This document discusses the anatomy, types of injuries, clinical presentation, investigations and classification of brachial plexus injuries. It describes the formation of the brachial plexus from the cervical nerve roots and its divisions. Injuries can be preganglionic or postganglionic, and include traction injuries, avulsions or lacerations. Clinical exam focuses on assessing motor and sensory deficits. Investigations include imaging like MRI/CT, myelography and EMG/NCV to localize the lesion. Seddon's classification is used to describe the severity of injury.

2.  5 weeks of gestation
 Afferent fibers from neuroblast located alongside
neural tube
 Efferent fibers from neuroblast in the basal plate
of tube from where they grow outside

3.  Afferent and efferent fibers join to form
the nerve
 Nerves divide into anterior and posterior
divisions
 There are connections between these
nerves in the brachial plexus

10.  There are few terminal branches of the roots trunks
and cords.
 ROOTS: a)dorsal scapular nerve b)branch to phrenic
nerve c)Long thoracic nerve
 TRUNKS: a)nerve to subclavius b) suprascapular
nerve
 CORDS: a) Lateral cord gives lateral pectoral nerve
b)Posterior cord gives upper subscapular, lower
subscapular and thoracodorsal nerve.

13.  Found in around 50%
 Most commonly pre-fixed(28-62%) and
post-fixed(16-73%)

16.  Anatomy of rootlets, roots and vertebral foramen
contribute to the type of injury
 Rootlets forming the cervical roots are intraspinal
and lack connective tissue or meningeal envelope.
 Vulnerable to traction and susceptibility to avulsion
at the level of cord.

17.  Fibrous attachment of spinal nerves to the
transverse process seen in the 4th through 7th
cervical roots
 This explains the high incidence of root avulsions
in C8-T1 roots
 The spinal nerve able to move freely in the
foramina due to non attachment to it

18.  Common :Birth injuries, motor vehicle
trauma, sports injuries
 Rare :Gunshot wound, Stab injury
Irradiation, Pancoast tumor
 Chronic microtrauma : Backpacker’s
palsy, Painters

19.  Narakus' "law of seven seventies," based on experience
with more than 1,000 patients over an 18-year
span, estimates the current demographics:
 70% of traumatic brachial plexus injuries (BPIs) are due to
motor vehicle accidents.
 70% of the vehicle accidents involve motorcycles or
bicycles.
 70% of the cycle riders have associated multiple injuries.
 70% have a supraclavicular lesion.
 70% of those with supraclavicular lesions have at least one
root avulsed.
 70% of patients with root avulsions have the lower roots
(C7, C8, Tl or C8, Tl) avulsed.
 70% of patients with lower-root avulsions experience
persistent pain

20.  Usually closed injuries
 95% traction injuries, 5% compression injuries
 Supraclavicular more common than infraclavicular
involvement
 Roots and trunks most commonly involved
 Root avulsions: 2 mechanisms
peripheral- common
central- rare

22.  Infraclavicular injuries occur at cords or peripheral
nerves and usually incomplete
 Caused by shoulder fracture or dislocation
 5- 25% of infraclavicular injuries are associated
with axillary artery injury
 Penetrating injuries are usually infraclavicular

25.  in as many as one in 250 births
 High birth weight, prolonged labor,breech
presentation, and shoulder dystocia
 Produced by traction on the neural elements for
example, stretching of the brachial plexus with
forced lateral flexion of the head and neck or
excessive pull of limbs over head

27.  Pain, especially of the neck and shoulder
 Pain over a nerve common with rupture, as
opposed to lack of percussion tenderness with
avulsion
 Paresthesias and dysesthesias
 Weakness or heaviness in the extremity
 Diminished pulses, as vascular injury may
accompany traction injury

28.  Sensory examination extremely important
 Deep pressure sensation may be the only clue to
continuity in a nerve with no motor function or
other sensation
 Apply full pinch to the nail base and pull the
patient's finger outward ;any burning suggests
continuity of the tested nerve

29.  According to the location of injury, extension
throughout the plexus, and the degree of the
damage
 Based on a thorough physical examination, BPI
divided into preganglionic and postganglionic
injuries.
 Prognostic and therapeutic implications

