Brachial plexus injuries by krr

BRACHIAL PLEXUS INJURIES

MODERATOR :DR. B C PATIL PROFESSOR DEPT OF ORTHOPAEDICS MRMC GULBARGA

PRESENTER :DR.RAMACHANDRA

• The Brachial Plexus is a large & very imp plexus of nerves.

• Situated partly in neck & partly in axilla.• Brachial Plexus formed by union of ventral

rami of nerves C5 to C8 & greater part of T1 ventral ramus.

• Rami that form Brachial Plexus are often referred to as roots of Brachial Plexus.

• They lie between scalenus anterior & medius muscle.

ANATOMY OF BRACHIAL PLEXUS

• The ventaral rami from C5 & C6 unite to form superior trunk.

• C7 continues as inferior trunk.• C8 & T1 unite to form inferior trunk.• Each of 3 trunks divides into anterior &

posterior divisions.

• The 3 posterior divisions unite to form posterior cord.

• Anterior divisions of superior & middle trunks unite to form lateral cord.

• Anterior division of inferior trunk continues as medial cord.

• Cords of Brachial Plexus bear their name in relation to their position to axillary artery.

• Each cord of Brachial Plexus divides into two terminal branches.

• Brachial Plexus includes five components• 5 Roots• 3 Trunks • 2 Divisions• 3 Cords • Terminal nerves

• Branches of the brachial plexus may be described as supraclavicular and infraclavicular.

Supraclavicular branches • Supraclavicular branches arise from roots or from trunks

as follows:From roots • 1. Nerves to scaleni and longus colli C5, 6, 7, 8 • 2. Branch to phrenic nerve C5 • 3. Dorsal scapular nerve C5 • 4. Long thoracic nerve C5, 6 (7) From trunks • 1. Nerve to subclavius C5, 6 • 2. Suprascapular nerve C5, 6

Infraclavicular branches

• Infraclavicular branches come from the cords, but their axons may be traced back to the spinal nerves:

Lateral cord • Lateral pectoral C5, 6, 7 • Musculocutaneous C5, 6 7 • Lateral root of median C(5), 6, 7

Medial cord • Medial pectoral C8, T1 • Medial cutaneous of forearm C8, T1 • Medial cutaneous of arm C8, T1 • Ulnar C(7), 8, T1

Posterior cord• Upper subscapular C5, 6 • Thoracodorsal C6, 7,8 • Lower subscapular C5, 6 • Axillary C5, 6 • Radial C5, 6, 7, 8, (T1)

CLOSED• a) Traction lesions

• b)Radiation induced

• c)Neoplastic

• d)Post operative

Brachial Plexus Lesions:ETIOLOGY:

OPEN• Gun shot wounds Lacerations• During surgeries

• Orthopaedic related

• Needles & cannulas

• MC cause in large series is motor cycle accidents of 70%.

• In 20% cases a/w rupture of subclavian or axillary artery.

Injury mechanisms:

– Traction or stretch of the

brachial plexus – Direct blow – Compression or impingement of the brachial plexus

CLASSIFICATION OF BRACHIAL PLEXUS INJURIES:

• Upper Plexus Injuries(Erb's Palsy)• Lower Plexus Injuries(Klumpke)

• Leffert classified injuries acc to mech & level of injury

• Preganglionic or supraganglionic injuries occuring proximal to neural foramen in which neurons have been seperated from spinal cord.

• Postganglionic or infraganglionic injuries occur distal to neural foramen & neurons remain connected to spinal cord.

Upper Brachial Plexus Injuries• Increase in angle between neck & shoulder• Traction (stretching or avulsion) of upper

rootlets (e.g., C5,C6)• Produces Erb’s Palsy

Lower Brachial Plexus Injuries• Excessive upward pull of limb• Traction (stretching or avulsion) of lower

rootlets (e.g., C8, T1)• Produces Klumpke’s Palsy

Lower brachialplexus injuries

Upper brachialplexus injuries

ERB'S PALSY

• Involves C5 & C6 nerve roots. • Limb is extended at elbow flaccid at side

of trunk & adducted & internally rotated.• Abduction impossible because of paralysis

of deltoid & supraspinatus m/s.• ER impossible because of paralysis of

infraspinatus & teres minor m/s.

