In the name of Allah

1. In the name of Allah

2. Nerve transfer in BPBP Reza Sh. Kamrani Ortopaedic surgeon Hand surgeon TUMS 16th Iranian Ortopaedic Surgeon Association Congress, Hand surgery symposium 9 / 8 /1387 Tehran IRAN

3. Neurotization • Definition • History • Nerve transfer

4. Nerve transfer in Brachial Plexus Birth Palsy • Classic transfer in brachial plexus • . • . • . • . • New concepts in nerve transfer ?

5. Nerve transfer in Brachial Plexus Inj. • Classic transfer in brachial plexus (When?) • .When nerve root is avulsed • .When nerve graft is not possible • . • . • New concepts in nerve transfer

6. Nerve transfer in Brachial Plexus Inj. • Classic transfer in brachial plexus (How?) • .Which function (root/trunk/branch) is in priority ? • .Which donor nerve is our choice ? • . • . • New concepts in nerve transfer

7. Nerve transfer in Brachial Plexus Inj. • Classic transfer in upper brachial plexus • .Which function (root/trunk/branch) is in priority • .Which donor nerve is our choice • . • . • New concepts in nerve transfer Elbow flexion Lateral cord MC Shoulder abd. Sup.Scap Axill.

8. Nerve transfer in Brachial Plexus Inj. • Classic transfer in upper brachial plexus • .Which function (root/trunk/branch) is in priority • .Which donor nerve is our choice • . • . • New concepts in nerve transfer Oberlin Mod. Oberlin Radial? Accessory Radial ICN.

9. Median to biceps Ulna to brachialis Accessory to Sup. Scapular

10. Accessory to Sup. Scapular

11. Nerve transfer in Brachial Plexus Inj. • Classic transfer in whole brachial plexus • .Which function (root/trunk/branch) is in priority • .Which donor nerve is our choice • . • . • New concepts in nerve transfer Elbow flexion Shoulder stability Sensation of medial border of the hand Wrist and finger function

12. Nerve transfer in Brachial Plexus Inj. • Classic transfer in whole brachial plexus • .Which function (root/trunk/branch) is in priority • .Which donor nerve is our choice • . • . • New concepts in nerve transfer Accessory / Pherenic Shoulder stability Sensation of medial border of the hand Wrist and finger function

13. Nerve transfer in Brachial Plexus Inj. • Classic transfer in whole brachial plexus • .Which function (root/trunk/branch) is in priority • .Which donor nerve is our choice • . • . • New concepts in nerve transfer Accessory / Pherenic Pherenic / Accessory Sensation of medial border of the hand Wrist and finger function

14. Nerve transfer in Brachial Plexus Inj. • Classic transfer in whole brachial plexus • .Which function (root/trunk/branch) is in priority • .Which donor nerve is our choice • . • . • New concepts in nerve transfer Accessory / Pherenic Pherenic / Accessory Contralateral C7 + vascularized ulna /ICN to Median

15. Pherenic to Sup. Scapular Acc. +graft to MC

16. Contralateral C7 + ulna to Median

17. ICN

18. Nerve transfer in Brachial Plexus Inj. • Classic transfer in brachial plexus • .When nerve root is avulsed • .When nerve graft is not possible • . • . • New concepts in nerve transfer

29. Nerve transfer in Brachial Plexus Inj. • Classic transfer in brachial plexus • .When nerve root is avulsed • .When nerve graft is not possible • . • . • New concepts in nerve transfer

31. Nerve transfer in Brachial Plexus Inj. • Classic transfer in brachial plexus • .When nerve root is avulsed • .When nerve graft is not possible • New concepts in nerve transfer

32. Nerve transfer in Brachial Plexus Inj. • Classic transfer in brachial plexus • . • . • New concepts in nerve transfer • .Even in ruptured roots • .Even in more distal injuries ? • .Even in penetrating injury ??

33. Treatment strategy in BPI • Classic • Nerve graft and plexus reconstruction whenever possible • New concept • Primary nerve transfer

34. Treatment strategy in UBPI pannupan oberlin

35. Treatment strategy in UBPI pannupan oberlin • Acc. to Sup. Scap • Mod. Oberlin • Rad. To Axill • Shoulder arthrodesis (manual worker) • ICN to Triceps (C5-7) • Pherenic to Sup. Scap • Oberlin

36. Treatment strategy in WBPI pannupan oberlin • Pherenic to Sup. Scap • Acc.+graft to MC • Contralat C7+ vascularized ulna to Median • Classic plexus reconstruction

37. Introduction • Nerve transfer in Brachial Plexus Inj. • Classic transfer in brachial plexus • . • . • . • . • New concepts in nerve transfer

38. Nerve transfer in Brachial Plexus Birth Palsy • Classic transfer in brachial plexus • . • . • . • . • New concepts in nerve transfer ?

39. Differences between Adult BPI and Obstetric BPI

40. Adult BP inj. Obstetric BP inj. • Adult • Infant • Shorter regeneration distance • Stronger potential for regeneration • Greater capacity for brain adaptation

42. Adult BP inj. Obstetric BP inj. • Goal • Goal

43. Upper BPI Adult BP inj. Obstetric BP inj. • Goal • Elbow flexion • Shoulder stability • Goal • Elbow flexion • Shoulder reanimation

44. Whole BPI Adult BP inj. Obstetric BP inj. • Goal • Elbow flexion • Shoulder stability • Medial border sensation • Wrist and finger function • Intrinsic function • Goal • Hand function • Elbow flexion • Shoulder reanimation

45. Nerve transfer Adult BP inj. Obstetric BP inj. • Classic nerve transfer • .Intra plexus • Avulsion is more common • . • New concept • Classic nerve transfer • .Intra plexus • Avulsion is less common • . • New concept

46. Nerve transfer Adult BP inj. Obstetric BP inj. • Classic nerve transfer • .Intra plexus • Avulsion is more common • .Extra plexus • Pherenic is available • Ulna can be sacrifized • New concept • Classic nerve transfer • .Intra plexus • Avulsion is less common • .Extra plexus • Pherenic is forbiden • Ulna must be reconstruct • New concept

47. Whole Adult BP inj. Obstetric BP inj. • Classic nerve transfer • Intra plexus • .C5 to upper trunk • .C6 to middle trunk • .C5/C6 Lateral cord/ Medial cord • ICN+Pherenic adding • New concept • Classic nerve transfer • Intra plexus • .C5 to C8T1 • .C6 to • .Acc. To Sup. Scap • ICN adding • New concept

49. Whole Adult BP inj. Obstetric BP inj. • Classic nerve transfer • Extra plexus • .Pherenic to Sup. Scap • .Acc. To MC • .Contra lateral C7 to Median • ICN adding • New concept • Classic nerve transfer • Extra plexus • .Acc. To Sup. Scap • ICN+ contralat C7 to median-ulna-radial • New concept

50. Upper Adult BP inj. Obstetric BP inj. • Classic nerve transfer • .Acc. To Sup. Scap • .Mod Oberlin • .Rad. To Axill • New concept • Classic nerve transfer • .RARE • .Acc. to Sup. Scap • .Oberlin • New concept