Knowledge, attitudes and practice towards postoperative nursing of patients with digit replantation and skin flap transplantation among new nurses in Beijing: a cross-sectional survey.

OBJECTIVE: To explore the knowledge, attitudes and practice (KAP) towards the postoperative nursing of patients with digit replantation and skin flap transplantation among new nurses. DESIGN: Cross-sectional survey. SETTING: Two tertiary medical centres in Beijing, China. PARTICIPANTS: New nurses with working experience within 2 years. PRIMARY AND SECONDARY OUTCOME MEASURES: The demographic characteristics of the nurses and their KAP towards the postoperative nursing of patients with digit replantation and skin flap transplantation were collected using a self-administered questionnaire. The primary outcome was the KAP scores towards the postoperative nursing of patients with digit replantation and skin flap transplantation. The secondary outcomes were the factors associated with the KAP scores and how the KAP dimensions interacted among them. RESULTS: A total of 206 valid questionnaires were collected. The mean KAP scores were 7.72±3.28 (total score 13; 59.3%), 37.95±6.05 (total score 50; 75.9%) and 38.23±6.12 (total score 45; 84.9%), indicating poor knowledge, moderately favourable attitudes and active practice. The structural equation model analysis showed that knowledge directly influences attitudes (ß=0.82, 95%CI 0.60 to 1.05, p<0.001) and that attitudes directly influence practices (ß=0.72, 95%CI 0.62 to 0.83, p<0.001). Knowledge had no direct influence on practices (ß=0.10, 95%CI -0.09 to 0.29, p=0.313), but the indirect influence was significant (ß=0.60, 95%CI 0.41 to 0.78, p<0.001). CONCLUSION: The lack of sufficient knowledge towards the postoperative nursing of patients with digit replantation and skin flap transplantation among nurses with <2 years of experience and the correlation among the KAP dimensions suggested the importance of proper training.

Clinical application of a free flap supplied by the osteocutaneous branch of the anterior interosseous artery.

OBJECTIVES: To explore the clinical application and efficacy of transplantation of free composite flaps supplied by radial osteocutaneous branch of the dorsal branch of the anterior interosseous artery for reconstructing bone and skin defects in the hand. MATERIAL AND METHODS: Anatomically, the radial osteocutaneous branch of the dorsal branch of the anterior interosseous artery has constant collateral anastomoses which can provide a large dorsoradial flap from the dorsum of the forearm. This flap was used for reconstruction in five cases of cutaneous and phalangeal defects. RESULTS: Reconstruction was successful in all five cases, with consolidated phalanx and good cosmetic results. All donor sites could be closed directly. CONCLUSION: Reconstruction with dorsoradial forearm flaps is a reliable procedure which causes minimal trauma. Thus, it is an ideal approach for repairing cutaneous and phalangeal defects.

Direct Repair of ruptured nerve stump to middle trunk for restoration of extrinsic finger extension in total brachial plexus injuries.

BACKGROUND: Attempts to restore independent hand function in total brachial plexus injuries (TBPI) have often failed due to the inconsistent results of fingers extension reconstruction. An innovative technique is described to achieve this by direct neurorrhaphy of residual (ruptured) roots with the middle trunk. METHODS: Direct coaptation of the ruptured roots to the middle trunk and, simultaneously, transferring the anterior division of the middle trunk to the posterior division of lower trunk was performed in 64 patients of TBPI. The return of extension of the elbow, wrist and fingers were monitored. RESULTS: The excellent and good muscle strength of finger extension was noted in 45.3% cases. The patients were divided into group A (>32 years) and group B (≤32 years) according to ROC curve analysis. The difference of excellent and good rates of finger and wrist extension muscle strengths between the two groups was statistically significant (χ 2=4.635, P=0.031 χ 2=6.615, P=0.010). CONCLUSIONS: Direct neurorrhaphy of ruptured nerve root stumps with the middle trunk could achieve satisfactory results for finger extension in TBPI for patients ≤32 years old. Long nerve defects (4-6.5 cm) could be overcome by freeing the nerve and adducting the arm against the trunk.

Outcome of Nerve Grafting for Radiation-Induced Brachial Plexopathy.

