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Dr. Zahoor Ahmad                     PGR,        Paediatric surgery,           SZMC/H, RYK,                  Pakistan
   Spinal nerves attach toSpinal Nerves       the spinal cord via roots                   Dorsal root                   ...
Spinal Nerves   31 pair     each contains thousands of nerve fibers     All are mixed nerves have both sensory and moto...
Formation of Rami Rami are lateral branches of a  spinal nerve Rami contain both sensory  and motor neurons Two major g...
Dermatomal Map   Spinal nerves indicated by capital letter and number   Dermatomal map: skin area supplied with sensory ...
Introduction to Nerve Plexuses    Nerve plexus      A network of ventral rami    Ventral rami (except T2-T12)      Bra...
   Dorsal RamusBranches of        Neurons within muscles of trunk and back                 Ventral Ramus (VR)Spinal    ...
Brachial Plexus                 Formed by ventral rami of                  spinal nerves C5-T1                 Five vent...
Brachial Plexus: Axillary Nerve                      Motor neurons stimulate                        Deltoid, teres minor...
Brachial Plexus: Radial Nerve                 Motor components stimulate                   Posterior muscles of arm, for...
Brachial Plexus:Musculocutaneous Nerve                      Motor components stimulate                          Flexors ...
Brachial Plexus: Ulnar Nerve                    Motor components                     stimulate                      Flex...
Brachial Plexus: Median Nerve                     Motor components                      stimulate                       ...
Dermatomes of the Posterior Arm
Dermatomes of the Anterior Arm
Etiology   traffic accidents   birth injuries   humerus luxations   brachial plexus neuritis   stab and bullet wounds...
Principles of Localization   Certain sites are prone to nerve    entrapments/injuries     Nerve opposing bone     ○ Ulna...
Principles of localization (cont.) Order in which branches arise Movements at specific joints     Single nerve     ○ El...
Brachial Plexus Injuries   Upper Lesions of the Brachial    Plexus (Erb’s Palsy): resulting from    excessive displacemen...
 Thiscauses excessive traction or even tearing of C5 and 6 roots of the plexus. It occurs in infants during a difficult d...
Effects:Motor: paralysis of   the supraspinatus,   infraspinatus,   subclavius,   biceps brachii,   part of brachial...
 Deformity: waiter   tip postionc. limb will hang by the side,d. medially rotated by sternocostal part   of the pectoral...
Erb-Duchenne palsy (waiters tip)
Lower Lesions of the Brachial Plexus(Klumpke Palsy) traction injuries by excessive abduction of  the arm i.e. occurs if ...
Motor Effects: paralysis of all the  small muscles of the hand.Sensory effects: loss of sensation  along the medial side o...
Axillary Nerve injuryCauses:crutch pressing upward into thearmpit,Downward shoulder dislocationsfractures of the surgic...
Motor       effects: Deltoidparalysis teres minor paralysis.Sensory effects: lossof sensation at lower ½ of deltoidD...
Radial Nerve injuryInjury in axilla :crutch pressing up into armpitdrunkard falling asleep with one arm over the back of...
 Motor  effects:paralysis of triceps Anconeus extensors of the wrist Extensors of fingers. Brachioradialis supinato...
Sensory       effects : small area of sansation  loss at arm and forearm sensory loss over lateral  part of the dorsum ...
Injuries at Spiral Groove Caused  by fracture shaft of humerus. Motor effects: paralysis of extensors of the wrist Ext...
 Deformity: Wrist  and finger drop Sensory effects: anesthesia is present over the  dorsal surface of the hand (lat.  ...
Median Nerveinjury  Motor effects: paralysis of pronator muscles long flexor muscles of the wrist  and fingers, Except...
Deformity:apelike hand3.thenar muscles wasted4.thumb is laterally rotated and  adducted.5.index and to a lesser extent  ...
Sensory: Sensory  loss on the lat. 3.5  fingers on palmar side Sensory loss over distal  phalynges of lat. 4 fingers on...
Ulnar nerve injury Motor   effects: paralysis of flexor carpi ulnaris medial half of the flexor digitorum  profundus A...
Deformity: partial        claw handSensory effects : Sensory loss over 1.5 fingers on  both surfaces
CARPAL TUNNEL  TUNNEL FORMED BETWEEN THE CONCAVITY OF THE   CARPAL BONES AND A LIGAMENT THAT COVERS   THIS( FLEXOR RETINA...
Diagnosis Relies mainly on clinical examination No specific lab. Studies CT myelography MRI Nerve conduction studies
Treatment  Most injuries recover without any Rx Rx is done in very highly specialized   centers Surgical optionsd. nerv...
Advances in nerve injury Rx Carlstedt obtained promising initial  results with the repair of preganglionic  lesions by re...
End-to-side radial sensory tomedian nerve transfer hasbeen reported to improvesensation and to relieve painin C5 and C6 ne...
