This document discusses brachial plexus injuries, including anatomy, classification, risk factors, diagnosis, and treatment approaches. It covers both pediatric obstetric brachial plexus injuries as well as adult traumatic injuries. Key points include the Narakas classification system for pediatric injuries, signs and symptoms of preganglionic versus postganglionic injuries, imaging and electrodiagnostic testing, conservative treatment protocols, surgical reconstruction options like nerve grafting and nerve transfers, and secondary reconstruction procedures.

1. BRACHIAL PLEXUS
INJURIES

2. ANATOMY

4. Brachial plexus
Injury
Paediatric/Obstetric
Upper/Erb’s
(C5C6,C7)
Lower/Klumpke’s
(C8 T1)
Adult

5. PAEDIATRIC/OBSTETRIC BRACHIAL
PLEXUS INJURY
• Incidence:0.38-1.56 /1000 live births
• Perinatal Risk Factors:
• 1)Macrosomia-Diabetic mother
• 2)Multiparous Pregnancy
• 3)Previous delivery with Brachial plexus
• 4)Prolonged labour
• 5)Shoulder Dystocia

6. Shoulder Dystocia

7. Preganglionic Vs Postganglionic

8. NARAKAS CLASSIFICATION
GROUPS NERVE ROOT DYSFUNCTION PROGNOSIS
I C5 C6 (ERBs) SHOULDER
ABDUCTION AND
EXTERNAL
ROTATION
ELBOW FLEXION
AND FOREARM
SUPINATION
SPONTANEOUS
RECOVERY IN 90%
II C5 C6 C7 WITH ABSENCE OF
WRIST EXTENSION
(WAITERS TIP)
POOR
III C5—T1 FLIAL EXTREMITY
WITHOUT
HORNERS
POOR
IV C5—T1 WITH
PREGANGLIONIC
AVULSION
HORNERS WITH
PHRENIC NERVE
POOR

9. DIAGNOSIS
1)CLINICALLY
• 1.Clavicle/ Humerus fracture
• 2.Neonatal Reflexes : Moro’s and tonic neck
• 3.Horner’s :
Miosis,Anhydrosis,Ptosis,Enophthalmos(T1)
• 4.Putti sign: Prominence of upper border of
Scapula
• 5.Trumpet sign

10. Neonatal reflexes
MORO’s Reflex

11. Kerchief Sign
/Towel test

13. Trumpet sign

14. Waiter Tip Deformity/Policeman tip

15. Upper plexus
• Physical Exam
• Most common obstetric brachial plexopathy
• Best prognosis
• Clinically, arm will be adducted, internally
rotated, at shoulder; pronated, extended at
elbow (“waiter’s tip”)
• C5 deficiency
– axillary nerve deficiency
– suprascapular nerve deficiency
– musculocutaneous nerve deficiency
• C6 deficiency
– radial nerve deficiency
Lower plexus
•Rare in obstetric
palsy
•Usually avulsion
injuries
•Frequently
associated with a
preganglion injury
and Horner's
Syndrome
•Poor prognosis
Deficit of all of the
small muscles of
the hand (ulnar and
median nerves)
•Clinically, presents
as “claw hand

16. 2)IMAGING
• Plain X ray of shoulder: clavicle and humerus #
and chest : Diaphragm palsy
• CT/MRI: Not indicated

17. 3)ELECTRODIAGNOSTIC STUDY
• After 4-6 weeks? (Wallerian Degeneration)
1)Root avulsion
2)Level/Type of Nerve Injury
3)Nerve recovery

18. TRIAD OF ROOT AVULSION
Normal SNAP( sensory nerve action potential)
ABSENT SEP(somatosensory evoked potential)
Denervation of Cervical muscles

19. PROGNOSIS
• Preganglionic avulsion : NO spontaneous
recovery . Surgery Indicated
• Postganglionic Stretch(Neuropraxia) :
Spontaneous recovery
• Postganglionic Rupture: Repair

20. TREATMENT PROTOCOL
CLINICALLY
ASSESS
Discuss with
parents and
reassurance
No mobilisation for 3
weeks
Gentle
manipulation Baseline EMG at
6 weeks and
Reasses at 6
weeks
3 Months Re
examine
EMG MUST
BICEPS FUCTION MUST
RETURN TO NORMAL
(If Not)
IF NOT OPERATE

