BRACHIAL PLEXUS INJURIES

Guides:
Dr. Manjunath Dargad
Dr. Anshu Shekhar
Contents:
• Anatomy of the Brachial Plexus

• Mechanisms of Brachial Plexus Injury

and Pathologies

• Neurological Evaluation for the Brachial Plexus and

Related Special Tests.

• Management of BPI.
Introduction
• The brachial plexus is a somatic nerve plexus.

• Ventral rami of C5-C8 and T1.

• It proceeds through the neck, the axilla and into the arm.

• The plexus is responsible for :

Motor innervation to all of the muscles of the upper limb except...

Sensory innervation of the upper limb except….

• Location:

The brachial plexus lies in the posterior triangle of the neck

between the scalenus anterior and scalenus medius muscles.
 At the root of the neck, it lies behind the clavicle.
 Grades of Injury
• Grade 1 – Neuropraxia
• Disruption in nerve function that produces numbness and tingling.
• Most common grade within athletics.
• Recovery of nerve conduction deficit is full, and requires days to weeks.

• Grade 2 – Axonotmesis
• Damage to the nerve’s axon.
• Symptoms = numbness, tingling, and affected function (may last several
days).
• Long nerves have a greater healing time than short nerves.

• Grade 3 – Neurotmesis
• Permanent nerve damage occurs.
• Occurs with high-energy trauma, fractures, and penetrating injuries.
 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.

• Divisions
• Each trunk splits into an anterior division and a posterior division.
• The anterior divisions usually supply flexor muscles.
• The posterior divisions usually supply extensor muscles.
• Cords
• The anterior divisions of the upper and middle trunks unite to form the
lateral cord.
• The anterior division of the lower trunk forms the medial cord.
• All 3 posterior divisions from each of the 3 cords all unite to form the
posterior cord.

The cords are named according to their position relative to the axillary artery.

• Terminal branches:
1.Musculo Cutaneous n.
2.Ulnar n.
3.Median n.
4.Axillary n.
5.Radial n.
Postfixed Brachial Plexus
 Mechanisms of Injury to the Brachial Plexus
A. Traction: B. Direct trauma:
Eg. Gymnast falls on beam Over Erb’s point.
:
C. Cervical Nerve Compression
Falling on Shoulder
Mode of Injury
• In military combat- Penetrating Wounds.

• In civilian life-
1. Motor vehicle Accidents
2. Injuries related to birth
3. Traction applied to the plexus during falls
4. Sports activities.

• Rupture Of the axillary or subclavian artery occurs in 20% cases.

• Common associated injuries:
1. Fractures of the proximal humerus
2. The scapula
3. The ribs
4. The clavicle
5. The transverse process of the cervical vertebrae
6. Dislocation of the shoulder, AC and SC joints.

Concomitant spinal cord injury is reported in 2%- 5% cases.

Leffert’s Classification

   I     Open
II    Closed
IIa  Supraclavicular
-Preganglionic
- Postgangionic
IIb Infraclavicular
 III    Radiation induced
IV    Obstetric
 IVa  Erb's  (upper trunk)
 IVb  Klumpke (lower trunk)
Clinical features
Symptoms:

• Patients generally present with pain and/or muscle weakness.

• Some patients may experience muscle atrophy.

Result:
 Anesthesia
Paralysis
1. Complete
2. Incomplete
 Autonomic disturbances.
Narakas and Birch et al. Clasification based on Clinical
findings:

1. Group I, C5-C6 paralysis of the shoulder and biceps;

2. Group II, C5-C7 paralysis of the shoulder, biceps, and
forearm extensors;
3. Group III, C5-T1 complete paralysis of the limb;
4. Group IV, complete paralysis of the limb, with Horner’s
syndrome.
Neurological Examination
Neurological Examination Cont…..
Peripheral Nerve Tests
Radial N.
• Sensory – 1st Dorsal web
Axillary N. space
• Sensory – Lateral arm • Motor – Wrist extension and
• Motor – Shoulder thumb extension
abduction
Median N.
• Sensory – Pad of Index finger
Musculocutaneous N. • Motor – Thumb pinch and
• Sensory – Anterior arm abduction
• Motor – Elbow flexion
Ulnar N.
• Sensory – Pad of little finger
• Motor – Finger abduction
Reflex Tests:

• C5 – Biceps brachii reflex

• C6 – Brachioradialis reflex

• C7 – Triceps brachii reflex

• C8 and T1 do not have reflex tests

Erb- Duchenne palsy

Injury to Superior part of Plexus.

Occurrence:
Due to excessive increase in the angle
between neck and the shoulder.

