Brachial plexus injury

Brachial plexus injury
Chung Weng Hong
15 February 2016
Hand Posting

Outline
• Anatomy
• History
• Physical examination
• Investigation
• Management

Anatomy
Check
Proximal
muscles

Dorsal
scapular
nerve (C5)
(rhomboids)

Long
thoracic
nerve
(C5,6,7)
(serratus
anterior)

Phrenic
nerve
(C3,4,5)
(diaphragm)

Suprascapular
nerve(C5,6)
(SS, IS)

Suprascapular
nerve(C5,6)
(SS, IS)
Erb’s point
(convergence of C5
& C6 root; 2-3cm
above clavicle)

Anatomy
Lateral (C5,6,7)
& medial
pectoral
nerves (C8, T1)
(Pectoralis
major)

Anatomy
Thoracodorsal
nerve (C6,7,8)
(Lattisimus
dorsi)

Terminal branches of roots & trunks:
• Dorsal scapular nerve C5 (rhomboids)
• Suprascapular nerve C5,C6 ( supra,infraspinatus)
• Long thoracic nerve C5,C6,C7 (serratus anterior)
• Accessory phrenic nerve C5
• Nerve to Subclavius C5,C6 (subclavius)
5 Roots form 5 Nerves
C5 Axillary
C6 Musculocutaneous
C7 Radial
C8 Median
T1 Ulnar

• C5: shoulder abductors, external rotators, &
extensors
• C6: biceps, brachioradialis, & wrist extensors
• C7: triceps, pronator teres, wrist flexors &
finger extensors
• C8: finger flexors
• T1: finger abd/adductors (intrinsic muscles of
hand)
Myotomes

Mechanism Of Injury
• Position of the arm at the time of injury
affects the levels involved

History
• MOI – RTA, fall, Stab, Missiles, GSW
• associated injuries
– # Ribs, cervical, clavicle; STD; vascular injuries, chest
trauma; head injury
• pain:
– lack of pain around neck  suggestive of preganglionic
• Smoking
• Occupation

Physical examination
• Aims :
1) Determine extent of injury
- Name by root value
2) Determine level/ proximity of injury
3) Donors
– Muscle donors
– Nerve donors

Complete BPI Incomplete BPI
Upper Trunk
(C5, 6)
Upper + Middle
Trunk
(C5,6,7)
Lower Trunk
(C8, T1)

Complete BPI
With recovery Without recovery

Incomplete BPI
Upper Trunk
(C5, 6)
Upper + Middle
Trunk
(C5,6,7)
Lower Trunk
(C8, T1)

Upper Trunk
(C5, 6)
unable to :
- Abduct shoulder (deltoid/ supraspinatus)
- ER shoulder (infraspinatus/ teres minor)
- Flex elbow (biceps/ brachialis/ brachioradialis)
- Supinate forearm (supinator)
- Sensory deficit over deltoid, lateral aspect of
forearm & hand

Upper + Middle
Trunk
(C5,6,7)
Upper Trunk
(C5, 6)
Unable to extend
elbow

• Weak intrinsic of hand
• Paralysis of wrist & fingers flexors
• Claw hand deformity
• Sensory deficit over medial aspect of arm, forearm & hand
Lower Trunk
(C8, T1)

Pre ganglionic Post ganglionic
Poor prognosis
• Involve CNS
• poorer nerve
regeneration
Better prognosis
• Involve PNS
• better nerve
regeneration

Pre ganglionic
Upper proximal
Paralysis :
• rhomboids (dorsal scapular
n)
• serratus anterior (long
thoracic n)
• Elevated hemidiaphragm
(phrenic n)
Lower proximal
Horner Syndrome (95% PPV)
• Ptosis
• Enopthalmos
• Miosis
• Reduced sweating
Absent Tinel’s sign
Reduced pain/sensation around the neck

Tinel sign
• Infraclavicular and supraclavicular
percussion (distal to proximal)
• Negative  preganglionic
Positive means:
– proximal axons available
– location of neuroma or regenerating axons
– does not exclude another distal lesion

• Tinel’s sign is positive
in 40% of preganglionic lesion
• Reasons:
– Shoulder region is also innervated by
cervical plexus.
– Induced by traction on scar tissue.

