Prospective study comparing outcomes of primary intraplexal repair versus distal nerve transfers in Narakas grade I birth brachial plexus palsy.

To compare the results of intraplexal repair and distal nerve transfer in babies with birth brachial plexus palsy (BBPP), children with Narakas group I obstetric palsy were assigned to two groups of 16 each. Children in group A were treated with classical intraplexal repair and those in group B were treated by distal nerve transfers. At 6 months, all the children in group B had achieved Modified Medical Research Council (MMRC) grade 3 elbow flexion along with 8 of the 16 children in group A, which was a statistically significant difference. At 6 months, all the children in group B achieved MMRC grade 3 or higher shoulder abduction and 8 of the 16 children in group A had done so, which was also statistically significant. At the final follow-up, the distal transfer surgical treatment group had a significantly higher Mallet score. Distal nerve transfers have a significant advantage in early recovery in elbow flexion and shoulder abduction, but the outcomes became similar after 9 months.Level of evidence: III.

Birth Brachial Plexus Palsy: An Indian Perspective.

Birth brachial plexus palsy (BBPP) is an unfortunate outcome of a difficult labor, which can often lead to long-lasting upper limb impairments. Spontaneous recovery may or may not occur. Timely diagnosis of the condition and initiation of the appropriate treatment can be instrumental in decreasing the functional impact. The management begins right from the day the child presents first and ranges from physiotherapy to surgical intervention such as nerve repair/transfer or grafts. The sequelae of the condition are also quite common and need to be detected preemptively with initiation of appropriate treatment. However, prevention is the key to reducing the incidence of secondary deformities. In this study, the team of authors, based on their considerable experience, discuss their approach to the management of BBPP. This is done in the background of Indian cultural practices and social constraints. A detailed discussion has been done on importance of preoperative passive joint mobilization regime and role of botulinum toxin in the authors' preferred ways of surgical correction of primary as well as secondary deformities. An extensive review of peer-reviewed publications has been done in this study, including clinical papers, review articles, and systematic review of the subject. Good results are possible with early and appropriate intervention even in severe cases.

A Tardy Ulnar Palsy with an Anomalous Course of Ulnar Nerve.

Variations are inherent feature of the intricate brachial plexus. They can be at the level of origin, the course, or the innervation pattern of each peripheral nerve. Knowledge of the various described variations can be worthwhile during the routine hand surgery procedures. We present a case of an elderly patient with anomalous intramuscular course of the ulnar nerve presenting with ulnar neuropathy at the elbow. Level of Evidence: IV.

Outcomes of Tendon Transfer Surgery for Correction of Ulnar Claw Hand: A Case Series.

This case series presents detailed postoperative physiotherapeutic rehabilitation and functional outcomes of 3 patients following tendon transfer surgery for the correction of claw hand due to traumatic nerve injury. Three patients with different etiologies of claw hand and sociodemographic characteristics presented to the hand therapy center after claw correction surgery. Two patients underwent flexor digitorum superficialis 4-tail tendon transfer, and 1 patient underwent the Zancolli lasso procedure. Hand therapy began after 4 weeks of appropriate postoperative immobilization. It began with the activation and strengthening of the new muscle-tendon unit and its integration into functional activities. All patients returned to work 12 weeks after surgery, followed by an assessment of outcomes at 16 weeks. Satisfactory improvements in the functional outcomes based on the Brand criteria, the Patient-Rated Wrist and Hand Evaluation, and the Patient-Specific Functional Scale were observed in all patients at 16 weeks.

Analysis of Results of Contralateral Hemi-C7 Root Used for Restoring Hand Function in Global Birth Brachial Plexus Palsy.

