FRCS Revision - Brachial Plexus & Hands
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This document discusses examination and treatment of brachial plexus injuries. It provides an overview of brachial plexus anatomy and classifications of injuries. Common clinical presentations are described including patterns associated with different levels and types of injuries. Timing of surgery is based on the severity and chronicity of the injury. Intraoperative assessment helps determine graftability and motor function to guide repair.
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FRCS Revision - Brachial Plexus & Hands
- 1. Hands II & Brachial Plexus Chye Yew Ng MBChB(Hons) FRCS(Tr&Orth) British Diploma in Hand Surgery European Board of Hand Surgery Diploma Consultant Hand & Peripheral Nerve Surgeon Upper Limb Fellowship Director Wrightington Hospital
- 2. www.slideshare.net/ChyeYewNg www.vumedi.com (search for chye yew ng) Clinical examination of brachial plexus Examination of a patient with upper roots BPI Nerve transfers for C5,C6 BPI Exploration of infraclavicular brachial plexus www.youtube.com (search for CY Ng or brachial plexus exam) @CY_Hand @Nerve_Clinic
- 3. Overview Peripheral nerve injuries Brachial plexus injuries Compression neuropathy CRPS Tendon transfers Dupuytren’s disease Extensor and flexor tendon injuries Skin coverage
- 4. Hierarchical Approach to FRCS Revision Why? (Indications) What? (Treatment options) When? (Timing of surgery) How? (Technical details) HOT Higher Order Thinking
- 6. Cross Section of a Peripheral Nerve Axon Fascicle Nerve Endoneuriu m Epineurium Perineurium EpiPEn = Epi – Peri – Endo A&E Extrinsic & Intrinsic vascular supply Longitudinal – Segmental - Interconnected
- 7. Central Neuronal Death & Neuroprotection Neuronal death after peripheral nerve injury Acetyl-L-carnitine Arrests sensory neuronal death Speeds up regeneration N-acetyl-cysteine Provides sensory and motor neuronal protection Hart et al. Neurological Research 2008
- 8. Mechanoreceptors Slowly Adapting Rapidly Adapting Cutaneous Low frequency vibration Merkel discs Meissner corpuscles Subcutaneous High frequency vibration Ruffini terminals Pacinian corpuscles
- 9. Mechanisms of Nerve Injuries Crush / compression Stretch / traction Laceration / transection Metabolic disturbance Ischaemia Radiation Electrical injury Thermal injury
- 10. Classification of Nerve Injuries Seddon BMJ 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve) Brain 1943 • Localised degeneration of the myelin sheaths • Complete interruption of axons • Preservation of supporting structures (Schwann tubes, endoneurium, perineurium) • All essential parts destroyed • Interruption can occur without apparent loss of continuity
- 11. Classification of Nerve Injuries Neurapraxia Axonotmesis Neurotmesis Motor - - - Sensory +/- - - Autonomic +/- - - NCS Conduction block at the site Distal conduction preserved Loss of conduction both at and distal to the lesion Loss of conduction both at and distal to the lesion EMG No fibrillation Fibrillation ++ Fibrillation ++ Recovery Days to weeks provided the cause is removed Months provided the cause is removed No recovery unless repaired
- 12. Nerve Conduction Studies Recording electrode Neurapraxia Axonotmesi s Neurotmesis Wallerian degeneration Recording electrode Recording electrode
- 13. In clinical practice, how do you distinguish? Axonotmesis versus Neurotmesis Nature of injury Serial observations Exploration Seddon BMJ 1942 (Imaging)
- 14. Classification of Nerve Injuries Sunderland 1951 I II III IV V Focal conduction block NO Wallerian degeneration Axonal Disruption Axon + Endoneurium Disruption Axon + Endoneurium + Perineurium Disruption Axon + Endoneurium + Perineurium + Epineurium Disruption Cross-innervation
- 15. Sunderland ‘VI’ Grabb & Smith’s Plastic Surgery 6th edition. Chapter 9 HOT
