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Traction lesions of the brachial plexus
Traction Lesions o/ the Brachial Plexus--Ian Fletcher
T R A C T I O N L E S I O N S OF T H E B R A C H I A L
PLEXUS
IAN F L E T C H E R , Roehampton During the past nine years at Roehampton, the author has had the opportunity of examining 180 people who have sustained either partial or complete lesions of the brachial plexus. Two of the cases suffered bilateral injuries.
Fig. 1. Right side of crash helmet worn by youth who sustained a lesion of the right brachial plexus. Note: black paint from the car involved in a head-on collision. MECHANISM OF INJURY
81% of the patients were under the age of twenty-four at the time of injury and 77% of the victims sustained their injuries in motor cycle accidents. Because of this alarmingly high figure an attempt was made to determine the mechanics of the lesions. Most of the motor cyclists questioned wore crash helmets and were involved in head-on collisions with another vehicle or some stationary object such as a tree or post. Many of the helmets showed evidence of an initial impact along the side corresponding to the plexus lesion (Fig. 1). Although associated injuries are common there has been a remarkable absence of actual shoulder injury and the clothing has been undamaged in this region. One patient made an interesting comment about his shirt collar which had split along its junction with the shirt in the supra-clavicular region on the side of his plexus injury. The history coupled with the findings suggest that the lesions in head-on collisions are due to the victim's head being forced laterally away from the shoulder and not, as we have tended to believe, due to the casualty falling heavily onto his shoulder. 129
Traction Lesions of the Brachiol Plexus--Ian Fletcher DIAGNOSIS AND PROGNOSIS
It is regrettable to relate that an accurate diagnosis and prognosis has been established late in some of the patients. This has been due, partly, to the fact that so many of the road accident victims have been unconscious and had other injuries. In addition to a careful clinical examination, diagnostic tests should include myelography which may reveal one or more meningoceles (Yeoman (1968)). Histamine and cold vasodilation tests (Bonney (1959)) are also of value in differentiating between preganglionic and postganglionic lesions of the plexus. For the latter type electro-myographic studies may prove helpful and if doubt still exists then exploration can be considered. Needless to say time for the reaction to degeneration must elapse but to postpone this operation unduly is to confuse the findings because scar tissue forms quickly. The presence of Homer's syndrome suggests irreparable damage to T.1. Because so many of these dreadful injuries affect young men on the threshold of their careers it is of great importance to ascertain the fate of the limb as soon as possible. The surgeon is then in a position to have a frank discussion with the patient about his future and decide upon the treatment most suitable to his individual needs. TREATMENT
Lesions which spare hand function
(a) Physiotherapy (b) Reconstructive surgery: Tendon transplants (Clark's and Zachary's). External rotation osteotomy of the humerus, usually necessary with a Zachary transplant, also as an isolated procedure. (c) Splints We occasionally provide splints with a hand-operated elbow lock (four positions). When indicated a shoulder support is included and this also restores the normal contour which so many patients value (Fig. 2).
Fig. 2. Flail-arm splint in polythene with shoulder cap and rotation mechanism above the elbow. 130
Traction Lesions of the Brachial Plexus--lan Fletcher
A rotation device may be incorporated to allow the wearer to position the limb anywhere within its natural limits. It is considered that powered splints for these patients are not only unnecessary but are more cumbersome and less efficient than the conventional type which are easy for the wearer to put on and use. (d) Bone-block for the flail elbow has been tried but many have failed, and this operation is not recommended. II
Lesions with no hand Sunction
Before advising any treatment for the patient with permanent paralysis of the hand, and possibly of the whole limb, it is imperative to know his background and ambitions. Many of the 180 patients referred to in this paper have been seen by the author prior to surgery (other than exploration) but with a reasonably definite prognosis. It has been found essential to spend an hour or more with each one in order to establish their make-up. It is vitally important to know about their occupations and pastimes, and the type of work they wish to undertake. It has often been necessary to have further talks with them and their relatives or fianc6es who may be closely concerned, particularly when amputation is a possible line of treatment. It is helpful for such people to meet and discuss the problem with another amputee who has alsc sustained a lesion of the brachial plexus. The author does not believe it is right to tell these patients that there is a clearcut line of treatment for the permanently paralysed limb. It is also of paramount importance that they are convinced of the prognosis before they agree to major surgery, particularly amputation. On the other hand the author does not agree with the advice, sometimes given, to wait three years or more when the surgeon himself knows the prognosis because this will condemn the man to a one-armed existence.
