Brachial Plexus injuries - PowerPoint Presentation

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Brachial Plexus injuries(Obstetric)

Dr

Kannan

K Kumar

Consultant Hand and Brachial Plexus surgeon

Hosmat

hospitalSlide2

Dr Paul Brand fellow in Hand surgery and brachial plexus, Christian medical college, Vellore

Kleinert

fellow in hand and microsurgery, University of Louisville, Kentucky, USA

Fellow in brachial plexus surgery, OGDH, Yamaguchi, JapanSlide3

AnatomyOrigin and formation of brachial plexus

Obstetric Brachial Plexus injuries

Treatment

Salvage procedures

CONTENTSSlide4

ANATOMY

Ventral

rami

, of the lower cervical and upper thoracic nerve rootsSlide5

Components of brachial plexus

It includes –

From above the fifth cervical vertebra to underneath the first thoracic vertebra(C5-T1). Slide6

The trunks pass laterally and lies around the

subclavian

artery

Behind the clavicle, each trunk splits into anterior and posterior divisions. Slide7
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FORMATION OF THE BRACHIAL PLEXUSSlide9

CadaverSlide10

FORMATION OF THE BRACHIAL PLEXUS

Roots

The ventral

rami

of spinal nerves C5 to T1 are referred to as the roots of the plexus.

Trunks

Shortly after emerging from the

intervertebral

foramina , these 5 roots unite to form three trunks.

–The ventral

rami

of C5 & C6 unite to form the Upper Trunk.

–The ventral

ramus

of C 7 continues as the Middle Trunk.

–The ventral

rami

of C 8 & T 1 unite to form the Lower Trunk.Slide11
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Divisions

Each trunk splits into an anterior division and a posterior division.

Cords

– Upper and Middle trunks - lateral cord.

– Lower trunk

-

medial cord.

– Posterior divisions - posterior cord.

– Position relative to the

axillary

arterySlide13

III.

BRANCHES :

From the Roots

Dorsal Scapular nerve

Derived from C5 root

Motor nerve to the

Rhomboideus

major and minor muscles

Long Thoracic nerve

Derived from C 5,6,7

Innervates the

serratus

anterior muscleSlide14

FORMATION OF THE BRACHIAL PLEXUSSlide15

From the Upper Trunk

Nerve to

subclavius

muscle

Suprascapular

nerve

From the Lateral Cord

Lateral Pectoral nerve

Innervates the

clavicular

head of the

pectoralis

major muscle

From the Medial Cord

Medial Pectoral nerve

Innervates the

sternocostal

head of the

pectoralis

major muscle

Innervates the

pectoralis

minor muscleSlide16

FORMATION OF THE BRACHIAL PLEXUSSlide17

Cutaneous distributionSlide18

The plexus may include ventral

rami

from C4 or T2 and these are designated as

Pre fixed- C4 added

Post fixed- T2 added.

ANATOMIC VARIATIONSSlide19

OBSTETRIC BRACHIAL PLEXUS PALSYSlide20

Early days – congenital deformity.Smillie [1768] – Obstetric origin

Danyau [1851] – Autopsy – lesion

Duchenne [1861]- traction injury, OBPI

ERB [1875]- pointed lesion at upper trunk

Kennedy [1903]- early surgical repair

Narakas [1981]- microsurgical results.

HISTORYSlide21

Incidence: 0.13 - 4/1000 live birthsSpectrum

Difficult to diagnose early on –

PseudoparalysisSlide22

Erb's

palsy

(

Erb-Duchenne

Palsy

) is a paralysis of the arm caused by injury to the upper trunk C5-C6.

Signs of

Erb's

Palsy

Deltoid, biceps, and

brachialis

muscles.

The arm hangs by the side and is rotated medially; the forearm is extended and

pronated

. commonly called "waiter's tip hand."

Erb’s

palsySlide23
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Erb’s

Palsy – Nerves AffectedSlide25

Left Erb’s pointSlide26

Variant involving the lower roots.

C8 and T1 nerves.

Affects, principally, the intrinsic muscles of the hand and the flexors of the wrist and fingers.

The classic presentation of

Klumpke's

palsy is the “claw hand” where the forearm is

supinated

and the wrist and fingers are

hyperextended

with flexion at

interphalangeal

and

metatarso

phalangeal

joints.

