brachial plexus injury

1. BRACHIAL PLEXUS INJURY
Prepared by:
Adeeb
Swathi
Raj
Supervisor:
Dr Mani

2. Brachial plexus
Nerve plexus formed by confluence
of nerve roots from C5-T1.

6. DEFINITION
● Sudden damage to brachial plexus causing weakness, loss of
feeling or movement in the shoulder, arm or hand
● Injuries to the brachial plexus can occur in one or more of
these areas
● Spinal Nerves
● Trunks
● Divisions
● Cords
● Branches

7. It is important to establish
1. Level of lesion
2. Type of damage
3. Pre vs post ganglionic

8. NERVE INJURY CLASSIFICATION
Low energy injury – neuropraxia
High energy injury / open wound – axonotmesis/neurometsis

10. CLASSIFICATION
• PREGANGLIONIC
-avulsion proximal to dorsal root ganglion
• POSTGANGLIONIC
-occurs distal to dorsal root ganglion

11. Pre-ganglionic Lesions
• Disruption of nerve roots proximal to the dorsal root ganglion
• Cannot recover or surgically irreparable
• Features:
Burning pain in an anesthetic hand
Paralysis of scapular muscles
elevated hemidiaphragm (phrenic nerve)
denervation of cervical paraspinal muscles seen in electromyography
examinations
Horner’s syndrome
Absence of Tinel’s sign
Severe vascular injury
Associated fracture of the cervical spine
Spinal cord dysfunction

12. Pre-ganglionic Lesions
• Histamine test: POSITIVE
Afferrent axons remain intact
Normal triple response with flare seen (redness, wheal, flare)
• CT myelography or MRI: pseudomeningoceles produced by
root avulsion

13. Pre-ganglionic Lesions
Horner’s syndrome – disruption of symptathetic chain (C8/T1 avulsion)
Drooping of eyelid
Pupillary constriction
Anhidrosis

14. loss of serratus anterior (long thoracic nerve) leads to medial winging
loss of rhomboids (dorsal scapular nerve) leads to lateral winging

15. Post-ganglionic Lesions
• Can be repaired and capable of recovery
• Histamine test: NEGATIVE (continuity between skin & dorsal
root ganglion interrupted)

17. AETIOLOGY
OF BRACHIAL PLEXUS INJURY

18. • TRAUMATIC PLEXOPATHIES
- High speed collision
- Direct blow to the shoulder region
- Gunshot
- Laceration/ animal bite
• NON- TRAUMATIC PLEXOPATHIES
- Neoplastic and radiation-induced brachial plexopathy
- Thoracic outlet syndrome
• OBSTETRIC INJURY
- Erb’s palsy
- Klumpke’s palsy

20. BURNER SYNDROME
• Is a transient neurapraxia resulting from a stretch or compression
of the upper roots of the brachial plexus.
• Three mechanisms of burners are known:
●The first is traction injury to the brachial plexus, which occurs
when the shoulder is depressed and the neck is forced laterally
away from the involved side, stretching the brachial plexus
●The second is a direct blow to the supraclavicular fossa
●The third is nerve compression by a combination of neck
hyperextension and ipsilateral lateral flexion

22. NEOPLASTIC AND RADIATION-INDUCED BRACHIAL
PLEXOPATHY
• Neoplastic plexopathies can result from direct pressure by a local
cancer mass
• Pain in the shoulder and axilla is the most common presenting
symptom of neoplastic brachial plexopathy.
• Invasion of the lower plexus (inferior trunk and medial cord)
occurs more frequently than invasion of the upper trunk.
• The toxic effects of radiation may injure axons directly causing
ischemic changes to axons with multifocal denervation.

30. INVESTIGATION
• Plain radiograph
• CT Myelography/MRI
• Electrodiagnostic test
• Electromyography (EMG)
• Nerve conduction velocity studies (NCV)

31. *
Plain radiograph
• Chest (inspiratory)
• Clavicle
• Cervical spine
• Scapular and shoulder
series

32. CT Myelography
• Gold standard to identify root
avulsions
• Important findings
• Pseudomeningocele
• Absence of roots
• Should be done 3-4 weeks post
trauma
• To ensure there is enough time for
blood clots to be absorbed
CT myelogram shows absence of the affected nerve roots
(arrow) and the intact nerve roots on the unaffected side
(arrowheads).

34. *
MRI
Neurotmesis. A 43-year-old woman with loss of function in the left upper
extremity following recent neck surgery - shows severed, enlarged, and
hyperintense C5 and C6 nerve roots with distal end bulb neuromas (arrows),
just proximal to the formation of the left upper trunk.

