Upper Extremity Reconstruction

Treating nerve damage

The brachial plexus is a bundle of nerves that originates from the spinal cord, then proceeds through the neck, the axilla (armpit region) and into the arm. It controls muscle movements and sensation in the shoulder, arm and hand. Injuries to this area occur by stretching or pinching of these nerves through injury and can often occur at the time of a spinal cord injury or brain injury.

Symptoms

• Burning or stinging feeling in one side of the neck, shoulder or in one arm
• Numbness or tingling in one side of the neck, shoulder, or in one arm
• Weakness or loss of movement in one shoulder or arm

Brachial plexus injury (BPI) program

Before deciding on a plan of treatment, the upper extremity team will evaluate your condition. The physician or another team member will ask about symptoms, complete a thorough medical history and physical examination. Additional tests, such as X-rays, electromyogram (EMG) or magnetic resonance imaging (MRI) may be used to verify the diagnosis and determine the extent of the injury.

Brachial plexus treatments

There are two primary treatment options for brachial plexus injuries.

• Occupational or physical therapy focuses on maintaining supple joints and healthy tissue, positioning or splinting, therapeutic exercise and strengthening, teaching techniques to make the individual as functional as possible. Therapy may be appropriate alone or combined with surgical interventions.
• Surgery may be recommended to repair the brachial plexus, depending on the type and location of the brachial plexus injury, Surgery may involve the removal of damaged nerves, nerve grafts, or transferring a nerve from its original attachment to another nerve site, which then restores functional ability. Microsurgical techniques are used to improve brachial plexus function using one or more of several methods.
  • Neurolysis: A procedure removes obstructing scar tissue.
  • Nerve grafts: Nerve tissue is inserted to bridge gaps between the ruptured or stretched nerves.
  • Nerve transfer or neurotization: Part of a functioning nerve is transferred to replace irreparably injured nerve roots to allow more rapid recovery of function.
  • Functional reconstruction: In severe or chronic cases, functional reconstruction may be explored through free muscle transfer, tendon transfer, or bone or joint stabilization.

Timeline for evaluation and treatment

Your treatment will depend on the type and severity of your brachial plexus injury.

The first step is for your primary physician to make a referral to the Hand and Upper Extremity Clinic for evaluation. The timeline may be longer than other physician consultations as the primary purpose is to establish a baseline of nerve and muscle functioning so progress of natural recovery can be followed over the course of a year.

• Initial observation: Some milder injuries will improve over several months, so your doctor may schedule regular appointments for 3 to 6 months to monitor your progress. Early diagnosis is still important so your physician can monitor your natural progress over the course of months.
• Surgery: If there is no improvement within 6 to 8 months, or the injury is severe, surgery may be needed to improve nerve function.

Restoring function

Tendon transfer surgery is a surgical option that is commonly used to effectively restore arm, wrist, and hand functions, such as wrist extension, grip, and pinch. Surgery involves transferring a muscle with good strength from its original attachment to another muscle site, which then restores functional ability.

Tendon transfer surgery is a type of surgery performed on the elbow or hand to improve or restore movement that may be lost because of paralysis or injury. A tendon attaches muscle to bones. In these procedures, a functioning tendon is detached from its original attachment and re-sewn into a different tendon. After the tendon transfer, when the muscle fires, it will produce a different movement, depending on where it has been inserted.

Tendon transfer program

Tendon transfer surgery may be appropriate for people with tetraplegia or other injuries that have resulted in paralysis of the arm or hand.There are a veriety of procedures that may be appropriate  depending on type of injury, strength and sensation of intact muscles, and goals of the individual. Microsurgical techniques are used to improve arm function by completing one or more procedures.

• Lateral pinch of the thumb: The active lateral pinch provides the ability to secure small objects between the thumb and index finger. The active lateral pinch will enhance function for activities of daily living, including self-catheterization, writing, feeding, and other fine-motor grasping activities.
• Elbow extension (bicep transfer to the triceps): Elbow extension transfer allows the patient to straighten the elbow. Active elbow extension will allow the individual to reach overhead and out in front, improve pressure-relief techniques, improve wheelchair propulsion on level and uneven surfaces, enhance transfer skills, and improve function for activities of daily living.
• Lateral pinch of the thumb and hand grip: The active gross-finger flexion(grip) will create an effective, hook-style hand grasp. The combination of both pinching and grasping will enhance function for activities of daily living, including grasping for propulsion of a manual wheelchair, opening doorknobs and grasping various-sized objects. The active lateral pinch will enhance functions, including writing, feeding, and self-catheterization. The combination of both pinch and grip will enhance many fine-motor grasping activities.

Rehabilitation after tendon transfers

The individual’s arm is immobilized for the first 3 to 4 weeks after the tendon transfer surgery. After the cast is removed, occupational or physical therapy will begin with a focus on muscle re-education with active movement of the transferred tendon, strengthening, and utilization of the new movement with activities of daily living. Therapy typically consists of treatment three times a week for 6 to 12 weeks, depending on what procedure was performed.

The Hand and Upper Extremity Rehabilitation Clinic also offers surgical options for other orthopedic-related issues, such as carpal tunnel syndrome, overuse syndromes, contractures, and trauma-related issues.