Hand clinics
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Functioning free-muscle transfers are now an important, even essential, tool in the current management of patients with brachial plexus injury. They are indicated for the restoration of elbow flexion in patients who delay presentation(those seen after 6 to 9 mo). Double free-muscle transfers provide the possibility of simple grasp function when combined with nerve transfers or grafts for restoration of shoulder motion, hand sensation, and triceps function.
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The reconstructive strategies for avulsion in-juries vary from patient to patient and over time,continue to evolve depending on the surgeon's philosophy, available facilities and therapy, the elapsed time from injury to intervention, the severity of injury, and patient age and motivation. The author's results show that nerve transfer can obtain an average of 60 degrees (range, 20 degrees - 180 degrees) of shoulder elevation without shoulder arthrodesis, M3 to M4 muscle strength of elbow flexion, M2 to M4 elbow extension, and M3 finger flexion and sensation. Intrinsic hand function was obtained with help of dynamic splinting for interphalangeal joint extension and arthrodesis of thumb joints asa post for opposition.
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There are two main goals for the surgeon treating injuries around the elbow joint: the maintenance of a stable, concentric reduction of the joint and the initiation of early motion to help prevent stiffness and maximize functional out-come. The presence of a fracture decreases joint stability and increases the risk for early subluxation or dislocation with motion. Operative repair thus is indicated for most of these injuries to restore sufficient osseoligamentous support to allow safe, early motion and provide a stable functional elbow in the long term.
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Radial head arthroplasty is indicated for displaced comminuted radial head fractures that cannot be managed reliably with open reduction and internal fixation and that have an associated elbow dislocation. Replacement also is indicated in patients with comminuted radial head fractures that have or are likely to have a disruption of the medial col-lateral, lateral collateral, or interosseous ligaments. ⋯ The early and midterm clinical experience with metallic radial head arthroplasty has been encouraging relative to earlier reports with silicone devices. Newer modular designs incorporate improved sizing to better reproduce the anatomy of the proximal radius and are easier to insert intraoperatively.
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The brachial plexus may be visualized simply as beginning with five nerves and terminating in five nerves. It begins with the anterior rami of C5, C6, C7, C8, and the first thoracic nerve. It terminates with the formation of the musculocutaneous, median, ulnar, axillary, and radial nerves. ⋯ The medial cord divides into the medial branch of the median nerve and the ulnar nerve. The posterior cord divides into the axillary and the radial nerves. The anatomy of the brachial plexus can be confusing, especially because of frequent variations in length and caliber of each of its components.