This 28 yr old male patient from Hyderabad presented to Plastic and Reconstructive Surgery department 7 months post road traffic accident with loss of sensation, absence of movements in the entire limb. He was told elsewhere there in not much treatment available for this condition and was misguided to alternative medicine. On clinical examination, all joints were found to be in severe contracture as a result of splintage practices of alternative medicine. It was a challenge to formulate the treatment plan as we were racing against time. An ideal Brachial plexus exploration for proximal reconstruction is performed before 6 months in a limb with supple joints which would provide best outcomes. Aggressive physiotherapy was administered along with shoulder manipulation under anesthesia to make the joints free so that surgery could be performed at the earliest. Gradually shoulder and elbow passive joint movements improved. MRI and Nerve conduction studies performed. Surgery was performed at 9 months from the date of injury. As proximal reconstruction was not an option in his case, nerve transfer along with free functional muscle transfer which are usually performed in 2 stages was combined into a single stage surgery.
Neurolysis of C5,6 nerve roots and suprascapular nerve performed in the neck, function was confirmed with intra operative nerve stimulation. 5th and 6th Intercostal nerves harvested and co-apted to the Musculocutaneous nerve to provide elbow flexion. Gracilis muscle harvested from the thigh, transferred to upper limb as a free functional muscle transfer to provide finger flexion which was neurotized with 3rd and 4th Intercostal nerves. The blood supply to the transferred Gracilis was restored by microsurgery to neck vessels. The patient recovered well after the marathon surgery and discharged with a pillow splint.
The best possible treatment was tailored as per his presentation and time frame.The aim of treatment in this case is to provide him a splint free hand, a hand to support the functioning opposite hand to help him with his day to day activity. The patient is due for follow up when he will resume his physiotherapy. His road to recovery is set but has a long way to go.
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