This document discusses brachial plexus injuries, including: - The brachial plexus is formed from spinal nerve roots C5-T1 and provides motor/sensory function to the shoulder, arm, and hand. - Injuries can be classified as upper (C5-C6) or lower (C8-T1) plexus injuries and can result from traction, blows, or compression. - Evaluation involves imaging, electrodiagnostic tests, and assessing individual nerve deficits. - Management depends on if the injury is open or closed. Exploration and repair may be done for open injuries, while closed injuries may recover on their own or later require exploration. -

1. BRACHIAL PLEXUS INJURIES
MODERATOR :DR. B C PATIL
PROFESSOR
DEPT OF ORTHOPAEDICS
MRMC GULBARGA
PRESENTER :DR.RAMACHANDRA

2. • The Brachial Plexus is a large & very imp
plexus of nerves.
• Situated partly in neck & partly in axilla.
• Brachial Plexus formed by union of ventral
rami of nerves C5 to C8 & greater part of
T1 ventral ramus.
• Rami that form Brachial Plexus are often
referred to as roots of Brachial Plexus.
• They lie between scalenus anterior &
medius muscle.
ANATOMY OF BRACHIAL PLEXUS

3. • The ventaral rami from C5 & C6 unite to
form superior trunk.
• C7 continues as inferior trunk.
• C8 & T1 unite to form inferior trunk.
• Each of 3 trunks divides into anterior &
posterior divisions.

4. • The 3 posterior divisions unite to form
posterior cord.
• Anterior divisions of superior & middle
trunks unite to form lateral cord.
• Anterior division of inferior trunk continues
as medial cord.
• Cords of Brachial Plexus bear their name
in relation to their position to axillary
artery.
• Each cord of Brachial Plexus divides into
two terminal branches.

5. • Brachial Plexus includes five components
• 5 Roots
• 3 Trunks
• 2 Divisions
• 3 Cords
• Terminal nerves

7. • Branches of the brachial plexus may be described as
supraclavicular and infraclavicular.
Supraclavicular branches
• Supraclavicular branches arise from roots or from trunks
as follows:
From roots
• 1. Nerves to scaleni and longus colli C5, 6, 7, 8
• 2. Branch to phrenic nerve C5
• 3. Dorsal scapular nerve C5
• 4. Long thoracic nerve C5, 6 (7)
From trunks
• 1. Nerve to subclavius C5, 6
• 2. Suprascapular nerve C5, 6

8. Infraclavicular branches
• Infraclavicular branches come from the
cords, but their axons may be traced back
to the spinal nerves:
Lateral cord
• Lateral pectoral C5, 6, 7
• Musculocutaneous C5, 6 7
• Lateral root of median C(5), 6, 7

9. Medial cord
• Medial pectoral C8, T1
• Medial cutaneous of forearm C8, T1
• Medial cutaneous of arm C8, T1
• Ulnar C(7), 8, T1
Posterior cord
• Upper subscapular C5, 6
• Thoracodorsal C6, 7,8
• Lower subscapular C5, 6
• Axillary C5, 6
• Radial C5, 6, 7, 8, (T1)

10. CLOSED
• a) Traction lesions
• b)Radiation induced
• c)Neoplastic
• d)Post operative
Brachial Plexus Lesions:
ETIOLOGY:
OPEN
• Gun shot wounds
Lacerations
• During surgeries
• Orthopaedic related
• Needles & cannulas

11. • MC cause in large series is motor cycle
accidents of 70%.
• In 20% cases a/w rupture of subclavian or
axillary artery.

12. Injury mechanisms:
– Traction or stretch of
the
brachial plexus
– Direct blow
– Compression or
impingement of the
brachial plexus

13. CLASSIFICATION OF BRACHIAL PLEXUS
INJURIES:
• Upper Plexus Injuries(Erb's Palsy)
• Lower Plexus Injuries(Klumpke)
• Leffert classified injuries acc to mech &
level of injury

14. • Preganglionic or supraganglionic injuries
occuring proximal to neural foramen in
which neurons have been seperated from
spinal cord.
• Postganglionic or infraganglionic injuries
occur distal to neural foramen & neurons
remain connected to spinal cord.