BACKGROUND: There is no consensus on the optimal treatment for radiation-induced brachial plexopathy (RIBP). OBJECTIVE: To present our experience of using nerve resection and autografting as a treatment strategy for this challenging condition. METHODS: From September 2014 to January 2020, 8 patients with RIBP were treated with segmental nerve resection and autografting, with or without other supplementary procedures. All patients underwent sural nerve grafting to the musculocutaneous nerve. All were female with a mean age of 53 (range 38-64) years. Seven were on the left, and 1 was on the right. The mean follow-up duration was 33 (range 17-72) months. RESULTS: By the final review, 7 of 8 patients regained at least antigravity elbow flexion. Four patients reached Medical Research Council (MRC) grade 4, 3 MRC grade 3, and MRC grade 2 recovery in the biceps. The mean Visual Analog Score for pain improved from 2.6 preoperatively to 0.6 postoperatively ( P = .042). CONCLUSION: Nerve resection and autografting may restore satisfactory elbow flexion in patients with RIBP.

Direct Repair of the Lower Trunk to Residual Nerve Roots for Restoration of Finger Flexion After Total Brachial Plexus Injury.

PURPOSE: Residual nerve root stumps have been used to neurotize the median nerve in an attempt to restore finger flexion function in patients suffering from total brachial plexus injury. However, the results have been unsatisfactory mainly because of the need to use a long nerve graft. The authors have tried to improve the quality of restored finger flexion by direct approximation of available (ruptured) ipsilateral root stumps to the lower trunk (LT). We sought to validate these results using objective outcome measures. METHODS: This is a study of 27 cases of total posttraumatic brachial plexus palsies. In each case, the neck was explored and ruptured root stumps identified. The LT was mobilized by separating it from the posterior division and the medial cutaneous nerve of the forearm distally. The mobilized LT was then approximated directly to an ipsilateral root stump. The arm was immobilized against the trunk for 2 months. The patients were observed for return of function in the paralyzed upper limb. The presence and strength of finger flexion was measured using the British Medical Council grading. RESULTS: The follow-up period was 36 to 74 months (average, 56.9 ± 13.7 months). Recovery of active finger flexion was M4 in 10 patients, M3 in 8 patients, and M2 to M0 in 9 patients. Meaningful recovery (M3 or greater) of finger flexion was achieved in 18 of 27 patients. CONCLUSIONS: The results of active finger flexion can be improved by direct approximation of the LT to an ipsilateral root stump. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Restoration of active pick-up function in patients with total brachial plexus avulsion injuries.

We designed multiple nerve transfers in one surgery to restore active pick-up function in patients with total brachial plexus avulsion injuries. Forty patients with total brachial plexus avulsion injuries first underwent multiple nerve transfers. These included transfer of the accessory nerve onto the suprascapular nerve to recover shoulder abduction, contralateral C7 nerve onto the lower trunk via the modified prespinal route with direct coaptation to restore lower trunk function and onto the musculocutaneous nerve with interpositional bridging by medial antebrachial cutaneous nerve arising from lower trunk to restore elbow flexion, and the phrenic nerve onto the posterior division of lower trunk to recover elbow and finger extension. At least three years after surgery, the patients who had a meaningful recovery were selected to perform secondary reconstruction to restore active pick-up function. Active pick-up function was successfully restored in ten patients after they underwent multiple nerve transfers combined with additional secondary functional hand reconstructions. LEVEL OF EVIDENCE: IV.

Functional connectivity of motor cortical network in patients with brachial plexus avulsion injury after contralateral cervical nerve transfer: a resting-state fMRI study.

