It is not uncommon for a severe traumatic brachial plexus injury to involve all 5 roots, resulting in a flail upper limb. In such cases, surgical reconstruction is often palliative, providing only rudimentary function. Nerve transfers are the mainstay of reconstructive strategies due to the predominance of root avulsions. Consistent results are obtained only for restoration of shoulder stability and elbow flexion, whereas restoring useful hand function remains a challenge. The transfer of the contralateral C-7 (cC-7) is commonly used in an attempt to restore basic hand function, but results are notoriously unreliable and inconsistent. Shu-feng Wang and colleagues recently proposed a potentially more successful permutation of this procedure. They advocated direct approximation of the cC-7 to the lower trunk on the paralyzed side, thus avoiding the interposition of nerve grafts. This technique involves a lengthy dissection of the cC-7 transfer across the midline via a prespinal route, as well as extensive mobilization of the ipsilateral lower trunk by cutting a subset of its branches, adducting the arm, and (if necessary) shortening the humerus. Each of these steps is indispensable to achieve direct approximation of the nerve ends. Many surgeons have tried to emulate Wang’s strategy. However, the technical difficulties involved have forced recourse to interposition of nerve grafts once again.The authors report their observations in the first 22 patients in whom they performed this procedure. Direct cC-7 repair via the prespinal route was performed in 12 patients. Shortening of the humerus was necessary in 9 of these 12 patients. In 10 patients, a direct repair was not feasible and nerve grafting was performed. The median follow-up period was 26 months for the direct coaptation group and 28.5 months for the nerve graft group.In the direct repair group, 10 of the 12 patients regained Medical Research Council Grade 3 flexion of the wrist and of the middle, ring, and little fingers, while the remaining 2 patients had Grade 2 function. Flexion appeared 12–14 months after the operation. At the latest follow-up, these patients could activate the wrist and hand without requiring significant augmentation maneuvers in the donor limb. In contrast, repair requiring interposition grafts resulted in Grade 3 strength in only 2 of 10 patients, while 7 had Grade 2 strength, and 1 experienced failure. In all grafted cases, the patient had to forcibly contract the contralateral pectoralis major and triceps muscles to produce the weak movements on the reconstructed side.In this small series, the authors demonstrated a distinct advantage associated with the avoidance of grafts when transferring the cC-7 to restore hand function. The authors conclude that efforts to achieve direct approximation of the donor C-7 and the recipient lower trunk are necessary and justified.

Introduction:Brachial plexus injury leading to flail upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgeries may preclude reinnervation of the paralysed muscles. Currently for such injuries nerve transfers are the preferred procedures. We here present a series of 93 cases of global brachial plexus palsy treated with nerve transfers.Materials and Methods:Ninety-three cases of global palsies out of 384 cases of brachial plexus injury operated by the senior surgeon (AB) were selected. Age varied from 4 to 51 years with 63 patients in 20 to 40 age group and all patients having a minimum follow up of at least 1 year post surgery ranging up to 130 months. The delay before surgery ranged from 15 days to 16 months (mean 3.2 months). The aim of the surgery was to restore the elbow flexion, shoulder abduction, triceps function and wrist and finger flexion in that order of priority. The major nerve transfers used were spinal accessory to suprascapular nerve, intercostal to musculocutaneous nerve and pectoral nerves, contralateral C7 to median and radial nerves. Nerve stumps were used whenever available (30 patients).Results:Recovery of ≥ grade 3 power was noted in biceps in 73% (68/93) of patients, shoulder abduction in 89% (43/49), pectoralis major in 100% (8/8). Recovery of grade 2 triceps power was seen in 80% (12/16) patients with nerve transfer to radial nerve. Derotation osteotomies of humerus (n=13) and wrist fusion (n=14) were the most common secondary procedures performed to facilitate alignment and movements of the affected limb. Better results were noted in 59 cases where direct nerve transfers were done (without nerve graft).Conclusion:Acceptable function (restoration of biceps power ≥3) can be obtained in more than two thirds (73%) of these global brachial plexus injuries by using the principles of early exploration and nerve transfer with rehabilitation.

Most of patients having soft tissue lesion on heel/foot reffered to plastic surgeon because reconstructive options for heel/foot are difficult for general surgeons/orthopedicians. So as a plastic surgeon we should be aware of this rare but local tumor of foot, so that we can diagnose it early and manage properly.We present a case series of 4 patients of verrucous carcinoma of the foot. This is a rare, locally invasive, well differentiated, low-grade squamous cell carcinoma, with HPV as a possible causative agent. It follows a chronic course and mimics a variety of skin lesions, delaying diagnosis by up to 15 years. The definitive diagnosis is made histologically, and treatment by wide local excision is recommended. Our patients underwent wide local excision and reconstructed. Three patients had lesion on heel, were managed using reverse peroneal artery flap and fourth patient had lesion on forefoot, was managed using reverse medial planter artery flap. There were no postoperative complications. There was no functional impairment.

Context:In surgical management of global brachial plexus injuries, direct repair of contralateral C7 (cC7) to the anterior division of the lower trunk, can produce good extrinsic finger flexion. The pitfalls associated with the pre-spinal passage have, perhaps, proved to be a deterrent for using this technique routinely.Aims:The aim of this study is to demonstrate an alternative to pre-spinal route for cC7 transfer in brachial plexus avulsion injuries.Methods:We noted that the mobilised lower trunk, which reaches the level of the scalenus anterior by passage deep to the clavicle, can be brought to the suprasternal notch when brought out from below the clavicle. This area was dissected in two cadavres, and safe passage was found through the carotid sheath with the common carotid artery medially and the internal jugular vein with the vagus nerve laterally. The cC7 root dissected medial to the scalenus anterior muscle can be directly transferred along this path to the subcutaneous plane at the suprasternal notch. This study allowed us to execute a direct repair in ten clinical cases of global brachial plexus injuries. In each case, the passage was prepared rapidly and uneventfully. The repair was technically simple and could be performed comfortably using suitable fine suture materials. In none of these cases, did we need to shorten the humerus.Results:The clinical outcome of this technique is awaited.Conclusions:We advocate carotid sheath route to approximate the cC7 to the injured lower trunk in global palsies, as the risks associated with the pre-spinal route can be readily avoided.

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