34. • Weak intrinsic of hand
• Paralysis of wrist & fingers flexors
• Claw hand deformity
• Sensory deficit over medial aspect of arm, forearm & hand
Lower Trunk
(C8, T1)
35. Physical examination
• Aims :
1) Determine extent of injury
- Name by root value
2) Determine level/ proximity of injury
3) Donors
– Muscle donors
– Nerve donors
36. 2) Determine level/ proximity of injury
Pre ganglionic Post ganglionic
Poor prognosis
• Involve CNS
• poorer nerve
regeneration
Better prognosis
• Involve PNS
• better nerve
regeneration
39. Tinel sign
• Infraclavicular and supraclavicular
percussion (distal to proximal)
• Negative preganglionic
Positive means:
– proximal axons available
– location of neuroma or regenerating axons
– does not exclude another distal lesion
40. • Tinel’s sign is positive
in 40% of preganglionic lesion
• Reasons:
– Shoulder region is also innervated by
cervical plexus.
– Induced by traction on scar tissue.
41. Physical examination
• Aims :
1) Determine extent of injury
- Name by root value
2) Determine level/ proximity of injury
3) Donors
– Muscle donors
– Nerve donors
43. 3) Donors
• Nerve donors
1) Intraplexus
– Adv: shorter distance hence better recovery
– Disadv: unsure if donor nerve is normal
2) Extraplexus
– Adv: donor nerve is normal
44. • Nerve donors
1) Intraplexus
– Median n
– Ulnar n
** only in upper plexus injury
3) Donors
45. 2) Extraplexus
• Spinal accessory n (trapezius)
• Intercostal n (chest tube scar)
• Contralateral C7 (sensation over tip of middle
finger)
• Phrenic n (chest percussion)
• Sural n (sensation over lateral aspect of foot) – as
a cable graft
• Hypoglossal nerve
3) Donors
49. • Observe how patient
removes his shirt
• Attitude of UL –
normally flail, IR,
adducted
• Wasted UL with dry
skin
• ? Scars/ bruises (Neck)
• ? Horner Syndrome
General Inspection
57. Others
Chest percussion (Phrenic n)
Any scar for previous chest tube
(Intercostal n, phrenic n)
Lat dorsi (cough, feel for
contraction)
Pectoralis major (Shoulder
adduction and extension)
Sural n (?Scar or sensation over
lateral aspect of dorsum foot)
59. Investigation
• Cervical Xray AP
– Transverse process avulsion fracture (scalene)
• CXR
– Elevated hemidiaphragm
• CT Myelogram
– After 3-4 weeks to allow blood clot to dissipate and meningocele to form
– to diagnose root avulsion
– look for pseudomeningocele
• MRI
– pseudomeningocele (T1WI)
– empty root sleeve(T2WI)
– shift of cord away from midline
• EMG
– posterior spinal nerve injury
60. Investigation
Pre ganglionic Post ganglionic
Cervical Xray: transverse process
fracture
Chest Xray: elevated hemidiaphragm
CT myelo/MRI: pseudomeningocele
EMG: loss of innervation to cervical
paraspinal muscles
NCS: Sensory nerve action potential
(SNAP) normal
64. Prognosis
• recovery of reconstructed plexus up to 3 years
• nerve regeneration - 1mm/day
• Poor prognosis
– Root avulsion (preganglionic)
– Lower plexus
– Supraclavicular injuries
– Smoking
– Delayed repair
65.