Thank you
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
Brachial plexus injuries
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Brachial plexus injuries

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Transcript of "Brachial plexus injuries"

  1. 1. Dr. Zahoor Ahmad PGR, Paediatric surgery, SZMC/H, RYK, Pakistan
  2. 2.  Spinal nerves attach toSpinal Nerves the spinal cord via roots  Dorsal root  Has only sensory neurons  Attached to cord via rootlets  Dorsal root ganglion ○ Bulge formed by cell bodies of unipolar sensory neurons  Ventral root  Has only motor neurons  No ganglion - all cell bodies of motor neurons found in gray matter of spinal cord 12-2
  3. 3. Spinal Nerves 31 pair  each contains thousands of nerve fibers  All are mixed nerves have both sensory and motor neurons) Connect to the spinal cord Named for point of issue from the spinal cord  8 pairs of cervical nerves (C1-C8)  12 pairs of thoracic nerves (T1-T12)  5 pairs of lumbar nerves (L1-L5)  5 pairs of sacral nerves (S1-S5)  1 pair of coccygeal nerves (Co1) 12-3
  4. 4. Formation of Rami Rami are lateral branches of a spinal nerve Rami contain both sensory and motor neurons Two major groups  Dorsal ramus ○ Neurons innervate the dorsal regions of the body  Ventral ramus ○ Larger ○ Neurons innervate the ventral regions of the body ○ Braid together to form plexuses (plexi) 12-4
  5. 5. Dermatomal Map Spinal nerves indicated by capital letter and number Dermatomal map: skin area supplied with sensory innervation by spinal nerves 12-5
  6. 6. Introduction to Nerve Plexuses  Nerve plexus  A network of ventral rami  Ventral rami (except T2-T12)  Branch and join with one another  Form nerve plexuses ○ In cervical, brachial, lumbar, and sacral regions ○ No plexus formed in thoracic region of s.c. 12-6
  7. 7.  Dorsal RamusBranches of  Neurons within muscles of trunk and back  Ventral Ramus (VR)Spinal  Braid together to form plexuses ○ Cervical plexus - VR of C1-C4Nerves ○ Brachial plexus - VR of C5-T1 ○ Lumbar plexus - VR of of L1-L4 ○ Sacral plexus - VR of L4-S4 ○ Coccygeal plexus -VR of S4 and S5  Communicating Rami: communicate with sympathetic chain of ganglia  Covered in ANS unit 12-7
  8. 8. Brachial Plexus  Formed by ventral rami of spinal nerves C5-T1  Five ventral rami form  three trunks that separate into  six divisions that then form  cords that give rise to nerves  Major nerves  Axillary  Radial  Musculocutaneous  Ulnar  Median 12-8
  9. 9. Brachial Plexus: Axillary Nerve  Motor neurons stimulate  Deltoid, teres minor ○ Abducts arm- deltoid ○ Laterally rotate arm-teres minor  Sensory neurons  Skin: inferior lateral shoulder 12-9
  10. 10. Brachial Plexus: Radial Nerve  Motor components stimulate  Posterior muscles of arm, forearm, and hand ○ Triceps, supinator, brachioradialis, extensors ○ Cause extension movements at elbow and wrist, thumb movements  Sensory components  Skin on posterior surface of arm and forearm, hand 12-10
  11. 11. Brachial Plexus:Musculocutaneous Nerve  Motor components stimulate  Flexors in anterior upper arm: (biceps brachii, brachialis) ○ Cause flexion movements at shoulder and elbow  Sensory: Skin along lateral surface of forearm 12-11
  12. 12. Brachial Plexus: Ulnar Nerve  Motor components stimulate  Flexor muscles in anterior forearm (FCU, FDP, most intrinsic muscles of hand)  Results in wrist and finger flexion  Sensory: Skin on medial part of hand 12-12
  13. 13. Brachial Plexus: Median Nerve  Motor components stimulate  All but one of the flexors of the wrist and fingers, and thenar muscles at base of thumb (Palmaris longus, FCR, FDS, FPL, pronator)  Causes flexion of the wrist and fingers and thumb  Sensory components  Stimulate skin on lateral part of hand 12-13
  14. 14. Dermatomes of the Posterior Arm
  15. 15. Dermatomes of the Anterior Arm
  16. 16. Etiology traffic accidents birth injuries humerus luxations brachial plexus neuritis stab and bullet wounds tumors (especially lung cancer) cervical rib, fibrous band from C7 (neurogenic thoracic outlet syndrome)
  17. 17. Principles of Localization Certain sites are prone to nerve entrapments/injuries  Nerve opposing bone ○ Ulnar nerve at the elbow  Closed spaces ○ Carpal tunnel  Adjacent structures ○ Median nerve at the elbow, adjacent to the brachial artery
  18. 18. Principles of localization (cont.) Order in which branches arise Movements at specific joints  Single nerve ○ Elbow extension  Radial  Multiple nerves ○ Elbow flexion  Musculocutaneous  Radial
  19. 19. Brachial Plexus Injuries Upper Lesions of the Brachial Plexus (Erb’s Palsy): resulting from excessive displacement of the head to opposite side and depression of shoulder on the same side.