INTRODUCTION: The purpose of this study is to assess the functional connectivity of the motor cortical network in patients with brachial plexus avulsion injury (BPAI) after contralateral C7 nerve transfer, using resting-state functional magnetic resonance imaging (RS-fMRI). METHODS: Twelve patients with total brachial plexus root avulsion underwent RS-fMRI after contralateral C7 nerve transfer. Seventeen healthy volunteers were also included in this fMRI study as controls. The hand motor seed regions were defined as region of interests in the bilateral hemispheres. The seed-based functional connectivity was calculated in all the subjects. Differences in functional connectivity of the motor cortical network between patients and healthy controls were compared. RESULTS: The inter-hemispheric functional connectivity of the M1 areas was increased in patients with BPAI compared with the controls. The inter-hemispheric functional connectivity between the supplementary motor areas was reduced bilaterally. CONCLUSIONS: The resting-state inter-hemispheric functional connectivity of the bilateral M1 areas is altered in patients after contralateral C7 nerve transfer, suggesting a functional reorganization of cerebral cortex.

Direct Coaptation of the Phrenic Nerve With the Posterior Division of the Lower Trunk to Restore Finger and Elbow Extension Function in Patients With Total Brachial Plexus Injuries.

BACKGROUND: To overcome the mismatch in nerve sizes in phrenic nerve transfer to the radial nerve for elbow and finger extension reanimation for patients with total brachial plexus injuries (TBPI), a selective neurotization procedure was designed. OBJECTIVE: To investigate the long-term results of phrenic nerve transfer to the posterior division of the lower trunk with direct coaptation in restoring elbow and finger extension after TBPI. METHODS: Phrenic nerve was transferred to and directly coapted with the posterior division of the lower trunk in 27 patients with TBPI. Seven patients were <18 years old (adolescent group), and the remaining 20 patients ≥18 years (adult group). RESULTS: Postoperative mean follow-up period was 54 ± 9 months (range, 48-85 months). The motor function attained M3 or greater in 81.5% of patients for elbow extension and in 48% of patients for finger extension. The percentage of patients who regained M3 or greater muscle power of finger extension in the adolescent group and the adult group was 71.4%, and 40%, respectively. Meanwhile, 85.7% in the adolescent group and 80% in the adult group achieved M3 or greater muscle power of elbow extension. There were no significant differences between the 2 groups. The elbow extension and finger extension were synchronous contractions and did not become independent of respiratory effort. CONCLUSION: This procedure simultaneously and effectively restores the function of elbow and finger extension in patients after TBPI. However, the patients could not do elbow and finger extension separately.

Complications of contralateral C-7 transfer through the modified prespinal route for repairing brachial plexus root avulsion injury: a retrospective study of 425 patients.

OBJECT: In this report, the authors review complications related to the modified prespinal route in contralateral C-7 transfer for repairing brachial plexus nerve root avulsion injury and suggest a prevention strategy. METHODS: A retrospective, nonselected amalgamation of every case of modified contralateral C-7 transfer through the prespinal route was undertaken. The study population comprised 425 patients treated between February 2002 and August 2009. The patients were managed according to a standardized protocol by one senior professor. The surgical complications were grouped into one of the following categories: those associated with tunnel making through the prespinal route, those related to the dissection and transection of the contralateral C-7 nerve root, and those that occurred in the postoperative period. RESULTS: The study population included 379 male and 46 female patients whose average age was 21 years (range 3 months to 56 years). A total of 401 patients were diagnosed with traumatic brachial plexus injury, the leading cause of which was motor vehicle accident, and 24 patients were diagnosed with obstetrical brachial plexus palsy. The contralateral C-7 nerve root was cut at the proximal side of the division portion of the middle trunk in 15 cases and sectioned at the distal end of the anterior and posterior divisions in 410 cases. The overall incidence of complications was 5.4% (23 of 425). Complications associated with making a prespinal tunnel occurred in 12 cases, including severe bleeding due to vertebral artery injury during the procedure in 2 cases (0.47%), temporary recurrent laryngeal nerve palsy in 5 cases (1.18%), pain and numbness in the donor upper extremity during swallowing in 4 cases (0.94%), and dyspnea caused by thrombosis of the brainstem 42 hours postoperatively in 1 case (0.24%); this last patient died 38 days after the operation. Complications related to exploration and transection of the contralateral C-7 nerve root occurred in 11 cases, including deficiency in extensor strength of the fingers and thumb in 4 cases (0.94%) due to injury to the posterior division of the lower trunk, unbearable pain on the donor upper extremity in 3 cases (0.71%), Horner's syndrome in 2 children (0.47%) who suffered birth palsy, a section of C-6 nerve root mistaken as C-7 in l case (0.24%), and atrophy of the sternocostal part of the pectoralis major in 1 case (0.24%). CONCLUSIONS: The most serious complications of using the modified prespinal route in contralateral C-7 transfer were vertebral artery laceration and injury to the posterior division of the lower trunk. The prevention of such complications is necessary to popularize this surgical procedure and attain good long-term clinical results.

