Treatment Of Brachial Plexus Injuries Research Articles

Comparative study of phrenic nerve transfers with and without nerve graft for elbow flexion after global brachial plexus injury

BackgroundNerve transfer is a valuable surgical technique in peripheral nerve reconstruction, especially in brachial plexus injuries. Phrenic nerve transfer for elbow flexion was proved to be one of the optimal procedures in the treatment of brachial plexus injuries in the study of Gu et al. ObjectiveThe aim of this study was to compare phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury. MethodsA retrospective review of 33 patients treated with phrenic nerve transfer for elbow flexion in posttraumatic global root avulsion brachial plexus injury was carried out. All the 33 patients were confirmed to have global root avulsion brachial plexus injury by preoperative and intraoperative electromyography (EMG), physical examination and especially by intraoperative exploration. There were two types of phrenic nerve transfers: type1 – the phrenic nerve to anterolateral bundle of anterior division of upper trunk (14 patients); type 2 – the phrenic nerve via nerve graft to anterolateral bundle of musculocutaneous nerve (19 patients). Motor function and EMG evaluation were performed at least 3 years after surgery. ResultsThe efficiency of motor function in type 1 was 86%, while it was 84% in type 2. The two groups were not statistically different in terms of Medical Research Council (MRC) grade (p=1.000) and EMG results (p=1.000). There were seven patients with more than 4 month's delay of surgery, among whom only three patients regained biceps power to M3 strength or above (43%). A total of 26 patients had reconstruction done within 4 months, among whom 25 patients recovered to M3 strength or above (96%). There was a statistically significant difference of motor function between the delay of surgery within 4 months and more than 4 months (p=0.008). ConclusionPhrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury had no significant difference for biceps reinnervation according to MRC grading and EMG. A delay of the surgery after the 4 months might imply a bad prognosis for the recovery of the function.

Patient Specific Functional Scale: Establishment of Validity in Patients with Upper Extremity Nerve Injury: Level 3 Evidence

REFERENCES 1. Ferraresi S, Garozzo D, Ravenni R, et al. Hemihypoglossal nerve transfer in brachial plexus repair: Technique and results. Neurosurgery 2002; 50: 332–5. 2. Zheng MX, Xu WD, Qiu YQ, et al. Phrenic Nerve transfer for elbow flexion and intercostal nerve transfer for elbow extension. J Hand Surg Am 2010; 35: 1304-9. 3. Monreal R. Restoration of elbow flexion by transfer of the phrenic nerve to musculocutaneous nerve after brachial plexus injuries. Hand 2007; 2: 206–11. 4. Siqueira MG, Martins RS. Phrenic nerve transfer in the restoration of elbow flexion in brachial plexus avulsion injuries: how effective and safe is it? Neurosurgery 2009; 65: A125-31. 5. Luedemann W, Hamm M, BLOMER U, et al. Brachial plexus neurotization with donor phrenic nerves and its effect on pulmonary function. J Neurosurg 2002; 96: 523–6. 6. Bowerson M, Nelson VS, Yang LJ. Diaphragmatic paralysis associated with neonatal brachial plexus palsy. Pediatr Neurol 2009; 42: 234-6. 7. Xu L, Gu Y, Xu J, et al. Contralateral C7 transfer via the prespinal and retropharyngeal route to repair brachial plexus root avulsion: a preliminary report. Neurosurgery 2008; 63: 553-9. 8. Lundborg G. Nerve injury and repair-a challenge to the plastic brain. J Peripher Nerv Syst 2003; 8: 209-26. 9. Terzis JK, Papakonstantinou KC. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 2000; 106: 1097–124. 10. Xu WD, Gu YD, Xu JG, et al. Full-length phrenic nerve transfer by means of video-assisted thoracic surgery in treating brachial plexus avulsion injury. Plast Reconstr Surg 2002; 110: 104–9.

Protocol Development for Infants with Orthopedic Complications in the Neonatal Intensive Care Unit: Brachial Plexus Injuries and Clubfoot

Currently, there is limited information to guide occupational therapy or physical therapy treatment of high-risk neonates with secondary orthopedic conditions in the Neonatal Intensive Care unit (NICU). This article describes one master of occupational therapy student capstone project that aimed to develop intervention protocols and parent education materials for the treatment of brachial plexus injuries (BPI) and clubfoot for a hospital NICU. A literature review and needs assessment were conducted to determine whether clinical practices and standards existed and to inform the development of the intervention protocols. The critical need to document, define, and examine best practices was validated. Clinical treatment protocols and parent education materials were developed and are presented.

