Brachial Plexus Injury Reconstruction: Nerve Transfer Technique and Workup

Yes, it varies significantly. For the arm, the golden period is 4 hours. For the forearm, 6 hours. For fingers, replantation can be attempted even at 8-10 hours. Early in his practice, proximal replantation was attempted at 10-12 hours, but the post-operative course was unpredictable enough that the lesson learned was not to attempt proximal replantation beyond 4, at most 6, hours.

Yes. For fingers, toe-to-hand transfer can restore good functional benefit even when the original finger wasn't salvaged in time. A few centres, though not this one yet, have started cadaveric hand transplant, though this is legally restricted in India to Indian citizens only, ruling it out for international patients. This centre is planning to start a hand transplant programme within about a year to a year and a half. In the meantime, options include toe transfer, cosmetic prostheses including osseointegrated ones, and myoelectric bionic hands.

Three things: clinical examination first, to map out the deformity pattern and plan; nerve conduction study and EMG, to identify how many donor nerves or muscles are available for transfer; and MRI, to map the brachial plexus itself. Both birth-related (obstetric) and adult traumatic or oncological brachial plexus injuries are managed with this same three-part workup.

For facial procedures, growth is considered complete by around 15-16 years, so a 15-year-old's face is functionally comparable to an adult's for surgical purposes, with parental consent sufficient at that age. For the rest of the body, 17-18 is considered the optimum age, since patients are mature enough by then to properly weigh their own body image and understand the implications of the procedure.

Plastic surgery was originally developed for reconstruction, so any wound that hasn't healed in three weeks, whether traumatic, burn, or post-cancer resection, needs plastic surgery intervention and can be referred directly. Any congenital defect, a hand anomaly, cleft, or other soft tissue deformity, should also be sent directly. Cancerous skin lesions, where excision and reconstruction go together, are handled by plastic surgery too. And any leg oedema that doesn't resolve with elevation and conservative management is a specific trigger for lymphoedema referral. These are the practical trigger points to know.

Clinical examination to map the deficit pattern, nerve conduction study and EMG to identify available donor nerves or muscles for transfer, and MRI to visualise the brachial plexus anatomy directly.

Results mature gradually; patients are often still recovering at six months, with meaningful improvement in elbow flexion and shoulder abduction typically becoming apparent around the one-year mark.