This document discusses the anatomy, clinical evaluation, and management of brachial plexus injuries. It begins with the anatomical components of the brachial plexus including roots, trunks, divisions, cords, and branches. It then covers the clinical evaluation including history, physical exam findings, and investigations like imaging and electrodiagnostic studies. Key aspects of the physical exam are described for assessing specific nerves and muscles. The document concludes with classifications of brachial plexus injuries and considerations for non-operative versus operative management.

1. Dr. Vijay Kumar Loya,
JR – II, Orthopaedics
JIPMER

2. ROOTS
TRUNKS
DIVISION
CORDS
BRANCHES
SUPRACLAVICULAR PLEXUS
RETROCLAVICULAR PLEXUS
INFRACLAVICULAR
PLEXUS
SURGICAL ANATOMY

3. Ref – (1)

5. ROOTS
TRUNKS
DIVISON
CORDS
BRANCHES
DORSAL SCAPULAR NERVE C5
LONG THORACIC NERVE C567
SUPERIOR- C56
SUPRASCAPULAR NERVE
N. SUBCLAVIUS

8. LATERAL – LATERAL PECTORAL NERVE
MUSCULOCUTANEOUS N.
LATERAL DIVISION OF MEDIAN N.
MEDIAL - MEDIAL CUTANEOUS N OF ARM
MEDIAL CUTANEOUS NERVE OF FOREARM
MEDIAL PECTORAL NERVE
MEDIAL BR OF MEDIAN NERVE
ULNAR NERVE
POSTERIOR – UPPER SUBSCAPULAR NERVE
THORACODORSAL NERVE
LOWER SUBSCAPULAR NERVE
AXILLARY NERVE
RADIAL NERVE

11. CLASSIFICATION
SEDDON’S SUNDERLAND
1. NEUROPRAXIA
2. AXONOTEMESIS
3. NEUROTEMESIS
 1 – ALL INTACT
 2 – AXON DISRUPTED
 3 - AXON &
ENDONEURIUM
 4- AXON, ENDO,
PERINEURIUM
 5 – ALL DISRUPTED
 6 – (MAKINNON) MIXED
INJURIES

14. NEUROPRAXIA – focal conduction block
may recover in hours to weeks
AXONOTEMESIS – SUNDERLAND GRADE II
d/t stretch – axon disrupted & wallerian degeneration occurs
recovery @ 1mm/day or 1inch/mo occur – weeks/years
sometimes proximal lesion with distal target→nerve
regenerates but no recovery due to muscle atrophy
GRADE III & IV – Recovery is variable & surgical intervention is needed
NEUROTEMESIS - GRADE V – Eg – Post-ganglionic ruptures & pre-ganglionic
avulsions
Sx must.

15. CAUSATIVE
CLOSED OPEN
 TRACTION
 COMPRESSION
 COMBINED
 SHARP
 GUNSHOT
 RADIATION

17.  Traction between two anchoring points – proximal
spinal cord & distal neuromuscular junction.
 Coracoid process – lever in forceful abduction of
shoulder.
 Direction & speed of application of force equally
important.
 Traction injuries in motor vehicle accidents & ski
crashes, worker’s arm caught & pulled by machine,
rugby players, football & volleyball players while
hitting smash
 Low energy & high energy

18.  If shoulder neck angle is widened – upper/middle
trunk injury
 If scapulo-humeral angle is widened – lower trunk
injury
 The structures protecting cervical nerve from traction
are – 1. cone shaped dural continuation into
epineurium
 2. fibrous attachments between epineurium of C5,6,7
& transverse process – which is absent in C8,T1.
 Thus avulsion is more common in C8,T1.
 Extra-foraminal rupture is more common in C5,6,7

21. Traction injury in OT
 Improper positioning ↓GA →traction injury
 In supine/lateral decubitus position – extension
& lateral bending of head can cause upper trunk
damage.
 Positioning of shoulder on sandbag or roll
 Suspension of arm from lateral decubitus when
other arm is in hyperabduction
 Excess abduction of both arms in prone or
supine for spine surgery.