15. Upper Brachial Plexus Injuries
• Increase in angle between neck & shoulder
• Traction (stretching or avulsion) of upper
rootlets (e.g., C5,C6)
• Produces Erb’s Palsy
Lower Brachial Plexus Injuries
• Excessive upward pull of limb
• Traction (stretching or avulsion) of lower
rootlets (e.g., C8, T1)
• Produces Klumpke’s Palsy

16. Lower brachial
plexus injuries
Upper brachial
plexus injuries

22. ERB'S PALSY
• Involves C5 & C6 nerve roots.
• Limb is extended at elbow flaccid at side
of trunk & adducted & internally rotated.
• Abduction impossible because of paralysis
of deltoid & supraspinatus m/s.
• ER impossible because of paralysis of
infraspinatus & teres minor m/s.

23. • Active flexion
impossible because
of paralysis
biceps,brachialis &
brachioradialis.
• Pralysis of supinator
m/s causes pronation
deformity of forearm.
• Called as WAITER'S
TIP.

25. Brachial Plexus Lesions of individual
nerve:
Long Thoracic Nerve(C5,6,7):
• Winging of scapula- Serratus Anterior.
Suprascapular Nerve(C5,6):
• Hard to start shoulder abduction.

26. Axillary Nerve(C5,6)
Motor Deficits
• Difficult abducting
arm to horizontal
• Loss of shoulder
roundness
Sensory Deficits
• Lateral side of arm
below point of
shoulder.

27. Musculocutaneous Nerve(C5,6,7)
Motor Deficits
• Very weak flexion of
elbow joint -Biceps &
Brachioradialis.
• Weak supination of
radioulnar joint-
Biceps
Sensory Deficits
• Lateral forearm

28. Radial Nerve(C5-T1) at elbow
Low lesions:
• BR, ECRL, & ECRB are spared.
• Can't extend MCP joints of hand.
• Thumb weakness of abduction & IP joints
extension.

29. Radial Nerve(C5-T1) at radial groove
High lesion:
Motor Deficits
• Wrist Drop-ECRL ,
ECRB & ECU but
triceps & anconeus
m/s spared.
• Difficulty making a fist
-synergy betn. wrist
extensors & finger
flexors.
Sensory Deficits
• dorsum of hand &
anatomical snuff box.

30. Radial Nerve(C5-T1)
Very high lesion
Motor Deficits:
• Saturday Night Palsy/
Crutch Palsy
• Along with weakness
of wrist & hand,
triceps also paralyzed
• Triceps reflex absent
• No sensory deficits as
it is Neuropraxia.
• Best prognosis.

31. Median Nerve(C5-T1) at Elbow
• Pronation of radioulnar
joints
• Weak wrist flexion-FCR
• Weak opposition of
thumb- Thenar m/s.
• Ape Thumb- Thumb
hyper extended &
adducted-Thenar m/s
• Papal Hand-Loss of
flexion of IP joints of
thumb fingers 1 & 2 -
FPL,FDS,FDP.
Sensory Deficits
• Radial portion of palm
• Palmar surface & tips of
radial 3 & 1/2 digits

32. Median Nerve(C5-T1) at Wrist
Motor Deficits
• Weak opposition of
thumb- Thenar m/s.
• Ape Thumb- Thumb
hyper extended &
adducted-Thenar m/s
Sensory Deficits
• Palmar surface & tips
of radial 3 & 1/2 digits

33. Ulnar Nerve(C8,T1)at Elbow
High Lesions:
• Clawing of fingers 3 &
4- MP jts hyper
extended; PIP flexed -
Interossei &
Lumbricals
• Loss of abdn &addn
of MP jts of fingers-
Interossei
• Thumb abd,extended-
Abductor pollices
• Loss of flexion of DIP
jts fingers 4 & 5-FDP
Sensory Deficits
• Ulnar & dorsal aspect
of palm & of ulnar 1 &
1/2 digits.

34. Ulnar Nerve(C8,T1)at Wrist
Low lesions:
Motor Deficits
• Clawing of fingers 3 &
4- MP jts hyper
extended; PIP flexed -
Interossei &
Lumbricals
• Loss of abdn &addn
of MP jts of fingers-
Interossei
• Thumb abd,extended-
Abductor pollices
Sensory Deficits
• Ulnar & dorsal aspect of
palm & of ulnar 1 & 1/2
digits.