[Corticoplasty for multiple enchondromatosis of hand].

OBJECTIVE: To evaluate the results of corticoplasty for multiple enchondromatosis of the hand. METHODS: Between February 2003 and January 2011, 6 patients with multiple enchondromatosis were treated. Of 6 cases, 1 was boy and 5 were girls with an average age of 10.8 years (range, 9-12 years); 5 cases presented with painless mass as first symptom, and 1 case was found to have mass by X-ray film because of hand injury. Physical examination at admission showed multiple mass on the hands, fingers deformity, and limited range of motion; X-ray film results showed large lesions in the phalanges and metacarpals. Corticoplasty and simple curettage without bone grafting were performed on 24 fingers (60 bones) with multiple enchondromatosis of the hand. The fingers active range of motion was used to evaluate the finger function; the diameter of the tumors was measured on the X-ray films; and according to Tordai's classification, tumor recurrence and new bone formation were observed. RESULTS: Once, twice, or three-time operations were performed in 2 cases, respectively. All patients were followed up 17-83 months with an average of 52.2 months. At last follow-up, the active range of motion was significantly increased from (230.8 +/- 53.2) degrees at preoperation to (255.0 +/- 28.7) degrees at postoperation (t = -3.829, P = 0.001); the tumor diameter was significantly decreased from (15.6 +/- 5.8) mm at preoperation to (10.7 +/- 3.7) mm at postoperation (t = 8.304, P = 0.000). Of 60 bones, 34 (56.7%) were rated as Tordai grade 1, and 26 (43.3%) as Tordai grade 2. During follow-up, clinical manifestation, characteristics of radiology and pathological examination showed no pathological fracture or malignant change. CONCLUSION: Corticoplasty is a safe and effective treatment for multiple enchondromatosis of the hand in children. The procedure can improve appearance and motion function of the hand.

Contralateral C7 Nerve Transfer with Direct Coaptation to Restore Lower Trunk Function After Traumatic Brachial Plexus Avulsion Injuries: Surgical Technique.

INTRODUCTION: We describe a new technique for treating traumatic brachial plexus avulsion injury with a contralateral C7 nerve transfer with direct coaptation that shortens the time to muscle reinnervation. STEP 1 EXPLORE THE INJURED BRACHIAL PLEXUS: Explore the brachial plexus carefully and confirm the nerve-root avulsion injuries from C7 to T1. STEP 2 HARVEST THE CONTRALATERAL C7 NERVE: Dissect the divisions of the contralateral C7 nerve root, divide the nerve at the junction between the divisions and cords, and mobilize it proximally. STEP 3 CREATE THE PRESPINAL ROUTE: Create the prespinal route to guide the contralateral C7 nerve to the injured side. STEP 4 HUMERAL SHORTENING OSTEOTOMY: If the contralateral C7 nerve does not reach the injured lower trunk, perform a humeral shortening osteotomy, generally with <5 cm of shortening in adults. STEP 5 NEURORRHAPHY: Suture one end of the sural nerve together with the medial antebrachial cutaneous nerve to the musculocutaneous nerve; anastomose the remainder of the contralateral C7 nerve directly with the lower trunk. STEP 6 POSTOPERATIVE CARE: Use a prefabricated brace to hold the head in the neutral position and immobilize the injured limb for six weeks. RESULTS: We evaluated the results of the technique in a study of seventy men and five women with a mean age (and standard deviation) of 28 ± 10 years (range, ten to fifty-three years).IndicationsContraindicationsPitfalls & Challenges.

Contralateral C7 nerve transfer with direct coaptation to restore lower trunk function after traumatic brachial plexus avulsion.

