Brachial
Plexus Reconstruction – A Case Capsule
A young
29-year-old Pakistani male was involved in a traumatic accident caused by a
concrete block wall falling on him while at work. He sustained multiple
injuries including head injury, rib fractures, clavicle fracture, scapula
fracture and developed pneumothorax. He
was seen at an outside hospital and was referred to Universal Hospital for
management.
The
patient was admitted to the ICU and managed by a multidisciplinary team
of doctors. He was stabilized and after
2 weeks underwent surgical repair of his clavicle and scapular fractures with
plate and screw fixation by Dr. Harikrishna, Specialist Orthopedic Surgeon. At this time, the patient was detected to
have a brachial plexus injury involving the left upper limb and was referred
for further management to Department of Plastic and Reconstructive Surgery.
The
patient had developed partial paralysis of his left upper limb and shoulder
which was not responding to conservative treatment. Upon clinical evaluation, the patient had
features of C5 and C7 plexopathy with grade 1(absent) shoulder abduction and
grade 2 elbow extension.
The
patient had an MRI done which was read by Dr. Imran Khan, Specialist
Radiologist, with findings of a postganglionic injury with neuroma
formation of divisions and cords of brachial plexus (infraclavicular portion).
A
neurology consultation was obtained and Dr. Fazil Thaha, Specialist
Neurologist, did a nerve conduction study with EMG which confirmed features
of postganglionic brachial plexus injury.
Three
months after the injury, with confirmation of the diagnosis and the fact that
the affected segments were not recovering, the patient was taken to surgery by Dr. Leon Alexander, Specialist Plastic Surgeon, and underwent a complex
surgical procedure lasting close to 11 hours for nerve reconstruction with
neurolysis, nerve grafting and nerve transfer.
The patient had the following:
Ø Nerve reconstruction was done
between C5 root to posterior cord (axillary fascicle) with 3 cable grafts of
sural nerve grafts ( 9 cm each) for shoulder abduction with 9-0 nylon under
microscope (12.5X magnification).
Ø Nerve reconstruction done between C7
root to posterior cord (radial fascicle) with 3 cable grafts of sural nerve (9 cm
each) for elbow extension with 9-0 nylon under microscope (12.5X
magnification).
Ø Nerve transfer done between spinal
accessory nerve (11th cranial nerve) to supra-scapular nerve for
shoulder abduction with 9-0 nylon under microscope (12.5X magnification).
Figure 1 –
Intraoperative findings confirming the postganglionic injury with neuroma
formation of cords and divisions (infraclavicular portion) of left brachial
plexus
Figure 2 - Brachial Plexus Reconstruction (neurolysis,
nerve grafting and nerve transfer done.)
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