• Active flexion impossible because of paralysis biceps,brachialis & brachioradialis.

• Pralysis of supinator m/s causes pronation deformity of forearm.

• Called as WAITER'S TIP.

Brachial Plexus Lesions of individual nerve:

Long Thoracic Nerve(C5,6,7):• Winging of scapula- Serratus Anterior.

Suprascapular Nerve(C5,6):• Hard to start shoulder abduction.

Axillary Nerve(C5,6)

Motor Deficits

• Difficult abducting arm to horizontal

• Loss of shoulder roundness

Sensory Deficits

• Lateral side of arm below point of shoulder.

Musculocutaneous Nerve(C5,6,7)

Motor Deficits

• Very weak flexion of elbow joint -Biceps & Brachioradialis.

• Weak supination of radioulnar joint-Biceps

Sensory Deficits

• Lateral forearm

Radial Nerve(C5-T1) at elbowLow lesions:

• BR, ECRL, & ECRB are spared.• Can't extend MCP joints of hand.• Thumb weakness of abduction & IP joints

extension.

Radial Nerve(C5-T1) at radial grooveHigh lesion:Motor Deficits

• Wrist Drop-ECRL , ECRB & ECU but triceps & anconeus m/s spared.

• Difficulty making a fist -synergy betn. wrist extensors & finger flexors.

Sensory Deficits• dorsum of hand &

anatomical snuff box.

Radial Nerve(C5-T1) Very high lesion

Motor Deficits:• Saturday Night Palsy/

Crutch Palsy• Along with weakness

of wrist & hand, triceps also paralyzed

• Triceps reflex absent

• No sensory deficits as it is Neuropraxia.

• Best prognosis.

Median Nerve(C5-T1) at Elbow

• Pronation of radioulnar joints

• Weak wrist flexion-FCR• Weak opposition of

thumb- Thenar m/s.• Ape Thumb- Thumb

hyper extended & adducted-Thenar m/s

• Papal Hand-Loss of flexion of IP joints of thumb fingers 1 & 2 - FPL,FDS,FDP.

Sensory Deficits• Radial portion of palm• Palmar surface & tips of

radial 3 & 1/2 digits

Median Nerve(C5-T1) at Wrist

Motor Deficits• Weak opposition of

thumb- Thenar m/s.

• Ape Thumb- Thumb hyper extended & adducted-Thenar m/s

Sensory Deficits• Palmar surface & tips

of radial 3 & 1/2 digits

Ulnar Nerve(C8,T1)at ElbowHigh Lesions:• Clawing of fingers 3 &

4- MP jts hyper extended; PIP flexed - Interossei & Lumbricals

• Loss of abdn &addn of MP jts of fingers-Interossei

• Thumb abd,extended- Abductor pollices

• Loss of flexion of DIP jts fingers 4 & 5-FDP

Sensory Deficits• Ulnar & dorsal aspect

of palm & of ulnar 1 & 1/2 digits.

Ulnar Nerve(C8,T1)at WristLow lesions:Motor Deficits

• Clawing of fingers 3 & 4- MP jts hyper extended; PIP flexed - Interossei & Lumbricals

• Loss of abdn &addn of MP jts of fingers-Interossei

• Thumb abd,extended- Abductor pollices

Sensory Deficits

• Ulnar & dorsal aspect of palm & of ulnar 1 & 1/2 digits.

