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Brachial plexus injury

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  • 1. SURGICAL ANATOMY OF BRACHIAL PLEXUS Sudhir suggala
  • 2. ANATOMY  A network of nerves starting from 5 nerve roots in upper spine & ending in nerves that control movement & sensation in the upper limb.
  • 3. ANATOMY contd…  Located where neck joins shoulder behind clavicle & between spine & upper arm just distal to axilla.  5 roots ant.primary rami after giving segmental supply to prevertebral muscles &scalene muscles.
  • 4. Levels  Roots  Trunks  Divisions  Cords  Branches
  • 5. ROOTS  THE ORIGIN NERVES ARE THE ANT. PRIMARY RAMI OF5th TO 8th CERVICAL VERTEBRAE AND T1.  ROOTS EMERGE FROM THE TRANSVERSE PROCESSES OF CERVICAL VERTEBRAE IMMED. POST. TO VERTEBRAL ARTERY  T1:VULNERABLE IN FRACTURE AND DISLOCATION OF FIRST RIB
  • 6. NERVES FROM ROOTS .  DORSAL SCAPULAR N. C5  ARISES FROM C5 JUST LAT. TO LONG THORACIC  TRAV. POST TO Plx  INNERVATES LEV.SCAPULAE, RHOMBOIDES
  • 7. Brachial Plexus Netter 2nd ed
  • 8. ROOTS contd…  LONG THORACIC N. OF BELL C567  IMMED. AFTER THEY ORIG. FROM INTERVERTEBRAL FORAMEN  ALSO PIERCES S.MED. AS IT PASSES POST TO Plx
  • 9. TRUNKS  IN THE POST. TRIANGLE OF NECK  C56: UPPER/SUPERIOR TRUNK  C7; MIDDLE TRUNK  C8 T1: LOWER/INFERIOR TRUNK  TRUNKS LIE IN FRONT OF ONE ANOTHER  RELATION b/w C5 AND PHRENIC NERVE
  • 10. NERVES FROM TRUNKS  SUPRASCAPULAR N. C5,6  SENSORY TO SHOULDER JT.  MOTOR TO SUPRASPINATUS AND INFRASPINATUS  N.TO SUBCLAVIUS C5,6
  • 11. DIVISONS  LIE DEEP TO CLAVICLE  POSTERIOR DIV. OF UPPER AND MIDDLE TRUNK LARGER  10% OF CASES NO POST. DIVISON OF LOWER TRUNK
  • 12. CORDS  NAMED LAT. ,POST. AND MEDIAL ACC. TO RELATION WITH AXILLARY ARTERY  LATERAL CORD: ANT. DIV OF UPPER & MIDDLE TRUNK  MEDIAL CORD: ANT. DIV. OF LOWER TRUNK  POSTERIOR CORD:POST./DORSAL DIVISONS OF ALL 3 TRUNKS
  • 13. FROM LAT.CORD  Lateral pectoral nerve- c5,c6,c7  Pierce clavipectoral fascia.  Communicate with medial pectoral across front of 1st part of axillary art.  Br. To P.major & P.minor  No cut. Br.
  • 14. FROM LAT. CORD contd…  Musculocutaneous nr.-c5,c6,c7  To biceps & brachialis.  Becomes lateral cut. Nr. Of forearm.  Lateral root of median nr.-c5,c6,c7  Continuation of lat.cord
  • 15. FROM MEDIAL CORD Medial pectoral nr.- behind 1st part of ax.art Perforates p.minor No cut.br. Medial root of median nr-. Crosses ax. Art to join lat root. Medial cut.nr. Of arm – smallest & most medial. Medial cut. Nr. Of forearm – Large nr. Runs down bet ax.art & ax. Vein in front of ulnar nr. Ulnar nr.- largest br. C7 C8 T1 To most of the hand muscles.
  • 16. FROM POST CORD contd…  Radial nr. – c5,c6,c7,c8,T1  Cont.of post cord  Largest in the whole plexus  Gives post cut nr. Of forearm.
  • 17. FROM POST.CORD  Upper subscapular- c5,c6  Small nr.  Enters upper part of subscapularis.  Thoracodorsal – c6,c7,c8  nr.to lat. Dorsi.  A large nerve.  Runs down post.ax. Wall.
  • 18. FROM POST CORD contd…  Lower subscapular –c5,c6  To lower part of subscapularis  Ends in teres major.  Axillary nr. – c5,c6  Circumflex nr.  A large terminal br.  No supply in axilla.  Br.to shoulder jt.  Ant. & post div.
  • 19. FROM POST CORD contd…  Radial nr. – c5,c6,c7,c8,T1  Cont.of post cord  Largest in the whole plexus  Gives post cut nr. Of forearm.