31.  Avulsion of the nerve root proximal to the spinal
ganglion
 Dorsal rami interrupted, denervation of dorsal neck
muscles ( rhomboids, serratus anterior, ) Changes
in EMG

32.  No proximal stump or neuroma formation, No Tinel
sign present
 Meningocele formation due to dural and arachnoid
lesion with avulsed roots
 Myelographic leak
 Roots not visible on CT

34.  Associated Horner's syndrome or a fracture of the
transverse process of the adjacent cervical vertebra
 Nerve fibres to skin in continuity with neurons in
the spinal ganglion
 No wallerian degeneration of sensory nerve fibres
 Positive nerve conduction

36.  Depending on the number of roots
avulsed, Preganglionic BPI generally falls into one
of three categories:
 A completely flail arm with avulsion of all roots
(C5-T1)
 A lower avulsion of the C8-T1 roots
 An upper lesion in which only the C5 and C6 roots
avulsed

37.  Limb extended at the elbow, flaccid at the side of
the trunk, and adducted and internally rotated
 Paralysis of the supinator muscle causes pronation
deformity of the forearm and inability to supinate
the forearm.
 Sensation absent over the deltoid muscle and the
lateral aspect of the forearm and hand.

38.  Segmental sensory and motor deficits involving C8
and T1

 The primary dysfunction : apparent in the intrinsic
musculature of the hand along with paralysis of the
wrist and finger flexors
 The sensory deficit along the medial aspect of the
arm, forearm, and hand

39.  Distal to the spinal ganglia (proximal stump with
neuroma formation)
 Tinel’s sign positive, myelography negative, EMG
normal, roots visible on CT, Nerve conduction
abnormal
 Postganglionic injuries further subdivided into
trunk and cord injuries

40.  Elicited by placing a drop of histamine on the skin
along the distribution of the nerve being examined
 Skin scratched through the drop of histamine :
cutaneous vasodilation, wheal formation, and flare
response
 Nerve interrupted proximal to the ganglion
:anesthesia along its cutaneous course, normal
axon response
 Injury is distal to the ganglion : anesthesia along
the course of the nerve, and vasodilation and wheal
formation seen, flare response absent

41.  Long thoracic nerve ( serratus anterior muscle)
intact
 Suprascapular nerve involved
 Upper trunk lesions ( paralysis of shoulder
muscles & biceps brachii)
 Middle trunk lesions :Radial nerve palsy
 Lower trunk lesions: ulnar & median nerve palsy

42.  Long thoracic nerve, Suprascapular nerve &
pectoral nerve intact
 Posterior, lateral cord & medial cord lesions

43.  Motor and sensory deficits in the distribution of :
 musculocutaneous nerve (paralysis of the biceps)
 lateral root of the median nerve (paralysis of the
flexor carpi radialis and pronator teres)
 lateral pectoral nerve (clavicular head of the
pectoralis major).
 Sensory deficit over the anterolateral aspect of the
forearm in the relatively small autonomous zone of
the musculocutaneous nerve

44.  Subscapular (paralysis of the subscapularis and
teres major)
 Thoracodorsal (paralysis of the latissimus dorsi)
 Axillary (paralysis of the deltoid and teres minor)
 Radial (paralysis of extension of the
elbow, wrist, and fingers)
 Sensory loss in the autonomous zone of the
axillary nerve overlying the deltoid muscle

45.  Motor deficit of a combined ulnar and median
nerve lesion (except for the flexor carpi radialis and
pronator teres)
 Extensive sensory loss along the medial aspect of
the arm and hand

46.  Upper plexus lesions (C5, C6)
 Extended upper plexus (C5,C6,C7 )
 C7 Lesions
 Lower plexus lesions (C8, T1 )
 Peripheral lesions

47. Seddon’s classification:
 Neurapraxia ( traction/ compression, recovery is
rule )
 Axonotmesis ( section of nerve with intact
sheath, wallerian degeneration, recovery in 6/8
weeks)
 Neurotmesis (complete section, surgical repair)