22.  Complex trauma with multiple fractures of the cervical
transverse process, clavicle, scapula, rib, and proximal
humerus can cause both compression and traction
injury to the brachial plexus.
 Disruption of brachial plexus can be found on more
than one site.
 Associated with vascular damage

23.  Assault by knife/sharp objects
 Associated with intrathoracic/vascular injuries.
 Only a part of plexus is involved – carries good
prognosis – t/t by intraplexal grafting/neurorraphy.
 Iatrogenic – during block/ tumour resection/central
line insertion.
 Gunshot injuries may require early repair or may form
pseudoaneurysm & can lead to progressive neural
compression & will require both nerve & vessel repair.
 Usually peripheral nerves are radioresistant & can
occur after I/L RT to axilla or breast in Ca.
 Can present with progressive deficit – surgical
exploration usually difficult d/t fibrous tissue

24. Pattern of
injury
Supraclavic
ular
Pre-
ganglionic
Post-
ganglionic
C5-C6 C5-C7 C8-T1 Pan plexu
Retro-
clavicular(
divisions)
Infra-
clavicular

25.  Burners & Stingers – transient injuries as a result of
trauma combined with factors – stenosis/degenerative
disc (spondylosis)
 Parsonage – turner syndrome - ?post-infectiuos
brachial plexopathy rapid onset severe pain in
shoulder & arm followed by wasting & weakness of
muscles.

26. Narakis anatomic classification
 Group 1 – c5, c6
 Group 2 – c5, c6, c7
 Group 3 – Panplexus lesions(C5-T1)
 Group 4 – Panplexus with Horner syndrome
 In Sx untreated cases Group 1 - 90% recover
 Group 2 – 25% recover
 Group 3 – no recovery but majority achieve good hand
function
 Group 4 – poor or no hand function

27. C5-C6
 15% of traumatic injuries – Erb’s point.
Erbs point – C5-C6 – 15% traumatic injuries
Shoulder abduction &
rotation
Supra & Infraspinatus
Deltoid
Subscapularis
Elbow flexion
Biceps
Brachialis
Brachioradialis
Supinator +
Sensory loss in C5-C6

28. C5-C7 injury – Erb’s plus
 20-35% - middle trunk injury
 Weakness of elbow extension along with variable
weakness of wrist & fingers as C7 contribution varies
between pateints
 Sensory – proximal arm, thumb, index & middle finger.

29. C8-T1 lesions
 <10% have supraclavicular lesions – vaiable weakness of
intrinsic muscles & finger extensors.
 Sensory loss – little finger, medial aspect of arm &
forearm.
 Horner’s syndrome – miosis, ptosis, anhidrosis &
enopthalmos

30. Pan-plexus injuries – C5-T1
 50-75% post-traumatic supra-clavicular ijuries.
 Completely flail arm & insensate hand.
 Associated with post-ganglionic injuries of c5 along
with pre-ganglionic injury of other nerves.

31. CLINICAL EVALUATION
HISTORY
• GENERAL PHYSICAL
EXAMINATION
• NEUROLOGICAL EXAMINATION
– MOTOR, SENSORY, VASCULAR,
MUSCULOSKELETAL
PHYSICAL
EXAMINATION
• XRAY, CT MYELOGRAPHY, MRI,
ANGIOGRAPHYINVESTIGATIONS
• EMG, NCS, SSEPELECTRODIAGNOSTIC
STUDIES

32.  The goal is first to determine whether there is potential
for spontaneous and functionally significant recovery.
 If no recovery is seen within the first 2 to 3 months,
surgery is indicated.
 preganglionic injury - lower probability of
spontaneous recovery, nerve root is nonfunctional,
cannot be repaired or grafted- earlier surgical
intervention may be warranted.
 H/O
 Lacerations need early
Exploration
 Gunshot wounds –
Lesions in continuity- can wait.
• MVA
• Low potential for
recovery – early
exploration
High-
energy
• falls
• Can observe
Low-
energy

33.  Emergency room –ABC
 Search for life & limb threatening injuries
 Search for spinal cord or head injury & vice-versa.
 Severe pain in anaesthetic extremity – d/t
deafferenation - s/o root avulsion injuries.
 EXAMINATION – MOTOR, SENSORY, VASCULAR &
MUSCULOSKELETAL

34.  Neuropathic pain in avulsion lesion of the lower roots
d/t deafferentation pain - appears a few weeks after
injury d/t sympathetic nervous system participation.
The causalgic pain, which has no precise distribution
and appears immediately after injury. The
pathogenesis of this syndrome is difficult to
determine, and a severe long-term deafferentation
pain can be expected.
 Brown-sequard syndrome may be seen in massive root
avulsion.
 10-16% have vascular injuries

35.  Progressive loss of motor and sensory function of the
affected extremity suggests an expanding hematoma or
aneurysm compressing the adjacent neural structure.
 # clavicle - bad prognostic sign - traction force directed
at the underlying soft structures (i.e., brachial plexus
and subclavian vessels).
 Cervical transverse process - high ruptures or avulsion.
 Scapulothoracic dissociation is often associated with
multiple root avulsions.
 First rib fracture is often associated with lesion of the
lower roots as well as vascular injuries.
 coracoid # - lateral cord injury, scapular & humeral neck
fractures - posterior cord lesion.