Klumpke

s palsySlide27

StretchingOverweight babies with cephalic presentations

Underweight babies with breech

Forceful widening of angle between the neck & shoulder.

Vacuum pump

Forceps

MECHANISMSlide28
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C-spine fractureTorticollis

Clavicle fracture

Shoulder dislocation

Humerus

fracture

Facial nerve palsy

Phrenic

nerve palsyAssociated injuriesSlide33

Lesions range from degree I[neuropraxia] – V [neurotmesis or root avulsions].Upper trunk –1

st

affected, most vulnerable part.

Upper trunk – mostly stretched

Lower trunks – mostly ruptured

PATHOLOGYSlide34
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Limb is flail & danglingArm is held in IR, adduction, active

abd

not possible, elbow extended, forearm

pronated

, thumb flexed.

Complete paralysis- vasomotor impairment, pale & marble like color

Horner’s sign

Associated # [clavicle,humerus,]Clinical assessmentSlide40

Complete Recovery (80%)Partial recoveryNo improvement.

PrognosisSlide41
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EMG

Performed at 3-4 wks- confirm

neuropraxia

or

axonotmesis

(difficult to perform)

At 2 months, signs of re-innervation.Slide48

Fluoroscopy- phrenic

nerve injury.

Lumbar puncture-

xanthochromic

CSF- in root avulsions.

C.T

myelogram

Fast spin Echo MRI: preganglionic nerve root injuries. (only if necessary)Large diverticulae and

meningoceles

are indicative of root avulsions Slide49
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Fracture of clavicle or humerus shaft or

physeal

separation

Septic arthritis /

osteomyelitis

Congenital malformation of plexus

Postinfectious

[varicella] plexopathy of muscles DDSlide51

Nature of injury

Lower plexus paralysis,

Global involvement,

Persistence of Horner’s and

phrenic

nerve palsy

Presence of Torticollis

Prognostic signsSlide52

Physiotherapy

ROM ex, facilitation of active

movt

, promotion of sensory awareness.

Avoid abduction & posterior projection of shoulder. Limb to be supported when holding baby

Goals: minimizing bony deformities,

Jt

contractues.Weight bearing activity-skeletal growth

TreatmentSlide53

Early nerve repair

Indications:

Failure of recovery of biceps or deltoid at 3 months

Group III& IV lesions

Presence of

Horners

sign.

SURGICAL Slide54

Cookie sign

Failure to flex the elbow, so as to take the hand to the mouth.

3-6months.Slide55

Diminishing potential for axon regeneration with ageCross innervation & muscle imbalance aborted

Provide better condition for tendon transfer

Nerve repair is superior to spontaneous recovery.

Advantages of nerve repairSlide56
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5 months – 1 year

TYPE OF SURGERY

Neurolysis

Direct repair

Nerve grafting

Nerve transfers

Free functioning muscle transfers

Timing of surgerySlide58

NeurolysisSlide59

Direct RepairSlide60

Direct RepairSlide61

Direct RepairSlide62
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Nerve GraftingSlide66

Nerve graftingSlide67
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Free functioning muscle transferSlide74

Spinal accessory (

XIth

) nerve.

Intercostal

nerves (commonly 3rd to 6th)

Fascicles of the median and

ulnar

nervesOpposite C7.

Common donorsSlide75

Order of priority of restoration of function

Elbow flexion(

Musculocutaneous

nerve)

Shoulder stability (

suprascapular

nerve and

axillary

nerve)

Hand

prehension

Common

recipient nerves Slide76

Nerve regeneration: some muscles recover earlier, others paretic  muscle imbalance

Recovery results from misdirection of regenerated axons  cross innervation

Late OBPPSlide77

Co-contraction of synergestic & antagonistic musclesDiminishing functional recoveryMuscle contracture

 deformity

Cross innervationSlide78
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In flaccid paralysis of complete lesionDifficult to manage & difficult to rehabilitate

If no active wrist extension & no possible transfers – W. fusion with comb inter-metacarpal

arthrodesis

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HAND DEFORMITYSlide80

Take home points

Obstetric brachial plexus injuries may be avoidable if timely C-section is performed.

Early referral to a brachial plexus surgeon once the diagnosis is made.

All is not lost – Nerve surgery or other secondary procedures can improve function drastically.Slide81

kumarhand@gmail.com

Thank you