49.  Radiographic evaluation
◦ In anteroposterior (AP) chest radiography, specific
attention directed to the distance between the
spinous processes of the thoracic spine and the
scapula
◦ If the radiograph not malrotated, an increase in
this distance compared with the contralateral side
may indicate scapulothoracic dissociation

50.  Gold standard
 The most reliable indicator of root avulsion : an
absent root shadow on plain myelography
 A common sign of a root avulsion: meningocele at
the affected level
 Delayed for 4 weeks so that any blood clot will not
be dislodged by the study and the meningocele can
be allowed to form

52.  Fast spin echo (FSE-MR)
 Useful in infants with obstetric palsy
 Noninvasive and can be performed under sedation
 Postmyelography MRI and CT : mainstays of
imaging brachial plexus injuries

53.  Confirm a diagnosis
 Localize lesions
 Define severity of axon loss and completeness of
lesion
 Serve as an important adjunct to thorough
history, physical exam and imaging study

54.  For closed injuries EMG and NCV best performed 3
to 4 weeks after the injury because wallerian
degeneration will occur by this time

55.  Denervation changes(fibrillation potentials) seen in
proximal muscles 10 to 14 days and 3 to 6 weeks
post injury in most distal muscles
 Reduced MUP(motor unit potential) recruitment
shown immediately after weakness from LMN injury
 Presence of active motor units with voluntary effort
and few fibrillations at rest good prognosis
 Distinguishing preganglionic from postganglionic
lesions

56.  NAP (nerve action potential )
 SEP (somatosensory evoked potential)
 CMAP (compound muscle action potential)

57.  Differentiates preganglionic from postganglionic
injuries
 If the injury proximal to the dorsal root ganglion
(DRG), no Wallerian degeneration; a SNAP observed
in a nerve with an anesthetic dermatome confirms
a preganglionic lesion
 SNAPs not useful for C5 evaluation, C5 does not
provide a significant contribution to a major
peripheral sensory nerve

58.  Intraoperative SSEPs are useful in brachial
plexus surgery.
 The presence of suggests continuity
between the peripheral nervous system and
the CNS via the DRG.
 Absent in postganglionic or combined pre-
and postganglionic lesions.

60.  A - acute exploration
• concomitant vascular injury
• open injury by sharp laceration
• crush or contaminated wound
 Open injury with low-velocity missile
• Early exploration not indicated, unless injuries to
adjacent vessels or viscera make immediate
treatment necessary
• Condition of the patient prevents extensive repair
or grafting of the plexus
• Injury inspected, its extent documented &
observed

61.  A correct diagnosis of the amount of damage to
the plexus established only by exploration.
 Functional assessment of the nerve made by intra-
operative nerve stimulation
 A non-conducting neuroma resected and the gap
reconstructed with nerve grafts

62.  B - early exploration (1- 2 weeks)
• Unequivocal complete C5- T1 avulsion injuries
• Facilities not available at initial exploration
• Concomitant injuries requiring early care

63.  Complete injuries with no recovery by clinical
examination or EMG at 12 weeks post injury
 Distal recovery without regaining clinical or
electrical evidence of proximal muscle function
 Any return has ceased
 Patient shows non-anatomical return of function
with isolated lack of proximal function in the
presence of good distal nerve recovery

64.  Evidence that the lesions at the postganglionic
level
 Anaesthetic limb, severe deafferentation
pain, Horner’s syndrome and pseudomeningoceles
on imaging
 Postganglionic lesions :follow patients
conservatively for up to 3 months to watch for
spontaneous motor recovery. In upper-plexus
injuries, if the biceps muscle not recovered within
3 months, then surgical exploration

66.  Stretch neurapraxia may regenerate healthy nerve
tissue
 Observation & physical therapy up to 8-10 weeks
for spontaneous recovery
 After 4 weeks a baseline electromyography and
CT/MR myelography should be performed.