66. Management
– observation
• guns shot wounds (in
absence of major
vascular damage can
observe for three
months)
– signs of neurologic
recovery
• advancing Tinel sign
Non-operative Operative
67. • Emergency
– Open injury
– Stab wound
– Iatrogenic
– Associated vascular repair
• Early (3w -3m)
– total palsy
– high velocity injuries
– gunshot wounds
• Routine (3m-6m)
• Secondary(>1y)
– reconstructive
Timing of repair
68. • Any repair surgery or neurotization should be done
within first 6 months
– NMJ degenerates after 1 year
– Nerve endings from direct repair/neurotization need to
reach NMJ
Post-ganglionic lesion
• Exploration, neurolysis/primary repair/nerve grafting
• Neurotization
• Preganglionic lesion
• Neurotization
Surgery
70. • If >6months, neurotization may be considered
for:
– Young patient (most important factor for success
of surgery)
– Short regeneration distance eg shoulder
• Otherwise, secondary reconstruction after 2
yrs
Surgery
71. Neurotization
• Nerve transfer
– Functioning but less important nerve to a distal
more important denervated nerve
• Indications:
– Preganglionic BPI
– some postganglionic injury with unpredictable
primary repair eg HE injury
72. • Principles:
– Prioritize function and identify the recipient nerve
– Identify available nerve donor
– Timing < 6mths (should reach NMJ by 1 year)
Neurotization
73. Goals of surgical treatment
1. Elbow flexion by biceps/brachialis muscle reinnervation
2. Shoulder stabilization, abduction, and external rotation by
suprascapular nerve reinnervation
3. Brachiothoracic pinch (adduction of the arm against the chest) by
reinnervation of the pectoralis major muscle
4. Sensation below the elbow in the C6-C7 area by reinnervation of
the lateral cord
5. Wrist ext/finger flexion
6. Reestablishment of thumb grip in opposition or lateral thumb grip
7. Finger extension
8. Restoration of function of the interrossei
**Important especially in complete BPI
74. Types of Surgery
< 6 months > 6 months
Complete BPI incomplete BPI
Upper plexus Lower plexus
82. SAN SCN
• divided after branching to trapezius
• Transferred to suprascapularis
• via sural nerve graft to mbtb of mscn or axillary nerve
• To FFMT gracilis (SAC n to obturator n)
84. Intercostal nerves
• poor result with interpositional
graft
• good result if direct repair
• C/I: anterior chest trauma with
ribs fracture; young girl/women
• usually 3rd-6th intercostal n;
both lateral cutaneous br and
anterior motor br can be used
• 2 or more icn use for each
transfer
• mcn either to mbtb or mcn
itself (mixed n) - for good result
use 3 icn,
• FFMT gracilis
87. Types of Surgery
< 6 months > 6 months
Complete BPI incomplete BPI
Upper plexus Lower plexus
88. • Oberlin procedure :
– Ulnar fascicle to motor branch of biceps (type 1)
– Median fascicle to motor branch of brachialis
(type 2)
• Somsak procedure :
– Spinal accessory nerve to suprascapular nerve
– Motor fascicle of long head of triceps to axillary
nerve
Upper plexus, < 6months
89. Oberlin’s procedure
Type 1: Ulnar nerve motor br to
biceps (12cm from acromion)
Type 2: Median nerve motor br
to brachialis (17cm from acromion)
1. Dissection of MBTB
2. Epineurectomy of the ulnar
nerve
3. Interfascicular dissection of
the ulnar nerve
4. Selection of fascicles
(posteromedial) and division
of 1-2 fascicles for transfer
5. Neurorrhaphy between MBTB
and fascicles of ulnar nerve
90. Nerve to long head of triceps to anterior branch
of axillary nerve (Somsak)
91. • Tendon transfer
• *** long distance for nerve endings to travel
to NMJ
Lower plexus
92. Types of Surgery
< 6 months > 6 months
Complete BPI incomplete BPI
Upper plexus Lower plexus
95. Trapezius transfer (Saha)
• Transfer entire
insertion of trapezius
along with:
• Lateral end of
clavicle
• Acromion
• AC joint
• Scapular spine
• Anchor distal to
tuberosity with 2
screws
96. Elbow
Local
transfer
Functioning free muscle
transfer (FFMT)
• Steindler’s flexopathy
• Triceps to biceps
transfer
• Pectoralis major
transfer (uni/bipolar)
• Lattisimus dorsi
transfer
• Gracilis
• Rectus femoris
• contralateral latissimus
dorsi
97. Steindler’s flexopathy
• transfer of origin of flexor-pronator
mass from ME to more proximal and
lateral position
• prerequisite - Steindler's effect
• adv: simple, cosmetically acceptable
• disadv: weak flexor, limited ext
98. Pectoralis
major
transfer
• Unipolar (Clarke)
• mobilised distal/3rd
(costal) origin with
strip of rectus sheath
biceps tendon
• bipolar
• Humeral insertion to
acromion
• sternoclav origin -
tube it and attached
to biceps tendon
• adv: powerful flexor
• disadv: cosmetically
unacceptable
104. Take home message
• Anatomy of brachial plexus is crucial
• Aims in examination:
1) Determine extent of injury
- Name by root value
2) Determine level/ proximity of injury
3) Donors
– Muscle donors
– Nerve donors
106. Q1
A 21-year-old football player has been diagnosed
with a left upper trunk brachial plexus injury
following a tackle. Which of the following would
most likely be normal on physical exam?
