Background:Epidemiological studies on traumatic brachial plexus injuries are few and these studies help us to improve the treatment, rehabilitation of these patients and to allocate the resources required in their management. Epidemiological factors can vary in different countries. We wanted to know the situation in an Indian centre.Materials and Methods:Data regarding age, sex, affected side, mode of injury, distribution of paralysis, associated injuries, pain at the time of presentation and the index procedure they underwent were collected from 304 patients. Additional data like the vehicle associated during the accident, speed of the vehicle during the accident, employment status and integration into the family were collected in 144 patients out of the 304 patients.Results:Road traffic accidents accounted for 94% of patients and of the road traffic accidents 90% involved two wheelers. Brachial plexus injury formed a part of multitrauma in 54% of this study group and 46% had isolated brachial plexus injury. Associated injuries like fractures, vascular injuries and head injuries are much less probably due to the lower velocity of the vehicles compared to the western world. The average time interval from the date of injury to exploration of the brachial plexus was 127 days and 124 (40.78%) patients presented to us within this duration. Fifty-seven per cent had joined back to work by an average of 8.6 months. It took an average of 6.8 months for the global brachial plexus-injured patients to write in their non-dominant hand.

BackgroundPurpose of this study was to evaluate the functional outcome of spinal accessory to suprascapular nerve transfer (XI-SSN) done for restoration of shoulder function and partial transfer of ulnar nerve to the motor branch to the biceps muscle for the recovery of elbow flexion (Oberlin transfer).MethodsThis is a prospective study involving 15 consecutive cases of upper plexus injury seen between January 2004 and December 2005. The average age of patients was 35.6 yrs (15–52 yrs). The injury-surgery interval was between 2–6 months. All underwent XI-SSN and Oberlin nerve transfer. The coaptation was done close to the biceps muscle to ensure early recovery. The average follow up was 15 months (range 12–36 months). The functional outcome was assessed by measuring range of movements and also on the grading scale proposed by Narakas for shoulder function and Waikakul for elbow function.ResultsGood/Excellent results were seen in 13/15 patients with respect to elbow function and 8/15 for shoulder function. The time required for the first sign of clinical reinnervation of biceps was 3 months 9 days (range 1 month 25 days to 4 months) and for the recovery of antigravity elbow flexion was 5 months (range 3 1/2 months to 8 months). 13 had M4 and two M3 power. On evaluating shoulder function 8/15 regained active abduction, five had M3 and three M4 shoulder abduction. The average range of abduction in these eight patients was 66 degrees (range 45–90). Eight had recovered active external rotation, average 44 degrees (range 15–95). The motor recovery of external rotation was M3 in 5 and M4 in 3. 7/15 had no active abduction/external rotation, but they felt that their shoulder was more stable. Comparable results were observed in both below and above 40 age groups and those with injury to surgery interval less than 3 or 3–6 months.ConclusionTransfer of ulnar nerve fascicle to the motor branch of biceps close to the muscle consistently results in early and good recovery of elbow flexion. Shoulder abduction and external rotation show modest but useful recovery and about half can be expected to have active movements. Two patients in early fifties also achieved good results and hence this procedure should be offered to this age group also. Surgery done earlier to 6 months gives consistently good results.

The current concepts of replantation surgery, a procedure that has been practiced for half a century, can be discussed in terms of patients' demands and expectations, present indications for the procedure, available evidence that influences decision making, and technical refinements practiced to produce better outcomes.

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Wrist flexion deformity in cerebral palsy is treated with flexor carpi ulnaris to extensor carpi radialis brevis transfer. The aim of the study was to assess the outcome of this procedure and analyse the determining factors for patient satisfaction. Fifteen patients were reviewed after a mean follow-up of 23 months. The functional and cosmetic outcome and patient satisfaction were evaluated using patient rated scales. There was a strong and significant correlation between the cosmetic outcome and patient satisfaction, but there was no significant correlation between functional improvement and patient satisfaction. When analysing the cosmetic outcome in relation to the time since surgery, there was a decrease in the patient rated improvement over time. It seems that patient satisfaction is mainly determined by the cosmetic result, but the improvement, or the perception of it, tends to diminish over time. Fourteen out of 15 patients felt that the procedure was worthwhile and eight of them felt that the result was good or excellent.

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Kienbock’s disease remains a condition of uncertain etiology and our understanding about the pathogenesis is still evolving. However, a lack of consensus on the treatment is the most striking as there are wide array of treatment options described ranging from ‘doing nothing’ to a free vascularized bone graft reconstruction of the lunate. Furthermore, most treatment modalities report equivalent success rate but cumulative evidence is lacking. This ‘black hole’ in the literature presents difficulties to surgeons treating the condition and even patient’s confidence with the treatment. All the treatment options described reliably relieve pain, thus improving function and patient satisfaction. However, the disease process is not reliably altered by any of the treatment options described till date. The operative treatment chosen depends on the stage of the disease, ulnar variance, age of the patient and surgeon preference. The treatment options in early stage (before lunate collapse) aim to preserve the lunate while once the lunate is collapsed its removal is performed. The lunate preserving operations basically are either decreasing the load on the lunate to possibly permit its revascularization or are the procedures which are aimed at augmenting the vascularity of the lunate. Radius shortening osteotomy is the most popular treatment in the early stages especially in the patients’ with negative ulnar variance and the proximal row carpectomy is most popular in the advanced stages of the disease. Authors present their algorithm of management of Kienbock’s disease and discuss the various treatment options described in the literature in an attempt to find the apt in 2020.

Anomalies of Flexor carpi ulnaris (FCU) are uncommon and predominantly consist of abnormal insertion or extra tendinous bands. The presence of two separate bellies of FCU muscle with separate tendons has been termed as Digastric FCU. It is a very rare anomaly with only six previously reported cases and no report of clinical use of such anomalous muscle. We describe a case of anomalous FCU found incidentally in a patient operated for complex Post Volkmann's ischemic contracture deficits. On table each head of FCU was found to form separate belly and tendon. One tendon was used for the thumb opposition while the other for index finger flexion. Postoperatively, the patient had independent movement of thumb and index finger. This is the first reported case of clinical application of digastric FCU. We reviewed the literature for supernumerary FCU in general and digastric FCU in particular. We propose a new classification for supernumerary FCUs based on the clinical appearance and the probable embryological basis of the anomaly: Type 1 (Split tendons)--single muscle with two tendons; Type 2 (Digastric FCU)--for each head of FCU forming separate muscle bellies and tendons; and Type 3 (Accessory FCU)--abnormal muscle adjacent to normal FCU with combined features of FCU and Palmaris longus.