67.  Restoration of elbow flexion
 Restoration of shoulder abduction
 Restoration of sensation to the medial border of
the forearm and hand

68.  Neurolysis
 Nerve repair
• Neurorrhaphy
• End to side coaptation
 Nerve graft
 Nerve transfer or neurotization
 Functional free muscle transfer
 Carlstedt et al :reimplantation of avulsed roots

69.  Direct intraoperative nerve stimulation and
recording required across damaged elements
• If nerve action potentials are obtained, simple
neurolysis indicated.
• If neural integrity completely lost, or if no nerve
action potentials recorded across a damaged
element, excision and nerve grafting are required

70.  In root avulsions of the upper plexus in which no
proximal neural stump is available for nerve
grafting, neurotization between the intercostal
nerves and the musculocutaneous nerve to restore
elbow flexion

71.  Effective only if scar tissue seen around nerve or
inside epineurium, preventing recovery or causing
pain
 Pre and post neurolysis direct nerve stimulation is
mandatory to evaluate improvement in nerve
conduction

72.  Sharp transection with excellent fascicular pattern
and minimal scar
 Lesions of the C5 and C6 nerve roots, the upper
trunk, and the lateral cord proximal to the origin of
the musculocutaneous nerve can be treated with
some success

73.  Excellent in small nerves with one function
 Viterbo :BR J Plast surg 1994
 Denervated nerve brought with its cross section
end to side with innervated nerve with creation of
epineural/perineural windows

74.  Indicated for well defined nerve ends without
segmental injuries
 Intraoperatively a good fascicular pattern should be
seen after the neuroma excision
 Possible sources: sural, brachial cutaneous
nerve, radial sensory and possibly ulnar nerve
 Before implantation graft orientation reversed to
minimize axonal branch loss
 Surgical technique the most important factor in
nerve graft

75.  A tension free nerve graft better than a primary
repair under tension
 Thin cutaneous grafts (e.g. sural nerve) prepared
 Graft should be 20% longer than the length of the
nerve defect
 Endoscopic harvesting of the sural nerve graft
devise to overcome the potential drawbacks of the
open technique

76.  Mackinnon et all
 Act as a temporary scaffold across which axons
regenerate
 Ultimately, the allograft tissue completely replaced
with host material
 Tacrolimus, greater potential and fewer side
effects than other
immunosuppressants, neuroregenerative and
neuroprotective effects

77.  Nerve repairs performed with fibrin sealants
produced less inflammatory response and
fibrosis, better axonal regeneration, and better
fiber alignment than the nerve repairs performed
with microsutures alone
 Fibrin sealant techniques were quicker and easier
to use
* J oint Reconstr Microsurg 2006

78.  Help in directing axonal sprouts from the proximal
stump to the distal nerve stump
 Provide a channel for diffusion of neurotropic and
neurotrophic factors and minimize infiltration of
fibrous tissue
 Tubes made of biological materials such as
collagen have been used with more success for
distances of less than 3 cm
 *PS Bhandari, LP Sadhotra, P Bhargava, AS Bath, MK Mukherjee, Pauline Babu Indian Journal of
Neurotrauma (IJNT), Vol. 5, No. 1, 2008

79.  For repair of severe brachial plexus injury, in which
the proximal spinal nerve roots have been avulsed
from the spinal cord
 Ideally performed before 6 months post injury but
may be better suited than grafting in situation after
the preferred 6 months time frame
 A proximal healthy nerve coapted to the
denervated nerve to reinnervate the latter by the
donated axons

80.  The concept is to sacrifice the function of a lesser
valued donor muscle to revive the function in the
recipient nerve and muscle that will undergo
reinnervation
 Transferring a pure motor donor nerve to a motor
recipient nerve gives the best result of motor
neurotization, for example, spinal accessory to
suprascapular neurotization

81.  Recipient site at the peripheral part of the plexus
such as the musculocutaneous nerve, the
suprascapular nerve, or the axillary nerve more
effective than a recipient in the central part such as
the posterior cord or the lower trunk
 Reinnervate the recipient nerve as close to the
target muscle as possible; ex. transfer of an ulnar
nerve fascicle directly to the biceps branch of the
musculocutaneous nerve in close proximity to its
entry into the muscle Frederic et all