Reversion of transcallosal interhemispheric neuronal inhibition on motor cortex after contralateral C7 neurotization

Contralateral C7 nerve transfer is widely applied for the treatment of brachial plexus injuries or central paralysis of the upper extremities. The surgical approach has evolved from the precervical subcutaneous route to the prespinal route, which is currently the most commonly used one. We report a patient with central paralysis of the right upper extremity treated with contralateral C7 nerve transfer via the posterior spinal route.A 59-year-old female patient was admitted on 3 July, 2018 with right hemiplegia. The muscle strength of the right lower and upper extremities was grade 4 and 0, respectively. On the basis of magnetic resonance imaging, she was diagnosed with central paralysis of the right upper extremity. Considering the short length of the patient's healthy C7 nerve, contralateral C7 nerve transfer via the posterior spinal route was performed. No intraoperative complication was encountered. The patient reported slight numbness of the volar side of the left thumb, middle finger, and index finger after surgery. The patient showed a right shrug movement 1.5 months after surgery.We propose carrying out contralateral C7 nerve transfer via the posterior spinal route because of the shorter distance, no need for nerve transplantation, and low occurrence of the complications encountered with the prespinal route (such as vertebral artery injuries, esophageal fistula, and upper extremity pain when swallowing).

Experimental Study on Mechanical Vibration Massage for Treatment of Brachial Plexus Injury in Rats

To investigate the curative effect of the self-made mechanical vibration massage instrument for treatment of brachial plexus injury in rats and to explore its mechanism. Brachial plexus injury models were made in 144 Wistar rats and one week after natural healing of the wound, they were randomly divided into 3 groups, mechanical vibration treatment group (MV group), nerve growth factor treatment group (NGF group) and model group, 48 rats in each group. Then again, the each group was randomly divided into 4 subgroups, 7-day group, 14-day group, 21-day group and 28-day group, 12 rats in each subgroup. The MV group were treated by mechanical vibration at acupoints on three-yang and three-yin channels of the hand with the mechanical vibration massage instrument; The NGF group were treated with injection of NGF into musculus pectoralis major on the affected side; And the model group were normally fed with no treatment. After treatment for 7, 14, 21 and 28 days, the diameter of both forelimbs were measured, the electrophysiological examination on the brachial plexus in vitro and the ultrastructure observation with electron microscope on the affected side were carried out, the motor nerve conduction velocity (MNCV) and motor nerve action potential (MNAP) of the brachial plexus on the affected side, NGF content of submaxillary gland as well as muscular Na+, K(+)-ATPase activity were determined respectively. The different rates of the forelimb diameter in the MV group and the NGV group on the 14th d, 21st d and 28th d were better than those in the model group (P < 0.05 or P < 0.001), and in the MV group were better than those in the NGF group on the 21st d and the 28th d (P < 0.05). MNCV in the MV group and the NGV group on the 21st d and 28th d was better than that in the model group (P < 0.05 or P < 0.001), and in the MV group was better than that in the NGF group on the 28th d (P < 0.05). MNAP in the MV group and the NGV group on the 14th d, 21st d and 28th d was better than that in the model group (P < 0.05 or P < 0.001), and in the MV group was better than that in the NGF group on the 21st d and 28th d (P < 0.05). The NGF mean gray index of submaxillary gland in the model group was higher than that in the MV group and the NGF group on the 7th d (P < 0.05); in the NGF group and the model group was higher than that in the MV group on the 14th d (P < 0.05); and in the NGF group and the MV group was higher than that in the model group on the 21st d and 28th d (P < 0.05). Na+, K(+)-ATPase activity in the model group and the MV group was higher than that in the NGF group (P < 0.05) on the 14th d, and in the MV group was higher than that in the model group on the 28th d (P < 0.05). As compared with the NGF group and the model group, mechanical vibration treatment can effectively accelerate repair of injured brachial plexus, slow down atrophy of skeletal muscle, and promote secretion of NGF in submaxillary gland.