- 16. Physiological Conduction Block Type A Intraneural circulatory arrest Metabolic block with no nerve fibre pathology Immediately reversible Type B Intraneural oedema Increased endoneurial fluid pressure Reversible within days or weeks
- 17. Classification of Nerve Injuries Lundborg 1988 Physiological conduction block Myelin damage Axonal damage Axon + Endo damage Axon + Endo + Peri damage Axon + Endoneuriu m + Perineurium + Epineurium damage Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve)
- 18. Classification of Nerve Injuries Lundborg 1988 Physiological conduction block Myelin damage Axonal disruption Axon + Endo Axon + Endo + Peri Axon + Endoneuriu m + Perineurium + Epineurium Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve) Non- degenerative Degenerative
- 19. Nerve in Danger! Pain, Pain, Pain • Burning • Severe Autonomic dysfunction • Absence of sweating • Smoothness & dryness of skin Tinel sign • Distal to Proximal • Regenerating touch fibres
- 20. BRITISH ORTHOPAEDIC ASSOCIATION STANDARDS for TRAUMA (BOAST) Sept 2012 BOAST 5: PERIPHERAL NERVE INJURY All surgeons undertaking Musculoskeletal Trauma Surgery will be involved in the management of peripheral nerve injury, either as a result of injury or a postoperative complication. Nerve repair and complex nerve injuries (e.g. brachial plexus) is now a specialist field but all surgeons involved in trauma surgery must be able to di- agnose nerve injuries and identify those that need referral to a specialist. These audit standards have been dis- tilled from the recent BOA blue book on peripheral nerve injury which provides evidence-based guidelines for management. • A careful examination of the peripheral nervous and vascular systems must be performed and clearly recorded for all injuries. This examination must be repeated and recorded after any manipulation or sur- gery. • If a laceration is near a nerve or associated with a neurological deficit, the urgent advice of a surgeon who treats nerve injuries should be obtained. • If a nerve injury is present with an unstable fracture or dislocation, the urgent priority (after life-saving interventions) is reduction and stabilisation of the skeleton. • When internal fixation of a fracture associated with a nerve injury is performed, in general, the nerve must be explored. Possible exceptions are an axillary nerve palsy associated with low-energy shoulder trauma and sacro-iliac screw fixation with a lumbosacral plexus injury. • If a nerve is explored during fracture surgery, this must be clearly recorded in the operation record in- cluding an indication of the nerve’s relationship to any internal fixation device. • Nerves will occasionally be damaged during surgery and recognition and urgent treatment is essential. Basic science evidence strongly supports very urgent repair as this will give the best possible outcome. • If a divided nerve is found at surgery, and the surgeon does not have the skills to perform a definitive repair, the nerve ends should be gently opposed with fine, coloured sutures. The patient should then be discussed with a surgeon experienced in nerve repair. • When a nerve or vascular deficit is identified following surgery, immediate measures include loosening bandages, splitting Plaster of Paris splints (to the skin) and gentle repositioning of the limb. If these measures are ineffective, a senior surgeon should be alerted to decide whether urgent re-exploration is required. • Painful, postoperative paralysis must be explored urgently. It may be due to compartment syndrome or nerve compression from bone fragments, suture, haematoma or hardware. • Pain and progressing loss of sensation is the hallmark of critical ischaemia. Immediate surgical explo- ration is required. By the time paralysis occurs it is too late. • Neurophysiological investigations are rarely needed in the acute injury and requesting neurophysiology must not delay referral or treatment. MRI is not essential before surgery but can assist in preoperative planning. Referral or surgery should not be delayed to wait for a scan. • Brachial plexus injuries should be discussed with a plexus/complex nerve injury specialist within 3 days of injury, or sooner if possible. Evidence Base: Predominantly retrospective case series but with good expert reviews and an evolved, multi-national, professional consensus over 15 years. HOT