83.  Direct suture without tension always superior to
indirect suture with a nerve graft
 Especially true for the weak donor nerves such as
intercostal nerves and the distal spinal accessory
nerve
 Ipsilateral nerve transfer always superior to the
contralateral nerve transfer
 Current trends in the management of brachial plexus injuries Indian Journal of Neurotrauma (IJNT), Vol.
5, No. 1, 2008

84.  A- intraplexal
 B- extraplexal
 Plexoplexal options are undamaged roots

85.  The transfer of a spinal nerve or more distal plexus
component with intact spinal cord connections to a
more important denervated nerve
 Ruptured proximal nerve used
 Examples include connecting the proximal stump
of C5 or C6 to the distal aspect of C8, lower
trunk, or median nerve, or the use of a portion of a
functional ulnar nerve to the musculocutaneous
nerve

86.  Transfer of a non brachial plexus component nerve
to the brachial plexus
 Sources commonly used include spinal accessory
nerve, intercostal nerves, phrenic nerve, deep
cervical motor branches, and contralateral C7
transfer

87.  Neuromuscular neurotization (direct implantation
of motor nerve fascicles in to denervated muscle)
from intraplexal sources

88.  Spinal accessory to surprascapular or
musculocutaneous
 Phrenic to axillary nerve
 Intercostal to musculocutaneous long
thoracic, radial and median nerve
 Long head of triceps nerve to anterior branch of
axillary nerve
 Partial ulnar nerve transfer for elbow flexion
 The contralateral C7 transfer preferred for hand
flexors and sensation in global plexopathies

91.  Through a lateral fourth-rib thoracotomy the motor
portion of the third, fourth, and fifth intercostal
nerves transferred subcutane-ously into the axilla
to be anastomosed to the musculocutaneous nerve

93.  If the interval from BPI to reconstruction delayed
beyond 12 months, the results of surgical
reconstruction with the intercostal nerves alone
have been poor
 Attributed to fibrosis of the motor end plates of the
biceps muscle.
 Under these circumstances, a free innervated
gracilis muscle to replace the biceps

95.  Attachment is made proximally with the gracilis
origin to the coracoid process and distally to the
biceps tendon. After successful vascular
anastomosis of the artery and vein, through an
ipsilateral thoracotomy, intercostal motor nerves to
the third, fourth, and fifth ribs are used to
successfully reinnervate the gracilis

97.  For upper trunk injury with intact lower trunk: 1 to
2 fascicles of ulnar nerve anastomosed to biceps
 Contra lateral C7 used in pan brachial plexopathy
with multiple avulsions and limited donor
possibility
 Contra lateral C7 root extended by means of
vascularised ulnar nerve graft in patient with C8 T1
avulsion and median nerve is the most frequent
recipient
 Another option is transferring nerve to long head
of triceps to anterior branch of axillary nerve

98.  After brachial plexus repair and reconstruction, 12
to 18 months required to determine the extent of
neural regeneration
 If recovery considered inadequate, peripheral
reconstruction considered

99.  The choice of the donor muscle-tendon unit or
units not interfere with existing function
 Adequate strength (a grade of at least 4 of 5) of the
donor muscle must be confirmed
 Avoid transferring a tendon when the muscle of
that tendon was previously paralyzed and has now
recovered.
 The excursion of the donor muscle-tendon unit
must be adequate

100.  Each tendon perform only one function
 The transfer employs a straight line of pull
 When possible, synergism should be employed
such that the simultaneous contractions of
different muscles combine to achieve a desired
function
 Manual or electrodiagnostic testing to check for
inphase firing of planned donors with
nearby, uninvolved motors should be performed
preoperatively, to ensure that transferred motors
and intact motors do not act as antagonists and
prevent active motion

101.  Functional range of motion
 Joint contractures released
 The joint congruent and reduced
 Skin supple without constricting scars
 Trapezius-to-deltoid transfer as described by Saha
to improve abduction and latissimus dorsi transfer
to improve external rotation as described by
L'Episcopo

102.  Deltoid and the clavicular head of the pectoralis
major as prime movers for abduction; they also lift
the humeral shaft
 Subscapularis, supraspinatus and infraspinatus are
a steering group which stabilise the humeral head
in the glenoid.
 The sternal head of pectoralis major, latissimus
dorsi, teres major and teres minor form a
depressor group which alsorotate the shaft and
pull the humeral head downwards during the last
few degrees of abduction.