End-to-side neurorrhaphy for phrenic nerve neurotization of the musculocutaneous nerve in the treatment of brachial plexus injuries:an experimental study in rats

Objective To investigate the feasibility of end-to-side neurorrhaphy between the musculocutaneous nerve and the phrenic nerve for treatment of brachial plexus root avulsion injuries.Methods Fifty-one male Sprague-Dawley rats were randomly divided into four groups:total brachial plexus root avulsion(A),end-to-end neurorrhaphy for phrenic nerve neurotization of the musculocutaneous nerve(B),end-to-side neurorrhaphy for phrenic nerve neurotization of the musculocutaneous nerve(C),and helicoid fashion end-to-side neurorrhaphy for phrenic nerve neurotization of the musculocutaneous nerve(D).Another 9 rats expressing green fluorescent proteins(GFP+)were used for morphological observation of the regenerated nerve with fluorescence microscope.Evaluation of functional recovery including behavioral observation,histology detection and electrophysiology study were performed at intervals of 1,2 and 3 months after the surgery.Results Functional recovery of the injured forelimbs was observed in rats of all the groups except group A.Muscle force recovery rate and muscle weight recovery rate of group C and D reached 76.4% and 86.3% of those in group B and 85.6%and 87.7% of those in group B,respectively.Meanwhile function of the diaphragm was preserved.The fluorescence study revealed an abundant collateral sprouting of phrenic nerve axons originating from the site of coaptation to the distal end of the musculocutaneous nerve in all the experimental groups.Conclusion Although inferior to end-to-end neurotization,the standard end-to-side neurotization and end-to-side neurotization in helicoids fashion were effective methods,the latter resulting in better recovery. Key words: Brachial plexus; Nerve transfer; Phrenic nerve

Treatment of brachial plexus injury with modified contralateral C7transfer

To study the curative effects of different surgical methods using a contralateral C(7) transfer technique for treatment of brachial plexus injury induced by root avulsion. Sixty-four patients with brachial plexus injury due to root avulsion were divided into two groups: 30 patients were included in Group A and 34 in Group B. In Group A, the contralateral C(7) roots were partially transected and anastomosed to one end of an ulnar nerve graft which had been removed from the affected limb. The other end of the ulnar nerve was divided into two parts and anastomosed to the distal ends of the recipient median and radial nerves, respectively. In Group B, the whole of the contralateral C(7) roots was transected and anastomosed to one side of an ulnar nerve graft, the other side of which was anastomosed eight months later to the distal ends of the recipient median and radial nerves. All subjects were followed up and the outcomes assessed. Neurological deficit and recovery time of the donor limb in group A were less than those in group B. The nerve transfer procedure to the affected limb was easily completed in group A with less morbidity, and the tension of the stoma in group A was less than that in group B. However, there was no statistical difference between group A and B in the recovery of motor function and results of electrophysiological testing of the affected side (P > 0.05). The method of partial C(7) root transfer results in equally good motor function as does transfer of the whole root, while occurrence of motor and sensory damage is less than that which occurs with transfer of the whole root.

Pan-limb Plexiform Neurofibroma-Hypothesis of Pathogenesis and Its Surgical Strategy

Plexiform neurofibroma is a multi-nodular and diffuse benign peripheral nerve sheath tumor and is usually associated with neurofibromatosis type 1. Plexiform neurofibroma of the brachial plexus is rare. Plexiform neurofibroma of the whole upper limb, presenting with multiple nodular tumor masses from cervical nerve roots along the course of the brachial plexus and at the termination of the peripheral nerves is especially rare. Here we report two cases of pan-limb plexiform neurofibroma with similarity in symptoms and signs: diffuse nerve tumor masses, cutaneous pigmentation (cafe-au-lait spots) and severe neurological deficits of the upper limb. Case 1, a 28-years-old lady with Von Recklinghausen's disease presented with diffuse swelling and weakness of the left upper limb. Case 2, a 3-years- old boy, presented with multiple masses over the right neck with dropped shoulder and progressive inability to flex his elbow over the duration of one year. Both of them received cervical spine surgery for cord decompression and peripheral nerve surgeries for the limb tumor growth. They both had multiple nerve tumors resection and received palliative reconstruction: by tendon transfer and nerve transfer. Based on the clinical and intraoperative findings of these two cases, we made our hypothesis in tumor genesis and progression. ”Neighboring transmission” in such ”pan-limb” plexiform neurofibroma is proposed. Although it is rare, once it develops, it often results in severe neurological deficits and is a big challenge to the surgeon for both tumor resection and reconstruction. Early radical excision to prevent pathological neurogenic tumor spreading is probably one of the best choices of treatment. Late reconstruction by tendon, muscle, or nerve transfer, similar to the treatment of brachial plexus injuries is then supplemented.

