2. 12-8
Brachial Plexus
Formed by ventral rami of
spinal nerves C5-T1
Five ventral rami form
three trunks that separate into
six divisions (ant. & post.) that
then form cords that give rise
to nerves
•The three posterior divisions unite to form
the posterior cord,
•the anterior divisions of the upper and
middle trunks unite to form the lateral
cord,
•and the anterior division of the lower
trunk continues alone to form the medial
cord.
These three cords embrace the axillary
artery in the relationships that their names
imply.
3. • The surgically important nerves arising from the brachial
• plexus are
•
• The long thoracic nerve C5, C6, and C7, innervates the serratus
anterior
• The dorsal scapular nerve arises from the C5 root, it innervates the
levator scapulae, the rhomboideus major, and the rhomboideus
minor.
• These two are the only nerves that leave the roots before their union
to form the trunks.
• The only surgically significant nerve to arise from a trunk is the
suprascapular,
• This is the first important branch seen when the plexus is explored
• superior to the clavicle.
• It supplies the supraspinatus muscle and, after proceeding
• around the lateral border of the scapular spine, supplies the
infraspinatus muscle.
• No branches arise from the divisions of the plexus.
4.
5. 1. Lateral Cord: Lateral pectoral nerve
Musculocutaneous nerve
Continues to join medial cord to form
median nerve
2. Medial Cord: Medial Pectoral nerve
Medial brachial cutaneous
Medial antebrachial cutaneous nerves
Median nerve
Ulnar nerve
3. Posterior cord: Upper and lower subscapular nerves
The thoracodorsal nerve,
Axillary nerve
Continues as Radial Nerve
8. ETIOLOGY AND CLASSIFICATION
OF BRACHIAL PLEXUS INJURIES
• In military combat, penetrating wounds
• In civilian life, injuries related to birth, missiles, stab
wounds, traction applied to the plexus during falls,
vehicular accidents, sports activities.
• In most large series, motorcycle accidents are the most
common cause.
9. • Common associated injuries include:
• fractures of the proximal humerus,
• the scapula,
• the ribs,
• the clavicle, and
• the transverse processes of the cervical vertebrae
• dislocation of the shoulder, the
acromioclavicular, and the sternoclavicular
joints.
10. Grades of Injury
• Grade 1 – Neuropraxia
– Disruption in nerve function that produces numbness and tingling
– Symptoms usually resolve within several minutes
– Due to temporary conduction block with demyelination at the site of
injury.
– The Tinel sign is absent and electrophysiologic studies are negative.
• Grade 2 – Axonotmesis
– Damage to the nerve’s axon
– Symptoms = numbness, tingling, and affected function (may last several
days) tinels sign +
– Electrophysiologic study reveals decreased nerve conduction velocity and
regional muscle denervation changes with fibrillations.
• Grade 3 – Neurotmesis
– Permanent nerve damage occurs
– “Occurs with high-energy trauma, fractures, and penetrating injuries”
– No conduction on electrophysiology and no recovery are expected unless
surgery is performed.
11. Classification
• Brachial Plexus injuries can be classified in various ways:
• As per site
▫ Root
▫ Cord
▫ Trunk
▫ or Nerve level injury
▫ Often a mixture of all
• Which roots
▫ Upper plexus i.e. C5C6+/-C7 or
▫ Lower plexus C8T1
▫ Global C5C6C7C8T1
• Relation to clavicle
▫ Supra clavicular
▫ Retro clavicular
▫ Infra clavicular.
Leffert classification
▫ Pre-ganglionic
▫ Post - ganglionic
12. • Patient evaluation
• Consists of:
• A detailed history and noting the date of injury
• Complete clinical examination Muscle charting
• Sensory charting
• Noting associated trauma like fracture clavicle
• Checking radial pulse for subclavian artery injury
• Horner's sign
• Detailed electrophysiology report
• Imaging.
13. DIAGNOSIS OF BRACHIAL
PLEXUS INJURIES
• Upper Lesions of the Brachial Plexus (Erb’s
Palsy): resulting from excessive displacement of
the head to opposite side and depression of
shoulder on the same side.
