PMC4627103_01
The 7-month-old boy has persistent flail arm after constriction band release with Z-plasty at 3 months of age at an outside hospital. The arm had limb length discrepancy but did show evidence of tone to hand and forearm.
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Physical examination at 6 months of age and 3 months following initial release revealed no peripheral motor or sensory nerve function below the site of the released constriction band; however, forearm and finger tone was present with no flexion or extension contractures (Figure 1).
Dissection of the median and ulnar nerves revealed narrowing of the nerves in the compressed regions (yellow dashes) with preservation of caliber and vascularity distally. The brachial artery (left vessel loop) abruptly ended at the proximal end of the constricting band with no radial or ulnar artery identified.
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Both the median and ulnar nerves were in continuity distal to the band; however, the nerves were clearly atrophic within the band (Figure 2).
Sural nerve was used to bridge the 5-cm defect in both the median and ulnar nerves with 9-0 nylon and Tisseel fibrin glue. Radial nerve exploration was not undertaken due to vascular threat to limb at this stage of operation.
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The 9-0 nylon epineural sutures were used to approximate the grafted sural nerve and Tisseel Fibrin Sealant (Baxter International Inc., Deerfield, IL, USA) was added for support (Figure 3).