Splinting for Brachial Plexus Surgeries
Splinting for Brachial Plexus Surgeries
Brachial plexus injuries limit the independence of thousands of youngsters every year through tearing, stretching or damage to the nerves connecting the spinal cord to the shoulder and arm. Ninety percent of these injuries, most of which occur during the birthing process, spontaneously resolve on their own or with therapy. But some result in severe limitations in the shoulder, elbow, arm, wrist or hand unless they receive surgical intervention.
"Most (of the children) can't raise the affected arm above their head," said Nancy Conte, OTR, assistant manager of occupational therapy at The Institute for Rehabilitation and Research (TIRR) in Houston, TX. "They can't put an earring on, can't toss a ball, can't wash their hair. They will get contractures of the muscles that aren't moving, and they may develop deformities, such as an arm length discrepancy, or scoliosis."
Conte heads TIRR's involvement in Baylor College of Medicine's brachial plexus surgery program. TIRR and Texas Children's Hospital both provide surgical facilities and multidisciplinary staff for the growing program. Children from all across the country and around the globe come to Houston for this procedure, performed by only a few facilities throughout the country.
Part of what makes the procedure unique in the Baylor program is the splint that Conte customizes for each patient after surgery. She originally pioneered its design while at Texas Children's Hospital, then brought the splint with her when she came to TIRR two years ago, making adjustments along the way. "I've utilized traditional splinting procedures to develop an effective, durable and patient/family-friendly splint specifically designed to meet the needs of this innovative surgical procedure," said Conte.
According to Conte, families of children with brachial plexus injuries have developed an extensive network of information and resources about the condition. Some families even organize annual summer camps, including one in Texas, where children from as far away as Michigan and New York are encouraged to participate in games and activities to facilitate use of the affected arm. Through this network, parents spread the word about programs such as the one at TIRR, which can help restore function to their children.
The Baylor team of surgeons works with physical medicine and rehabilitation physicians, nurses and occupational therapists at TIRR to perform either primary or secondary brachial plexus surgeries. Which procedure a patient receives is determined by his or her age. Each procedure involves a two-night stay at the hospital: the patient checks in and has his or her surgery on day one; on day two, Conte or another OT splints the affected upper extremity; and on day three, after the patient and family are seen by OT for follow-up, they are discharged.
The primary surgery is done on infants up to 12 months, although the ideal age is six to nine months, when the team of surgeons - including two plastic surgeons, a neurosurgeon, a neurologist, and physical medicine and rehabilitation physician - can most successfully surgically repair the nerves that have been damaged.
Before the surgery, Conte meets with the parents of the infant and explains what will occur in therapy the following day. "I describe how their baby's arm will be positioned when they come out of surgery, and I show them an immobilizer such as the one that I will apply the next day," Conte explained. "I explain that the nurse and I will remove the 'wrapping' that the doctor applied in the OR which positions the baby's arm, we will change the incision dressing and apply the new immobilizer. We give them an opportunity to practice taking it off and putting it on. I give them a copy of the protocol for the next four weeks so they can review it prior to the appointment the next day and answer any questions they may have at the time."
The following day, a nurse and Conte remove the dressing directly over the incision on the side of the neck, where the team performed the repair to the brachial plexus. They remove the post-op dressing, applied to keep the child's arm close to the trunk with the elbow flexed. One parent must support the child's arm above the head while Conte fits the child with an immobilizer. Once the immobilizer is secure, Conte spends the rest of the therapy session instructing the parents on caring for the affected limb for the next four weeks and providing some ideas on how to facilitate function of the arm and hand.
"I give them a written protocol, and we review it in detail," she explained. The protocol details incision care, dressing changes, bathing, scar massage and range of motion. After four weeks, the immobilizer can be removed and the child can resume a full therapy program with no restrictions.
The child spends one more night in the hospital for observation. On the third day at TIRR, Conte visits to check on the patient and family. She makes any necessary modifications based on how the child responded overnight, and answers any last-minute questions the parents may have.
The secondary surgery is performed on older patients. Since the patient is too old for effective nerve repair, the surgeons focus on muscle and tendon transfer and releases. According to Conte, the surgeons have performed this procedure at TIRR on youths up to 18 years of age who have suffered obstetric brachial plexus injuries, and on young adults up to 23 years of age who have suffered brachial plexus injuries through trauma or other accidents.
Before the surgery, Conte explains to her patient her part in the process. "On the first day, I meet with the family and the patient and prepare them," she said. "I bring a doll that is wearing the same type of splint that I will fabricate and a small photo album which illustrates the splinting process. I tell them they are going to be in therapy for two to three hours so they can prepare and bring anything that will keep the child happy and distracted."
As with the primary surgery, she provides a written protocol, addressing care for the next twelve weeks. In addition, Conte instructs the patient and family in scar massage, range of motion, incision care and bathing.
The day following the secondary surgery, the child is brought to therapy. Conte again removes the dressing, but the splint she fabricates - which has become known as the "Statue of Liberty splint" - is very different from the immobilizer used on infants who undergo the primary procedure.
"A typical order following this type of procedure," she explained, "is for the arm to be abducted to 150 degrees at the shoulder with full external rotation, full elbow extension and full supination of the forearm."
While the parent is supporting the arm of the child above the head, Conte takes a paper towel and makes a pattern for the splint. She then transfers that pattern to a piece of thermoplastic and cuts out the splint shape. She lines the thermoplastic, giving the parents an extra liner so they can change and wash the liner when they change the incision dressing, and fits the child with the splint.
Conte calls this splint her "Houdini" design because the strapping is secured out of reach of the child's free arm so that he or she cannot remove it. The patients adjust very well to wearing the splint and are remarkably active.
Conte recalls her first experiences with this unique splint design. "One of the orders I received for this surgery indicated that the arm should be abducted to 120 degrees and externally rotated, the elbow straight, the wrist at fifteen and the MCPs at thirty," she remembered comically. "I thought, 'This will be challenging!' But we just kind of did what we had to do to meet the order."
The splint must be worn day and night for six weeks and then at night for a second six weeks. After the first six weeks the child may resume restricted therapy, limited only to active and passive range of motion. Conte also recommends that the family encourage the child to participate in functional activities that facilitate shoulder movement, and to avoid any activity which could result in injury to the affected arm or which involves any kind of resistance. After the full 12 weeks, therapy continues with no restrictions and now includes strengthening and resistance activities.
"Generally patients gain really good functional recovery," Conte says of the secondary procedure. "They are not going to look the same, like there was never an injury. But we observe good functional results, and they are able to do things they wouldn't have been able to do before."
Thanks to Conte's work and her unique splint, TIRR and Baylor are able to offer this program to children and their families from as far away as Poland and Saudi Arabia.
"Nancy has been instrumental to the successful implementation of the brachial plexus program at TIRR," said Louisa Adelung, President and CEO of TIRR. "She has worked with therapists, physicians, nurses, administrators and parents to develop an exciting new service. Nancy has made the brachial plexus program one that we are all proud of."
For more information on the brachial plexus program, contact Jennifer MacMillian at TIRR, at (713) 942-6161.
Jill Diffendal is ADVANCE associate editor.