  20. 20.  Thiscauses excessive traction or even tearing of C5 and 6 roots of the plexus. It occurs in infants during a difficult delivery or in adults after a blow to or fall on shoulder.
  21. 21. Effects:Motor: paralysis of the supraspinatus, infraspinatus, subclavius, biceps brachii, part of brachialis, coracobrachialis; deltoid teres minor.Sensroy: sensory loss on the lateral side of the arm.
  22. 22.  Deformity: waiter tip postionc. limb will hang by the side,d. medially rotated by sternocostal part of the pectoralis major;e. pronated forearm (biceps paralysis)
  23. 23. Erb-Duchenne palsy (waiters tip)
  24. 24. Lower Lesions of the Brachial Plexus(Klumpke Palsy) traction injuries by excessive abduction of the arm i.e. occurs if person falling from a height clutching at an object to save himself or herself. Can be caused by cervical rib. T1 is usually torn (ulnar and median nerves)
  25. 25. Motor Effects: paralysis of all the small muscles of the hand.Sensory effects: loss of sensation along the medial side of the arm.deformity: claw hand caused by hyperextension of the metacarpophalangeal joints and flexion of the interphalangeal joints.
  26. 26. Axillary Nerve injuryCauses:crutch pressing upward into thearmpit,Downward shoulder dislocationsfractures of the surgical neck of thehumerus.
  27. 27. Motor effects: Deltoidparalysis teres minor paralysis.Sensory effects: lossof sensation at lower ½ of deltoidDeformity: Wasting of deltoid
  28. 28. Radial Nerve injuryInjury in axilla :crutch pressing up into armpitdrunkard falling asleep with one arm over the back of a chair.fractures of proximal humerus.
  29. 29.  Motor effects:paralysis of triceps Anconeus extensors of the wrist Extensors of fingers. Brachioradialis supinator muscle Deformity: Wrist and finger drop
  30. 30. Sensory effects : small area of sansation loss at arm and forearm sensory loss over lateral part of the dorsum of the hand (lat. 3.5 fingers without distal phalynges)
  31. 31. Injuries at Spiral Groove Caused by fracture shaft of humerus. Motor effects: paralysis of extensors of the wrist Extensors of fingers
  32. 32.  Deformity: Wrist and finger drop Sensory effects: anesthesia is present over the dorsal surface of the hand (lat. 3.5 fingers)
  33. 33. Median Nerveinjury  Motor effects: paralysis of pronator muscles long flexor muscles of the wrist and fingers, Exception:e. flexor carpi ulnarisf. medial half flexor digitorum profundus.
  34. 34. Deformity:apelike hand3.thenar muscles wasted4.thumb is laterally rotated and adducted.5.index and to a lesser extent the middle fingers tend to remain straight on making6.Weakening of lat. 2 fingers
  35. 35. Sensory: Sensory loss on the lat. 3.5 fingers on palmar side Sensory loss over distal phalynges of lat. 4 fingers on dorsal surface
  36. 36. Ulnar nerve injury Motor effects: paralysis of flexor carpi ulnaris medial half of the flexor digitorum profundus All interossei 3-4 lumbricals loss of abduction and adduction of fingers Wasting of hypothenar
  37. 37. Deformity: partial claw handSensory effects : Sensory loss over 1.5 fingers on both surfaces
  38. 38. CARPAL TUNNEL TUNNEL FORMED BETWEEN THE CONCAVITY OF THE CARPAL BONES AND A LIGAMENT THAT COVERS THIS( FLEXOR RETINACULAM) TENDONS OF THE FLEXORS PASS THROUGH MEDIAN NERVE ALSO PASSES THROUGH CROWDED TUNNELCARPAL TUNNEL SYNDROME- CAUSED DUE TO COMPRESSION OF THE NERVE IN THE TUNNEL- CAUSES-- 1. SWELLING OF THE TEDONS( OVERUSE)- 2. PREGNANCY( EDEMA)- 3. ARTHRITISSYMPTOMS- TINGLING OR NUMBNESS-LATERAL PART OF HAND, WEAKNESS IN THUMB MOVEMENTTREATMENT- REST, SPLINTING,ANTI-INFLAMMATORY DRUGS, SURGERY
  39. 39. Diagnosis Relies mainly on clinical examination No specific lab. Studies CT myelography MRI Nerve conduction studies
  40. 40. Treatment Most injuries recover without any Rx Rx is done in very highly specialized centers Surgical optionsd. nerve transferse. nerve graftingf. muscle transfersg. free muscle transfersh. neurolysis of scar around the brachial plexus in incomplete lesions.
  41. 41. Advances in nerve injury Rx Carlstedt obtained promising initial results with the repair of preganglionic lesions by replanting nerve rootlets directly into the spinal cord. This is a dramatic advance because preganglionic lesions were previously thought to be irreparable
  42. 42. End-to-side radial sensory tomedian nerve transfer hasbeen reported to improvesensation and to relieve painin C5 and C6 nerve rootavulsion
  43. 43. Thank you
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