Fig. 3. Flail-arm splint with driving attachment fitted to palm area. Hand completely paralysed. 131
Traction Lesions o.f the BrachiaI P l e x u s - - l a n Fletcher ALTERNATIVE TREATMENTS
(a) Reconstructive surgery without amputation is unlikely to result in useful function. (b) Splints--these have proved disappointing and most patients, wi~h paralysed hands, issued with splints have discarded them, although they prove useful for driving a car when the appropriate appliance was fitted (Fig. 3). (The fitments are similar to those available to arm amputees and snap easily in and out of a fixture located in the palm or wrist area of the splint.)
(c) Ampu:ation--this has proved to be the most successful line of treatment for the majority of patients engaged in manual or industrial occupations. If it is decided upon then it must be combined with a stabilising operation upon the shoulder if this is seriously affected. Occasionally a Zachary transplant (combined with a rotation osteotomy) is possible but most of the patients in this series, who accepted an amputation required (and had), an arlhrodesis. To date 106 amputations have been performed and six other patients are on waiting lists.
Fig. 4. Below-elbow amputee with arthodesed shoulder. Triceps 0, Clark's transplant 4. A shoulder saddle, arm corset, jointed side steels and elbow lock have been added to conventional prosthesis. Fig. 5. Above-elbow amputee with arthrodesed shoulder, actively flexing the elbow of his artificial limb. 132
Traction Lesions of the Brachial Plexas--lan Fletcher SITES OF A M P U T A T I O N
When there is good elbow control it should be preserved but it is necessary to have strong biceps and triceps to obtain the best use of a prosthesis. The latter muscle is the one required to activate terminal appliances. Reconstructive surgery, such as Clark's transplant to provide active flexion when the triceps is also weak or inactive is of little or no value to the patient. The power of the transplant is often insufficient to overcome the weight of the prosthesis so we have to add jointed side steels with an external locking mechanism and a wide fitting leather cuff above the elbow (Fig. 4). Such a prosthesis is still less efficient than the type supplied for an above-elbow amputee. It is both surprising and very regrettable to know that there are still many surgeons who do not believe that arm amputees can make good functional use of a prosthesis. It amazes them to learn that there are bilateral above-elbow amputees who are completely independent and leading normal lives which includes driving cars with ordinary controls. It is, however, only fair to state that the majority of amputees who have suffered traction lesions of the brachial plexus are less proficient with a prosthesis than those with normal control of the stump. Many have returned to industry despite this fact and find their prosthesis invaluable.