- 21. Nerve Surgery Neurolysis Nerve repair Nerve grafting Nerve transfer
- 22. Prerequisites for Nerve Repair Skeletal stability Healthy tissue bed Healthy nerve ends No undue tension Adequate soft tissue coverage
- 23. Epineurial versus Group Fascicular Repairs Epineurial Less exact Simple Group Fascicular Better alignment More dissection (scarring) The functional results of group fascicular repair has not been shown to be more superior than that of epineurial repair. Lee & Wolfe. Peripheral nerve injury & repair. JAAOS 2000
- 24. Prognostic Factors of Outcomes • Age • DM, alcohol Patient factors • Level of injury (distal vs proximal) • Type of nerve (pure vs mixed) • Condition of nerve ends Injury factors • Delay to repair • Length of gap Surgical factors
- 25. Which of the following is false regarding fibrin glue? a) Fibrin glue is nontoxic and does not block axon regeneration b) It may be used in combination with suture repair c) The outcome of fibrin glue repair is inferior to that of suture repair d) The common components of fibrin sealants include fibrinogen, thrombin and calcium chloride e) It has low tensile strength Tse & Ko. Nerve glue for upper extremity reconstruction. Hand Clinics 2012
- 26. Nerve Grafts/Conduits Autologous Source Nerve autograft Vein (+/- muscle) Off-the-shelf Type I collagen Caprolactone Polyglycolic acid (PGA) Submucosal ECM Processed nerve allograft Lin et al. Nerve Allografts & Conduits in Peripheral Nerve Repair. Hand Clinics 2013 Kaushik & Hammert. Options for Digital Nerve Gap. JHSAm 2015
- 27. A 35 year-old male presented with numbness along the radial border of his right index finger 9 months after he sustained a cut in his first web. After surgical exploration and debridement, there is a 3.5cm nerve defect in the radial digital nerve. What is the most appropriate surgical reconstructive option? a) Flexion of digit to achieve primary repair before gradual distraction b) Type I collagen nerve conduit c) Autologous vein graft d) Posterior interosseous nerve graft e) Polyglycolic acid (PGA) conduit
- 28. Principles of Motor Nerve Transfers Donor nerve near target motor end plates Expendable donor nerve Pure motor donor nerve Donor-recipient size match Donor function synergy with recipient function Motor re-education improves function Mackinnon SE, Novak CB. Hand Clin 1999
- 30. Brachial Plexus Injuries • Time• Breadth • Length• Depth Severity (Seddon, Sunderland) Level (Supra vs Infra clavicular) Acute vs Chronic Number of roots (C5-T1) HOT
- 31. Leffert Classification I Open II Closed IIA Supraclavicular Pre-ganglionic Post-ganglionic IIB Infraclavicular III Radiation induced IV Obstetric IVA Erb’s (upper root) IVB Klumpke’s (lower root) IVC Mixed
- 32. Objectives of Examination Where is the lesion? What functions are lost? What functions are present? How can you improve functions of the limb?
- 34. Draw the brachial plexus
- 39. C5 C6 C7 C8 T1
- 46. C5 C6 C7 C8 T1 MC MEDIAN ULNAR R AxLTN LPSSDS USs TD LSs MP MBC MABC Sc Roots Trunks Divisions Cords Terminal branches
- 47. C5 C6 C7 C8 T1 MC MEDIAN ULNAR R AxLTN LPSSDS USs TD LSs MP MBC MABC Sc Roots Trunks Divisions Cords Terminal branches Upper Lowe r Middle Lateral Medial Posterior Posterior Anterior Anterior
- 48. Dermatomes
- 49. Myotomes
- 50. Common Clinical Patterns Closed traction BPI Supraclavicular Upper roots Total palsy Infraclavicular Cord(s) Terminal branch(es) Motorcycle accident Shoulder trauma
- 51. Common Clinical Patterns 25yo RTA polytrauma No shoulder motion No elbow flexion GOOD HAND 25yo RTA polytrauma FLAIL UPPER LIMB 65yo anterior dislocation of shoulder NO DELTOID C5, C6 C5 – T1 Axillary nerve