3) Donors
Nerve donors Muscle donors
Intraplexus extraplexus

3) Donors
• Nerve donors
1) Intraplexus
– Adv: shorter distance hence better recovery
– Disadv: unsure if donor nerve is normal
2) Extraplexus
– Adv: donor nerve is normal

• Nerve donors
1) Intraplexus
– Median n
– Ulnar n
** only in upper plexus injury
3) Donors

2) Extraplexus
• Spinal accessory n (trapezius)
• Intercostal n (chest tube scar)
• Contralateral C7 (sensation over tip of middle
finger)
• Phrenic n (chest percussion)
• Sural n (sensation over lateral aspect of foot) – as
a cable graft
• Hypoglossal nerve
3) Donors

• Muscle donors
– Trapezius (spinal accessory n)
– Pectoralis major (med & lat pectoral n)
– Latissimus dorsi (thoracodorsal n)
– Triceps (radial n)
3) Donors

• Observe how patient
removes his shirt
• Attitude of UL –
normally flail, IR,
adducted
• Wasted UL with dry
skin
• ? Scars/ bruises (Neck)
• ? Horner Syndrome
General Inspection

Inspection of Upper Limb
Comment on muscle bulk
(behind  front) & (proximal
 distal)
• Deltoid
(? sulcus sign; ? reducible)
• Supra/ Infraspinatus
• Winging of scapula
• Biceps/ Triceps
• Forearm
• Hand (Intrinsics)
? Clawing
• scoliosis

Palpation
• Deep muscle
tenderness
• ?deformity/ plate
• Tinel’s sign over
supraclavicular area
• Quick screening for
joint stiffness (passive
ROM)

Move
Back -> front; Proximal -> distal
? pre or post ganglionic lesion
Trapezius (spinal accessory n) –
shrug shoulder *donor
Rhomboids (dorsal scapular n) –
shoulder retraction *may have
contribution from C4
Serratus anterior (long thoracic n)
– winging of scapular; shoulder
protraction

Move
Shoulder
Abduction
• Supraspinatus
(Suprascapular n)
• Deltoid (axillary n)
Flexion/ Abd/ Ext
• Deltoid – anterior,
middle & posterior
fibers

Move
Elbow
Flexion
• Biceps
(musculocutaneous n)
** look for Steindler’s
effect
Extension
• Triceps (radial n)
**Diagnosis and donor

Move
Wrist
Extension (radial n)
Flexion (median, ulnar n)
Hand/ Fingers
Abduction (ulnar n)
Adduction (ulnar n)
Flexion (median, ulnar n)
Extension (PIN)

Neurovascular
Sensation
According to dermatomes
Pain or light touch
**check contralateral tip of
middle finger (contralateral
C7)
Pulses
Radial pulse (compare to
normal side)

Others
Chest percussion (Phrenic n)
Any scar for previous chest tube
(Intercostal n, phrenic n)
Lat dorsi (cough, feel for
contraction)
Pectoralis major (Shoulder
adduction and extension)
Sural n (?Scar or sensation over
lateral aspect of dorsum foot)

Investigation
• Cervical Xray AP
– Transverse process avulsion fracture (scalene)
• CXR
– Elevated hemidiaphragm
• CT Myelogram
– After 3-4 weeks to allow blood clot to dissipate and meningocele to form
– to diagnose root avulsion
– look for pseudomeningocele
• MRI
– pseudomeningocele (T1WI)
– empty root sleeve(T2WI)
– shift of cord away from midline
• EMG
– posterior spinal nerve injury

Investigation
Pre ganglionic Post ganglionic
Cervical Xray: transverse process
fracture
Chest Xray: elevated hemidiaphragm
CT myelo/MRI: pseudomeningocele
EMG: loss of innervation to cervical
paraspinal muscles
NCS: Sensory nerve action potential
(SNAP) normal

Spontaneous recovery
• Clinical recovery not tally with Imaging and
initial ENMG studies
• Types of recovery
–Sensory
– Motor
– Autonomic