PURPOSE: To analyze the outcome of the use of contralateral hemi-C7 for the restoration of hand function in patients with birth brachial plexus global palsy. METHODS: From 2004 to 2017, 19 infants with Narakas types III and IV birth brachial plexus palsy underwent transfer of contralateral hemi-C7 (posterior division of the contralateral C7 root) to the lower trunk or medial cord on the affected side. All the patients were evaluated for shoulder function using the Gilbert and Mallet scores, elbow flexion using the modified Medical Research Council score for children, and hand function using the Raimondi score. After the surgery, the children were followed-up at 3-month intervals for the first year and 6-month intervals thereafter. Hand function achieving Raimondi scores of 3-5 was considered a useful outcome. RESULTS: The patients were followed-up for a mean duration of 88 months, with a minimum of 35 and a maximum of 192 months of follow-up. All patients attained a Gilbert score of ≥3, whereas 9 patients attained a score of ≥4. Similarly, all patients attained a minimum aggregate Mallet score of 15, and 9 patients attained a score of ≥20. All patients attained a modified Medical Research Council score of ≥3, used for assessing elbow flexion. Useful hand function was attained in 73% (14/19) of the cases (a Raimondi score of ≥3). There was no clinically recorded deficit on the donor side. CONCLUSIONS: Contralateral hemi-C7 transfer in infants with brachial plexus root avulsions helped regain useful hand function in 73% (14/19) of the children treated. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Correlation of Magnetic Resonance Imaging (Neurography) and Electrodiagnostic Study Findings with Intraoperative Findings in Post Traumatic Brachial Plexus Palsy.

Background The majority of brachial plexus injuries (BPIs) are caused by trauma; most commonly due to two-wheeler road accidents. It is important to determine whether the lesion in question is pre-ganglionic or post-ganglionic for purposes of surgical planning and prognosis. Diagnostic testing helps the surgeon to not only decide whether surgical intervention is required, but also in planning the procedure, thereby maximizing the patient's chances of early return to function. The aim of the study was to determine the diagnostic efficacy of electrodiagnostic studies (Edx) and magnetic resonance imaging (MRI) individually, and in unison, in detecting the type and site of BPI by comparison with intraoperative findings (which were used as the reference standard) in patients with posttraumatic BPI. Methods It is an observational cross-sectional prospective randomized study, wherein 48 patients with BPI underwent a detailed clinical and neurological examination of the upper limb, Edx, MRI neurography and were subsequently operated upon. We assessed a total of 240 roots. The diagnosis of all spinal roots was noted on Edx. MRI was performed to look for root avulsion, pseudomeningocoele, and/or rupture injury. The patients were subsequently operated upon. All roots were traced from infraclavicular level right up to the foramen to ensure continuity of root or note rupture/ avulsion. The findings were tabulated. Results MRI accurately diagnosed 138 of the 147 injured roots and MRI sensitivity for the detection of BPI was 93.88%, whereas Edx correctly identified 146 out of 147 injured roots and thus, had sensitivity of 99.32%; however, both lacked specificity (18.28 and 20.43%, respectively). With Edx and MRI in unison, sensitivity was 100% which meant that if a given patient with a BPI is subjected to both tests, not a single abnormal root will go unnoticed. Conclusion Edx and MRI are two highly sensitive investigation modalities whose combined sensitivity is 100% for the detection of a root injury. Therefore, we recommend both tests as they are excellent screening tests.

Management of Birth Brachial Plexus Injury Including Use of Distal Nerve Transfers.

Birth Brachial plexus injury continues to remain a problem despite significant care from obstetricians to prevent it. Many children show spontaneous recovery but a significant proportion do not have adequate recovery. This review article discusses, etiology, assessment, investigations and overall strategy to treat the condition. Surgical strategy consists of primary intraplexal repair as the standard of care but of late the distal nerve transfers used in adult plexus injuries are increasingly being used in infants too. We discuss the history, current usage and pros and cons of distal nerve transfers, the usage of Botulinum Toxin and finally given an overall algorithm for the management.

A Method of Shoulder Spica Cast Application In Shoulder Muscle Transfer Patients In Supine Position.

Background Children with birth brachial plexus injury (BBPI) often require secondary surgery for the shoulder. The shoulder spica is necessary after shoulder muscle transfer surgery in babies with BBPI. However, its application can be difficult in the supine position under anesthesia. The authors describe a simple and cost-effective method of applying the shoulder spica cast without changing the supine position under anesthesia. Technique While still under anesthesia, the child is placed in a supine position and then elevated on the wooden bar. The POP roll is wrapped around in a cylindrical manner, starting from the level one inch above the anterior superior iliac spine. The contralateral shoulder is also incorporated into the cast. Conclusion The spica application technique described comprises commonly available materials, such as a wooden plank, pair of bolsters, plaster of Paris rolls, and dressing materials overcoming the need for customized apparatus or the operation table. The materials are easy to assemble and thereby applicable just about anywhere. The task also becomes less challenging for the anesthetic in the supine position. This technique is easily reproducible and cost-effective.

