BRACHIAL PLEXUS

INJURY
13th Post Graduate Intensive Course in Orthopaedics
4th April 2007 - HUKM

Brachial Plexus Injury

Complex anatomy
Surgical limitations
Long recovery
Controversial

Brachial Plexus Injury

Union of ventral rami of
spinal nerves of C5 -T1

C5/C6
C7
C8/T1

Upper trunk
Middle trunk
Lower trunk

Brachial Plexus Injury

Innervation of Muscles
C5 arm abductors, external rotators, & extensors
C6 biceps, brachioradialis, & wrist extensors
C7 triceps, pronator teres, wrist flexors

&finger extensors

C8
T1

finger flexors
intrinsic mucsles of hand

Brachial Plexus Injury

Terminal branches of roots & trunks

Dorsal scapular
Suprascapular
Long thoracic
Accessory phrenic
Subclavian

C5 (rhomboids)
C5,C6 ( ss,is)
C5,C6,C7 (sa)
C5
C5,C6 (subclavian)

Brachial Plexus Injury

Lateral cord
musculocutaneous
lateral root of median
lateral pectoral

Medial cord
ulnar
medial root of median
medial cut. n of arm & f/arm
medial pectoral

Brachial Plexus Injury

Posterior cord
axillary
radial
thoracodorsal
subscapular

Brachial Plexus Injury

5 ROOTS FORM 5 NERVES

C5
C6
C7
C8
T1

Axillary
Musculocutaneous
Radial
Median
Ulnar

Brachial Plexus Injury

Tractional force on nerves

Magnitude
Rate

Brachial Plexus Injury

Mechanism of traumatic plexus injuries
1. Anteromedial dislocation shoulder joint

2. Severe traction upper arm in forced abduction

3. Fall on shoulder girdle
4. Parallel traction

Brachial Plexus Injury

Mechanism of traumatic plexus injuries
1. Anteromedial dislocation shoulder joint

2. Severe traction upper arm in forced abduction

3. Fall on shoulder girdle
4. Parallel traction

Brachial Plexus Injury

Mechanism of traumatic plexus injuries
1. Anteromedial dislocation shoulder joint
2. Severe traction upper arm in forced abduction
3. Fall on shoulder
girdle
1. Parallel traction

Brachial Plexus Injury

Mechanism of traumatic plexus injuries
1. Anteromedial dislocation shoulder joint

2. Severe traction upper arm in forced abduction

3. Fall on shoulder girdle
4. Parallel traction

Brachial Plexus Injury

Mechanism of root avulsions
Peripheral mechanism

Brachial Plexus Injury

Mechanism of root avulsions
Central mechanism

SSEP

Brachial Plexus Injury

Scope of the Problem

Open injuries
Closed injuries
Supra, infra, sub clavicular
Combined
Postanaesthetic palsy

Radiation injury
Obstetric palsy

Brachial Plexus Injury

Classification
Open or closed
Number of lesion
eg. upper trunk

Site of lesion
preganglionic or
postganglionic

Severity of lesion
eg. rupture or
lesion-in-continuity
Sunderland class

Brachial Plexus Injury

Classification of severity of nerve injuries
Seddon - 1943

Sunderland1978

Brachial Plexus Injury

Location of Brachial Plexus Paralysis

Upper Trunk(C5,C6)
shoulder control
elbow flexion

Upper & Middle Trunk(C5,C6,C7)

extension of elbow,wrist,finger,thumb

Lower Trunk(C8,T1)
thumb & finger flexion, finger extension
Intrinsic

Global

Brachial Plexus Injury

Open injury
Upper roots- C5 & C6
Postganglionic
Sunderland 5 (Neurotmesis)

Brachial Plexus Injury

Assessment
History
General condition
Associated fractures
Vascular injury

Brachial Plexus Injury

Vascular injury (Case 1)

Brachial Plexus Injury

Vascular injury

Brachial Plexus Injury

Vascular injury

Brachial Plexus Injury

Vascular injury

Brachial Plexus Injury

Vascular injury (Case 2)

Brachial Plexus Injury

Vascular injury (Case 2)

Brachial Plexus Injury

Vascular injury (Case 2)

Brachial Plexus Injury

Clinical evaluation of BP

Determine the extent of the injury

Then determine whether he is for early

reconstruction or a period of
observation

Brachial Plexus Injury

Clinical evaluation of BP
General examination
Manual muscle testing
Sensory dermatome
Pain & psycho-social evaluation

Clinical Examination
Posture

Drooping of the shoulder

CNXI injury

Torticolis
tilting away from the affected side
due to neck muscle paralysis
preganglionic

Clinical Examination
Horners

Sign
Supraclavicular
fullness, tenderness
Squeeze test
Tinels sign

Brachial Plexus Injury

Signs of Preganglionic injury

Horners syndrome (95% PPV)
ptosis,miosis,decrease perspiration face
strongly suggest C8/T1 root avulsion and often
entire plexus

