Designing, developing and deploying a brachial plexus v2

Designing, Developing and Deploying a Brachial Plexus Service in Cambodia - Conception,

Training and Establishment

V Rajaratnam, Senior Consultant Hand SurgeonKhoo Teck Puat Hospital, Singapore

W Lam, J K Yong, Keo V, J Gollogly

Introduction

Methodology – ADDIE Model

Severe burn contractures

Severe venomous injuries

• Community-oriented curriculum• Needs analysis of surgeons• Personalised programme• Targeted training • Feedback and Practice• Assessment• Evaluation of the programme

Methods – Community-oriented Curriculum

Discerning the Community Needs:Six trips by hand surgeons

Cases Percentage

Burn and trauma deformity 36 40%

Congenital 18 18%Nerve Injuries 23 24%

Tumour 3 3%

Brachial Plexus 16 16%

Total: 96 100%

Designing the Curriculum TOPICS LEARNING PROCESS TIME

Basic Science Hand Assessment Workshop

6 mths

Deformity 1:Burn contractures

Flap design workshop

1-2 yrs

Deformity 2: Tendons Tendon workshop 6 mths

Deformity 3 Fracture and dislocations Osteomyelitis

Fracture fixation workshop

1 yr

Nerve 1: Paralysis, cerebral palsy and spasticity

Micronueral workshop

1-2 yrs

Nerve 2: Brachial plexus

Micronueral workshop

1-2 yrs

Congenital Hand Deformities Lectures, tutorials, supervised operating

2-3 yrs✔

Learning needs analysis of surgeons

1. Identify surgeon2. Assess skill level3. Develop personalized training program4. Show and Supervise5. Assess independent practice

Personalised program

• Plexus assessment - CBD• Decision making and planning - CBD• Surgical option generation – Lectures,

CBD• Selection/execution under supervision

- DOP• Deliberate practice/Feedback –

simulation• Independent

performance/assessment - DOP

Selected Workshops Microneural Workshop Nov 2013

Selected Nerve Transfers (CSC Reconstructive Strategy for Total Plexus Injury (C5-T1) < 6 months)

Reconstructive Strategy:SHOULDER ABDUCTION:• Spinal accessory nerve ->

Suprascapular Nerve

ELBOW FLEXION:• Phrenic Nerve -> Sural Nerve

Graft -> Branch to Biceps (Musculocutaenous nerve)

Useless Limb -> Assisting Limb

Method – 4. Selected Nerve Transfers (CSC Reconstructive Strategy for Upper Plexus Injury (C5,6 +/- 7) < 6 months)

Reconstructive Strategy:SHOULDER ABDUCTION:• Spinal accessory nerve ->

Suprascapular Nerve

ELBOW FLEXION:• Ulnar nerve fascicle to biceps

branch (Oberlin)

ELBOW EXTENSION:• Triceps branch to axillary nerve Weak Limb -> Useful Limb

Results

BEFORE AFTER THE FUTURE

1.375 4.46 4.875

DEFORMITY

BEFORE AFTER THE FUTURE

1.625 4.41 4.5

CONGENITAL HANDS

BEFORE AFTER THE FUTURE

1.25 4.375 4.28

BRACHIAL PLEXUS INJURIES

Not confident Very confident

1 2 3 4 5

Results (18)

0

1

2

3

4

5

6

Pan PlexalUpper Plexus

May 2013

Dec 2013

May 2014

Nov2014

Feb2015

May2015

Results - Innovations

Thank you

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