BPI slide.pptx

ANATOMY

The brachial plexus is formed by the confluence of nerve roots from C5 to T1.

The plexus, as it passes from the cervical spine between the muscles of the neck and beneath the clavicle en route to the arm, is vulnerable to injury.

ANATOMY

Thompson, J. Netter’s Concise Orthopaedic Anatomy 2nd Edition. Kansas : Elsevier

ANATOMY

Thompson, J. Netter’s Concise Orthopaedic Anatomy 2nd Edition. Kansas : Elsevier

ANATOMY

Thompson, J. Netter’s Concise Orthopaedic Anatomy 2nd Edition. Kansas : Elsevier

ANATOMY

Thompson, J. Netter’s Concise Orthopaedic Anatomy 2nd Edition. Kansas : Elsevier

ANATOMY

Thompson, J. Netter’s Concise Orthopaedic Anatomy 2nd Edition. Kansas : Elsevier

ANATOMY

Thompson, J. Netter’s Concise Orthopaedic Anatomy 2nd Edition. Kansas : Elsevier

ANATOMY

Thompson, J. Netter’s Concise Orthopaedic Anatomy 2nd Edition. Kansas : Elsevier

ANATOMY

Thompson, J. Netter’s Concise Orthopaedic Anatomy 2nd Edition. Kansas : Elsevier

PATHOANATOMYBRACHIAL PLEXUS

INJURY

TRACTION INJURIES1. UPPER ROOT INJURY (C5-7)/ ERB’S PALSY

2. LOWER ROOT INJURY (C8-T1)/ KLUMPKE’S PALSY

3. TOTAL PLEXUS INJURY

OBSTETRICAL TRAUMATIC

1. SUPRACLAVICULAR LESIONS (65%)

2. INFRACLAVICULAR LESIONS (25%)

3. COMBINED (10%)

CLINICAL PRESENTATION

• In upper plexus injuries (C5 and 6) the shoulder abductors and external rotators and the forearm supinators are paralysed. Sensory loss involves the outer aspect of the arm and forearm.

• Pure lower plexus injuries are rare. Wrist and finger flexors are weak and the intrinsic hand muscles are paralysed. Sensation is lost in the ulnar forearm and hand.

• If the entire plexus is damaged, the whole limb is paralysed and numb.

CLINICAL PRESENTATION

UPPER ROOT INJURY (C5,6,7)

LOWER ROOT INJURY (C8,T1)

PRE & POST-GANGLIONIC LESION

1. Avulsion of a nerve root from the spinal cord

2. Disruption proximal to the dorsal root ganglion

3. This cannot recover and it is surgically irreparable

1. Rupture of a nerve root distal to the ganglion, or of a trunk or peripheral nerve

2. Disruption distal to the dorsal root ganglion

3. Surgically reparable and potentially capable of recovery

PREGANGLIONIC LESION

POSTGANGLIONIC LESION

SIGNS OF ROOT AVULSIONS

Crushing or burning pain in an anaesthetic hand

Paralysis of scapular muscles or diaphragm

Horner’s syndrome Severe vascular injury Associated fractures of the cervical spine Spinal cord dysfunction (e.g. hyper-

reflexia in the lower limbs).

Examination

What is the level of lesions?

Preganglionic

Postganglionic

What type?

PHISYCAL EXAMINATION

The level of lesions

Upper plexus injuries (C5 and 6) the shoulder abductors, external rotators

and the forearm supinators are paralysed. Sensory loss involves the outer aspect of

the arm and forearm. Lower plexus injuries

Wrist and finger are weak Intrinsic hand muscles are paralysed. Sensation is lost in the ulnar forearm and

hand.

Cont….

Lateral and posterior cord injury. Preservation of the dorsal scapular nerve

(rhomboids), long thoracic nerve (serratus anterior) and suprascapular nerve (supraspinatus).

Loss of musculocutaneous nerve function (biceps), radial nerve (triceps) and axillary nerve (deltoid)

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Pre or Postganglionic lesions?

Preganglionic Crushing or burning pain in an anaesthetic hand Paralysis of scapular muscles or diaphragm Horner’s syndrome – ptosis, miosis, enophthalmos

and anhidrosis Severe vascular injury Associated fractures of the cervical spine Spinal cord dysfunction (e.g. hyperreflexia in the

lower limbs). The histamine test

Preganglionic (+) Postganglionic (-)

Imaging

CT myelography or MRI Root avulsion - show pseudo-meningoceles

Nerve conduction studiesPreganglionic lesion - sensory conduction

from an anaesthetic dermatome Plain radiographs CT scans

Management

The patient is likely to be admitted to a general unit where fractures and other injuries will be given priority.

All other closed injuries are left until detailed examination and special investigations have been completed

The Pattern of Injury

Surgical exploration reveals three typical patterns of injury:

C5,6(7) avulsion or rupture with C(7)8, T1 intact: this group has the most favourable outcome as hand function is preserved and muscles innervated from the upper roots often recover after plexus repair or nerve transfer.

C5,6(7) rupture with avulsion of C7,8,T1: these may recover shoulder and elbow movement after repair and grafting of the upper levels, but hand function is irretrievably lost.

C5–T1 avulsion: these cases have a poor outcome. There are few donor axons available to neurotize the upper levels (shoulder and elbow function) and no recovery will take place in the hand.

Nerve Graft & Nerve Tranfers Nerve grafting is often necessary and the results

for restoration of shoulder and elbow function are quite good; however, the outcome for lesions affecting the forearm and hand is disappointing

Nerve transfer is an alternative way of providing functioning axons. If C5 and C6 are avulsed, then the spinal accessory nerve can be transferred to the suprascapular nerve; or two or three intercostal nerves can be transferred to the musculocutaneous nerve