Brachial plexus lesion, diagnosis and management How does it occur,Erb klumpke. MAnagement, surgeries etc

1. PRESENTED BY : Harjot singh gurudatta
MODERATOR : Dr. Rohit Sharma

2. 12-2
 Formed by ventral rami of
spinal nerves C5-T1
 Pre and post fixed
 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

4. 1) Root value of lateral cord & all its branches is
C5,6,7 with NO EXCEPTION.
2) Root value of medial cord & all its branches is C8 &
T1 with ONE EXCEPTION; Ulnar nerve; whose
root value is C7,8 & T1.
3) Root value of posterior cord branches is C5,6 with
TWO EXCEPTIONS :
@ Thoracodorsal nerve; C6,7,8.
@ Radial nerve; C5,6,7,8 & T1.
4) Root value of upper trunk & its branches is C5,6.
*Things to Notice*

5.  Some mnemonics for remembering the branches:
 Posterior Cord Branches
 STAR - Subscapular (upper and lower), Thoracodorsal,
Axillary, Radial
 ULTRA or ULNAR- Upper subscapular, Lower
subscapular, Thoracodorsal, Radial, Axillary
 Lateral Cord Branches
 LML or LLM "Lucy Loves Me" - Lateral pectoral, Lateral
root of the median nerve, Musculocutaneous
 Medial Cord Branches
 M4U or MMMUM "Most Medical Men Use Morphine" -
Medial pectoral, Medial cutaneous nerve of arm, Medial
cutaneous nerve of forearm, Ulnar, Medial root of the
median nerve

6. M shape
formed by
1. Musculocutaneous N.
2. Lat. & Med. Root of
median N. of both lat. &
med. Cords.
3. Ulnar N.
1
2
3

8. DERMATOMES OF UPPER LIMB

9. ERB’S PARALYSIS
• Erb’s point
• Causes Downward traction
• Nerve roots involved
• Muscles Paralysed
• Deformity
• Disability
•deltoid –supraspinatus–
infraspinatus–biceps -brachialis

10. LEFT SIDE PARALYSIS

11. Klumpke’s paralysis-
Site of injury
Cause of injury
Nerve roots involved
Muscles paralysed
Deformity
Disability

12. CLAW HAND HORNER SYNDROME

13.  High-energy trauma to the upper
extremity and neck causes a variety of
lesions to the brachial plexus.
 The common mechanism is violent
distraction of the entire forequarter
from the rest of the body ie motorcycle
accident or a high-speed motor vehicle
accident. A fall from a significant
height may also result in brachial
plexus injury. DIRECT BLOW AND
TRACTION.
 Sports most commonly associated with
brachial plexus injuries include: Am
football, baseball, basketball,
volleyball, fencing, wrestling, and
gymnastics
 Nerve injuries can result from blunt
force trauma, poor posture, or chronic
repetitive stress
 Patients generally present with pain
and/or muscle weakness
 Over time, some patients may
experience muscle atrophy
 Loss of useful function of the upper
extremity is common

14. Millesi classification*
 Supraganglionic
 Infraganglionic
 Trunk
 Cord
Anatomical
Classification
 C5-6 waiters tip (Erbs
palsy)
 C5-7 as above, elbow
slightly flexed
 C5-T1 flail limb, claw
hand, vasomotor
changes, +/- Horners
syndrome

16.  Nerve root avulsion
 dorsal & ventral rootlets
 invested by pia mater / dural funnel
 etiology: traction (occasionally missile, knife)
 Significant traction causes dural rupture / root
vulnerability
 ventral > dorsal root (esp C8-T1) at higher risk
 POOR Prognosis!

17.  Grade 1 – Neuropraxia
 Disruption in nerve function that produces numbness and tingling
 Most common grade within athletics
 Symptoms usually resolve within several minutes
 Grade 2 – Axonotmesis
 Damage to the nerve’s axon
 Symptoms = numbness, tingling, and affected function (may last several days)
 Long nerves have a greater healing time than short nerves
 Rare within athletics
 Motor march, Tinel sign
 Grade 3 – Neurotmesis
 Permanent nerve damage occurs
 Very rare within athletics
 “Occurs with high-energy trauma, fractures, and penetrating injuries”

18. How do you Rx the patient knocked off his
motorcycle with clavicle # and flail arm?
 Manage acute injury according to ATLS
principles; look for concomitant injury ie c-
spine.
 History
 Age, handedness, occupation, special skills
 Cause of injury: arm hyperabducted vs neck laterally
flexed
 Immediate or delayed arm weakness
 Concomitant injury
 General health: PMH, DH, Smoker

19. Examination (use pre-printed brachial plexus diagrams): determine level
 Look at face: does he have Horner’s? (=lower root lesion C8 T1)
 Undress upper torso
 Look from front at posture of arm, scars, muscle wasting,
asymmetry/swelling
 Look at back again for scars, muscle wasting, asymmetry
 Test sp. Accessory n (shrug shoulders)
 Supraspinatus responsible for 1st 20 of shoulder abduction (resisted arm
abduction)
 Rhomboids (touch back of head)
 Lat dorsi (press both hands into hips and cough)
 Look at vascularity of arm
 Check sensation both upper limbs (root levels)
 Check movement both upper limbs from shoulder to fingers (AROM +
PROM)
 Reflexes
 Function of phrenic nerve