- 52. Common Clinical Patterns 25yo RTA polytrauma No shoulder motion No elbow flexion GOOD HAND C5, C6 XR neck chest shoulder MRI cervical spine, BP NCS/EMG at 3 weeks 25yo RTA polytrauma FLAIL UPPER LIMB C5 – T1 XR MRI NCS/EMG at 3 weeks 65yo anterior dislocation of shoulder NO DELTOID Axillary nerve NCS/EMG at 6 weeks if no recovery
- 53. Pre- versus Post-ganglionic? Clinical Horner’s syndrome Rhomboid, serratus anterior, paraspinal muscles paralysis Absent Tinel sign Histamine test (historical) Radiology Phrenic nerve palsy (raised hemidiaphragm) Cervical transverse process /1st rib♯ Pseudomeningoceles Rootlets abnormalities Neurophysiology Preserved SNAP (but insensate)
- 54. Intraoperative Assessment - Is there a graftable nerve stump? • Direct inspection • Palpation Surgical • Somatosensory Evoked Potentials (SSEP) • Motor Evoked Potentials (MEP) Neurophysiology • Frozen section (fascicles / scar) • Choline acetyltransferase (CAT) activity – identify motor fascicles Laboratory
- 55. Timing of Surgery Emergent - Open injury - Arterial injury - Deteriorating neurology Early (<3months) - Closed injury - Complete/partial palsy - Neurolysis/grafts/ transfers Late (>12months) - Muscle transfers - Bony procedures
- 56. Surgical Priorities 1 – Restore elbow flexion 2 – Restore shoulder abduction & ER (stability) 3 – Restore hand function
- 57. Common Nerve Transfers Palsy Donor Recipient C5, 6 Spinal accessory Radial (long head of triceps) Ulnar fascicle Median fascicle Suprascapular Axillary (anterior) Biceps branch Brachialis branch C5, C6, C7 Spinal accessory Intercostals Ulnar fascicle Median fascicle Suprascapular Axillary (anterior) Biceps branch Brachialis branch C8, T1 Brachioradialis or brachialis branch Supinator branch AIN PIN
- 58. Common Clinical Patterns ?Prognosis 25yo RTA polytrauma No shoulder motion No elbow flexion GOOD HAND C5, C6 Regain good elbow flexion, moderate shoulder movement Return to work 25yo RTA polytrauma FLAIL UPPER LIMB C5 – T1 Poor-to-fair function Long-term disability 65yo anterior dislocation of shoulder NO DELTOID Axillary nerve Fair-to-good recovery
- 60. What do (I think) you need to learn? Carpal tunnel syndrome Cubital tunnel syndrome Guyon canal syndrome Radial tunnel syndrome / PIN palsy Pronator syndrome / AIN palsy
- 61. Carpal Tunnel Syndrome A collection of symptoms and signs due to increased pressure within the carpal tunnel leading to compression of the median nerve • Pins & needles or Tingling • Numbness • Pain • Weakness or clumsiness • Wasting of thenar muscles
- 62. What are the contents of the carpal tunnel? Median nerve FDS x4 FDP x4 FPL
- 63. Anatomical variations of the recurrent motor branch of median nerve
- 64. Who is affected? Risk Factors Age: 45- 65 Females > males Family history Pregnancy Medical conditions: Diabetes mellitus, Rheumatoid arthritis, Hypothyroidism Obesity Vibration Anatomical abnormalities of the wrist
- 65. What is the Gold Standard? CTS Signs Symptoms Neurophysiology
- 66. Treatment Options Comments Nocturnal neutral wrist splint • Those with night symptoms Steroid injection • Consider in pregnancy-related CTS • 1 in 4-5 symptom-free at 1 year Carpal tunnel release • Complete division of transverse carpal ligament • Open and endoscopic CTR both equally effective. Endoscopic CTR may offer earlier return to work but this may not be justifiable by its increased risks of nerve injury and costs (in the NHS).
- 68. Cubital tunnel syndrome What is your preferred surgical treatment for primary cubital tunnel syndrome?
- 69. Cubital tunnel syndrome What is your preferred surgical treatment for primary cubital tunnel syndrome? I would perform in-situ decompression because meta- analyses have shown comparable clinical outcomes but lesser complications/morbidity when compared to anterior transposition.
- 70. Cubital tunnel syndrome What are the indications of anterior transposition?
