donors • Sacrifice contra lateral side? Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  35. Spinal Cord Paralysis • Level of Injury • Cranial nerves always spared • Cervical plexus always spared Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  36. Spinal Cord Paralysis • Prioritize Function • Arm Abduction • Triceps • Bicep • Wrist Extension • Finger Extension/Flexion • Individualize for Patient Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  37. 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 Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  38. 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 Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  39. Stroke Why can’t we treat a stroke patient like a brachial plexus patient? • Medical problems • Spasm Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  40. Spinal Cord InjuryPressure Sores • Can occur over any bony prominence • Sacrum most common • Scalp • Ischium • Hip • Heels Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  41. Spinal Cord InjuryPressure Sores • Prevention • Prevention • Prevention • Prevention • Prevention • Prevention • Prevention Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  42. Spinal Cord InjuryPressure 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 Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  43. 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 Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  44. Spinal Cord InjuryPressure Sore Treatment • High recurrence rate • Maximize everything • Quality of soft tissue coverage • Bed trial • Social support • Prognosis Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  45. Spinal Cord InjuryPressure Sores • Prevention • Prevention • Prevention • Prevention • Prevention • Prevention • Prevention Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  46. Spinal Cord InjuryPressure Sores • Neurotization for protective sensibility Center for Treatment of Paralysis and Reconstructive Nerve Surgery

  47. Spinal Cord InjurySummary • 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 Center for Treatment of Paralysis and Reconstructive Nerve Surgery

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