Surgical Procedures for Complete Brachial Plexus Injuries after one year of accident

Free functioning muscle transfer (For elbow flexion)

Achieving elbow flexion is one of the main major goals in reconstruction of complete brachial plexus injuries. So this is the first surgery advised to the patientswhen they present after one year of accident-to restore his or her elbow flexion. In this surgery muscle is taken from the thigh, transferred to the arm mimicking the action of biceps muscle to bring the movement of elbow flexion.

It is also done in cases where the primary nerve repair procedures have failed to yield any response even after one and a half years of the surgery.

In few cases even after the nerve transfer and nerve grafting techniques, within the appropriate period, functional restoration of the hand might be disappointing. For this reason, functioning free muscle transplantation in addition to nerve transfer and grafting should be considered in cases delayed more than 9 - 12 months post traumatically.

Restoration of elbow flexion and wrist extension may succeed using the reinnervated free-muscle transfer technique.

For this repair, patient is admitted and routine pre-operative investigations, pre-anesthetic checkup is done.The surgery is done under General Anaesthesia. Informed written consent form is signed before surgery.During the surgery, area of the arm and the forearm is explored fordonor nerve and vesselsand a tunnel is created for inset of muscle. Gracilis muscle is harvested from the thigh along with its vessels and nerve. This muscle/flaptransferred to the paralysed arm and sutured. The vessels and the nerveare anastomosed under microscope by microsurgical technique.

Patient is kept under observation for about 10-12 days after surgery, free flap being monitored continuously, splintage given and then discharged. Dressings changed frequently in between, and patient called for follow up after 1 week or even later. After about 1-1.5 months of surgery, once the flap is settled, patient is advised for physiotherapy, TENS therapy. Follow up is done every month initially for stability, later every 3-6 months.

The time period required for any elbow flexion to appear is minimum between 6 to 9 months and the complete recovery may take around one to one and a half years

Wrist joint fusion (arthrodesis for wrist)

In cases where the hand has some function, wrist joint fusionwill stabilize the wrist joint and provide motor units for tendon transfer,so as to enhance finger function and increase grip strength. Fusion places the wrist in a stable functional position, and subsequent tendon transfers can improve movement and power in the elbow also.

For this repair, patient is admitted, routine pre-operative investigations and pre-anesthetic checkup is done. The surgery is done with incision on the back of thehand and distal forearm, wrist joint is exposed and fused with adynamic compression plate.Patient is kept under observation for about 2 days after surgery, splintage given and then discharged. Dressings changed once or twice in between, and patient called for follow up after 1 week for removal of sutures. For about 4-6 weeks, splintage is given after surgery, patient is advised for physiotherapy to keep the distal joints supple. Follow up is done every month initially for stability, later every 3-6 months.

Free functioning muscle transfer (For fingerflexion)

Achieving finger flexion is also one of the goals in reconstruction of complete brachial plexus injuries. This surgery is often done after the wrist is fused and stabilised. The patient should be able to extend his wrist and/or fingers after the primary FFMT surgerydone for elbow flexion and wrist extension. In this surgery muscle is taken from the thigh, transferred to the forearm mimicking the action of flexor muscle of fingers to bring the movement of finger flexion.

This gives functional restoration of the hand after complete breaker plexus injuries

For this repair, patient is admitted and routine pre-operative investigations, pre-anesthetic checkup is done. The surgery is done under General Anaesthesia. Informed written consent form is signed before surgery. During the surgery, area of the arm and the forearm is explored for donor nerve and vesselsand a tunnel is created for inset of muscle. Gracilis muscle is harvested from the thigh along with its vessels and nerve. This muscle/flap transferred to the paralysed arm and sutured. The vessels and the nerve are anastomosed under microscope by microsurgical technique.

Patient is kept under observation for about 10-12 days after surgery, free flap being monitored continuously, splintage given and then discharged. Dressings changed frequently in between, and patient called for follow up after 1week or even later. After about 1-1.5 months of surgery, once the flap is settled, patient is advised for physiotherapy, TENS therapy. Follow up is done every month initially for stability, later every 3-6 months.

The time period required for any finger flexion to appear is minimum between 6 to 9 months and the complete recovery may take around one to one and a half years

Trapezius transfer (for shoulder)

There is complete loss of movement of the shoulder incomplete brachial plexus injuries. Partial restoration of shoulder joint in form of abduction is possible with either shoulder joint fusion or trapezius muscle transfer.

If the patient is seen after a year of the accident, first surgery is done forrestoring elbow flexion. Surgery to restore movement of the shoulder joint can be done in the second stage but must be done after all the other surgeries as a final stage procedure.

Shoulder joint fusion is not very commonly tolerated by Indian patients but it is a very good procedure for patients with complete brachial plexus injuries.

The trapezius muscle is spared because of its innervation by the spinal accessory nerve in addition to contributions from C3 and C4. However, it is also usually hypertrophied (increase in bulk) after deltoid muscle paralysis, which is why trapezius transfer is the most commonly done tendon transfer for shoulder abduction movement in adult brachial palsy.

For this repair, patient is admitted, routine pre-operative investigations and pre-anesthetic checkup is done and muscle strength is confirmed. Horizontal incision is given over the shoulder region, trapezius muscle is dissected, mobilised and brought forward and fixed to the bone in the arm. Patient is kept under observation for about 3-4 days after surgery, splintage given and then discharged. Dressings changed once or twice in between, and patient called for follow up after 2 weeks for suture removal. Once the scars are matured, after about one month of surgery, he is advised for physiotherapy. Follow up is done every month initially for recovery, later every 3-6 months.

Three pillars of kayakriti