22. Wall test for serratus ant (winging scapula)
Note weak trapezius (asymmetric shrug)

23. Brachial Plexus
 Cervical Compression
Test
 Cervical Distraction
Test
 Spurling’s Test
 Brachial Plexus
Traction Test
Thoracic Outlet
Syndrome
Adson’s Test
Allen’s Test

24. Axillary N.
 Sensory – Lateral arm
 Motor – Shoulder
abduction
Musculocutaneous N.
 Sensory – Anterior arm
 Motor – Elbow flexion
Radial N.
 Sensory – 1st Dorsal web
space
 Motor – Wrist extension
and thumb extension
Median N.
 Sensory – Pad of Index
finger
 Motor – Thumb pinch
and abduction
Ulnar N.
 Sensory – Pad of little
finger
 Motor – Finger
abduction

25.  C5 – Biceps brachii reflex (anterior arm near
antecubital fossa)
 C6 – Supinator reflex (lateral aspect of forearm)
 C7 – Triceps brachii reflex (at insertion of tricep
brachii)
 C8 and T1 do not have reflex tests

26. Imaging: Xray: AP chest (look for teeth and fractures ), AP + lat
views shoulder, C-Spine (AP, lat, odontoid peg), Fine-cut CT,
MRI

27.  Sensory nerve action potentials (SNAPs):
differentiate preganglionic from postganglionic
injuries. …histamine..
 Electromyography (EMG): In the first week after
injury, EMG cannot be used to exclude a complete
disruption unless voluntary motor unit action
potentials are observed. If no signs of denervation
are present in a paralyzed muscle by 3 weeks after
injury, EMG can be used to confirm a neuropraxia.
 Somatosensory evoked potentials (SSEPs): In
general, SNAPs are more reliable than SSEPs.
Many difficulties exist with SSEPs, and they are
not widely used.

28.  Medical: MDT
 physio: maintain supple joints with FROM
 Orthoptists / splinting
 Pain control
 Surgical options:
 nerve transfers
 nerve grafting
 muscle transfers
 free muscle transfers
 neurolysis of scar in incomplete lesions
 Arthrodesis to stabilise joints

29.  Open wounds
 Sharp injury
 Bullet injury
 Closed injuries

30. Chest tube

32.  Bullet woundClavicle osteotomy
Junction of trunk and cords

33. Laceration

34. Nerve repair and graft

35. Laceration

36. Nerve graft

37.  Closed injury, (tractional injuries)

38.  Closed injury, (tractional injuries)
 Early exploration
 Underobservation
 Decision for the time of delay exploration
 Decision for the type of the treatment
 Late recostruction

39.  Closed injury, (tractional injuries)
 Early exploration
 Underobservation
 Decision for the time of delay exploration
 Decision for the type of the treatment
 Late recostruction
Peripheral reconstruction

40.  Closed injury, (tractional injuries)
 Early exploration vascular reconstruction

41.  Closed injury, (tractional injuries)
 Early exploration
 Underobservation
First 6-12 weeks
Stabilization of the patient
Stabilization of the injury
Evaluation of the improvement
After 2-3 months
No improvement; exploration
Progressive improve; wait & watch
Non-anatomic recovery; explor.
Based on severity

42.  Closed injury, (tractional injuries)
 Early exploration
 Underobservation
 Decision for the time of delay exploration
 No recovery
 After 6-12 weeks (based on the severity of the trauma)
 Progressive improvement
 Wait for further improvement
 Non-anatomic recovery
 Exploration before 9-12 months

43.  Closed injury, (tractional injuries)
 Early exploration
 Underobservation
 Decision for the time of delay exploration
 Decision for the type of the treatment

44.  Neurolysis
 Nerve repair
 Nerve graft
 Nerve transfer
 Tendon transfer
 Arthrodesis
 Functional muscle flaps
Straight on Brachial Plexus
Early exploration
Delay exploration
Peripheral reconstruction
Late reconstruction
Danger of more damage
Failure is obvious

45.  Neurolysis….check…potential
 Nerve repair
 Nerve graft
 Nerve transfer
 Tendon transfer
 Arthrodesis
 Functional muscle flaps

46.  Gun shot injury

47. After neurolysis from scar tissue

48.  Neurolysis
 Nerve repair…
 Nerve graft
 Nerve transfer
 Tendon transfer
 Arthrodesis
 Functional muscle flaps

49.  Neurolysis
 Nerve repair
 Nerve graft
 Nerve transfer
 Tendon transfer
 Arthrodesis
 Functional muscle flaps
Sural
medial cutaneous forearm
ulnar (vascularised)
 Self transfer (i.e. Sural
Nerve)
 Manufactured Nerve
 Processed Nerve
 Cadaver Transplant
 Living Related Transplant