21. WHY 3 MONTHS?
• Muscle Survives Denervation For 1.5 years
• Nerve Grows at 3cm/month

22. Splinting to avoid
ADDUCTION AND INTERNAL
ROTATION CONTRACTURE

23. Surgical Options
• MICROSURGERY: 1)SUPRASCAPULAR TO SPINAL
ACCESSORY COAPTATION
• 2)Thoracic Intercostal nerves to
Musculocutaneous
• Newer Donor Nerves: 1) Opposite C7 root For C8
T1
• 2)OBERLIN: Ulnar to Musculocutaneous

24. LATE PRESENTATION
WITH CONTRACTURES
MALLET GRADING

26. ZANCOLLI CLASSIFICATION OF
SHOULDER SEQUELE

27. Lateral Rotation Osteotomy Of
Humerus

29. Post Op Care
• Splinting for 6 weeks
• Gradual ROM of Shoulder and Elbow

30. Zancolli Procedure

32. Post op Care
• Splinting for 4 weeks
• Passive ROM of Elbow 4 times a day with
supination and pronation
• Night times A Plastic Splint Maintaining
Forearm in Full Pronation and Elbow in 30 deg
Flexion

33. DIFFERENTIAL DIAGNOSIS
• Fracture Clavicle/Humerus
• Septic Arthritis of Shoulder/acute
osteomyelitis
• Spinal cord/Plexus Tumors: RARE
• Parsonage-Turner Symdrome:RARE

34. ADULT/TRAUMATIC BRACHIAL PLEXUS
INJURY
NARAKAS RULE OF 70
• 70% RTA
• 70% MOTORCYCLISTS
• 70% COMBINED INURIES
• 70% SUPRACLAVICULAR
• 70% ONE ROOT AVULSION
• 70% C7 C8 T1

35. MECHANISM OF INJURY
• Increased Shoulder-neck angle—Upper Trunk
• Increased Scapulohumeral angle—Lower trunk
• Supporting tissue anchoring to vertebral
foramina for C5 C6>>>C8 T1
• Cranial structures Stretch/Rupture
• Caudal Structures Avulsed

39. CLINICAL FEATURES
• INSPECTION: Clavicle area
Muscle wasting
• PALPATION : Clavicle
Tinel sign: Absent Avulsion is
suspected
C6 Thumb
C7 Middle finger
C8 Little finger

40. CLAVICLE #

41. PREGANGLIONIC SIGNS
• Horner’s : Ptosis,Miosis,Enophthalmos
• Anhydrosis,Ciliospinal reflex—CNS Problem
• Winging of Scapula
• Absent Tinels
• Global Palsy
• Profound Neurologic pain

42. “WALK” ALONG NERVES
• Phrenic (Diaphragm)
• Long Thoracic Nerve(Serratus Anterior)
• Dorsal Scapular nerve(Rhomboids)
• Suprascapular nerve(Supraspinatus,Infraspinatus)
• Axillary nerve(Deltoid Teres Minor)
• Thoracodorsal nerve(Latissimus dorsi)
• Upper and Lower subscapular nerve(Subscapularis,Teres Major)
• Medial and Lateral Pectoral nerve (Pectoralis major)
• Musculocutaneous nerve(Biceps Brachii)
• Radial Nerve
• Median Nerve
• Ulnar nerve

43. MOTOR SYSTEM
ROOTS
SERRATUS ANTERIOR
(C5,6,7)

44. RHOMBOIDS(C4,5)

45. TRUNKS
Suprascapular nerve C5 C6

46. LATISSIMUS DORSI C6,7,8

47. Subscapular nerve (C5,6)

49. BURNER-STINGER SYNDROME
• Also known as "dead
arm syndrome" or
brachial plexopathy
– refers to transient
brachial plexus
neuropraxi

50. • Presentation
• Symptoms
– unilateral tingling in arm not typically isolated to a single
dermatome
– usually resolve quickly in 1-2 minutes
• Physical exam
– full cervical ROM
– no tenderness
– unilateral transient weakness in C5, C6 muscles (deltoid,
biceps)
• Investigations:
• Xray : C spine
• MRI: Only in Bilateral cases
• Treatment:
• Conservative

51. INVESTIGATIONS
• DAY 1: XRAY CLAVICLE
CHEST
• 3-4 WEEKS:CT/MRI:Pseudomeningocele
• Electrodiagnostic : 1)Root avulsion
2)Level/Type of Nerve injury
3)Nerve recovery