BACKGROUND: Contralateral C7 nerve transfer to the median nerve has been used in an attempt to restore finger flexion in patients with total brachial plexus avulsion injury. However, the results have not been satisfactory mainly because of the requirement to use a long bridging nerve graft, which causes an extended nerve regeneration process and irreversible muscle atrophy. A new procedure involving contralateral C7 nerve transfer via a modified prespinal route and direct coaptation with the injured lower trunk is presented here. METHODS: Contralateral C7 nerve transfer via the modified prespinal route and direct coaptation with the injured lower trunk was performed in seventy-five patients with total brachial plexus avulsion injury. Thirty-five required humeral shortening osteotomy (3 to 4.5 cm) in order to accomplish the direct coaptation. The contralateral C7 nerve was also transferred to the musculocutaneous nerve through the bridging medial antebrachial cutaneous nerve arising from the lower trunk in forty-seven of the seventy-five patients. Recovery of finger, wrist, and elbow flexion was evaluated with use of the modified British Medical Research Council muscle grading system. RESULTS: The mean follow-up period (and standard deviation) was 57 ± 6 months (range, forty-eight to seventy-eight months). Motor function with a grade of M3+ or greater was attained in 60% of the patients for elbow flexion, 64% of the patients for finger flexion, 53% of the patients for thumb flexion, and 72% of the patients for wrist flexion. CONCLUSIONS: Contralateral C7 nerve transfer via a modified prespinal route and direct coaptation with the injured lower trunk decreases the distance for nerve regeneration in patients with total brachial plexus avulsion injury. There was satisfactory recovery of finger flexion and wrist flexion in this series. In addition, contralateral C7 nerve transfer was successfully used to repair two different target nerves: the lower trunk and the musculocutaneous nerve.

Electrophysiological study of the dominant motor innervation to the extensor digitorum communis muscle and long head of triceps brachii at posterior divisions of brachial plexus.

BACKGROUND: Restoration of elbow and finger extension function is still challenging in management of complete brachial plexus avulsion injury, mainly because of fewer available donor nerves for transfer to the radial nerve. Selective neurotization could be a potentially alternative for overcoming this dilemma. This study was designed to identify the innervation dominance of the extensor digitorum communis muscle (EDCM) and long head of the triceps brachii (LTB) at the level of division of brachial plexus. METHODS: From February 2008 to October 2009, 17 patients with complete brachial plexus avulsion injury underwent the procedure of contralateral C7 nerve root transfer. The posterior divisions of brachial plexus on the healthy donor side were intraoperatively stimulated and the compound muscle action potentials (CMAPs) from the extensor digitorum communis muscle and long head of triceps brachii were recorded by an electrophysiological device. RESULTS: In 13 out of 17 patients (76.5%), the maximal amplitude of CMAP from EDCM was induced by stimulation of the posterior division of lower trunk (PDLT). The mean amplitudes of CMAP from EDCM with stimulation of the posterior division of upper trunk (PDUT), middle trunk (PDMT), and PDLT were 0.64 ± 0.95, 1.64 ± 1.56, and 5.32 ± 4.67 mV (P < 0.05), respectively. The maximal amplitude of CMAP from LTB was induced mainly by stimulation of the PDMT) and PDLT (6 out of 11 and 5 out of 11 patients). The mean amplitudes of CMAP from LTB with stimulation of the PDUT, PDMT, and PDLT were 0.15 ± 0.24, 5.20 ± 4.27, and 7.48 ± 9.90 mV, respectively. The differences of CMAPs between stimulation of PDUT and other two divisions were significant (P < 0.05). CONCLUSIONS: From the electrophysiological point of view, this study showed that the PDLT was the major motor division innervating EDCM, and the PDMT and PDLT shared the similar proportion of LTB innervation.

[The clinical study of reconstruction of traumatic brachial plexus root avulsion injury in children].