• This causes excessive traction or even tearing
of C5 and C6 roots of the plexus. It occurs in
infants during a difficult delivery or in adults after
a blow to or fall on shoulder.
14. Effects: Motor:
paralysis of
the supraspinatus,
infraspinatus,
biceps brachii,
part of brachialis,
coracobrachialis;
deltoid
teres minor.
Supinator
Sensroy: sensory loss on d e l t o i d a n d the
lateral side of the forearm and hand
Abduction impossible
Ext roatation impossible
Flexion impossible
Flexion impossible
Flexion impossible
Abdduction impossible
Ext roatation impossible
Supination impossible
15. Deformity:
waiter tip postion
c. limb will hang by the side,
d. medially rotated by sternocostal part
of the pectoralis major;
e. pronated forearm (biceps paralysis)
17. • Injury in which the roots of the upper plexus are
avulsed from the spinal cord always should be
recognized because surgical repair is impossible.
• It can be diagnosed by finding segmental motor
and sensory deficits involving the C5 and C6
roots with paralysis of the serratus anterior, the
levator scapulae, and the rhomboids, indicating
that the lesion of the nerve roots is medial to the
emergence of the long thoracic and dorsal
scapular nerves that supply these muscles.
18. Lower Lesions of the Brachial Plexus
(Klumpke Palsy)
traction injuries by excessive abduction of
the arm
i.e. occurs if person falling from a height
clutching at an object to save himself or
herself.
Can be caused by cervical rib.
T1 is usually torn (ulnar and median
nerves)
19. Motor Effects: paralysis of all the
small muscles of the hand.
Sensory effects: loss of sensation
along the medial side of the arm,
forearm and hand
Deformity: claw hand caused by
hyperextension of the
metacarpophalangeal joints and
flexion of the interphalangeal
joints.
20.
21. Injuries to the upper or lower trunks of the plexus produce essentially the
same sensory and motor deficits as do injuries to their respective rami
except for preservation of function of the long thoracic and dorsal scapular
nerves in the upper trunks and absence of Horner syndrome in the lower
trunks.
Isolated injuries of the divisions of the plexus are extremely rare.
22. Injuries of the cords produce fairly regular patterns of altered function.
Injuries of the lateral cord :
cause motor and sensory deficits in the distribution of the
•Musculocutaneous nerve (paralysis of the biceps),
•the lateral root of the median nerve (paralysis of the flexor carpi radialis and
pronator teres),
•and the lateral pectoral nerve (clavicular head of the pectoralis major).
Glenohumeral subluxation may result.
23. Injuries of the posterior cord
cause motor and sensory deficits in the distribution of the following nerves:
•Subscapular nerve (paralysis of the subscapularis and teres major),
•the thoracodorsal (paralysis of the latissimus dorsi),
•the axillary (paralysis of the deltoid and teres minor),
•and the radial (paralysis of extension of the elbow, wrist, and fingers).
The disability consists mainly of inability to internally rotate the shoulder, elevate the
limb, and extend the forearm and hand.
Sensory loss most often is apparent only in the autonomous zone of the axillary nerve
overlying the deltoid muscle.
24. Injuries of the medial cord :
produce the motor deficit of a combined ulnar and median nerve lesion (except
for the flexor carpi radialis and pronator teres) and extensive sensory
loss along the medial aspect of the arm and hand.
25. Peripheral Nerve Tests
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
• Sensory – Pad of Index
• finger
• Motor – Thumb pinch
and abduction
• Sensory – Pad of little
finger
• Motor – Finger abduction
Median N.
Ulnar N.