- 71. Cubital tunnel syndrome What are the indications of anterior transposition? • Revision • Subluxation/Instability of ulnar nerve • Poor tissue bed for the nerve • (Elbow trauma surgery)
- 72. Sensory branch (after PB) Ulnar artery aneurysm or thrombosis Guyon’s canal What you need to know? Mixed LEFT HAND
- 73. Superficial branch (sensory only after Palmaris brevis) Ulnar artery aneurysm or thrombosis Deep motor branch Ganglion or hook of hamate fracture (zones 1 & 2) MixedLEFT HAND
- 74. Posterior Interosseous Nerve Radial tunnel syndrome Pain syndrome EMG normal PIN palsy Motor deficit EMG abnormal Common Sites of Compression: Fibrous band btw brachialis & BR Recurrent leash of Henry Extensor carpi radialis brevis edge Arcade of Fröhse Supinator muscle edge
- 75. Proximal Median Nerve Pronator syndrome Pain (forearm) syndrome Paraesthesia EMG/NCS inconclusive AIN palsy Motor deficit only EMG/NCS abnormal Sites of Compression: Supracondylar process Ligament of Struthers Lacertus fibrosus Btw two heads of pronator teres FDS arch Sites of Compression: Tendinous edge of deep head of PT Lacertus fibrosus FDS arch Accessory head of FPL (Gantzer’s muscle) Accessory muscle from FDS to FDP Aberrant muscles (FCRB, palmaris profundus) Thrombosis of ulnar collateral vessels Aberrant radial artery Bicipital bursa
- 76. Complex Regional Pain Syndrome
- 77. Disproportionate Pain Sensory changes Abnormal skin color Temperature change Abnormal sudomotor activity Oedema Joint stiffness EXCLUSION OF OTHER CAUSES!
- 78. International Association for Study of Pain CRPS Type I Reflex sympathetic dystrophy (RSD) No definable nerve injury CRPS Type II Causalgia Definable nerve injury Symptoms NOT restricted to dermatome
- 79. CRPS – Budapest Criteria
- 80. Management of Suspect CPRS Prevention (Vitamin C – distal radius fractures) Treat any treatable cause Physiotherapy (Desensitisation, mirror therapy) Pain specialist Multimodal analgesics Regional blockade Bisphosphonate infusion Psychology
- 81. Tendon Transfers
- 82. Indications Restore function Muscle paralysis/nerve injuries Irreparable injuries to the musculotendinous units Restore balance Stroke, cerebral palsy, tetraplegia Why?
- 83. Decision making What is missing What needs reconstructing (think of FUNCTION) What is available What is appropriate What? HOT
- 84. Principles Tissue equilibrium is achieved Bony stability Good soft tissue envelope/gliding plane Full passive range of motion Expendable donor Minimum 1 wrist extensor, 1 wrist flexor 1 extrinsic flexor & extensor to each digit When?
- 85. Force proportional to cross-sectional area of muscle Average fibre length proportional to potential excursion Amplitude/Excursion (The 3-5-7 rule) Wrist flexors/extensors: 33mm Finger extensors, FPL, EPL: 50mm Finger flexors: 70mm Tenodesis effect +20mm Expect decrease of one MRC grade after transfer PrinciplesHow?
- 86. Single line Single joint Single function Synergy Sensibility PrinciplesHow? Ideal principles but not obeyed all the times
- 87. Median Nerve Palsy Low Donor Tendon Camitz Palmaris longus Burkhalter Extensor indicis proprius Bunnell FDS IV Huber Abductor digiti minimi High Lost Function Donor Tendon Opposition EIP APB Thumb IPJ flexion Brachioradialis FPL Index finger flexion FDP I Sutured to neighbour FDPs
- 89. Radial Nerve Palsy PIN High Lost Function Donor Tendon Wrist extension PT ECRB Fingers extension FCR EDC Thumb extension PL EPL Lost Function Donor Tendon Fingers extension FCR EDC Thumb extension PL EPL
- 90. Ulnar Nerve Palsy Low Lost Function Donor Tendon Clawing (Grasp) FDS III slips lateral bands Thumb adduction ECRB + PL graft Adductor pollicis Index finger abduction Accessory APL 1st dorsal interosseous Little finger adduction (Wartenberg sign) EDM radial lateral band High Lost Function Donor Tendon In addition to low FDP IV/V DIPJ flexion Side-to-side tenorrhaphy FDP III
- 91. Anti-clawing Procedures Static Zancolli capsulodesis Fasciodermadesis Tenodeses Dynamic MCPJ flexion MCPJ flexion + IPJ extension Bouvier manoeuvre?
