1. CASE 2 Marci Jones, MD Director of Hand Fellowship U of Massachusetts Medical School

2. Case 2 S/P MVA Grade 2 open humerus fracture ORIF Ulnar nerve dysfunction at presentation Ulnar nerve identified, intact, and transposed at initial surgery

3. Case 2 S/P MVA Grade 2 open humerus fracture ORIF Ulnar nerve dysfunction at presentation Ulnar nerve identified, intact, and transposed at initial surgery

4. Case #2 24 y/o R HD female, c L distal humerus fx MVA EDX 3 months later – no ulnar motor or sensory Needle study with spontaneous activity in all ulnar innervated muscles, incl FCU 0 MUAPS in 1 st DI and ADM, Recruitment reduced in FCU Faren H. Williams, M.D., M.S. 4

5. Case 2 S/P MVA Decreased ulnar nerve function persisted 6 months post-op Nonunion of humerus No clinical recovery of ulnar nerve

6. Case 2 S/P MVA Returned to OR for revision of fixation Planned exploration of ulnar nerve with potential nerve transfer

7. Case 2 S/P MVA What information is needed for pre- operative planning? 1. Is the nerve intact? 2. What is the prognosis for recovery?

8. Case 2 S/P MVA Pre-operative EMG

9. EDX 5 mos s/p MVA Left ulnar motor not obtainable Left ulnar dorsal cutaneous not obtainable Left ulnar sensory from little finger not obtainable Needle study with more firing MUAPs in FCU FDP –ulnar, polyphasic MUAPS, reduced recruit 0 MUAPs in 1 st DI and ADM Faren H. Williams, M.D., M.S. 9

10. Polyphasic MUAPs –FDP, ulnar Faren H. Williams, M.D., M.S. 10

11. Case 2 S/P MVA Longstanding denervation leads to irreversible changes nerve and muscle Muscle atrophy Apoptosis and fibrosis Schwann cells less supportive of axons Decreased motor neuron regeneration

12. Case 2 S/P MVA Nerve transfer Use of healthy, less important donor nerve to re-innervate a peripheral target

13. Case 2 S/P MVA Nerve transfer Use of healthy, less important donor nerve to re-innervate a peripheral target What if recovery is expected, but delayed??

14. Case 2 S/P MVA “Babysitter” procedure Terzis 1984 Facial reanimation Preserve muscle while axonal regeneration through nerve grafts occurs Cross facial nerve graft AND immediate, expendable nerve transfer

15. Case 2 S/P MVA “Babysitter” procedure Applied to peripheral nerve Anticipated recovery of motor end plate >18 months AIN to ulnar motor nerve transfer Sassu, Plast Aesthet Res 2015;2:195-201

16. Case 2 S/P MVA Anterior interosseous nerve

17. Case 2 S/P MVA Kale et al, J Hand Surg 2011:1631-1639

18. Case 2 S/P MVA End to side nerve transfer Implantation of injured axons (end) inside the epineurium of the healthy nerve (side)

19. Case 2 S/P MVA Reverse end to side nerve transfer Implantation of healthy donor axons (end) inside the epineurium of the injured nerve (side)

20. Case 2 S/P MVA Reverse End to side nerve transfer Kale, J Hand Surg 2012;37A:2150 –2159

21. Case 2 S/P MVA Outcomes Barbour Plast. Reconstr. Surg.136: 344e, 2015 n=55 49% 1 st DIO recovery < 12 months EMG evidence of response of 1 st DIO from stimulation of median and ulnar nerve

22. Case 2 S/P MVA Outcomes Barbour Plast. Reconstr. Surg.136: 344e, 2015 n=55 Predictor of poor muscle recovery: Absent CMAP in ulnar nerve (p=0.04) Difficult to determine contribution of AIN transfer Important to have motor re-education and targeted exercises.

23. L Ulnar Motor, s/p Revision surgery Faren H. Williams, M.D., M.S. 23

24. L Ulnar sensory, s/p Revision Surgery Faren H. Williams, M.D., M.S. 24

25. Summary- EDX Prognosis Type of Nerve Injury Timing s/p Injury NCS’s in combination with needle EMG Complete vs Incomplete Lesion Distance from Lesion to Muscles Clinical Correlation with EDX findings Serial Electrodiagnostic Studies Faren H. Williams, M.D., M.S. 25

26. References Campbell, W., Evaluation and Management of Peripheral Nerve Injury, 2008. Malikowski, T., Micklesen, P J, Robinson, L., Prognostic Values of Electrodiagnostic Studies, Muscle and Nerve, Sept 2007, p. 364- 367. Robinson, L.R., Traumatic Injury to Peripheral Nerves. AAEM Minimonograph #28, p 863-873. Sahin et al. Correlation of Neurodiagnostics with Recovery. Hand, 2014. Faren H. Williams, M.D., M.S. 26