A. Sensation over the lateral aspect of shoulder
B. Biceps reflex
C. Shoulder abduction
D. Sensation over radial aspect of forearm
E. Finger abduction
107. Q2
A 26-year-old male sustains a traction injury to his left arm after a
motorcycle crash with resulting weakness in this left upper extremity.
An electromyography (EMG) done shows normal cervical paraspinal
muscle activity. Which of the following statements is TRUE regarding
this injury?
A. The injury has likely resulted in the avulsion of several nerve roots
B. Physical exam would likely reveal drooping of his left eyelid and
anhidrosis
C. Intact paraspinal musculature on EMG is suggestive of a post-
ganglionic lesion
D. Immediate surgical intervention with neurotization would eliminate
weakness and restore function
E. The patient would show a normal histamine test
108. Q3
A patient sustains a transection of the posterior
cord of the brachial plexus from a knife injury. This
injury would affect all of the following muscles
EXCEPT?
A. Subscapularis
B. Latissimus dorsi
C. Supraspinatus
D. Teres minor
E. Brachioradialis
109. Q4
The following nerves are not used as a donor nerve
in neurotization during brachial plexus surgery.
A. Phrenic nerve
B. Spinal accessory nerve
C. Contralateral C7
D. Intercostobrachial nerve
E. 3rd and 4th intercostal nerve
110. Q5
Which symptoms does not suggest a pre-
ganglionic lesion in brachial plexus injury?
A. Miosis of pupil
B. Winging of scapula
C. Loss of rhomboid contraction
D. Loss of trapezius contraction
E. Ptosis
111. Q1
A 21-year-old football player has been diagnosed
with a left upper trunk brachial plexus injury
following a tackle. Which of the following would
most likely be normal on physical exam?
A. Sensation over the lateral aspect of shoulder
B. Biceps reflex
C. Shoulder abduction
D. Sensation over radial aspect of forearm
E. Finger abduction
112. Q2
A 26-year-old male sustains a traction injury to his left arm after a
motorcycle crash with resulting weakness in this left upper extremity.
An electromyography (EMG) done shows normal cervical paraspinal
muscle activity. Which of the following statements is TRUE regarding
this injury?
A. The injury has likely resulted in the avulsion of several nerve roots
B. Physical exam would likely reveal drooping of his left eyelid and
anhidrosis
C. Intact paraspinal musculature on EMG is suggestive of a post-
ganglionic lesion
D. Immediate surgical intervention with neurotization would eliminate
weakness and restore function
E. The patient would show a normal histamine test
113. Q3
A patient sustains a transection of the posterior
cord of the brachial plexus from a knife injury. This
injury would affect all of the following muscles
EXCEPT?
A. Subscapularis
B. Latissimus dorsi
C. Supraspinatus
D. Teres minor
E. Brachioradialis
114. Q4
The following nerves are not used as a donor nerve
in neurotization during brachial plexus surgery.
A. Phrenic nerve
B. Spinal accessory nerve
C. Contralateral C7
D. Intercostobrachial nerve
E. 3rd and 4th intercostal nerve
115. Q5
Which symptoms does not suggest a pre-
ganglionic lesion in brachial plexus injury?
A. Miosis of pupil
B. Winging of scapula
C. Loss of rhomboid contraction
D. Loss of trapezius contraction
E. Ptosis