INVESTIGATIONS

• Imaging Studies• Electromyogram• Nerve Conduction Velocity• Somatosensory Evoked Potentials• Intraoperative Nerve Action Potential• Myelography• CT scan for any tumours• MRI

Plain RadiographsPlain X ray film Findings Significance

Chest Elevated hemidiaphragm

Phrenic injury, proximal plexus, and possible preganglionic avulsion

First rib fracture Subclavian or axillary artery injury – Lower trunk injury

C – spine Fracture or dislocation Cervical spine injuryTransverse process # Preganglionic avulsion

injuryClavicle Fracture Possible traction injury

to plexus or pseudoparalysis

Shoulder Glenohumeral dislocation

Infraclavicular injury

Scapulothoracic dislocation

Severe neurovascular injury

MANAGEMENT

• Closed Brachial Plexus Injury• Open Brachial Plexus Injury

Closed Brachial Plexus Injury

• Barnes divided Upper & Lower Plexuses injuries caused by traction into four groups

• 1)Injuries at C5 & C6• 2)Injuries at C5,C6 & C7• 3)Degenerative lesions of entire plexus• 4)Injuries at C7,C8 & T1 (rare)

• Barnes reported that spontaneous recovery in group 1 & 2 cases

• But in case of Degenerative plexuses injuries there is partial recovery.

• EMG should be done at 3 to 4 wks • At 6 to 8wks additional studies like

myelography & axon reflex evaluaton can be done if return of functions not seen.

• Exploration is justified at 3 to 6 mths after injury if function has not returned.

Open Brachial Plexus Injury

• Indications for Surgery:

• Injuries caused by sharp objects or missiles.

• When pt seen soon after injury & pt's general condition permits exploration & primary repair can be done.

• When pt not seen soon after injury but only after initial management,

• It is best to wait for wound healing & stabilization of any other injuries.

• During this period locate neurological deficit for level of injury.

• EMG performed 3 to 4 wks after injury.• Exploration of plexus & neurorrhaphy,

autogenous interfascicular nerve grafting or neurolysis is indicated 3 to 6wks after injury.

• Motor function recovered to a grade of 3 or better in half of pts.

• Best results obtained in upper trunk & lateral cord & posterior cord injuries.

• Poor prognosis can be expected in lower trunk injuries.

SURGICAL GOALS

In order of priority as follows:

1)Restoration of elbow flexion2)Restoration of shoulder abduction3)Restoration of sensation of medial border

of forearm & hand.

• Depending on extent of injury various surgical techniques may be required:

• Primary neurorrhaphy• Neurolysis• Nerve grafting • Neurotization

• Direct intraoperative nerve stimulation & recording used to repair nerve.

• If nerve action potentials are obtained simple NEUROLYSIS is indicated.

• If neural integrity is completely lost or if no nerve action potentials recorded across a damaged element EXCISION & NERVE GRAFTING is required.

• In ROOT avulsion of upper plexus in which no proximal neural stump is available for nerve grafting,

• To restore ELBOW FLEXION neurotization between intercostal nerves or FCU motor fascicles of ulnar nerve & musculocutaneous nerve may be considered.

• For ELBOW FLEXION latismus dorsi & triceps muscle transfers to be the most reliable as reviewed by Marshall et al..

• Amputation considered when dead weight of a functonless upper extremity is disabling & prosthetic fitting may be helpful.

• Amputation should never be performed for pain relief.

• To restore SHOULDER ABDUCTION & ER neurotization of suprascapular nerve using the spinal accessory nerve done.

• Neurotization of axillary nerve with fascicles of radial nerve innervating lateral, medial, or long head of triceps can be used.

After Brachial plexus repair & regeneration 12 to 18 mths required to determine extent of neural regeneration.

If recovery inadequate

Peripheral reconstruction considered

Can be divided into 3 groups • 1) Tendon transfer without open reduction • 2) Open reduction with concomitant

tendon transfer • 3) Salvage procedures for older pts with

severe glenohumeral deformity

SURGICAL INTERVENTION

• To improve shoulder ABDUCTION & ER

• Tendon transfer around shoulder considered include TRAPEZIUS TO DELTOID transfer as described by Saha FOR ABDUCTION &

• LATISMUS DORSI & TERES MAJOR transfer as described by L'Episcopo FOR ER of shoulder jt.

• Anterior shoulder release:

• First described by Fairbanks & modified by Sever

• Main indication is iatrogenic internal rotation contracture & imbalance betn shoulder internal & external rotation.

Guidelines for arthroscopic treatment of contractures & deformity sec to brachial plexus birth palsy

DHANYAVAAD