  • 20. VARIATIONS  GREATEST VARIATION IN FORMATION OCCURS IN LATERAL CORD  10% OF CASES MUSCULOCUT. N. MAY ARISE AS 2-3 BRANCHES  LATERAL ROOT OF MEDIAN N. MAY ARISE AS 2-3 BRANCHES
  • 21. BLOOD SUPPLY  From subclavian & vertebral art.  Vertebral art.- c5, c6. & more proximal cervical nerves  C8, T1,- br. From costocervical trunk.
  • 22. MICRO ANATOMY  120,000-150,000 Myelinated fibres  C5 &T1-least no. of myelin.fibres  C8 –largest no. of myelin.fibres.  Proportion of motor fibres highest in c5, then c8 & least in c7 & t1.  Sensory greatest in c7, then c6, then c8.  Segregation of nr fibres well established proximally.
  • 23. PREFIXATION & POSTFIXATION  PREFIXED: CONTRIBUTION FROM C4 IS LARGE ,T2 IS OFTEN ABSENT  POSTFIXED: CONTRIBUTION FROM T1 IS LARGE, T2 IS ALWAYS PRESENT,C4 IS ABSENT,C5 IS REDUCED IN SIZE
  • 24. Anatomy
  • 25. BRACHIAL PLEXUS SHEATH  C.t. of prevertebral fascia  Blends with fascia of biceps & brachialis.  C.t. septae compartmentalize components of the sheath.  Controversies – septae may limit spread of solutions during BP block.
  • 26. Brachial Plexus Branches & Muscular Innervations Dorsal Scapular N.  Levator Scapulae  Rhomboid Major/Minor Lateral Pectoral N.  Pectoralis Major/Minor Suprascapular N.  Infraspinatus  Supraspinatus Musculocutaneous N.  Biceps Brachii  Brachialis  Coracobrachialis
  • 27. Brachial Plexus Branches & Muscular Innervations Axillary N.  Deltoid  Teres Minor Upper Subscapular N.  Subscapularis Middle Subscapular or Thoracodorsal N.  Latissimus Dorsi Lower Subscapular N.  Subscapularis  Teres Major
  • 28. Brachial Plexus Branches & Muscular Innervations Median N.  Abductor Pollicis Brevis/Longus  Flexor Carpi Radialis  Flexor Digitorum Superficialis  Flexor Digitorum Profundus (Lat. 2)  Flexor Pollicis Brevis (Lat.) & Longus  Lumbricales (Lat. 2)  Opponens Pollicis  Palmaris Longus  Pronator Quadratus  Pronator Teres * Radial N.  Abductor Pollicis Brevis  Anconeus  Brachioradialis  Extensor Carpi Radialis Brevis/Longus  Extensor Carpi Ulnaris  Extensor Digiti Minimi  Extensor Digitorum Communis  Extensor Indicis  Extensor Pollicis Brevis/Longus  Supinator  Triceps Brachii
  • 29. Brachial Plexus Branches & Muscular Innervations Ulnar N.  Abductor Digiti Minimi  Adductor Pollicis  Dorsal Interossei  Flexor Carpi Ulnaris  Flexor Digiti Minimi  Flexor Digitorum Profundus (Med. 2)  Flexor Pollicis Brevis (Med.)  Lumbricals (Med. 2)  Opponens Digiti Minimi  Palmar Interossei Long Thoracic N.  Serratus Anterior Medial Pectoral N.  Pectoralis Major Medial Brachial Cutaneous N. (sensory) Medial Antebrachial Cutaneous N. (sensory)
  • 30. FUNCTIONAL DISTRIBUTION MOTOR  C5-SHOULDER ABDUCTION  C6-WRIST EXTENSION  C7-WRIST FLEXION AND FINGER EXTENSION  C8-FINGER FLEXION  T1-FINGER ABDUCTION AND ADDUCTION
  • 31. SENSATION  C5-LATERAL ARM  C6-LAT.FOREARM ,THUMB,INDEX FINGER  C7-MIDDLE FINGER  C8-MEDIAL FOREARM,RING,SMALL FINGER  T1-MEDIAL ARM  T2-AXILLA
  • 32. TRANSITIONAL ZONE  BERTHOLD (1993):JUNC. b/w ROOTS AND SPINAL CORD  A CENTRAL-PERIPHERAL TRANSITIONAL ZONE  2 TYPES OF INTRADURAL INJURY- RUPTURE AND AVULSION
  • 33. RUPTURE & AVULSION  INTRADURAL RUPTURE IS TEARING OF ROOTLETS AT OR PERIPHERAL TO T.Z  AVULSION IS ROOTLETS ARE TORN FROM SPINAL CORD ITSELF AND INJURY IS CENTRAL TO TRANSITIONAL ZONE .
  • 34.  UPPER PLEXUS INJURY (ERB’S PARALYSIS)  LOWER PLEXUS INJURY(KLUMPKE’S PARALYSIS)  INJURY AT LEVEL OF ROOTS
  • 35. CORDS INJURY  LATERAL  POSTERIOR  MEDIAL
  • 36. NEOPLASTIC RADIATION
  • 37. THANK YOU

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