The Surgical Treatment of Brachial Plexus Injuries in Adults

After studying this article, the participant should be able to: 1. Evaluate clinically a patient with brachial plexus paralysis and define the appropriate electrophysiologic and radiographic studies. 2. Differentiate between preganglionic (root) avulsion and postganglionic lesions and identify appropriate motor donors and nerve grafts. 3. Describe various nerve reconstructive strategies and make appropriate selection of secondary procedures for shoulder stability, elbow flexion, and hand reanimation. 4. Anticipate the possible functional outcome.

Direct repair (nerve grafting), neurotization, and end-to-side neurorrhaphy in the treatment of brachial plexus injury

The authors present the long-term results of nerve grafting and neurotization procedures in their group of patients with brachial plexus injuries and compare the results of "classic" methods of nerve repair with those of end-to-side neurorrhaphy. Between 1994 and 2006, direct repair (nerve grafting), neurotization, and end-to-side neurorrhaphy were performed in 168 patients, 95 of whom were followed up for at least 2 years after surgery. Successful results were achieved in 79% of cases after direct repair and in 56% of cases after end-to-end neurotization. The results of neurotization depended on the type of the donor nerve used. In patients who underwent neurotization of the axillary and the musculocutaneous nerves, the use of intraplexal nerves (motor branches of the brachial plexus) as donors of motor fibers was associated with a significantly higher success rate than the use of extraplexal nerves (81% compared with 49%, respectively, p = 0.003). Because of poor functional results of axillary nerve neurotization using extraplexal nerves (success rate 47.4%), the authors used end-to-side neurorrhaphy in 14 cases of incomplete avulsion. The success rate for end-to-side neurorrhaphy using the axillary nerve as a recipient was 64.3%, similar to that for neurotization using intraplexal nerves (68.4%) and better than that achieved using extraplexal nerves (47.4%, p = 0.19). End-to-side neurorrhaphy offers an advantage over classic neurotization in not requiring sacrifice of any of the surrounding nerves or the fascicles of the ulnar nerve. Typical synkinesis of muscle contraction innervated by the recipient nerve with contraction of muscles innervated by the donor was observed in patients after end-to-side neurorrhaphy.

Treatment of brachial plexus injury by exterior-and interior-meridian acupoints

Exterior-and interior-meridian acupoints were used, mainly by selection of local acupoints along meridian. According to the state of disease, electroacupuncture and acupoint injection were combined to treat brachial plexus injury. Among 12 patients, 6 cases were basically cured, 4 cases got effectiveness and 2 cases had no effectiveness. The therapeutic effect of exterior- and interior-meridian acupoints in brachial plexus injury was satisfactory.

Posterior Approach for Double Nerve Transfer for Restoration of Shoulder Function in Upper Brachial Plexus Palsy

Restoration of shoulder function is one of the most critical goals of treatment of brachial plexus injuries. Primary repair or nerve grafting of avulsion injuries of the upper brachial plexus in adults often leads to poor recovery. Nerve transfers have provided an alternative treatment with great potential for improved return of function. Many different nerves have been utilized as donor nerves for transfer to the suprascapular nerve and axillary nerve for return of shoulder function with variable results. As our knowledge of shoulder neuromuscular anatomy and physiology improves and our experience with nerve transfers increases, so evolve the specific transfer procedures. This article presents a technique and rationale for reconstructing shoulder function by transferring the distal spinal accessory nerve to the suprascapular nerve and the nerve branch to the medial head of the triceps to the axillary nerve, both through a posterior approach.

