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Brachial plexus anatomy, diagnosis and orthopaedic treatment

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Brachial plexus lesion, diagnosis and management

How does it occur,Erb klumpke.

MAnagement, surgeries etc

Published in: Health & Medicine
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Brachial plexus anatomy, diagnosis and orthopaedic treatment

  1. 1. PRESENTED BY : Harjot singh gurudatta MODERATOR : Dr. Rohit Sharma
  2. 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
  3. 3. 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*
  4. 4.  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
  5. 5. 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
  6. 6. DERMATOMES OF UPPER LIMB
  7. 7. ERB’S PARALYSIS • Erb’s point • Causes Downward traction • Nerve roots involved • Muscles Paralysed • Deformity • Disability •deltoid –supraspinatus– infraspinatus–biceps -brachialis
  8. 8. LEFT SIDE PARALYSIS
  9. 9. Klumpke’s paralysis- Site of injury Cause of injury Nerve roots involved Muscles paralysed Deformity Disability
  10. 10. CLAW HAND HORNER SYNDROME
  11. 11.  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
  12. 12. 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
  13. 13.  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!
  14. 14.  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”
  15. 15. 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
  16. 16. 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
  17. 17. Wall test for serratus ant (winging scapula) Note weak trapezius (asymmetric shrug)
  18. 18. Brachial Plexus  Cervical Compression Test  Cervical Distraction Test  Spurling’s Test  Brachial Plexus Traction Test Thoracic Outlet Syndrome Adson’s Test Allen’s Test
  19. 19. 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
  20. 20.  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
  21. 21. Imaging: Xray: AP chest (look for teeth and fractures ), AP + lat views shoulder, C-Spine (AP, lat, odontoid peg), Fine-cut CT, MRI
  22. 22.  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.
  23. 23.  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
  24. 24.  Open wounds  Sharp injury  Bullet injury  Closed injuries
  25. 25. Chest tube
  26. 26.  Bullet woundClavicle osteotomy Junction of trunk and cords
  27. 27. Laceration
  28. 28. Nerve repair and graft
  29. 29. Laceration
  30. 30. Nerve graft
  31. 31.  Closed injury, (tractional injuries)
  32. 32.  Closed injury, (tractional injuries)  Early exploration  Underobservation  Decision for the time of delay exploration  Decision for the type of the treatment  Late recostruction
  33. 33.  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
  34. 34.  Closed injury, (tractional injuries)  Early exploration vascular reconstruction
  35. 35.  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
  36. 36.  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
  37. 37.  Closed injury, (tractional injuries)  Early exploration  Underobservation  Decision for the time of delay exploration  Decision for the type of the treatment
  38. 38.  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
  39. 39.  Neurolysis….check…potential  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps
  40. 40.  Gun shot injury
  41. 41. After neurolysis from scar tissue
  42. 42.  Neurolysis  Nerve repair…  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps
  43. 43.  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
  44. 44.  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
  45. 45.  Motor cycle accident open wound
  46. 46. C5 C6 Vertebral foramen
  47. 47.  Accessory to suprascapular
  48. 48. Accessory Injured upper trunk Superascapular nerve
  49. 49.  Oberlin nerve transfer
  50. 50. Oberlin nerve transfer Biceps m. Ulnar n. Anastamosis
  51. 51. Radial to axillary transfer
  52. 52. Axillary n (inverted) Radial n.
  53. 53. ICN 4 ICN 5 ICN 6 Musclocutaneus n
  54. 54.  Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps
  55. 55.  Triceps to Biceps
  56. 56. Latismus dorsi m.
  57. 57. Latismus dorsi transfer to flexion elbow and extension finger
  58. 58. Deltoid paralysis
  59. 59.  Trapez to Deltoid
  60. 60.  Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps
  61. 61.  Shoulder arthrodesis in BPI
  62. 62.  Neurolysis  Nerve repair  Nerve graft  Nerve transfer  Tendon transfer  Arthrodesis  Functional muscle flaps
  63. 63. Gracillis harvest Accessory n.
  64. 64. First stage of Doi procedure
  65. 65. Partial ulnar n. as a donor nerve
  66. 66.  Extra plexus donor
  67. 67. 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
  68. 68.  Root value- C5  Supply – Rhomboid major & minor muscle Posterior view
  69. 69. LONG THORACIC NERVE Root value- C5,C6,C7 Supply – Serratus anterior muscle
  70. 70. BRANCHES OF UPPER TRUNK NERVE TO SUBCLAVIUS Root value – C5,C6 SUPRASCAPULAR NERVE Root value – C5,C6
  71. 71. Root value- C5,C6,C7 MEDIAL PECTORAL NERVE Root value- C8,T1
  72. 72. MUSCULOCUTANEOUS NERVE Root value – C5,C6,C7
  73. 73. 12-88 MEDIAN NERVE
  74. 74. MEDIAL CUTANEOUS NERVE OF ARM Root value- C8,T1 MEDIAL CUTANEOUS NERVE OF FOREARM Root value- C8,T1
  75. 75. 12-90 ULNAR NERVE Root value-(C7),C8,T1
  76. 76. UPPER SUBSCAPULAR Root value-C5,C6 LOWER SUBSCAPULAR Root value- C5,C6 NERVE TO LATISSIMUS DORSI Root value-C6,C7,C8
  77. 77. AXILLARY NERVE
  78. 78. RADIAL NERVE
  79. 79. Test for ulnar nerve Card test Froment’s sign Egawa’s test
  80. 80. CONTENT  Axillary artery & its branches  Axillary vein & its tributaries  Infraclavicular part of brachial plexus  Axillary lymph nodes  Axillary fat
  81. 81. Carpal tunnel syndrome Epidemiology Signs &symptoms Motor changes Sensory changes Vasomotor changes Trophic changes
  82. 82. Tests done Tinel sign Phalen’s maneavure
  83. 83. 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)
  84. 84. 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)
  85. 85. 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
  86. 86. 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)
  87. 87. 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)
  88. 88. 12-108  Spinal nerves indicated by capital letter and number  Dermatomal map: skin area supplied with sensory innervation by spinal nerves
  89. 89. 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.
  90. 90. 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
  91. 91. 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

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