Praveen Bhardwaj

Functional outcome of nerve transfer for restoration of shoulder and elbow function in upper brachial plexus injury

Background Purpose of this study was to evaluate the functional outcome of spinal accessory to suprascapular nerve transfer (XI-SSN) done for restoration of shoulder function and partial transfer of ulnar nerve to the motor branch to the biceps muscle for the recovery of elbow flexion (Oberlin transfer). Methods This is a prospective study involving 15 consecutive cases of upper plexus injury seen between January 2004 and December 2005. The average age of patients was 35.6 yrs (15–52 yrs). The injury-surgery interval was between 2–6 months. All underwent XI-SSN and Oberlin nerve transfer. The coaptation was done close to the biceps muscle to ensure early recovery. The average follow up was 15 months (range 12–36 months). The functional outcome was assessed by measuring range of movements and also on the grading scale proposed by Narakas for shoulder function and Waikakul for elbow function. Results Good/Excellent results were seen in 13/15 patients with respect to elbow function and 8/15 for shoulder function. The time required for the first sign of clinical reinnervation of biceps was 3 months 9 days (range 1 month 25 days to 4 months) and for the recovery of antigravity elbow flexion was 5 months (range 3 1/2 months to 8 months). 13 had M4 and two M3 power. On evaluating shoulder function 8/15 regained active abduction, five had M3 and three M4 shoulder abduction. The average range of abduction in these eight patients was 66 degrees (range 45–90). Eight had recovered active external rotation, average 44 degrees (range 15–95). The motor recovery of external rotation was M3 in 5 and M4 in 3. 7/15 had no active abduction/external rotation, but they felt that their shoulder was more stable. Comparable results were observed in both below and above 40 age groups and those with injury to surgery interval less than 3 or 3–6 months. Conclusion Transfer of ulnar nerve fascicle to the motor branch of biceps close to the muscle consistently results in early and good recovery of elbow flexion. Shoulder abduction and external rotation show modest but useful recovery and about half can be expected to have active movements. Two patients in early fifties also achieved good results and hence this procedure should be offered to this age group also. Surgery done earlier to 6 months gives consistently good results.

Motor grading of elbow flexion – is Medical Research Council grading good enough?

Restoration of elbow flexion is top priority in reconstruction following brachial plexus injury. Medical Research Council (MRC) Grading is the most commonly used scale to grade muscle power. Though simple to use, it has several limitations. Each grade represents a very wide range and hence precludes accurate assessment of function and outcome following a given procedure. Wide range of Grade 4 is most worrisome. Definitely all grade 4 labeled can not equate to good functional results. With most of the nerve transfer procedures described now claiming grade 4 recoveries in more than 80% of the reported cases a need for more detailed and accurate assessment of this grade is greatly felt. A modified MRC grading system is described which is comprehensive and easy to use.

An epidemiological study of traumatic brachial plexus injury patients treated at an Indian centre.

Background: Epidemiological studies on traumatic brachial plexus injuries are few and these studies help us to improve the treatment, rehabilitation of these patients and to allocate the resources required in their management. Epidemiological factors can vary in different countries. We wanted to know the situation in an Indian centre. Materials and Methods: Data regarding age, sex, affected side, mode of injury, distribution of paralysis, associated injuries, pain at the time of presentation and the index procedure they underwent were collected from 304 patients. Additional data like the vehicle associated during the accident, speed of the vehicle during the accident, employment status and integration into the family were collected in 144 patients out of the 304 patients. Results: Road traffic accidents accounted for 94% of patients and of the road traffic accidents 90% involved two wheelers. Brachial plexus injury formed a part of multitrauma in 54% of this study group and 46% had isolated brachial plexus injury. Associated injuries like fractures, vascular injuries and head injuries are much less probably due to the lower velocity of the vehicles compared to the western world. The average time interval from the date of injury to exploration of the brachial plexus was 127 days and 124 (40.78%) patients presented to us within this duration. Fifty-seven per cent had joined back to work by an average of 8.6 months. It took an average of 6.8 months for the global brachial plexus-injured patients to write in their non-dominant hand.

Reconstruction of the thumb amputation at the carpometacarpal joint level by groin flap and second toe transfer.

INTRODUCTION Traumatic loss of thumb at the carpometacarpal (CMC) joint level is very disabling to an individual. Pollicisation is the recommended technique of reconstruction for loss of thumb at this level. On occasions, injury to the rest of the hand or amputation of additional fingers may make pollicisation an impossible option. Microsurgical transfer of second toe is an option in such situations. Although many large series of toe transfers are available in the literature, no series deals exclusively with this subset of patients. MATERIALS AND METHODS Eight patients who had amputation of the thumb at or proximal to the CMC joint level were reconstructed by second toe transfer by us in the period 2002-2011. All had preliminary groin flap cover in the area of the thumb during the acute stage of treatment. Second toe with the metatarsal was transferred for thumb reconstruction after a mean duration of 3 months after flap cover. Patients were assessed for their ability to pinch, hold large objects and opposition achieved by Kapandji score. Average follow up is 4 years and 6 months with a minimum of 1 year. RESULTS All toe transfers survived. They reached their maximum functional potential by 1 year. All patients actively used the reconstructed thumb for day to day activities. Pinch was possible in all patients except two patients who did not have any fingers. Six of them registered grip strength of at least 50% of the opposite hand. When fingers were present, opposition was possible in all patients with Kapandji scores ranging from 5 to 8. Extent of usage was less in patients who did not have good function in other fingers. CONCLUSION Second toe transfer is a viable option for reconstruction of thumb loss at or proximal to the CMC joint level. Proper planning of the preliminary flap cover determines the length of the thumb reconstruction. Strategic position of the transferred toe of adequate length and the functional status of the other fingers are important determinants of functional outcome.