103.  When any two of the steering group of muscles
were paralysed a single muscle transfer to replace
the deltoid would not provide abduction beyond
90°
 Transfer of pectoralis minor, the upper two
digitations of serratus anterior, latissimus dorsi
and teres major in various combinations.
 Transfers of the levator
scapulae, sternocleidomastoid, scalenus
anterior, scalenus medius and scalenus capitis

104.  Saha’s logical modification of the trapezius transfer
described by Bateman
 Provides a more distal fixation of the transfer after
a more proximal release.
 Greater lever arm, and fracture of the bony
insertion transferred from the acromion allows
better fixation to the narrow cylindrical shaft of the
humerus.
 An important modification to consider transfer for
paralysed musclesof the rotator cuff, to improve
control of the humeral head and prevent
subluxation

105.  Adduction and internal rotation contracture
:Release or recession of subscapularis muscle
 Isolated abduction contracture: Release or
recession of deltoid muscle
 Abduction and external rotation contracture:
Transfer of infraspinatus tendon to teres minor
tendon;release or recession of infraspinatus and
supraspinatus tendons with or without release of
deltoid muscle

106.  Dysfunction of anterior and middle parts of deltoid
muscle (partial reinnervation of paralyzed deltoid
muscle) :Anterior transfer of posterior part of
deltoid muscle
 Dysfunction of supraspinatus or infraspinatus
muscle :Transfer of latissimus dorsi tendon to
greater tuberosity
 Dysfunction of deltoid muscle Transfer of trapezius
muscle with bone to lateral aspect of humerus;
bipolar transfer of latissimus dorsi muscle

107.  Dysfunction of subscapularis muscle :Transfer of
serratus anterior muscle; transfer of
pectoralismajor tendon
 Internal or external rotation deformity with
incongruent glenohumeral joint :Humeral
derotation osteotomy
 Severe dysfunction of shoulder with pain or
instability :Glenohumeral arthrodesis

108.  Reviewed 26 patients treated by trapezius transfer
for deltoid paralysis due to brachial plexus injury
or old poliomyelitis.
 Assessed the power of shoulder abduction and the
tendency for subluxation.
 Good results in 16 patients (60%); five were fair
and five poor.
 Trapezius transfer appears to give reasonable
results in the salvage of abductor paralysis of the
shoulder.
 J Bone Joint Surg [Br] 1998;80-B:114-6.

109.  Division of the clavicle
and the acromion to
allow transfer of the
insertion of the central
part of the trapezius

110.  The transfer unit is
fixed to the humeral
shaft with screws

111.  Radiograph after
operation

112. Active abduction before Active abduction after
surgery. surgery.

113.  Failure due to
persistent anterior
subluxation after
trapezius transfer

117.  Severe combined lesions and the surgeon cannot
reasonably expect to achieve glenohumeral
stability with any of the described soft-tissue
procedures
 To enhance the power of weak elbow flexion or
extension transfers by isolating the forces of the
transfer to the elbow

120.  Fusion in this attitude permits scapular
motion, when combined with elbow motion, to
allow the patient to reach all four major functional
areas: face, midline, perineum, and rear trouser
pocket

121.  Restoration of elbow flexion primary importance
 Elbow flexion restored by intercostal neurotization
or tendon transfer.
 When the pectoralis major and latissimus dorsi
areavailable for transfer, superior results
anticipated

122.  Dysfunction of biceps muscle :Unipolar or bipolar
transposition of pectoralis major muscle; bipolar
transposition of latissimus dorsi muscle; free
microvascular transfer of gracilis rectus
muscle;modified Steindler flexorplasty; anterior
transfer of triceps tendon
 Dysfunction of triceps muscle :Transfer of
latissimus dorsi muscle

123.  When the medial epicondylar muscles a weak or full
extension of the elbow essential for transfer or
ambulation, an alternative procedure considered
 Steindler's procedure when the elbow flexors reach
only grade 2, contrarily contraindicated when the
elbow flexors are classified as grade 0, when the
wrist flexors are weak, or when wrist and finger
extensors are paralyzed

124.  proximal transfer (4 –
5 cm) and fixation of a
piece of the medial
epicondyle with its
attached origin of the
flexor-pronator muscle
group in the middle of
the anterior aspect of
the humerus.