Fig. 6. Ideal site of amputation and position of arthrodesis. Fig. 7. Flexing the arthrodesed stump. Note: This range of stump movement is adequate tor controlling the prosthetic elbow. (See Fig. 5.) 133
Fraction Lesions of the Brachial Plexus--lan Fletcher
STUMP LENGTHS
For amputations above the elbow we recommend a bone length of seven or eight inches measured from the tip of the acromion process. Disarticulation of the elbow is, in the author's opinion, a bad amputation in a non-paralysed limb and should certainly never be performed following a brachial plexus lesion. The prosthesis has, of necessity, to be very bulky since it contains the wide humeral condyles and external jointed side steels with a locking mechanism on one. Provided there is a minimum clearance of five inches below the end of an above-elbow stump and the position of the elbow joint the manufacturers can incorporate a fully automatic device which includes an elbow spindle, seven locking positions and a rotation device which is particularly valuable when an arthrodesis has been performed. The importance of the arthrodesis is the provision of effective humeral flexion which is essential for flexing the artificial elbow (Figs. 5 and 7). Below-elbow stumps should have a bone length of about six to seven inches, measured from the tip of the olecranon. SHOULDER ARTHRODESIS
Provided trapezius and serratus anterior are not paralysed, which is usually the case even in otherwise flail limbs, an arthrodesis of the shoulder is well advised if there is no active humeral flexion and the patient has accepted amputation. 20°-25 ° of abduction of the humerus, measured from the medial border of the scapula, is a recommended angle. Too little abduction causes discomfort f r o m the socket of the prosthesis pressing against the chest wall when an above-elbow amputation has been performed. 15°-20 ° of humeral flexion has proved to be ideal for activating the prosthesis (Figs. 6 and 7). This angle may seem excessive but when the prosthesis is fitted the stump becomes more vertical and is in good contact with the socket. If the humerus is insufficiently flexed there is lost motion in an above-elbow socket while the below-elbow amputee finds his elbow swings posteriorly when it is held in flexion. The scar of the arthrodesis should be away from the acromion process, a half to one inch below will allow a comfortable fitting of an artificial limb. Amputation scars should be either terminal or slightly posterior because the pressure of the prosthesis, when activating a terminal device, is anterior to the tip of the stump in above-elbow and antero-lateral in below-elbow amputations. AMPUTATION--INDICATIONS AND CONTRA-INDICATIONS
Efficient as an upper limb amputee may be with a prosthesis it must be clearly understood, by a patient ready to embark upon ablation following brachial plexus palsy, that an artificial arm is very remote from the human limb it tries to replace. Nevertheless it does have great functional value. The patient must realise what he will lose and what he is likely to gain. Many of the patients have remarked on the freedom of action after losing the dead weight of a completely insensitive limb. They have been able to resume many sporting activities (without the prosthesis) which they found difficult with the flail limb. They have commented favourably on their improved appearance with the artificial limb which restores the contour of the wasted shoulder as well as providing a cosmetic hand, if such is required. The advantage at work and for home activities can be considerable but, as stressed above, this is a matter to be discussed prior to the amputation. If the non-dominant limb is affected and the man is in a sedentary occupation with little or no mechanical hobbies and not particularly interested in sporting activities the author has usually advised against amputation as little would be gained. 134
Traction Lesions of the Brachial Plexus--lan Fletcher
Fig. 8. Same amputee as shown in Figs. 5, 6 and 7. He is an Engineering Draughtsman. Many of the victims of brachial plexus palsy experience pain, in some cases it is intense and the author considers it is unwise to amputate when the pain is really severe because it limits the function of the prosthesis and removes the psychological relief so many of the patients have from gripping the paralysed limb when the pain is almost intolerable. A large number of the amputees in this survey have returned to their former occupations or are gainfully employed in two-handed activities. This includes electric welding; engineering draughtsmanship (Fig. 8); spray-painting; professional photography and commercial travelling. One patient is a general practitioner, another a taxi driver. There is also a crane driver and a garage mechanic, both of whom have an amputation above the elbow. An electro-plater and engraver in the printing industry had his indentures cancelled following a motor cycle accident when he was an apprentice. After we had made representations his indentures were restored and now in his final year he gained the highest prize at the College. His work demands the skilled use of both hands in addition to lifting slabs of lead weighing over half a hundredweight. This he achieves with the aid of a prosthesis for an amputation above the left elbow. P A T I E N T S OPINIONS
About a year or more after they elected to have an amputation the author sent a very detailed questionnaire to seventy-three patients. Sixty-nine were completed and returned revealing that 91% w e a r the prosthesis at work and 66% find it is essential. 100% maintain they are very glad they chose to have the amputation. 135
Traction Lesions of the BrachiaI PIexus--lan Fletcher CONCLUSION
These figures do not prove that amputation is the treatment of choice for the permanently paralysed limb but the author considers that it does indicate the importance of a careful discussion with the patient so that the correct procedure for that individual may be advised. 8:
8:
8:
Below are a few of the replies to the question: - "Knowing the alternative was keeping a paralysed arm are you now glad you had an amputation?" The first three replies are from below-elbow amputees and the remainder are from above-elbow amputees. P.T.