Paralysis of rhomboids(ds), serratus ant(lt),

teres major(subscap), hemidiaphragm(phr)
indicate bp avulsed centrally

Brachial Plexus Injury

Signs of Preganglionic injury

Post. spinal nerve injury
EMG, hypoaesthesia

Lack of pain around the neck

Fractures of clavicle,ribs,scapula
Fractures of transverse processes
avulsion of scalene

Absence of SSEP
Absence of Tinels sign

Tinels sign
Infraclavicular and supraclavicular
percussion (distal to proximal)
Paraesthesia radiates distally
proximal axons available
location of neuroma or regenerating axons
does not exclude another distal lesion

Brachial Plexus Injury

TINELS is not always a good

sign to differentiate between
pre and postganglionic lesions.

Brachial Plexus Injury

TINELS positive
in

40% preganglionic lesion

Reasons
1.

2.

Shoulder region also

innervated by cervical plexus.
Induced by traction on scar tissue.

Brachial Plexus Injury

Spontaneous recovery
Types of recovery

Sensory
Motor
Autonomic

Brachial Plexus Injury

INVESTIGATION

EMG/NCV
questionable value
probably not useful

CT Myelography
Pseudomeningocele
PPV 50%
NPV 93%

MRI
Pseudomeningocele
empty root sleeve
shift of cord

Brachial Plexus Injury

Timing of repair
Emergency
Open injury
Stab wound
Iatrogenic
Associated vascular repair

Brachial Plexus Injury

Early (3w -3m)

total palsy
high velocity injuries
gunshot wounds

Routine (3m-6m)
Secondary(>1y)

Brachial Plexus Injury

TIMING OF RECONSTRUCTION (ADULT)
ONSET OF
INJURY

EARLY

LATE

Complete BPI
FFMT

LATE

Partial BPI
Tendon Transfer

Partial or Complete BPI

Pre and Post-ganglionic

EMERGENCY Open and vascular injuries

12

18

24 months

Brachial Plexus Injury

Types of repair for Post- ganglionic
lesions
Primary repair
Anatomical nerve
grafting
Non anatomical
plexo-plexal
nerve grafting

Brachial Plexus Injury

Types of repair for
Pre- ganglionic lesions
Nerve transfer
(Neurotization) partial
Functioning free
muscle transfer total avulsion

Brachial Plexus Injury

Nerve transfer (Neurotization)
intercostal
spinal accessory
phrenic
contralateral C7
ulnar (Oberlin)
cervical plexus
hypoglossal

Brachial Plexus Injury

Nerve transfer ( Neurotization )
spinal accessory

Brachial Plexus Injury

Nerve transfer ( Neurotization )
ulnar (Oberlin)

Brachial Plexus Injury

12 months post nerve transfer
-cnxii ->ss
-phrenic -> msc

Brachial Plexus Injury

9 months post nerve transfer (phrenic -> ss)

Brachial Plexus Injury

24 months post nerve transfer (phrenic -> msc)

Brachial Plexus Injury

Functioning free muscle transfer
Gracilis
vascularized
neurotized

Brachial Plexus Injury

Physical Rehabilitation - Pre op

Maintain full PROM

Enhance residual motor & sensory function
Education on care & protection of flail &
anaesthetic limb
Stabilisation of flail limb with orthoses
Pain management

Brachial Plexus Injury

Physical Rehabilitation - Post op

Immobilisation of the limb to protect surgery of

nerve / tendon / muscle transfers
Re-education & strengthening of reinnervated
or transferred muscles
Sensory re-education thru functional activities
Functional training to achieve independence in
ADL
Vocational re-training

Brachial Plexus Injury

SECONDARY RECONSTRUCTION Partial BPI

Shoulder
arthrodesis shoulder
trapezius transfer

Elbow flexoplasty

steindlers transfer
bipolar latissimus dorsi transfer
bipolar pect major transfer
triceps to biceps transfer

Hand reconstruction
transfers, tenodesis, fusion

Steindler Flexorplasty
Proximal transfer of flexor insertion
Move insertion from medial epicondyle to
3 - 4 finger breadths proximally and
anteriorly to humerus

Brachial Plexus Injury

SECONDARY RECONSTRUCTION Complete BPI
Delayed / Neglected cases

Functioning free muscle transfers

Double gracilis transfer
Elbow flexion
Wrist-driven prehension

TOTAL BRACHIAL PLEXUS INJURY

MANAGEMENT STRATEGY
GOALS

ELBOW FLEXION
SHOULDER STABILITY
WRIST / HAND PREHENSION
SENSORY

TOTAL BRACHIAL PLEXUS INJURY

MANAGEMENT STRATEGY
GOALS

Basic reconstruction
Total reconstruction

What is a realistic
standard?
For global paralysis
- restore elbow flexion
- shoulder control
Only after that we may go further for hand prehension