Full-Length Ulnar Nerve Harvest by Means of Endoscopy for Contralateral C7 Nerve Root Transfer in the Treatment of Brachial Plexus Injuries

To avoid long scar formation after contralateral C7 transfer for treatment of brachial plexus avulsion injuries, endoscopy was used for full-length harvest of the ulnar nerve. The surgical procedure and its clinical effect are reported here. From July to August of 2001, two patients with total root avulsion were recruited. Three 2- to 3-cm-long incisions were made in the mid upper arm, elbow, and wrist, and the full-length ulnar nerve was harvested using the Endoscope Vessel Harvest System endoscope system. The surgical time was recorded, the vascularity of the dissected ulnar nerves was observed, and the recovery of the injured limb after contralateral C7 nerve root transfer was measured. Compared with the traditional technique, there were no significant differences in surgical time, vascularity of the dissected ulnar nerve, or recovery of the injured limb when the full-length ulnar nerve was harvested with endoscopy (as part of the contralateral C7 nerve root transfer operation), but the degree of scarring after surgery was markedly reduced. Although the same level of curative effect was ensured, the new endoscope-aided method for harvesting the full length of the ulnar nerve for contralateral C7 nerve root transfer was not complicated and caused markedly less scarring.

Harvesting Full-Length Ulnar Nerves by Means of the Endoscope for Contralateral C7 Nerve Root Transfer in Treatment of Brachial Plexus Injuries

Harvesting Full-Length Ulnar Nerves by Means of the Endoscope for Contralateral C7 Nerve Root Transfer in Treatment of Brachial Plexus Injuries

Restoration of shoulder abduction by transfer of the spinal accessory nerve to suprascapular nerve through dorsal approach

In recent years, transfer of the spinal accessory nerve to suprascapular nerve has become a routine procedure for restoration of shoulder abduction. However, the operation via the traditional supraclavicular anterior approach often leads to partial denervation of the trapezius muscle. The purpose of the study was to introduce transfer of the spinal accessory nerve through dorsal approach, using distal branch of the spinal accessory nerve, to repair the suprascapular nerve for restoration of shoulder abduction, and to observe its therapeutic effect. From January to October 2003, a total of 11 patients with a brachial plexus injury and an intact or nearly intact spinal accessory nerve were treated by transferring the spinal accessory nerve to the suprascapular nerve through dorsal approach. The patients were followed up for 18 to 26 months [mean (23.5 +/- 5.2) months] to evaluate their shoulder abduction and function of the trapezius muscle. The outcomes were compared with those of 26 patients treated with traditional anterior approach. And the data were analyzed by Student's t test using SPSS 10.5. In the 11 patients, the spinal accessory nerves were transferred to the suprascapular nerve through the dorsal approach successfully. Intact function of the upper trapezius was achieved in all of them. In the patients, the location of the two nerves was relatively stable at the level of superior margin of the scapula, the mean distance between them was (4.2 +/- 1.4) cm, both the nerves could be easily dissected and end-to-end anastomosed without any tension. During the follow-up, the first electrophysiological sign of recovery of the infraspinatus appeared at (6.8 +/- 2.7) months and the first sign of restoration of the shoulder abduction at (7.6 +/- 2.9) months after the operation, which were earlier than that after the traditional operation [(8.7 +/- 2.4) months and (9.9 +/- 2.8) months, respectively; P < 0.05]. The postoperative shoulder abduction was 62.8 degrees +/- 12.6 degrees after transfer of the spinal accessory nerve, better than that after the traditional (51.6 degrees +/- 15.7 degrees). All the 11 patients could extend and externally rotate the shoulder almost normally. The accessory nerve transfer through dorsal approach is a safe and reliable procedure for the treatment of brachial plexus injury. Its postoperative effect is confirmed, which is better than that of the traditional operation.

Modified Steindler procedure for the treatment of brachial plexus injuries

A retrospective follow-up study was completed on ten patients who suffered from a brachial plexus injury that was treated with a modified Steindler procedure. The mean postoperative period was 6.8 years. The postoperative elbow joint range of motion was -42 degrees of extension (range -5 degrees to -65 degrees ) and 107 degrees of flexion (range 90 degrees -130 degrees ). Manual muscle testing showed grade 4 or 5 in eight patients and grade 3 in two patients. In the subjective assessment, the patients scored 20 out of 30 points and were able to perform almost all activities with the exception of shoulder elevation. Innervation of the musculocutaneous nerve was evaluated by electromyography and no correlation was seen between preoperative and postoperative amplitude of the biceps brachii by electromyogram. Based on these results, we concluded that a modified Steindler procedure is useful for reconstruction of upper brachial plexus injuries, and recovery of the biceps brachii was difficult to predict by an electromyogram.