There can be no other alternative but to have the arm amputated as it is useless whereas an artificial arm can be used.
T.J.
Yes indeed. I was absolutely fed up with the dead weight and having to put it in (my) pocket with the other hand.
P.C.
Very definitely yes. With a paralysed arm it is always noticeable and can be unpleasant whereas the artificial hand is very seldom noticed. It is also far more comfortable not to have a useless limb which only gets in the way.
D.R.
Yes, most definitely. A "dead" or paralysed limb is completely useless. Acts only as a hindrance. After keeping the useless limb for two years I am very glad I decided to have it removed, I have never regretted this.
J. Mc.
Yes, I ' m glad and very thankful to the doctors who advised and carried out the amputation. I would also like to thank the limb fitters for carrying out a wonderful job.
M.B.
Yes, permits the driving of a conventional floor change motor and makes life much more carefree.
W.H.
Very glad. A paralysed arm is useless. With an artificial arm there are very few, if any things, I cannot do. If I had kept my arm I would not have been able to continue my job and I don't know that I am wearing an artificial arm. I am very pleased I took the R I G H T decision.
M.B.
Definitely yes. After the amputation I had a sense of freedom from a burden. Speaking impartially from experience it is my belief the decision I made to part with my useless arm was one of the best decisions I ever made.
B.J.
Yes. I have now more confidence in myself and can earn a new place in society. My arm is so much a part of me. I, for one, would certainly be lost without it and I may add it comes in handy on the football pitch to keep it on and I find the opposition give me a wide berth. REFERENCES
BONNEY, G. (1959) Prognosis in Traction Lesions of the Brachial Plexus. Journal of Bone and Joint Surgery 41-B, 4. YEOMAN, P. M. (1968) Cervical Myelography in Traction Injuries of the Brachial Plexus. Journal of Bone and Joint Surgery 50-B, 253. 136
T R A C T I O N L E S I O N S OF T H E B R A C H I A L
PLEXUS
IAN F L E T C H E R , Roehampton During the past nine years at Roehampton, the author has had the opportunity of examining 180 people who have sustained either partial or complete lesions of the brachial plexus. Two of the cases suffered bilateral injuries.
Fig. 1. Right side of crash helmet worn by youth who sustained a lesion of the right brachial plexus. Note: black paint from the car involved in a head-on collision. MECHANISM OF INJURY
81% of the patients were under the age of twenty-four at the time of injury and 77% of the victims sustained their injuries in motor cycle accidents. Because of this alarmingly high figure an attempt was made to determine the mechanics of the lesions. Most of the motor cyclists questioned wore crash helmets and were involved in head-on collisions with another vehicle or some stationary object such as a tree or post. Many of the helmets showed evidence of an initial impact along the side corresponding to the plexus lesion (Fig. 1). Although associated injuries are common there has been a remarkable absence of actual shoulder injury and the clothing has been undamaged in this region. One patient made an interesting comment about his shirt collar which had split along its junction with the shirt in the supra-clavicular region on the side of his plexus injury. The history coupled with the findings suggest that the lesions in head-on collisions are due to the victim's head being forced laterally away from the shoulder and not, as we have tended to believe, due to the casualty falling heavily onto his shoulder. 129
Traction Lesions of the Brachiol Plexus--Ian Fletcher DIAGNOSIS AND PROGNOSIS
It is regrettable to relate that an accurate diagnosis and prognosis has been established late in some of the patients. This has been due, partly, to the fact that so many of the road accident victims have been unconscious and had other injuries. In addition to a careful clinical examination, diagnostic tests should include myelography which may reveal one or more meningoceles (Yeoman (1968)). Histamine and cold vasodilation tests (Bonney (1959)) are also of value in differentiating between preganglionic and postganglionic lesions of the plexus. For the latter type electro-myographic studies may prove helpful and if doubt still exists then exploration can be considered. Needless to say time for the reaction to degeneration must elapse but to postpone this operation unduly is to confuse the findings because scar tissue forms quickly. The presence of Homer's syndrome suggests irreparable damage to T.1. Because so many of these dreadful injuries affect young men on the threshold of their careers it is of great importance to ascertain the fate of the limb as soon as possible. The surgeon is then in a position to have a frank discussion with the patient about his future and decide upon the treatment most suitable to his individual needs. TREATMENT
Lesions which spare hand function
(a) Physiotherapy (b) Reconstructive surgery: Tendon transplants (Clark's and Zachary's). External rotation osteotomy of the humerus, usually necessary with a Zachary transplant, also as an isolated procedure. (c) Splints We occasionally provide splints with a hand-operated elbow lock (four positions). When indicated a shoulder support is included and this also restores the normal contour which so many patients value (Fig. 2).
