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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
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
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 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
Thank you
This work is licensed under a Creative Commons Attribution 4.0 International License.