Surgical treatment of brachial plexus injuries in adults

We carried out a retrospective review of 32 consecutive patients (30 adults and two children) with total or partial lesions of the brachial plexus who had surgical repair using nerve grafting, neurotisation, and neurolysis between January 1991 and December 2003. The outcome measures of muscular strength were correlated with the type of lesion, age, preoperative time, length and number of grafts, and time to reinnervation of the biceps. The function of the upper limb was also evaluated. There was a significant correlation between muscular strength after surgical repair and both the preoperative time and the length of the nerve graft. There was also a significant correlation between muscular strength and the number of grafts. Muscular strength was better when the neurolysis was done before six months. When neurosurgical repair and reconstructive procedures were performed, the function of the upper limb was improved.

Outcomes of surgical treatment of brachial plexus injuries using nerve grafting and nerve transfers.

Between 1993 and 1998, 32 male patients with brachial plexus injuries were surgically treated. Eighteen interfascicular grafting and 71 extraplexal neurotization procedures were performed separately or in combination. Donor nerves were the intercostals, spinal accessory, phrenic, contralateral C7, and cervical plexus, in order of frequency. Patients were followed for a minimum of 24 (average, 35) months. Biceps function was best following grafting the musculocutaneous nerve itself, or neurotization with the phrenic nerve (100 percent grade 4), followed by neurotization with the intercostals (89.5 percent grade 3 or more) and last, grafting the C5 root or upper trunk (grade 3 in one of three patients). Phrenic to suprascapular neurotization produced the best results of shoulder abduction (40 to 90 degrees), followed by combined neurotization of the spinal accessory to suprascapular and phrenic to axillary (20 to 90 degrees). Sensory recovery over the lateral forearm and palm varied from S2 to S3+, according to the method of reconstruction.

The Surgical Treatment of Brachial Plexus Injuries in Adults

Posttraumatic brachial plexus palsy is a severe injury primarily affecting young individuals at the prime of their life. The devastating neurological dysfunction inflicted in those patients is usually lifelong and creates significant socioeconomic issues. During the past 30 years, the surgical repair of these injuries has become increasingly feasible. At many centers around the world, leading surgeons have introduced new microsurgical techniques and reported a variety of different philosophies for the reconstruction of the plexus. Microneurolysis, nerve grafting, recruitment of intraplexus and extraplexus donors, and local and free-muscle transfers are used to achieve optimal outcomes. However, there is yet no consensus on the priorities and final goals of reconstruction among the various centers.

Treatment of brachial plexus injury

A brachial plexus injury is the most severe nerve injury of the extremities. To achieve good results from treatment, correct diagnosis and early nerve repair are mandatory. The brachial plexus should be explored as early as possible if there is an incised wound, if clinical findings or diagnostic imaging indicate that at least one root is avulsed, if there is damage to the subclavian artery, and if there is total-type injury. With an upper-type injury with no clinical signs of a preganglionic lesion, the patient should be treated conservatively for 3 months and if there are no signs of recovery, then the brachial plexus should be explored. During this exploration, recording of the spinal cord evoked potential (ESCP) or the somatosensory evoked potential (SEP) is mandatory to determine the site of injury. Nerve grafting is indicated for a rupture in the root demonstrating a positive ESCP or SEP potential, in the trunk or in the cord. Exploration of the brachial plexus should be extended distally as far as possible to achieve good results after nerve grafting; when this was done more than M3 (MRC grading) power of the infraspinatus, deltoid, and biceps was achieved in more than 70% of our 32, 30, 33 patients, respectively. Results of nerve grafting for the forearm muscles have been very poor. Intercostal nerve transfer is recommended to restore elbow flexion in root avulsion type of injury, with elbow flexion to more than M3 being regained in 70% of our 221 patients. The best results of intercostal nerve transfer were achieved in patients younger than 30 years who received the operation within 6 months after injury. Motor recovery of hand function after intercostal nerve transfer was poor but protective sensation was restored in fingers innervated by the median nerve. The recommended treatment for each type of injury is described according to the results achieved.