125.  Liu TK. Yang RS. Sun JS. Clinical Orthopaedics & Related Research. (296):104-8, 1993 Nov
 Seventy-one consecutive patients treated with a modified
Steindler flexorplasty from 1970 to 1987. Additional
operative procedures included shoulder fusion (45
patients), tendon transfer (20 patients), and wrist
tenodesis (3). Follow-up averaged 8.2 years. The outcome
excellent in 32%, good in 47%, fair in 13%, and poor in 8%.
Postoperatively, the mean arc of active elbow flexion 114
degrees; the average elbow extension loss, 28 degrees;
the mean active pronation, 74 degrees; and supination, 30
degrees. Wire breakage found in two cases. Additional
tendon transfer of flexor carpi ulnaris to extensor carpi
radialis brevis improved the outcomes in the patients
without active supination.
 The modified Steindler flexorplasty provided predictable
functional improvement in carefully selected patients with
paralyzed upper extremities.

126.  An early but cosmetically unacceptable procedure :
transfer of the sternocleidomastoid muscle which
involves detaching this muscle from its insertion
and linking it to the insertion of the biceps muscle
by means of a long strip of fascia lata

127. Extension Flexion

131. Flexion Extension

133.  In hands in which the superficial flexors of the
fingers and thenar muscles of opposition
denervated, usually as the result of high median-
nerve or brachial plexus injury, thumb opposition
restored by transfer of the superficial flexor of the
ring finger to the thumb through a dynamic pulley
made from the distal segment of flexor carpi
ulnaris which is attached to the extensor carpi
ulnaris, combined with transfer of the proximal
segment of flexor carpi ulnaris to the transferred
paralyzed superficial ring-finger flexor tendon

134.  C5-6 type :
 complete loss of voluntary shoulder and elbow
control, although many can still extend the wrist by
using finger extensors and the extensor carpi
ulnaris. Thumb and index finger sensation
impaired
 Figure-of-8 harness and Bowden cable a used to
provide body-powered elbow flexion, sometimes
with an elbow hinge that can be locked in several
positions; Shoulder subluxation also reduced by su

136.  C5-7 type
 adds radial palsy to the above picture, sensory loss
in the hand increase, but all active extension at the
wrist, hand, and fingers lost
 Possible to add either static or spring-assisted
wrist, hand, and finger extension to the previous
orthosis.

138.  c7- 8 Tl type
 Good shoulder and elbow function but loses finger
flexors, extensors, and intrinsics
 Surgical reconstruction often of particular value
 Those who sustain a concomitant traumatic
transradial amputation : body-powered or switch-
controlled terminal device

139.  C8, Tl type
 Enjoys the greatest percentage of orthotic success
since motor rather than sensory loss significant
 Although finger flexors and intrinsics are
paralyzed, sensory loss is limited to the ring and
small digits, which are not involved in pinch
prehension

143.  In view of the substantial percentage of BPI
amputees who reject prosthetic devices, it has been
argued that orthotic restoration is an equally
plausible alternative. Wynn Parry has reported his
experience with a series of over 200 cases and
states that 70% continue to use a full-arm orthosis
for work or hobby activities after 1 year
 Wynn Parry CB: Rehabilitation of patients following traction lesions of the brachial plexus. Clin Plast Surg 1984

146.  A thorough physical examination including manual and
EMG muscle testing required to assess rehabilitation
potential.
 The patient actively involved in all prescription decisions
from the outset; without a motivated and cooperative
individual, even heroic prosthetic/orthotic interventions
are doomed to failure.
 Full-arm orthosis during the recovery period, beginning as
soon as the patient has come to terms with the serious
and potentially permanent nature of his injuries.
 Once surgical reconstruction and spontaneous recovery
are complete, amputation and trial with a prosthesis can
be considered.
 Psychological and social work consultation may be useful
to help the patient discuss the altered body image and
employment possibilities that will follow amputation.

