Thread by @PlasticsFella

19/

Delayed BP Injuries

Consider Anatomy of the injury
Influence of time
+ and - function
Expendability
Priorities (elbow + shoulder)
Don't burn bridges

20/

Goals: Optimise Limb Position and Maximise Re-animation potential

21/

Shoulder Tendon Transfers Consider:
- Lower Trapzeius to Tereis mInor
- Contralateral lower trapezius transfer

22/
Shoulder:
If tendon transfer not possible, glenohumeral arthrodesis and reduce pain. associated with a high complication rate

23/

Elbow consider:

1. Local transfer (Steindler-Flexorplasty)
2. Regional transfer (Bipolar LD, pec major)
3. Free Tissue Transfer

24/

Forearm consider Functional Repositioning by Correction multiple-level osteotomy

Hand:
Intrinsic vs Extrinsic Baland
Ulnar Hand --> Grasp
Radial hand --> Prehensile/Dexterity

25/

Brachial Plexus Nerve Injury at Birth

1 in 1000 live births
30% complete recovery
Assessments challening

26/ Brachial Plexus Nerve Injury at Birth

Common risk factors :
- vertex delivery
- large baby
- maternal diabetes
- prolonged delivery
- shoulder dystocia

27/ Brachial Plexus Nerve Injury at Birth

Avulsion - No spontaneous recovery
Stretch - spon. recovery 1-2 months
Rupture - limited spon recovery 4-5 months

28/ Brachial Plexus Nerve Injury at Birth

1. Do they need Exploration, if needed, at 3-6 months
2. Is it affecting shoulder development

Signs:
- Horners
-Winging on back
- Hemidiaphragm paralysis

29/ Brachial Plexus Nerve Injury at Birth

Hospital for Sick Children - Active Movement Scale
15 movements on a 0-7 scale
Understand muscle recovery and strength

30/ Brachial Plexus Nerve Injury at Birth

Predictors of Recovery?
Anti-gravity elbow flexion if not redeemed then explore at 3-5 months (literature varies)

Cookie Test
Success is cookie to moth with less than 45 deg neck flexion. If cannot do this by 9 months, then plateua

31/ Brachial Plexus Nerve Injury at Birth

Indications for surgery
- 3 months: Flail limb and horners
- 6 months: antigravity biceps, toronto score <3.5
- 9 months: cookie test

31/ Brachial Plexus Nerve Injury at Birth

Nerve Surgery Options include
1. Neuroma Resection and Grafting
2. Nerve Transfers (Oberlin, Somsak, SAN to SSN)

32/ Secondary Recons after BP Injury for:

Shoulder:
- IR con rotation contracture
- Glenohumeral dysplasia
- Abduction contracture

Elbow/Forearm:
-Elbow flexion deficit
- Flexion contracture
- Supinaiton contracture

Wrist/Hand
- flexion Contracture

33/ Secondary Recons after BP Injury

Indications for surgery - when all else fails, consider
- Subscapular release
- Shoulder reduction
- tendon transfer (LD +/- Teres Minor)

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