36. INVESTIGATIONS
• Imaging Studies
• Electromyogram
• Nerve Conduction Velocity
• Somatosensory Evoked Potentials
• Intraoperative Nerve Action Potential
• Myelography
• CT scan for any tumours
• MRI

37. Plain Radiographs
Plain X ray film Findings Significance
Chest Elevated
hemidiaphragm
Phrenic injury, proximal
plexus, and possible
preganglionic avulsion
First rib fracture Subclavian or axillary
artery injury – Lower
trunk injury
C – spine Fracture or dislocation Cervical spine injury
Transverse process # Preganglionic avulsion
injury
Clavicle Fracture Possible traction injury
to plexus or
pseudoparalysis
Shoulder Glenohumeral
dislocation
Infraclavicular injury
Scapulothoracic Severe neurovascular

38. MANAGEMENT
• Closed Brachial Plexus Injury
• Open Brachial Plexus Injury

39. Closed Brachial Plexus Injury
• Barnes divided Upper & Lower Plexuses
injuries caused by traction into four groups
• 1)Injuries at C5 & C6
• 2)Injuries at C5,C6 & C7
• 3)Degenerative lesions of entire plexus
• 4)Injuries at C7,C8 & T1 (rare)

40. • Barnes reported that spontaneous
recovery in group 1 & 2 cases
• But in case of Degenerative plexuses
injuries there is partial recovery.
• EMG should be done at 3 to 4 wks
• At 6 to 8wks additional studies like
myelography & axon reflex evaluaton can
be done if return of functions not seen.
• Exploration is justified at 3 to 6 mths after
injury if function has not returned.

41. Open Brachial Plexus Injury
• Indications for Surgery:
• Injuries caused by sharp objects or
missiles.
• When pt seen soon after injury & pt's
general condition permits exploration &
primary repair can be done.

42. • When pt not seen soon after injury but
only after initial management,
• It is best to wait for wound healing &
stabilization of any other injuries.
• During this period locate neurological
deficit for level of injury.
• EMG performed 3 to 4 wks after injury.
• Exploration of plexus & neurorrhaphy,
autogenous interfascicular nerve grafting
or neurolysis is indicated 3 to 6wks after
injury.

43. • Motor function recovered to a grade of 3
or better in half of pts.
• Best results obtained in upper trunk &
lateral cord & posterior cord injuries.
• Poor prognosis can be expected in lower
trunk injuries.

44. SURGICAL GOALS
In order of priority as follows:
1)Restoration of elbow flexion
2)Restoration of shoulder abduction
3)Restoration of sensation of medial border
of forearm & hand.

45. • Depending on extent of injury various
surgical techniques may be required:
• Primary neurorrhaphy
• Neurolysis
• Nerve grafting
• Neurotization

46. • Direct intraoperative nerve stimulation &
recording used to repair nerve.
• If nerve action potentials are obtained
simple NEUROLYSIS is indicated.
• If neural integrity is completely lost or if no
nerve action potentials recorded across a
damaged element EXCISION & NERVE
GRAFTING is required.

47. • In ROOT avulsion of upper plexus in
which no proximal neural stump is
available for nerve grafting,
• To restore ELBOW FLEXION
neurotization between intercostal nerves
or FCU motor fascicles of ulnar nerve &
musculocutaneous nerve may be
considered.

48. • For ELBOW FLEXION latismus dorsi &
triceps muscle transfers to be the most
reliable as reviewed by Marshall et al..
• Amputation considered when dead weight
of a functonless upper extremity is
disabling & prosthetic fitting may be
helpful.
• Amputation should never be performed for
pain relief.

49. • To restore SHOULDER ABDUCTION &
ER neurotization of suprascapular nerve
using the spinal accessory nerve done.
• Neurotization of axillary nerve with
fascicles of radial nerve innervating lateral,
medial, or long head of triceps can be
used.

51. After Brachial plexus repair & regeneration
12 to 18 mths required to determine extent
of neural regeneration.
If recovery inadequate
Peripheral reconstruction considered

52. Can be divided into 3 groups
• 1) Tendon transfer without open reduction
• 2) Open reduction with concomitant
tendon transfer
• 3) Salvage procedures for older pts with
severe glenohumeral deformity
SURGICAL INTERVENTION

53. • To improve shoulder ABDUCTION & ER
• Tendon transfer around shoulder
considered include TRAPEZIUS TO
DELTOID transfer as described by Saha
FOR ABDUCTION &
• LATISMUS DORSI & TERES MAJOR
transfer as described by L'Episcopo FOR
ER of shoulder jt.

54. • Anterior shoulder release:
• First described by Fairbanks & modified by
Sever
• Main indication is iatrogenic internal
rotation contracture & imbalance betn
shoulder internal & external rotation.

60. Guidelines for arthroscopic treatment of contractures &
deformity sec to brachial plexus birth palsy

61. DHANYAVAAD