52.  Neurolysis
 Nerve repair
 Nerve graft
 Nerve transfer..neurotization
 Tendon transfer
 Arthrodesis
 Functional muscle flaps
Accessory nerve
Cervical plexus
Phrenic nerve
Intercostal nerves
Ulnar ECU nerve
Crossed C7
Hypoglossal nerve

53.  Motor cycle accident open wound

54. C5
C6
Vertebral foramen

55.  Accessory to suprascapular

56. Accessory
Injured upper trunk
Superascapular nerve

57.  Oberlin nerve transfer

58. Oberlin nerve transfer
Biceps m.
Ulnar n.
Anastamosis

59. Radial to axillary transfer

60. Axillary n
(inverted)
Radial n.

61. ICN 4
ICN 5
ICN 6
Musclocutaneus n

62.  Neurolysis
 Nerve repair
 Nerve graft
 Nerve transfer
 Tendon transfer
 Arthrodesis
 Functional muscle flaps

64.  Triceps to Biceps

67. Latismus dorsi m.

68. Latismus dorsi transfer
to flexion elbow
and extension finger

69. Deltoid paralysis

71.  Trapez to Deltoid

72.  Neurolysis
 Nerve repair
 Nerve graft
 Nerve transfer
 Tendon transfer
 Arthrodesis
 Functional muscle flaps

74.  Shoulder arthrodesis in BPI

75.  Neurolysis
 Nerve repair
 Nerve graft
 Nerve transfer
 Tendon transfer
 Arthrodesis
 Functional muscle flaps

76. Gracillis harvest Accessory n.

77. First stage of Doi procedure

78. Partial ulnar n. as a donor nerve

80.  Extra plexus donor

81. Brachial plexus injury
Open sharp injury Shot gun Tractional injury
Immediate exploration under observation
Exploration No improvement in 2-3 m
Explor. In 12 m. Non-anatomic improvement
Peripheral reanimation > 12m .
Gradual improvement

83.  Root value- C5
 Supply – Rhomboid major &
minor muscle
Posterior view

84. LONG THORACIC NERVE
Root value- C5,C6,C7
Supply – Serratus anterior
muscle

85. BRANCHES OF UPPER
TRUNK
NERVE TO SUBCLAVIUS
Root value – C5,C6
SUPRASCAPULAR NERVE
Root value – C5,C6

86. Root value-
C5,C6,C7
MEDIAL PECTORAL NERVE
Root value- C8,T1

87. MUSCULOCUTANEOUS
NERVE
Root value – C5,C6,C7

88. 12-88
MEDIAN NERVE

89. MEDIAL CUTANEOUS NERVE OF ARM
Root value- C8,T1
MEDIAL CUTANEOUS NERVE OF
FOREARM
Root value- C8,T1

90. 12-90
ULNAR NERVE
Root value-(C7),C8,T1

91. UPPER SUBSCAPULAR
Root value-C5,C6
LOWER SUBSCAPULAR
Root value- C5,C6
NERVE TO LATISSIMUS DORSI
Root value-C6,C7,C8

92. AXILLARY NERVE

93. RADIAL NERVE

97. Test for ulnar nerve
Card test
Froment’s sign
Egawa’s test

98. CONTENT
 Axillary artery & its
branches
 Axillary vein & its
tributaries
 Infraclavicular part of
brachial plexus
 Axillary lymph nodes
 Axillary fat

99. Carpal tunnel syndrome
Epidemiology
Signs &symptoms
Motor changes
Sensory changes
Vasomotor changes
Trophic changes

100. Tests done
Tinel sign Phalen’s
maneavure

101. Radial Nerve
Injury in axilla
• Causes of injury
Motor effects:paralysis of
 triceps,anconeus
 extensors of the wrist
 Extensors of fingers.
 Brachioradialis
 supinator muscle
• Deformity: Wrist and finger drop
Sensory effects -small area of sensation loss at arm
andforearm
 sensory loss over lateral part of the dorsum of the
hand (lat. 3.5 fingers without distal phalynges)

102. Injuries at Spiral Groove
 Caused by fracture shaft of humerus.
• Motor effects: paralysis of
 extensors of the wrist
 Extensors of fingers
• Deformity:
 Wrist and finger drop
• Sensory effects:
 anesthesia is present over the dorsal
surface of the hand (lat. 3.5 fingers)

105. 12-105
 Spinal nerves attach to
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

106. 12-106
 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)

107. 12-107
 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)

108. 12-108
 Spinal nerves indicated by capital letter and number
 Dermatomal map: skin area supplied with sensory
innervation by spinal nerves

109. 12-109
 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.

110. 12-110
 Dorsal Ramus
 Neurons within muscles of trunk and
back
 Ventral Ramus (VR)
 Braid together to form plexuses
 Cervical plexus - VR of C1-C4
 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

111. 12-111
 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