- 92. Donor options to correct clawing
- 94. Dupuytren’s Disease A benign proliferative disease that occurs in the fascia of the palm and digits resulting in nodules, cords and contractures. Epidemiology Caucasian of northern European ancestry 5th-7th decades M>F until 70 then M=F Autosomal dominant pattern with variable penetrance Ectopic manifestations Ledderhose disease (plantar fascia) Peyronie's disease (dartos fascia of penis) Garrod’s pads (knuckle pads)
- 96. Components of Spiral Cord? 4 – Grayson ligament 3 – Lateral digital sheet 2 – Spiral band 1 – Pretendinous band
- 97. Luck Stages of Dupuytren Proliferative (Myofibroblasts predominate) Involutional (Type III > I collagen) Residual (Fibrocytes predominate)
- 98. Risk factors / associations Hueston diathesis Caucasians Positive family history Bilateral disease Ectopic lesion Male Age of onset < 50 Other conditions Diabetes mellitus Alcoholism HIV Anti-epileptics Trauma (Vibration)
- 99. Indications for Intervention Tabletop test MCPJ 30°contracture PIPJ any contracture Functional limitation Traditional teaching
- 100. Treatment Options 5-year recurrence rates Needle fasciotomy 85% Collagenase 50% Fasciectomy 20% Dermofasciectomy 10% Increasingdowntimeandcomplexity
- 101. Collagenase clostridium histolyticum (CCH) AUX-I AUX-II Class I Class II Cleaves terminal ends of collagen Cleaves internal sections of collagen
- 102. Extensor & Flexor Tendon Injuries
- 104. Extensor Tendon Compartments Compartment Tendons Conditions 1 APL EPB de Quervain’s tenovaginitis 2 ECRL ECRB Intersection syndrome 3 EPL Attrition rupture post-distal radial fracture 4 EIP EDC Tenosynovitis 5 EDM Vaughan-Jackson syndrome 6 ECU Subluxation / Snapping
- 105. Zones Treatment I (II) • Mallet injury • Open: repair and pin • Closed: splint 8/52 • If chronic, risk of Swan-neck III (IV) • Open: repair and splint • Closed: immobilise PIPJ for 3/52 & leave DIPJ free • If chronic, risk of Boutonniere V VI • Watch out for fight bites! • Rehab: Static vs Dynamic vs EAM VII • Repair retinaculum • Splint wrist in extension for 4/52 VIII • Core suture-type tendon repair IX • Muscle belly injury • Beware of PIN injury
- 109. Flexor Tendon Repair Challenges Rupture, adhesion, joint stiffness, infection Surgical Aim To restore continuity to the tendon with a repair that is robust for EAM Philosophy/Concept Managing a number of compromises according to a hierarchy of priorities
- 110. How do you manage a zone II flexor tendon injury? Anaesthesia GA, regional, Wide-awake technique (LA + adrenaline) Core suture At least 4 strands (Kessler, Cruciate, Adelaide) 4-0 monofilament (Prolene) Epitendinous suture Continuous configuration 6-0 monofilament (Prolene) Rehabilitation Dorsal splint for 6 weeks Early active mobilisation
- 111. Skin Coverage
- 112. Reconstructive Ladder Free Tissue Transfer Distant flap Local & Regional flap Skin graft Primary closure Healing by secondary intention Elevator
- 113. Summary • Most injuries are mixed • Pain, Autonomic dysfunction & Tinel sign Peripheral nerve injuries • 4 dimensions Brachial plexus injuries • Carpal & cubital tunnel syndromes Compression neuropathy • Budapest criteriaCRPS
- 114. Summary •What is missing •What function needs reconstructing •What is available •What is appropriate Tendon transfers • Luck stages • Spiral cord • Collagenase (AUX-I & II) Dupuytren disease • Zone of injuries Extensor and flexor tendon injuries • Reconstructive ladder & elevatorSkin coverage
- 115. Thank you and good luck! @CY_Hand