Fig. 2. Flail-arm splint in polythene with shoulder cap and rotation mechanism above the elbow. 130
Traction Lesions of the Brachial Plexus--lan Fletcher
A rotation device may be incorporated to allow the wearer to position the limb anywhere within its natural limits. It is considered that powered splints for these patients are not only unnecessary but are more cumbersome and less efficient than the conventional type which are easy for the wearer to put on and use. (d) Bone-block for the flail elbow has been tried but many have failed, and this operation is not recommended. II
Lesions with no hand Sunction
Before advising any treatment for the patient with permanent paralysis of the hand, and possibly of the whole limb, it is imperative to know his background and ambitions. Many of the 180 patients referred to in this paper have been seen by the author prior to surgery (other than exploration) but with a reasonably definite prognosis. It has been found essential to spend an hour or more with each one in order to establish their make-up. It is vitally important to know about their occupations and pastimes, and the type of work they wish to undertake. It has often been necessary to have further talks with them and their relatives or fianc6es who may be closely concerned, particularly when amputation is a possible line of treatment. It is helpful for such people to meet and discuss the problem with another amputee who has alsc sustained a lesion of the brachial plexus. The author does not believe it is right to tell these patients that there is a clearcut line of treatment for the permanently paralysed limb. It is also of paramount importance that they are convinced of the prognosis before they agree to major surgery, particularly amputation. On the other hand the author does not agree with the advice, sometimes given, to wait three years or more when the surgeon himself knows the prognosis because this will condemn the man to a one-armed existence.
Fig. 3. Flail-arm splint with driving attachment fitted to palm area. Hand completely paralysed. 131
Traction Lesions o.f the BrachiaI P l e x u s - - l a n Fletcher ALTERNATIVE TREATMENTS
(a) Reconstructive surgery without amputation is unlikely to result in useful function. (b) Splints--these have proved disappointing and most patients, wi~h paralysed hands, issued with splints have discarded them, although they prove useful for driving a car when the appropriate appliance was fitted (Fig. 3). (The fitments are similar to those available to arm amputees and snap easily in and out of a fixture located in the palm or wrist area of the splint.)
(c) Ampu:ation--this has proved to be the most successful line of treatment for the majority of patients engaged in manual or industrial occupations. If it is decided upon then it must be combined with a stabilising operation upon the shoulder if this is seriously affected. Occasionally a Zachary transplant (combined with a rotation osteotomy) is possible but most of the patients in this series, who accepted an amputation required (and had), an arlhrodesis. To date 106 amputations have been performed and six other patients are on waiting lists.