OBJECTIVE: To observe the primary result of finger flexion reconstruction in the procedure of direct anastomosis of contralateral C(7) transferred through the prespinal route with lower trunk in children suffered traumatic brachial plexus root avulsion injury. METHODS: On the healthy side, the C(7) nerve root was identified anatomically and transected at the level of division by dissecting its anterior and posterior division as far distal as possible up to the level where the nerve fibers interweaving with other division, then the contralateral C(7) nerve root was dissected proximally up to the neuroforamina. The contralateral C(7) nerve root was transferred to contralateral side through the prespinal route. The entire brachial plexus of suffered side was exposed through the union incision superior and inferior to the clavicle, The lower trunk was identified and dissected proximally to the C(8) and T(1) nerve root which were severed at the lateral margin of anterior scalenus, and then the dorsal division and anterior medial pectoral nerve of lower trunk were severed. The median nerve, ulnar nerve and medial antebrachial cutaneous nerve were identified from the origin and dissected distally continue to the midpoint of upper arm, and lateral head of the median nerve was severed so that the lower trunk, medial cord and median nerve, ulnar nerve and medial antebrachial cutaneous nerve can be fully mobilized. Anteriorly flexion and adduction of the should at 0 degrees and flexion elbow at 90 degrees , this could allow considerable length to be gained when pulling the lower trunk proximally, direct anastomosis of contralateral C(7) with lower trunk was performed. If there was any tension exist, the appropriate humerus shorten osteotomy should be performed. From August 2004 to December 2008, 20 children including 13 cases with total brachial plexus nerve root avulsion injury and 7 cases with middle and lower trunk avulsion injury were repaired by this procedure. Twenty cases including 16 males and 4 females, the average age was 13 years with a range of 5 to 18 years. The interval from injury to operation ranged 1 to 11 months with a mean of 4.6 months. Eleven patients were performed the humeral shorten osteotomy, the length of the humeral shorten was 2.0 - 4.5 cm, with the mean of (3.1 +/- 0.7) cm. RESULTS: The follow up period was 12 to 51 months, with the average of 26 months. The muscle strength of finger flexion attained M 4 in 18 cases, M 2 in 2 cases. The motor function of thumb flexion gained M 4 in 10 cases, M 3 in 8 cases, M2 in 2 cases. Of the 2 cases achieved motor function of intrinsic muscles of the hand of M3. CONCLUSIONS: The direct anastomosis of contralateral C(7) with lower trunk in children with traumatic brachial plexus avulsion injury can improve the effect of reconstructing the function of finger flexion because it reduces one never anastomosis site and decreases the distance of nerve regeneration compared with the traditional method. With this modified procedure, the functional recovery of intrinsic muscles of the hand in children with traumatic brachial plexus avulsion injury is becoming possible.

Management of intra-articular fracture of the fingers via mini external fixator combined with limited internal fixation.

BACKGROUND: Intra-articular fractures of the fingers are common problems to emergency physicians and hand surgeons. Inappropriate management of these injuries may result in chronic pain, stiffness, deformity, or post traumatic arthritis. Ideal treatment necessitates the restoration of a stable and congruent joint that will allow early mobilization. The purpose of this study was to investigate the results of intra-articular fracture of the fingers by mini external fixator combined with limited internal fixation. METHODS: From May 2005 to May 2007, a total of 26 patients with intra-articular fracture of the fingers were treated by mini external fixator combined with limited internal fixation. Of the 26 cases, 11 involved in metacarpophalangeal joint, and 15 interphalangeal joint in proximal interphalangeal. Kirschner wire, mini wire and absorbable suture were used for limited internal fixation. All patients were followed up and patients were accomplished with total active motion (TAM) of fingers. RESULTS: All patients were reviewed by an independent observer. The mean follow up was 13 months (range 9 to 24 months). Subjective, objective and radiographic results were evaluated. X-ray films revealed fracture union and the average radiographic union time was 7 weeks with a range of 5 - 12 weeks and the phalange shortening or rotation in 2 cases, joint incongruity (less than 1 mm) and joint space narrowing in 3 cases respectively. Phalangeal shortening or rotation was observed in 2 cases and joint incongruity or joint space narrowing was observed in 3 cases. An artificial implant was performed on one case for traumatic arthritis 1.5 years after surgery. Based on TAM the overall good-excellent rate of joint motion function was 80.8%. CONCLUSION: Mini external fixator combined with limited internal fixation is a reliable and effective method for treatment of intra-articular fracture of the fingers.