Prognosis
• recovery of reconstructed plexus up to 3 years
• nerve regeneration - 1mm/day
• Poor prognosis
– Root avulsion (preganglionic)
– Lower plexus
– Supraclavicular injuries
– Smoking
– Delayed repair

Management
– observation
• guns shot wounds (in
absence of major
vascular damage can
observe for three
months)
– signs of neurologic
recovery
• advancing Tinel sign
Non-operative Operative

• Emergency
– Open injury
– Stab wound
– Iatrogenic
– Associated vascular repair
• Early (3w -3m)
– total palsy
– high velocity injuries
– gunshot wounds
• Routine (3m-6m)
• Secondary(>1y)
– reconstructive
Timing of repair

• Any repair surgery or neurotization should be done
within first 6 months
– NMJ degenerates after 1 year
– Nerve endings from direct repair/neurotization need to
reach NMJ
Post-ganglionic lesion
• Exploration, neurolysis/primary repair/nerve grafting
• Neurotization
• Preganglionic lesion
• Neurotization
Surgery

Nerve graft
Sural nerve Vascularised ulnar nerve

• If >6months, neurotization may be considered
for:
– Young patient (most important factor for success
of surgery)
– Short regeneration distance eg shoulder
• Otherwise, secondary reconstruction after 2
yrs
Surgery

Neurotization
• Nerve transfer
– Functioning but less important nerve to a distal
more important denervated nerve
• Indications:
– Preganglionic BPI
– some postganglionic injury with unpredictable
primary repair eg HE injury

• Principles:
– Prioritize function and identify the recipient nerve
– Identify available nerve donor
– Timing < 6mths (should reach NMJ by 1 year)
Neurotization

Goals of surgical treatment
1. Elbow flexion by biceps/brachialis muscle reinnervation
2. Shoulder stabilization, abduction, and external rotation by
suprascapular nerve reinnervation
3. Brachiothoracic pinch (adduction of the arm against the chest) by
reinnervation of the pectoralis major muscle
4. Sensation below the elbow in the C6-C7 area by reinnervation of
the lateral cord
5. Wrist ext/finger flexion
6. Reestablishment of thumb grip in opposition or lateral thumb grip
7. Finger extension
8. Restoration of function of the interrossei
**Important especially in complete BPI

Types of Surgery
< 6 months > 6 months
Complete BPI incomplete BPI
Upper plexus Lower plexus

2) Extraplexus
• Spinal accessory n
• Intercostal n
• Contralateral C7
• Phrenic n
• Sural n – as a cable graft
• Hypoglossal nerve
3) Donors

Complete BPI, < 6 months
• Spinal accessory nerve  suprascapular nerve,
axillary, motor branch to biceps (via sural n graft)
• Phrenic nerve  suprascapular, axillary nerve (via
sural nerve graft)
• Phrenic nerve  motor branch to biceps
(musculocutaneous n) Via sural nerve graft or
VATS
• Intercostal nerve (3-5) motor branch to biceps,
musculocutaneous nerve
• Contralateral C7 via vascularised ulnar nerve graft
to median nerve

Surgical
approach
Infraclavicular
approach
Supraclavicular
approach

Surgical
approach
Upper plexus
Lower plexus

SAN  SCN
• divided after branching to trapezius
• Transferred to suprascapularis
• via sural nerve graft to mbtb of mscn or axillary nerve
• To FFMT gracilis (SAC n to obturator n)

Intercostal nerves
• poor result with interpositional
graft
• good result if direct repair
• C/I: anterior chest trauma with
ribs fracture; young girl/women
• usually 3rd-6th intercostal n;
both lateral cutaneous br and
anterior motor br can be used
• 2 or more icn use for each
transfer
• mcn either to mbtb or mcn
itself (mixed n) - for good result
use 3 icn,
•  FFMT gracilis

• Oberlin procedure :
– Ulnar fascicle to motor branch of biceps (type 1)
– Median fascicle to motor branch of brachialis
(type 2)
• Somsak procedure :
– Spinal accessory nerve to suprascapular nerve
– Motor fascicle of long head of triceps to axillary
nerve
Upper plexus, < 6months