36.  To assess terminal branches (median, ulnar and radial
nerves), elbow (musculocutaneous and high radial
nerves), and shoulder (suprascapular or axillary
nerves).
 lats dorsi – posterior cord, sternal head pectoralis
major – medial cord & clavicular head pect major -
lateral cord.
 Involvement of the suprascapular nerve – upper trunk
injury.
 Involvement of serratus or rhomboids – preganglionic
injury.

37. *Mansat M: Surgical topographic anatomy of the brachial plexus, Rev Chir Orthop
Reparatice Appar Mot 63:20-26, 1977
 Variations in brachial plexus – prefixed (28-62%),
post-fixed(16-73%)*
 Sometimes lesions at C5 may also show electric
activity in rhomboids
 SIGNS OF PRE-GANGLIONIC INJURY –
 Weakness of rhomboids/serratus anterior – upper root
avulsion
 Presence of Horner syndrome – lower root avulsion
 Absence of Tinel’s sign or tenderness to percussion on
neck
 Muscle atrophy of paraspinal muscles – cervical
scoilosis

38.  POST-GANGLIONIC INJURY-
 Tenderness or percussion in supraclavicular or
infraclavicular region.
 Absence of sweating in distribution of injured nerve.
 Minimal preservation of movement (partial injury)
 Advancing tinel’sign.

39.  A thorough motor,
sensory (sympathetic),
vascular &
musculoskeletal
examination is thus
waarranted.
 Vascular examination
by palpation or doppler or
MRA
 Normal pulses doesnt
rule out vascular injury.
 Esp imp in FFMT

41. MUSCULOSKELETAL E/N
 Associated clavicular # is bad prognostic sign – as it
allows all traction force to transferred to plexus &
vessels
 Cervical transverse process # associated with high
ruptures or avulsions.
 Scapulothoracic dissociation associated with multiple
root avulsions
 Coracoid process – lateral cord & scapular & humeral
neck # with posterior lesions.
 1st rib# - vascular injury & lower root avulsions
 Rib fractures - important if the intercostal nerves are
to be considered for nerve transfers

42. MYOTOMES
 ABDUCTION of shooulder at glenohumeral joint – C5
 FLEXION of forearm at elboow – C6
 EXTENSION of forearm at elbow – C7
 FLEXION of fingers – C8
 ABDUCTION & ADDUCTION of index, middle & ring
fingers – T1.

44. DERMATOMES
 SUPRACLAVICULAR REGION – C3, C4
 UPPER LATERAL REGION ARM – C5
 PALMAR PAD THUMB – C6
 INDEX FINGER PAD – C7
 PAD OF LITTLE FINGER – C8
 MEDIAL ASPECT ELBOW – T1

49. TESTING PECTORALS
 The arrow illustrates the
direction of the
examiner’s force against
the patient’s
 resistance. The posterior
deltoid muscle works as
the antagonist.

50. TESTING STERNAL HEAD
 Fixation - Examiner places one hand on opposite iliac
crest to hold the pelvis firmly on the table, if
abdominals are weak the thorax should be stabilized
instead of the pelvis, while the triceps maintains
extension
 Test - In elbow extension & shoulder flexion & slight
medial rotation, adduction of the humerus obliquely
toward the opposite iliac crest
 Pressure - Against the forearm obliquely in a lateral &
cranial direction

51. TESTING SERRATUS
 Flex arm to 90`, flex
elbow so that hand
touches to shoulder.
 One hand over spine &
other cupping the elbow.
 Ask the pt to force his
bent arm forward as if
touching the wall.

52. TESTING BICEPS
 The arrow illustrates the
direction of the
examiner’s force against
the
 patient’s resistance. The
triceps muscle works as
the antagonist.

53. TESTING POSTERIOR DELTOID
 The arrow illustrates the
direction of the
examiner’s force
 against the patient’s
resistance. The pectoral
muscle works as
 the antagonist.