26. Reflex Tests
• C5 – Biceps brachii reflex (anterior arm near
antecubitalfossa)
• C6 – Brachioradialis reflex (lateral aspect of
forearm)
• C7 – Triceps brachii reflex (at insertion of
tricepbrachii)
• C8 and T1 do not have reflex tests
27. Investigations
1. Clinical Examination/History
2. CT scan
3. CT Myelogram
4. MRI
5. The cutaneous axon reflexes have been found to be
useful in differentiating preganglionic intraspinal lesions
from postganglionic extraspinal lesions
5. Electrodiagnostic studies can be obtained as early as 3
to 4 weeks after injury to confirm the diagnosis, localize the
lesion, and assist in determining the severity of axonal loss
and completeness of the injury.
6. Sensory nerve action potentials (SNAPs): differentiate
preganglionic from postganglionic injuries.
28. Treatment
INDICATIONS FOR SURGERY
Open injuries : caused by sharp objects or missiles. When components of the
plexus have been cut by sharp objects, when the patient is seen soon after injury,
and when the patient’s general condition permits, exploration and primary repair
can be attempted.
Usually, injuries to adjacent vessels or to the mediastinal or thoracic viscera must
be treated first, however, and repair of the plexus injury must be delayed. In these
situations, the plexus should be inspected and the injured parts marked with wire
sutures to make later evaluation and treatment easier.
When the patient is not seen soon after injury but only after the initial
management, it is best to wait for healing of the wound and stabilization of any
other injuries. During this waiting period, the extremity should be examined
carefully and the neurological deficits should be documented to determine
the level of injury and to determine a baseline for later evaluation. EMG
performed 3 to 4 weeks after injury also is helpful in determining the level of the
injury.
29. •Closed injuries: most often are either lower plexus injuries or upper plexus.
• Infraclavicular brachial plexus injuries are less common than supraclavicular injuries,
•These injuries usually are associated with fractures or dislocations around the shoulder.
•Surgical treatment rarely is necessary.
•In treating closed injuries, EMG should be done at 3 to 4 weeks as in open injuries.
•Observation and physical therapy should be continued, and at 6 to 8 weeks, additional
studies, including myelography and axon reflex evaluation, can be done if return of
function is not seen.
•Exploration is justified at 3 to 6 months after injury if function has not returned, if
any return has ceased, or if the patient shows nonanatomical return of function.
30.
31. SURGICAL GOALS
Order of priority:
(1) restoration of elbow flexion,
(2) restoration of shoulder abduction, and
(3) restoration of sensation to the medial border of the forearm and hand.
Depending on the extent of injury, various surgical techniques
may be required, including primary neurorrhaphy, neurolysis, nerve grafting, and
neurotization.
32. Neurolysis
When the nerve lesion is in continuity, neurolysis may help. It is of great importance to
maintain the interfascicular structure and the nerve sheath. Usually an anterior
epineurectomy is performed, excising the fibrous tissue. Use of direct nerve stimulation
before and after neurolysis helps us demonstrate the improvement in nerve
conductance.
33. Nerve Grafting
Nerve grafting is the predominant technique for clear cut injuries with a healthy
proximal stump and with no axial damage.
The outcome is influenced by the length of the nerve graft, the presence of scar
tissue at the wound site, the number of grafts used, the presence of a healthy
proximal stump available for grafting and the nerve gap to be covered.
Postoperatively, the nerve should respond to somatosensory evoked potentials
(SEPs).
When damage is extensive, prioritization of certain nerves for repair by grafting is
necessary, especially those associated with elbow flexion, shoulder abduction and
sensation of the forearm.
34. •The sural nerve, the sensory branch of ulnar nerve, and the medial cutaneous nerve of
the forearm are the usual donor nerves.
•The sural nerve may provide up to 40 cm of neural tube.
•The donor site should be in situ until the recipient site is ready.
•Generally, use of nerve grafts shorter than 10 cm results in better functional and clinical
outcomes compared with longer grafts .
•Another choice is vascular nerve grafts when the ulnar nerve is often used.
•Surgical aim is always towards achieving the best fixation without any tension at the
point of anastomosis of the graft .
35. Neurotization
This type of procedure is used for preganglionic root injury in BPI. Neurofibres are
transferred to an irreparable paralytic muscle. Motor branches are used as donors
aiming to achieve motor reinnervation.