Fig. 4. Below-elbow amputee with arthodesed shoulder. Triceps 0, Clark's transplant 4. A shoulder saddle, arm corset, jointed side steels and elbow lock have been added to conventional prosthesis. Fig. 5. Above-elbow amputee with arthrodesed shoulder, actively flexing the elbow of his artificial limb. 132
Traction Lesions of the Brachial Plexas--lan Fletcher SITES OF A M P U T A T I O N
When there is good elbow control it should be preserved but it is necessary to have strong biceps and triceps to obtain the best use of a prosthesis. The latter muscle is the one required to activate terminal appliances. Reconstructive surgery, such as Clark's transplant to provide active flexion when the triceps is also weak or inactive is of little or no value to the patient. The power of the transplant is often insufficient to overcome the weight of the prosthesis so we have to add jointed side steels with an external locking mechanism and a wide fitting leather cuff above the elbow (Fig. 4). Such a prosthesis is still less efficient than the type supplied for an above-elbow amputee. It is both surprising and very regrettable to know that there are still many surgeons who do not believe that arm amputees can make good functional use of a prosthesis. It amazes them to learn that there are bilateral above-elbow amputees who are completely independent and leading normal lives which includes driving cars with ordinary controls. It is, however, only fair to state that the majority of amputees who have suffered traction lesions of the brachial plexus are less proficient with a prosthesis than those with normal control of the stump. Many have returned to industry despite this fact and find their prosthesis invaluable.
Fig. 6. Ideal site of amputation and position of arthrodesis. Fig. 7. Flexing the arthrodesed stump. Note: This range of stump movement is adequate tor controlling the prosthetic elbow. (See Fig. 5.) 133
Fraction Lesions of the Brachial Plexus--lan Fletcher
STUMP LENGTHS
For amputations above the elbow we recommend a bone length of seven or eight inches measured from the tip of the acromion process. Disarticulation of the elbow is, in the author's opinion, a bad amputation in a non-paralysed limb and should certainly never be performed following a brachial plexus lesion. The prosthesis has, of necessity, to be very bulky since it contains the wide humeral condyles and external jointed side steels with a locking mechanism on one. Provided there is a minimum clearance of five inches below the end of an above-elbow stump and the position of the elbow joint the manufacturers can incorporate a fully automatic device which includes an elbow spindle, seven locking positions and a rotation device which is particularly valuable when an arthrodesis has been performed. The importance of the arthrodesis is the provision of effective humeral flexion which is essential for flexing the artificial elbow (Figs. 5 and 7). Below-elbow stumps should have a bone length of about six to seven inches, measured from the tip of the olecranon. SHOULDER ARTHRODESIS
Provided trapezius and serratus anterior are not paralysed, which is usually the case even in otherwise flail limbs, an arthrodesis of the shoulder is well advised if there is no active humeral flexion and the patient has accepted amputation. 20°-25 ° of abduction of the humerus, measured from the medial border of the scapula, is a recommended angle. Too little abduction causes discomfort f r o m the socket of the prosthesis pressing against the chest wall when an above-elbow amputation has been performed. 15°-20 ° of humeral flexion has proved to be ideal for activating the prosthesis (Figs. 6 and 7). This angle may seem excessive but when the prosthesis is fitted the stump becomes more vertical and is in good contact with the socket. If the humerus is insufficiently flexed there is lost motion in an above-elbow socket while the below-elbow amputee finds his elbow swings posteriorly when it is held in flexion. The scar of the arthrodesis should be away from the acromion process, a half to one inch below will allow a comfortable fitting of an artificial limb. Amputation scars should be either terminal or slightly posterior because the pressure of the prosthesis, when activating a terminal device, is anterior to the tip of the stump in above-elbow and antero-lateral in below-elbow amputations. AMPUTATION--INDICATIONS AND CONTRA-INDICATIONS