Effect of static wrist position on grip strength.

Background: Grip strength after wrist arthrodesis is reported to be significantly less than normal. One of the reasons suggested for this decrease in grip strength is that the arthrodesis was performed in a suboptimal position. However, there is no consensus on the ideal position of wrist fusion. There is a paucity of studies evaluating the effect of various fixed positions of the wrist on grip strength and therefore, there is no guide regarding the ideal position of wrist fusion. The authors′ aim was to determine the grip strength in various fixed positions of the wrist and subsequently to find out in which position of wrist fusion the grip strength would be maximal. Materials and Methods: One hundred healthy adults participated in the study. For the purpose of this study, the authors constructed splints to hold the wrist in five different fixed positions: 45, 30 and 15 degrees of wrist extension, neutral and 30 degrees of wrist flexion. The grip strength in all the participants was measured bilaterally, first without a splint and then with each splint sequentially. Results: The average grip strength without the splint was 34.3 kg for right and 32.3 kg for the left hand. Grip strength decreased by 19–25% when the wrist was splinted. The maximum average grip strength with a splint on was recorded at 45 degrees of extension (27.9 kg for right and 26.3 kg for left side). There was a gradual increase in the grip strength with increase in wrist extension but the difference was not statistically significant (P = 0.29). The grip strength was significantly less in flexed position of the wrist (P < 0.001).

Wing flaps: perforator-based pedicled paraumbilical flaps for skin defects in hand and forearm.

Background:Single large-area or 2 small- to moderate-sized raw areas in the hand and forearm are difficult to cover with conventional groin or superficial inferior epigastric artery (SIEA) flaps. Though abdomen is a favorable donor site for a pedicled distant flap for soft tissue coverage of the hand and forearm, pedicle flaps based on paraumbilical perforators are not commonly used. Methods:We herein describe a method of soft tissue coverage using 2 flaps based on 1 paraumbilical perforator in certain difficult clinical situations, unsuitable to be covered with groin or SIEA flaps. By virtue of having a very narrow common pedicle for 2 substantially large flaps close to the chosen paraumbilical perforator, the configuration of it prompted us to call these twin flaps “wing flaps,” or a winged version of paraumbilical pedicle flaps. The wing flap described was used to cover twin raw areas (in 6 cases) and a large area (in 1 case) in the hand and forearm. Results:All 7 flaps went on to heal very well and served the purpose. The only complication observed was a minor thumb web contracture in one case, which improved with physiotherapy. Conclusion:The winged version of pedicled paraumbilical perforator flaps should find a place in the surgical armamentarium for soft tissue coverage in the hand and forearm in difficult situations. The advantages and simplicity of these flaps have been described, based on our experience in a small series of 7 cases.

Local flap coverage following posteromedial release in clubfoot surgery in older children

We present our experience of avoiding skin problems in older children with severe clubfoot deformity. We used a local transpositional flap coverage during wound closure following posteromedial release. We present our experience in five cases.RésuméNous présentons une façon de régler les problème cutanés dans la chirurgie du pied bot sévère chez les grands enfants. Nous utilisons un lambeau local de couverture lors de la fermeture cutanée après la libération posteromediale. Nous présentons notre expérience dans cinq cas.

Correlation between clinical findings and CT scan parameters for shoulder deformities in birth brachial plexus palsy.

PURPOSE The shoulder is the most common site of secondary deformities after birth brachial plexus palsy. The severity and the pattern of deformity vary in patients and have implications for clinical decision making. This study aimed to find the correlation between clinical findings and computed tomography (CT) scan parameters for these deformities. METHODS This prospective study included 75 patients aged 3 to 23 years. The clinical parameters included age, extent of involvement (nerve roots affected), degree of shoulder abduction, active and passive external rotation, and Mallet score. These were correlated with 3 CT scan parameters: elevation of the scapula above the clavicle, relative glenoid version, and percentage of the humeral head anterior to the scapular line. RESULTS There was a significant correlation between lack of active and passive external rotation and relative glenoid version and humeral head subluxation. There was a significant correlation between active abduction and elevation of the scapula above the clavicle. There was no significant correlation between age or Mallet score with any of the CT scan parameters. CONCLUSIONS These results suggest that presence of active and passive external rotation beyond 10° is associated with significantly lesser shoulder deformity irrespective of the degree of shoulder abduction. Hence, a patient with more than 10° external rotation does not need a screening CT scan evaluation regardless of the degree of shoulder abduction present. Conversely, a lack of external rotation beyond 10° strongly suggests relative glenoid retroversion and posterior subluxation of the humeral head and should be considered a clinical indicator of shoulder deformation. TYPE STUDY/LEVEL OF EVIDENCE Diagnostic II.

Pseudarthrosis of Cervical Rib: An Unusual Cause of Thoracic Outlet Syndrome

Thoracic outlet syndrome is uncommon in adolescence. Cervical rib fracture is an extremely rare cause of thoracic outlet syndrome in this age group. We report an unusual case of thoracic outlet syndrome in a 14-year-old girl caused by pseudarthrosis of the cervical rib. A magnetic resonance imaging scan showed significant compression of the brachial plexus by the pseudarthrosis mass. Excision of the cervical rib through a supraclavicular approach gave excellent results in this case.

Concomitant avascular necrosis of the scaphoid and lunate.

Simultaneous avascular necrosis of multiple carpal bones is rare. Concomitant avascular necrosis of scaphoid and lunate has been reported only once. We report one more case of this rare condition which can be a cause of wrist pain. Steroid intake is a known risk factor for avascular necrosis but in our case the patient had been taking herbal medicines for joint pain the composition of which was not known. Probably the presence of steroid in these medicines was the cause of avascular necrosis in this case.