Brachial plexus injuries presentation and Restoration of lost functions of upper limb. Plastic surgery

1. M O E E Z F A T I M A
Brachial Plexus Injury

5. Cervical Nerve Root Dermatomes and Myotomes

10. Mechanism of Injury
 Traction Injury
 Gun Shot Injury
 Laceration

11. COMMON PATTERNS Of BRACHIAL PLEXUS
INJURY
 C5-6 Injury.
 C5-7 Injury.
 C8-T1 Injury.
 Pan-plexus Injury
 Infraclavicular and Terminal branch injury.

12. Upper brachial plexus Injury

13. C5-C6 Injury
 15%
 Deficits in shoulder stability, abduction, and external and
internal rotation (supraspinatus and infraspinatus, deltoid,
subscapularis)
 In elbow flexion (biceps, brachialis, and brachioradialis) and
forearm supination (supinator).
 Sensory deficit will be present in the C5 and C6 distributions.

 Know as Erb’s or Erb-Duchenne palsy.

14. C5-C7 Injury
 20% to 35%
 Variable weakness of the elbow, wrist, and sometimes finger
extensors.
 The C7 contribution to wrist and finger extension and even to
the flexor digitorum profundus muscles varies between
patients and leads to different degrees of weakness.
 Sensory disturbances in the proximal part of the arm, as well
in the thumb and index and middle fingers,
 “Erb’s-plus” pattern.

15. Lower Brachial Plexus Injury

16. C8-T1 Injury
 10%.
 These patients will have weakness of the hand intrinsics, as well as
variable weakness of the hand extrinsics and finger extensors,
depending on the C7 contribution to these territories.
 Sensory loss in the ulnar digits, medial aspect of the forearm, and
distal part of the arm may be present.
 Involvement of the lower roots can result in Horner’s syndrome,
which is noted on examination by miosis .
 This rare pattern of injury is often referred to as Klumpke’s or
Dejerine-Klumpke palsy.

17. Pan-plexus (C5-T1) Injury
 50% to 75%
 These patients most commonly have a completely
flail arm and insensate hand.
 Even with complete pan-plexus injuries,
postganglionic injury (particularly of C5) is often
present, with preganglionic lesions affecting other
nerves.

18. PRE-OPERATIVE EVALUATION
 History.
 Physical Examination.
 Imaging.
 Pulmonary Function test
 Electrodiagnostic Studies.

20. Indication of Surgery
 No hope for spontaneous recovery or for further
recovery.
 All patients with laceration injuries in proximity to
the brachial plexus should undergo exploration
because in the vast majority of these injuries (sharp
or blunt),
 No definitive study or sign is sufficiently reliable.

21. Contraindications of Surgery
 Stiffness and contractures.
 Age.
 Medical comorbidity.
 Associated traumatic brain injury.
 Associated spinal cord injury
 Unrealistic goals .
 Rare patient with a C8-T1 lesion is a relative
contraindication.
 If more than a year has passed since the injury, primary
plexus reconstruction is generally contraindicated.

22. Timing of Surgery
3 Principles.
(1) Better functional outcomes occur in patients with
spontaneous recovery who do not require a surgical
intervention.
(2) Surgical intervention is indicated for patients with no
hope for spontaneous recovery or for further recovery.
(3) Most series demonstrate that surgical outcome is
inversely proportional to the time interval from injury to
surgery (i.e., outcomes are better if surgery is performed
earlier).

23. Multiple factors
 Mechanism of injury.
 Physical examination
 Imaging
 Surgeon’s preference.
Primary nerve reconstruction may ideally be initiated
immediately (within days)
Delayed fashion (within months).

24. Primary Reconstruction
Immediate Surgery
 A sharp open injury: immediate exploration plus
repair is indicated.
 Blunt laceration injury to the plexus: A subacute
(within 3 to 4 weeks) surgical intervention may be
preferable.
 If the nerves are avulsed, reconstruction can be
performed immediately or at a second setting,
depending on the situation and condition of the
patient.
 If the nerves are stretched but in continuity, a period
of observation will be necessary.

25. Primary Reconstruction
Delayed Surgery
 Patients who have a potential for spontaneous
recovery or for injuries that require time to become
better defined, as explained earlier (blunt laceration
injuries).
 In patients with closed traction injuries or gunshot
wound injuries (because most are in continuity

26. Secondary Reconstruction
 Patients initially seen late (i.e., more than 12 months
after the injury), primary nerve reconstructive
procedures are associated with significantly poorer
results.
 Secondary reconstructive procedures, such as tendon
transfer, FFMT (gracilis muscle), and bony or soft
tissue procedures, may be indicated and can be done
at any time.

27. OPERATIVE TECHNIQUE

28. Informed Consent
 The possible surgical options.
 Risk-benefit ratio.
 Postoperative rehabilitation program.
 Expected outcome with or without surgery.
 Long re-innervation period.

29. Preparation and Positioning
 Intraoperative stimulation and recordings.
 Long-acting paralytic agents, muscle relaxants, and agents depressing
cortical responses should be avoided. Adequate vascular access.
 Indwelling urinary.
 Anesthesia and intubation.
 Supine position.
 The head is turned to the contralateral side.
 The upper part of the body is elevate.
 Small pillow is placed beneath the ipsilateral scapula to bring the shoulder
forward.
 Proper padding and positioning .
 Surgical preparation and draping should include the ipsilateral neck,
mandible, hemithorax, axilla, entire upper extremity, and both lower
extremities (for possible nerve grafts).
 Tight circumferential elastic drapes are avoided .

30. INCISION

32. Intraoperative Decisions and Priorities of Repair
 When only some elements of the brachial plexus are
injured or the nerve gaps are short: Re-establish
continuity to all injured parts by using every
available donor nerve.
 When all brachial plexus elements are injured or the
nerve gaps are long: this approach becomes
impossible;

33. Three factors:
(1) functional significance
(2) Likelihood of regaining function after nerve
reconstruction (proximal muscles are reinnervated
more successfully than distal muscles)
(3) The degree of difficulty in restoring the function by
secondary reconstructive surgery

34. Pan-plexal Injury
 Priorities of repair, in order of importance:
1. Elbow flexion by reinnervation of the biceps/brachialis muscle.
2. Shoulder stabilization, abduction, and external rotation by
reinnervation of the suprascapular and axillary nerves.
3. Hand sensation by reinnervation of the lateral cord (C6-7
distribution).
4. Wrist and finger flexion. When performed, the triceps muscle
should also be considered for reinnervation because it is a useful
antagonist of elbow flexion; as such, it potentiates the strength of
an FFMT that crosses the elbow joint.
5. Wrist and finger extension.
6. Intrinsic hand muscle function.

36. C5-6 Injury
Aim is to regain:
 Elbow flexion
 shoulder stability
 Abduction
 external rotation.
Elbow flexion: Reinnervation of the biceps and brachialis muscles (via the
anterior division of the upper trunk, the musculocutaneous nerve proper,
or the motor branches to the biceps and brachialis).
Shoulder stability, abduction, and external rotation are usually obtained with
reinnervation of the deltoid (via the posterior division of the upper trunk,
the axillary nerve proper, or the anterior division of the axillary nerve) and
supraspinatus and infraspinatus muscles (via the suprascapular nerve).
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