54. TESTING TRICEPS
 arrow illustrates the
direction of the
examiner’s force against
the
 patient’s resistance. The
biceps brachii muscle
works as
 the antagonist.

55. TESTING ECRB
 The arrow illustrates the
direction of the
examiner’s
 force against the
patient’s resistance. The
flexor carpi radialis
muscle
 works as the antagonist.

56. TESTING RHOMBOIDS
 With hand on hip, resist
the elbow being pushed
forward.
 Absence of activity
indicates lesion proximal
to root (cord avulsion)

57. TESTING SUPRASPINATUS
 To abduct against
resistance
 To feel for contraction in
supraspinatus fossa
 First branch of trunk –
upper trunk injury

58. MYELOGRAPHY
 Performed >3 weeks when dural tear has healed.
 Findings- obliteration of nerve root sleeve, defect root
sleeve shadow, pseudomeningocele (Nagano six
categories)
 98% specific, 95% sensitive when correlated with
intra-OP SSEP & extradural inspection.
 Doesn’t detect partial root avulsions.
 Ventral root more vulnerable for avulsions as lesser
tensile strength.

60.  MRI findings – hematoma in verterbral canal, empty
dural sleeve, shift of spinal cord away from midline.
 MRI with slices of 3mm provide accurate diagnosis of
root avulsion in 52% when compared with intradural
inspection.
 Cant be used in acute setting due to edema.
 Angiography – in penetrating lesions
 PFT – chest wall trauma, phrenic nerve dysfunction.
 Unless PFT<40% pt can tolerate upto 4-5 intercostal
transfers even in the presence of phrenic nerve injury.

61. EDx
 Baseline at 3-4 weeks.
 EMG evaluates electrical activity at rest & voluntary
activity - changes s/o fibrillation (at rest) &
(complete)or reduced(partial injury) motor unit
potential with voluntary effort.
 Reinnervation –nascent motor potentials (low
amplitude, polyphasic configuration of variable
duration)
 Rhomboids, serratus, cervical ms-preganglionic injury
 Trapezius EMG if planned for transfer

62.  NCS- SNAP help in evaluating the level of injury.
 If lesion is proximal to DRG – SNAP is preserved
but the pt is insensate.
 Finding of intact SNAP in dermatomal anaesthesia
is pathognomic of root avulsion injury.
 If lesion is segmental with both pre &
postganglionic injury – SNAP absent.
 Motor conduction will be absent in both pre &
post-ganglionic injury as cell body is located in
anterior horn of spinal cord.
 To be repeated after 2-3 months, Tinel’s sign &
nascent findings can suggest reinnervation but
doesn’t preclude surgery.

63. I & C/I
 In lesions & lacerations– no spontaneous recovery
 Gunshot wounds & traction injuries – usually lesions in
continuity – not for primary exploration.
 Even if no clinical recovery in the presence of Edx
recovery – explore
 C/I – C8-T1 lesions where regneration may not reach
hand & forearm nerve transfer or 2`reconstruction with
tendon transfer may yeild practical results.
 >1 yr post-injury - primary reconstruction C/I except in
young & distal nerve transfers (where upto 18 months
Sx can be done)

64. TIMING
 Timing of brachial plexus reconstructive surgery is
based on three principles:
 (1) better functional outcomes occur in patients with
spontaneous recovery who do not require a surgical
intervention;
 (2) surgical intervention is indicated for patients with
no hope for spontaneous recovery or for further
recovery,
 (3) surgical outcome is inversely proportional to the
time interval from injury to surgery (i.e., outcomes are
better if surgery is performed earlier).

65.  POSITION – Pt supine,
head turned to C/L side,
the upper part of the
body is elevated, and a
small pillow is placed
beneath the ipsilateral
scapula to bring the
shoulder forward.
 APPROACH –
SUPRACLAVICULAR
INFRACLAVICULAR

66.  SUPRACLAVICULAR –
nerve, trunks,
suprascapular nerve.
 From angle of jaw to
posterior border of SCM
to mid-clav acular area
 Can also be accessed by
transverse incisions
 Cords & terminal
branches by
INFRACLAVICULAR
approach.
 Divisions -
retroclavicular by both of
them
 Clavicular insertion of
SCM to coracoid process
to deltopectoral groove.

67.  Neurolysis
 Nerve repair
• Neurorrhaphy
• End to side coaptation
 Nerve graft
 Nerve transfer or neurotization
 Functional free muscle transfer
Surgical options

68. Thank you