52. Acute Cases
TREATMENT
OPEN/VASCULAR
IMMEDIATE Surgery
CLOSED
1)Passive
Mobilisation
2)Pain Management
3)Splints

53. Aeroplane Splint

54. Indications for Conservative
Management
• Post Ganglionic (Neuropraxia)
• Progressive Motor March
• Progressive TINEL sign

55. Indications for Surgical management
• Pre ganglionic Avulsion at 6 weeks
• Post Ganglionic after 3 months

56. AIMS OF SURGERY
• Shoulder Stability : Abduction and External
rotation
• Elbow Flexion
• Median Nerve Sensations
• Finger Flexion

57. • C5 6 7 –can repair
• C8 T1 – Inaccessible,close to Major vessels
very short and direct repair is difficult

58. Primary Nerve Reconstruction
• Neurolysis:Neuroma In Continuity
• Direct Nerve repair-Rarely Possible
• Nerve Grafting
• Nerve Transfer
• Functioning Free Muscle transfer (FFMT)

59. Approach

60. Nerve Grafting
• Indications : Post ganglionic rupture
• Prerequisites : Proximal nerve available
Muscle targets Not Distal
Graft Length (<10cm)

62. Nerve Transfer
• Def: Transfer of normal fascicle or nerve
branch to a important motor/sensory that has
sustained irreparable damage
• Indications:
• Irreparable preganglionic
• Selected post ganglionic
• Reinnervation of FFMTs

63. Spinal Accessory to Suprascapular
• Indications:C5 6 7 and Complete plexus injury
<6-9 months
Post op care:
Shoulder immobilsation 3 weeks
EMG at 6 months

66. Ulnar to Musculocutaneous
• Indications:Elbow flexion with C5 6
Occassionally for C5-7 with
preserved ulnar/median nerve
Post op care:Immobilisation for 3 weeks
Reinnervation at 6 months

69. Intercostal Nerve Transfer to
Musculocutaneous
• Indications:C5-7
• 3-6 intercostal nerves
• Risk of pleural tear

71. FFMT(Functioning Free Muscle
transfer)
• Definition:Microvascular transfer of muscle with
its nerve to restore function
• Prerequisites:
• First 3-6 months
• Restoration of Shoulder stability
• Antagonist muscle—Normal (eg;In elbow Triceps
should be Normal)

72. Selection of Donor Muscle
• Must have Vascular
Pedicle
• Sufficient Length
• Sufficient Excursion
• Adequate Force
• Expendable
• GRACILIS
• Latissimus Dorsi
• Rectus Femoris

73. PROCEDURE

75. Post op Protocol
• Elbow immobilised in 100 deg flexion and
neutral supination for 6 weeks
• After 6 weeks—Passive Mobilisation
• Extension avoided beyond 30 deg for 3
months

76. SAHA TRAPEZIUS TRANSFER
• Indications for trapezius transfer:
Failure of nerve repair
• Late brachial plexus injuries
• Trapezius full strength against resistance
• A normal glenohumeral joint and Passive abduction of at
least 80°
Contraindications for trapezius transfer:
Trapezius strength less than M4 on MRC scale
• Advanced degenerative arthritis of glenohumeral joint
• Old unreduced shoulder dislocation

78. SECONDARY RECONSTRUCTION
1)SHOULDER
• Trapezius
• Latissimus dorsi
• Pectoralis Muscle transfer
• Shoulder Arthrodesis

79. SHOULDER ARTHRODESIS
Indications
• Neglected/Failed cases with Gleno-humeral
instability.
• Total/upper Plexus Palsy
• Good strength of Trapezius/Rhomboid
Complications
Post op Fracture of Humerus
Risk of Non-union

81. Post op Care
• Shoulder immobilisation for 3 months

82. 2)Elbow
• STEINDLERs RELEASE(Flexor-Pronator Muscle
Transfer)
• Triceps-Biceps Transfer
• Latissimus Dorsi Transfer

83. Steindler’s Release
Indications
• Inadequate elbow flexion
• Normal power of Forearm Pronator-Flexor

85. Post op care
• Immobilisation elbow 100 deg flexion for 6
weeks
• Passive flexion of elbow,wrist,fingers after
surgery
• Active by 3 weeks

86. THANK YOU

87. References
GREENs OPERATIVE HAND SURGERY
Tachdjian's Pediatric Orthopaedics
Netters Atlas of Anatomy