The nerve transfer may be extraplexus or intraplexus.
Intraplexus transfer options include intact nerve roots. Other choices include the use of
the medial thoracic nerve and inferior medial cord/ulnar nerve.
Oberlin et al. described nerve transfer to the biceps muscle using part of the ulnar nerve
for C5-C6 avulsion of the brachial plexus.
Extraplexus transfer options include the use of intercostal and spinal accessory nerves.
The phrenic nerve—accessed using an anterior neck approach—and deep motor
branches of the cervical plexus (C3-C4) may be used as donor nerves.
The Oberlin technique is recommended for patients with avulsion of the upper roots and
intake of the lower roots of the brachial plexus .
36. Donor nerves Recipient nerves
Spinal accessory nerve
Suprascapular nerve or
musculocutaneous nerve
Phrenic nerve or intact C5
root
Axillary nerve
Intercostal nerve
Musculocutaneous, long
thoracic nerve, radial, and
medial nerve
Contralateral root C7 Medial nerve
Donor and recipient nerves.
37. If nerve action potentials are obtained during intraop nerve stimulation , simple
neurolysis is indicated.
If neural integrity is completely lost, or if no nerve action potentials are recorded
across a damaged element, excision and nerve grafting is required
In root avulsions of the upper plexus in which no proximal neural stump is available
for nerve grafting, neurotization between the intercostal nerves or flexor carpi ulnaris
motor fascicles of the ulnar nerve and the musculocutaneous nerve to restore elbow
flexion may be considered.
Neurotization of the suprascapular nerve using the spinal accessory nerve as well as
neurotization of the axillary nerve with fascicles of the radial nerve innervating the
lateral, medial, or long head of the triceps can be used to restore shoulder
abduction and external rotation.
38. After brachial plexus repair and reconstruction, 12 to 18 months is required to
determine the extent of neural regeneration. If recovery is considered inadequate,
peripheral reconstruction should be considered.
Tendon transfers around the shoulder that may be considered include:
1. Trapezius-to-deltoid transfer as described by Saha to improve abduction of
shoulder
2. Latissimus dorsi transfer to improve external rotation as described by
L’Episcopo to improve external rotation.
The principles of successful tendon transfer procedures are:
1) supple joints prior to transfer, 2) soft tissue equilibrium, 3) donor of
adequate excursion, 4) donor of adequate strength, 5) expendable donor, 6)
straight line of pull, 7) synergy, and 8) single function per transfer.
39. Restoration of elbow flexion is of great importance for a good clinical and functional
outcome. Depending on the level of injury and the degree of reinnervation there are
different types of surgical procedure. The surgical goal is to restore good muscle
strength through a range of elbow motion (30 to 130 degrees). The most commonly
used procedures for elbow are as follows:
•Transfer of the common origin of the flexor forearm muscles to a proximal
section as described by Steindler.
•Transfer of latissimus dorsi muscle to the tendon of the biceps brachialis
provides great muscle strength,
•Transfer of pectoralis major brachial branch tendon to biceps (Clark
technique).
40. Shoulder arthrodesis is helpful if active scapulothoracic motion is
preserved and has been shown to improve elbow flexion by preventing
uncontrolled internal rotation of the shoulder.
Secondly, the motion mobility of the peripheral hand is important as
shoulder arthrodesis has no clinical effect on a paralytic hand whatsoever.
The acromioclaviclural joint, sternum-claviclural joint, and
spaculothoracic joint should be intact. Any dysfunction may affect the
success of arthrodesis.
The shoulder should be fused with only 20 degrees of abduction, 30
degrees flexion, and 30 degrees of internal rotation to allow the patient to
be independent in his daily life with a mean range of 60 degrees abduction
and flexion through the scapulothoracic joint
41. Amputation rarely is performed.
If the patient is certain that the dead weight of a functionless upper extremity is
disabling, amputation and prosthetic fitting may be helpful.
Amputation should never be performed for pain relief.