Peripheral Nerve Injury to the Lower Limb: Repair and Secondary Reconstruction.

This article is based on literature review of relevant articles as well as the authors' own experiences in treating peripheral nerve injuries of the lower limb. The article deals with causative factors of lower limb nerve injuries, various grading systems of the injuries, approaches to such injuries, and techniques to repair lower limb nerve injuries. It also enumerates several reasons to explain the poorer prognosis of peroneal nerve injuries and the possible distal nerve transfers in lower limb albeit with poorer outcomes.

A simple and effective way of maintaining the microvascular field clean and dry during anastomosis.

During microvascular anastomosis, it is important to maintain the microsurgical field irrigated yet dry so as to achieve a good view of the vessels for approximation. In this method, an infant feeding tube (size 4), with its tip sandwiched between layers of dry gauze and a surgical glove component placed in the anastomotic field and the other end connected to a suction apparatus, is used to maintain the microsurgical field free from flooding. It also has the additional advantage of providing a stable platform for microvascular anastomosis.

Brachial plexus injury in adults: Diagnosis and surgical treatment strategies.

Adult post traumatic Brachial plexus injury is unfortunately a rather common injury in young adults. In India the most common scenario is of a young man injured in a motorcycle accident. Exact incidence figures are not available but of the injuries presenting to us about 90% invole the above combination This article reviews peer-reviewed publications including clinical papers, review articles and Meta analysis of the subject. In addition, the authors' experience of several hundred cases over the last 15 years has been added and has influenced the ultimate text. Results have been discussed and analysed to get an idea of factors influencing final recovery. It appears that time from injury and number of roots involved are most crucial.

Unfavourable results in pollicisation.

Pollicisation of the index finger is perhaps one of the most complex and most rewarding operations in hand and plastic surgery. It however has a steep learning curve and demands very high skill levels and experience. There are multiple pitfalls and each can result in an unfavourable result. In essence we need to: Shorten the Index, recreate the carpo metacarpal joint from the metacarpo phalangeal (MP) joint, rotate the digit by about 120° for pulp to pulp pinch, palmarly abduct by 40-50° to get a new first web gap, Shorten and readjust the tension of the extensors, re attach the intrinsics to form a thenar eminence capable of positioning the new thumb in various functional positions and finally close the flaps forming a new skin envelope. The author has performed over 75 pollicisations personally and has personal experience of some of the issues raised there. The steps mentioned therefore are an algorithm for helping the uninitiated into these choppy waters.

The outcome of Jarcho-Levin syndrome treated with a functional latissimus dorsi flap - A series of three cases.

INTRODUCTION: Jarcho-Levin syndrome is manifested by vertebral body and rib malformations. Large rib defects with paradoxical chest motion lead to early deathdue to progressive respiratory insufficiency, hence it is a lethal syndrome. The only means of improving survival is early stabilisation of the chest wall defect by containing the thoracic herniation. Nitcher et al. and Thatte et al. showed that reconstruction of the chest wall was life saving. Thatte et al. had postulated that early coverage of the lungs and thoracic contents with functional latissimus dorsi may prevent the visceral overgrowth and secondary pleural changes. MATERIALS AND METHODS: Our three cases which had medium- and long-term follow-up help to support this postulation. Three patients were assessed retrospectively. Their ages at surgery were 6 months, 8 months and 1 year, respectively. All had laboured breathing and paradoxical respiration. All of them were operated with ipsilateral latissimus dorsi flap. RESULTS: The results were evaluated clinically. The patients had reduced or no respiratory infections. The lung compliance improved and they had no tachypnoea on walking, running or playing. CONCLUSION: Hence, this can be used as a life-saving procedure for Jarcho-Levin syndrome on a long-term basis.