147.  Most of these injuries resolve without operative
intervention
 Joint mobilization and range-of-motion exercises
performed by the parents and guided by a physical
or occupational therapist can help to maintain a
congruent glenohumeral joint and to minimize
contractures
 For severely affected, however, a variety of
procedures are available

148.  3-9 mnths : Exploration and repair of brachial
plexus
 12-24 nths : Release of contractures
 24-60 mnths : Tendon and muscle transfers
 >60 (and incongruent joint) :Osseous procedures

149.  As long as the glenohumeral joint is
congruent, tendon and muscle transfers may be
performed at a later date, but they should be
considered at these earlier times to maximize
functional recovery
 Joint incongruity increase with the patient’s age
 Patients with incomplete recovery who are seen
more than six months after birth frequently have
muscle contractures due to unopposed muscle
forces and are no longer candidates for direct
repair of the plexus

150.  Performed in patients first seen when they are
older than five years of age
 Humeral rotational osteotomy for persistent
internal rotation contracture and glenohumeral
arthrodesis in the setting of severe
pain, instability, or arthritic changes
 For posterior dislocation of the humeral head
:posterior capsular plication

151.  Highly dependent on pattern of injury
 Complete C4 to T1 injuries a considered most
severe and virtually irreparable
 Avulsion injuries from C5 toT1 amenable to
restoration of shoulder and elbow function only
 Ideal candidate for surgery are patients with
proximal rupture or avulsion and sparing of lower
trunk

152.  Since 1995 to 2002 , 505 patients studied for
functional and occupational outcome after surgery
for BPI
 In India BPI most common due to RTA with Rt side
involved in 2/3
 40% cases have pan BPI
 85% of cable graft yielded improvement in motor
power compared 68% in neurotized nerve and 66%
in patients undergoing neurolysis

153.  Most effective donor nerve for musculocutaneous
neurotization was medial pectoral nerve (63.6%)
patient improved
 Accessory nerve was most effective for
neurotization of suprascapular nerve (100%)
 Thoracodorsal axillary neurotization gave (66.7%
improvement)
 50% patients either remained unemployed or had
to change there jobs

154.  Sedel reported results of surgical treatment of 63
traumatic brachial plexus palsies, 32 complete and
31 partial.
 Of the 32 complete palsies, 26 had repair
procedures; 21 were improved.
 Of the 31 partial palsies, 23 had repair
procedures, and 20 were improved.
 Results of nerve transfer were disappointing

155.  Solonen et al. reviewed 52 brachial plexus injuries
treated surgically :Grafts used in 24
avulsions, neurolyses in 14, direct suture in 2, and
intercostal neurotization in 12.
 Good results seen in 19 patients after fascicular
grafting with return of function of the biceps
muscle.
 Neurotization produced function in 4 of 12
patients.

156.  Narakas reported surgical treatment by
repair, grafting, or neurolysis in 164 patients with
traction injuries and found that 85% of 20 patients
with infraclavicular injuries improved after
surgery, and that only 55% of 58 patients with
supraclavicular injuries improved

157.  Barnes found that 13 patients with plexus injuries
but without EMG evidence of degenerative changes
at 3 weeks recovered rapidly and completely.
 Of 33 patients with upper plexus injuries, 22
spontaneously regained significant function of the
muscles of the shoulder, elbow, and wrist. Of 26
with lower plexus injuries, 18 regained some
proximal muscle function.

158.  In 1977, Millesi, using the interfascicular
autogenous nerve grafting technique, reported
return of M3 or better power (Highet) in 38 (70%) of
54 patients
 In 1984, Millesi :134 patients with complete
brachial plexus lesions treated with
neurolysis, nerve grafting, and neurotization.
Useful function was regained in 47 of 65 patients
(72%) after nerve grafting. In 72 patients with injury
to the upper plexus only, useful function returned
in 21 of 28 patients (75%) after nerve grafting

159. Thank you