Efficient as an upper limb amputee may be with a prosthesis it must be clearly understood, by a patient ready to embark upon ablation following brachial plexus palsy, that an artificial arm is very remote from the human limb it tries to replace. Nevertheless it does have great functional value. The patient must realise what he will lose and what he is likely to gain. Many of the patients have remarked on the freedom of action after losing the dead weight of a completely insensitive limb. They have been able to resume many sporting activities (without the prosthesis) which they found difficult with the flail limb. They have commented favourably on their improved appearance with the artificial limb which restores the contour of the wasted shoulder as well as providing a cosmetic hand, if such is required. The advantage at work and for home activities can be considerable but, as stressed above, this is a matter to be discussed prior to the amputation. If the non-dominant limb is affected and the man is in a sedentary occupation with little or no mechanical hobbies and not particularly interested in sporting activities the author has usually advised against amputation as little would be gained. 134
Traction Lesions of the Brachial Plexus--lan Fletcher
Fig. 8. Same amputee as shown in Figs. 5, 6 and 7. He is an Engineering Draughtsman. Many of the victims of brachial plexus palsy experience pain, in some cases it is intense and the author considers it is unwise to amputate when the pain is really severe because it limits the function of the prosthesis and removes the psychological relief so many of the patients have from gripping the paralysed limb when the pain is almost intolerable. A large number of the amputees in this survey have returned to their former occupations or are gainfully employed in two-handed activities. This includes electric welding; engineering draughtsmanship (Fig. 8); spray-painting; professional photography and commercial travelling. One patient is a general practitioner, another a taxi driver. There is also a crane driver and a garage mechanic, both of whom have an amputation above the elbow. An electro-plater and engraver in the printing industry had his indentures cancelled following a motor cycle accident when he was an apprentice. After we had made representations his indentures were restored and now in his final year he gained the highest prize at the College. His work demands the skilled use of both hands in addition to lifting slabs of lead weighing over half a hundredweight. This he achieves with the aid of a prosthesis for an amputation above the left elbow. P A T I E N T S OPINIONS
About a year or more after they elected to have an amputation the author sent a very detailed questionnaire to seventy-three patients. Sixty-nine were completed and returned revealing that 91% w e a r the prosthesis at work and 66% find it is essential. 100% maintain they are very glad they chose to have the amputation. 135
Traction Lesions of the BrachiaI PIexus--lan Fletcher CONCLUSION
These figures do not prove that amputation is the treatment of choice for the permanently paralysed limb but the author considers that it does indicate the importance of a careful discussion with the patient so that the correct procedure for that individual may be advised. 8:
8:
8:
Below are a few of the replies to the question: - "Knowing the alternative was keeping a paralysed arm are you now glad you had an amputation?" The first three replies are from below-elbow amputees and the remainder are from above-elbow amputees. P.T.
There can be no other alternative but to have the arm amputated as it is useless whereas an artificial arm can be used.
T.J.
Yes indeed. I was absolutely fed up with the dead weight and having to put it in (my) pocket with the other hand.
P.C.
Very definitely yes. With a paralysed arm it is always noticeable and can be unpleasant whereas the artificial hand is very seldom noticed. It is also far more comfortable not to have a useless limb which only gets in the way.
D.R.
Yes, most definitely. A "dead" or paralysed limb is completely useless. Acts only as a hindrance. After keeping the useless limb for two years I am very glad I decided to have it removed, I have never regretted this.
J. Mc.
Yes, I ' m glad and very thankful to the doctors who advised and carried out the amputation. I would also like to thank the limb fitters for carrying out a wonderful job.
M.B.
Yes, permits the driving of a conventional floor change motor and makes life much more carefree.
W.H.
Very glad. A paralysed arm is useless. With an artificial arm there are very few, if any things, I cannot do. If I had kept my arm I would not have been able to continue my job and I don't know that I am wearing an artificial arm. I am very pleased I took the R I G H T decision.
M.B.
Definitely yes. After the amputation I had a sense of freedom from a burden. Speaking impartially from experience it is my belief the decision I made to part with my useless arm was one of the best decisions I ever made.
B.J.
Yes. I have now more confidence in myself and can earn a new place in society. My arm is so much a part of me. I, for one, would certainly be lost without it and I may add it comes in handy on the football pitch to keep it on and I find the opposition give me a wide berth. REFERENCES
BONNEY, G. (1959) Prognosis in Traction Lesions of the Brachial Plexus. Journal of Bone and Joint Surgery 41-B, 4. YEOMAN, P. M. (1968) Cervical Myelography in Traction Injuries of the Brachial Plexus. Journal of Bone and Joint Surgery 50-B, 253. 136