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Brachial plexus injuries
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Brachial plexus injuries

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  • 1. Dr. Zahoor Ahmad PGR, Paediatric surgery, SZMC/H, RYK, Pakistan
  • 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. 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. 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. Dermatomal Map Spinal nerves indicated by capital letter and number Dermatomal map: skin area supplied with sensory innervation by spinal nerves 12-5
  • 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.  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. 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. 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. 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. 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. 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. 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. Dermatomes of the Posterior Arm
  • 15. Dermatomes of the Anterior Arm
  • 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. 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. 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. 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.  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. 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.  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. Erb-Duchenne palsy (waiters tip)
  • 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. 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. Axillary Nerve injuryCauses:crutch pressing upward into thearmpit,Downward shoulder dislocationsfractures of the surgical neck of thehumerus.
  • 27. Motor effects: Deltoidparalysis teres minor paralysis.Sensory effects: lossof sensation at lower ½ of deltoidDeformity: Wasting of deltoid
  • 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.  Motor effects:paralysis of triceps Anconeus extensors of the wrist Extensors of fingers. Brachioradialis supinator muscle Deformity: Wrist and finger drop
  • 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. Injuries at Spiral Groove Caused by fracture shaft of humerus. Motor effects: paralysis of extensors of the wrist Extensors of fingers
  • 32.  Deformity: Wrist and finger drop Sensory effects: anesthesia is present over the dorsal surface of the hand (lat. 3.5 fingers)
  • 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. 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. 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. 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. Deformity: partial claw handSensory effects : Sensory loss over 1.5 fingers on both surfaces
  • 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. Diagnosis Relies mainly on clinical examination No specific lab. Studies CT myelography MRI Nerve conduction studies
  • 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. 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. End-to-side radial sensory tomedian nerve transfer hasbeen reported to improvesensation and to relieve painin C5 and C6 nerve rootavulsion
  • 43. Thank you

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