35. Electrophysiology Studies (EPS)
• Electromyography (EMG)
• More sensitive towards motor nerves
• Nerve conduction studies (NCS)
• More sensitive towards sensory nerves
• Sensory nerve action potentials
(SNAPs) helps to localize lesions
• Preserved in pre-ganglionic lesions
• Absent in post-ganglionic or combined pre and
post-ganglionic lesions
• Serial EPS helps to assess progress
of recovery / re-innervation

37. Conservative Surgical
MANAGEMENT

39. Conservative Management
• Aim
• Maintain range of motion of extremities
• Strengthen the remaining functional muscles
• Protect denervated dermatomes
• Manage Pain
Immobilise :
Splint and sling
(decrease the
edema)
Physiotherapy :
Joint mobility,
muscle strength
Pain
Management

40. Splint / Orthosis
• Aim
• Prevent subluxation of shoulder
joint
• Prevent contractures
• Cosmesis
• Types
• Flail Arm Splint
• Wilmer Orthosis
• Stanmore Orthosis
• Dynamic Assist Elbow Flexion
Orthosis

41. Surgical Management
Aim of surgery :
1. Restore elbow flexion
2. Restore shoulder abduction, stability of shoulder
3. Elbow extension
4. Restore wrist extension
5. Restore finger flexion

42. Timing of surgical intervention
Immediate (<1week) Late (3 - 6months)
● Vascular injury
● Open penetrating injury
● Open infected
crushing/stretching wounds
● Complete traumatic palsy of
C5-T1 roots
• Traumatic palsy injuries with
no clinical sign of functional
restoration or
electromyography signs of
denervation.
• Plateau in neurologic recovery

43. Modes of surgical intervention
Direct End
to End
Repair
Nerve
grafting
Nerve
transfer

44. Direct End to End Repair
• Usually only possible for acute
and sharp penetration injuries
• Types
• Group fascicular repair
• Epineural repair
• Perineural repair

45. Nerve grafting
•Transfer of donor nerve from other part of
the body to replace the damaged nerve
•Donor sites:
1.Sural nerve
2.Sensory branch of ulnar nerve
3.Medial cutaneous nerve of forearm
•Predominantly used in clear cut injuries
with healthy proximal stump and with no
axial damage

47. Neurotization (Nerve Transfer)
• For preganglionic root injury
• A healthy but less valuable nerve
is transferred in order to
reinnervate a more important
motor territory that has lost its
innervation through irreparable
damage to its nerve
• Motor branches are used as donor

50. *
Intraoperative picture showing musculocutaneous nerve neurotization by three
intercostal nerves

51. *

52. *
Secondary Operation
Tendon
Transfer
Muscle
Transfer
Arthrodesis
• need in the absence of spontaneous recovery or when the first
surgical procedure does not provide satisfactory outcomes

53. *
Free functioning muscle transplantation
• Transplant of a muscle
with its neurovascular
pedicle to a new
location
• Gracilis muscle - to
restore elbow flexion
• Alternative muscle
• Rectus femoris
• Lats dorsi

54. *

55. *
Tendon Transfer
• Upper or lower brachial plexus
traumatic injury with only partial
paralysis
• Goal is to restore good muscle
strength through a ROM of 30-
130’

56. *
Arthrodesis
• Done as the last
resort
• Usually reserved for
unstable or painful
shoulder
• To achieve shoulder
stability

57. Targeted Muscle Reinnervation
• To provide intuitive
prosthetic control to
upper extremity
amputees
• Rely on signals
acquired from muscles
just above the
amputation sites

59. Post-op Care
Surgical
Exploration
and Primary
Intervention
Rehab and
Reassess.
Migrating Tinel
sign?
If No, Re-
explore +/-
Nerve
Reconstruction
Rehab and
Reassess
If No
Improvement,
Secondary
Intervention
Rehab and
Reassess
Joint Fusion /
Splinting

60. *
Prognosis
• Regeneration of nerve ~1mm/day
• Recovery of BPI may take up to 3 years
• Better prognosis – Upper plexus injury (hand preserved function)
• Poor prognosis – root avulsion (pre-ganglionic), not repairable

61. References
• Apley’s Orthopedics
• Hsueh, Y.-H., & Tu, Y.-K. (2020). Surgical Reconstructions for
adult brachial plexus injuries. Part I: Treatments for combined
C5 and C6 injuries, with or without C7 injuries. Injury.
• Maldonado, A. A., Kircher, M. F., Spinner, R. J., Bishop, A. T., & Shin, A.
Y. (2017). Free Functioning Gracilis Muscle Transfer With and Without
Simultaneous Intercostal Nerve Transfer to Musculocutaneous Nerve
for Restoration of Elbow Flexion After Traumatic Adult Brachial Pan-
Plexus Injury. The Journal of Hand Surgery, 42(4), 293.e1–293.e7.
• Seal, A., & Stevanovic, M. (2011). Free Functional Muscle
Transfer for the Upper Extremity. Clinics in Plastic Surgery,
38(4), 561–575.

62. • Sakellariou, Vasileios I et al. “Treatment options for brachial
plexus injuries.” ISRN orthopedics vol. 2014 314137. 14 Apr.
2014
• Wolford, Larry M, and Eber L L Stevao. “Considerations in
nerve repair.” Proceedings (Baylor University. Medical
Center) vol. 16,2 (2003): 152-6