Oberlin’s procedure
Type 1: Ulnar nerve  motor br to
biceps (12cm from acromion)
Type 2: Median nerve  motor br
to brachialis (17cm from acromion)
1. Dissection of MBTB
2. Epineurectomy of the ulnar
nerve
3. Interfascicular dissection of
the ulnar nerve
4. Selection of fascicles
(posteromedial) and division
of 1-2 fascicles for transfer
5. Neurorrhaphy between MBTB
and fascicles of ulnar nerve

Nerve to long head of triceps to anterior branch
of axillary nerve (Somsak)

• Tendon transfer
• *** long distance for nerve endings to travel
to NMJ
Lower plexus

> 6 months
Secondary
reconstruction
Shoulder Elbow Hand

Shoulder
GH Stiffness
Arthrodesis
No GH Stiffness
• Trapezius
transfer (Saha)
• Teres major +
latissimus dorsi
(L-episcopo
transfer)

Trapezius transfer (Saha)
• Transfer entire
insertion of trapezius
along with:
• Lateral end of
clavicle
• Acromion
• AC joint
• Scapular spine
• Anchor distal to
tuberosity with 2
screws

Elbow
Local
transfer
Functioning free muscle
transfer (FFMT)
• Steindler’s flexopathy
• Triceps to biceps
transfer
• Pectoralis major
transfer (uni/bipolar)
• Lattisimus dorsi
transfer
• Gracilis
• Rectus femoris
• contralateral latissimus
dorsi

Steindler’s flexopathy
• transfer of origin of flexor-pronator
mass from ME to more proximal and
lateral position
• prerequisite - Steindler's effect
• adv: simple, cosmetically acceptable
• disadv: weak flexor, limited ext

Pectoralis
major
transfer
• Unipolar (Clarke)
• mobilised distal/3rd
(costal) origin with
strip of rectus sheath
 biceps tendon
• bipolar
• Humeral insertion to
acromion
• sternoclav origin -
tube it and attached
to biceps tendon
• adv: powerful flexor
• disadv: cosmetically
unacceptable

Latissimus
dorsi transfer
• insertion to
coracoid process,
origin to biceps
tendon
• adv: powerful flexor
• disadv: cosmetically
unacceptable

FFMT gracilis
Elbow flexion
and finger
extension

Take home message
• Anatomy of brachial plexus is crucial
• Aims in examination:
- Name by root value
3) Donors
– Muscle donors
– Nerve donors

Q1
A 21-year-old football player has been diagnosed
with a left upper trunk brachial plexus injury
following a tackle. Which of the following would
most likely be normal on physical exam?
A. Sensation over the lateral aspect of shoulder
B. Biceps reflex
C. Shoulder abduction
D. Sensation over radial aspect of forearm
E. Finger abduction

Q2
A 26-year-old male sustains a traction injury to his left arm after a
motorcycle crash with resulting weakness in this left upper extremity.
An electromyography (EMG) done shows normal cervical paraspinal
muscle activity. Which of the following statements is TRUE regarding
this injury?
A. The injury has likely resulted in the avulsion of several nerve roots
B. Physical exam would likely reveal drooping of his left eyelid and
anhidrosis
C. Intact paraspinal musculature on EMG is suggestive of a post-
ganglionic lesion
D. Immediate surgical intervention with neurotization would eliminate
weakness and restore function
E. The patient would show a normal histamine test

Q3
A patient sustains a transection of the posterior
cord of the brachial plexus from a knife injury. This
injury would affect all of the following muscles
EXCEPT?
A. Subscapularis
B. Latissimus dorsi
C. Supraspinatus
D. Teres minor
E. Brachioradialis

Q4
The following nerves are not used as a donor nerve
in neurotization during brachial plexus surgery.
A. Phrenic nerve
B. Spinal accessory nerve
C. Contralateral C7
D. Intercostobrachial nerve
E. 3rd and 4th intercostal nerve

Q5
Which symptoms does not suggest a pre-
ganglionic lesion in brachial plexus injury?
A. Miosis of pupil
B. Winging of scapula
C. Loss of rhomboid contraction
D. Loss of trapezius contraction
E. Ptosis

Brachial plexus injury

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