Roots Involved:
 C5 and C6

Muscles Involved:
 Shoulder
 Arm
Clinical Appearance:

Motor Loss:
 Adducted Shoulder
 Medially Rotated Arm
 Extended Elbow

Sensory Loss:
Over the deltoid and Lateral aspect of Upper Limb.

Biceps Reflex - Absent

Diagnosis
1. Clinical features
• Segmental motor and sensory deficits involving C5 and C6 roots
• With paralysis of serratus anterior, levator scapulae and rhomboids.

2. Myelography
• Shows a pseudomeningocele or complete absence of root shadows
• May be inaccurate early after injury.
• Delay of 6- 12 weeks is recommended.

3. CT Myelography

4. MRI Myelography
• Preferred imaging technique in patients with traction injury.
Cont….
• Cutaneous Axon Reflexes
• Helps differentiate preganglionic intraspinal lesions from
postganglionic extraspinal lesions.
• Drop of histamine is placed along the distribution of the nerve
being examined
• Sequential Response- Cutaneous vasodilation, wheal
formation and flare response.

• Inference: Negative axonal response suggests injury at a site

where recovery might be possible after repair.

• Cold vasodilation test and sensory nerve velocity studies may

assist in differentiating the level of injury.
Klumpke paralysis or Palsy
Injury to Inferior part of Plexus.

Associated with Horner’s syndrome.

Occurrence:
Excessive abduction of arm.

Roots Involved:
 C8 and T1
Person grasping something to prevent a fall
Baby’s upper limb is pulled excessively during delivery
Cervical Rib

Involves Inferior part of

Plexus
Clinical Appearance:

Motor Loss:
 Small muscles of Hand along with paralysis of the wrist and
finger flexors.

Sensory Loss:
 Medial aspect of Upper Limb.
Claw Hand

Aetiology:
•Brachial plexus lesion
(C8-T1).
•Ulnar, and/ or Median nerve
injury.

Appearance:
• Hyperextension at the MCP
joints
• Flexion of the IP joints.
Claw Hand
 NOTE
Clinically, post- ganglionic BPI is differentiated from pre-
ganglionic BPI by:

Preservation of function of the Long thoracic and Dorsal

Scapular nerves in the upper trunk and absence of Horner’s
syndrome in the lower trunk.
Related Special Tests

Thoracic Outlet Syndrome

1. Adson’s Test

2. Allen’s Test

3. Military Brace Position

Management

• Medical:

• Physiotherapy: maintain supple joints with FROM

• Orthoptists / Splinting
• Pain control.

• Surgical
Surgical options: Immediate vs delayed
• Indications for Surgery at time of injury
• Open injury
• High energy injury
• Supraclavicular injury
• Associated depressed clavicle fracture
Sx: Explore and immediate repair / nerve grafts

• Surgery 3months post injury IF CLOSED (and no sign recovery):

nerve grafts or nerve transfer

• Surgery >1 year post injury:

local or free muscle transfer starting at proximal joint.
Surgical Goals:
• In order of priority:
1. Restoration of elbow flexion
2. Restoration of shoulder abduction
3. Restoration of sensation to the medial border of forearm and hand.

• After BPI repair and reconstruction, 12- 18 months is

required to determine the extent of neural regeneration.

• If inadequate recovery then peripheral reconstruction.

How to manage a BPI victim???

• Open wounds
• Sharp injury
• Bullet injury

• Closed injuries
Sharp Injury
 Junction of trunk and cords

• Bullet wound
Clavicle osteotomy
Laceration
Nerve repair and graft
Closed injury (tractional injuries)

• Early exploration
• Under observation
• Decision for the time of delay exploration
• Decision for the type of the treatment

• Late reconstruction Peripheral Reconstruction.

• Early exploration Vascular Reconstruction.

• Under observation
• First 6-12 weeks
Stabilization of the patient
Stabilization of the injury
Evaluation of the improvement

• After 2-3 months

No improvement---- exploration
Progressive improvement---- wait & watch
Non-anatomic recovery---- exploration.
• Decision for the time of delay exploration

• No recovery
• After 6-12 weeks (based on the severity of the trauma)
• Progressive improvement
• Wait for further improvement
• Non-anatomic recovery
• Exploration before 9-12 months
Decision for the type of the treatment:

1. Neurorrhaphy
2. Neurolysis
3. Nerve graft
4. Neurotization

5. Tendon transfer
6. Arthrodesis
7. Functional muscle flaps
Nerve grafts:
1. Sural
2. Medial cutaneous forearm
3. Posterior interosseous nerve
4. Ulnar (vascularised)

Nerve transfers:
5. Spinal Accessory nerve
6. Intercostal nerves
7. Ulnar FCU nerve
8. Axillary Nerve
5. Medial pectoral nerve transfer for elbow flexion
Nerve Transfer

Accessory n.
Injured upper trunk

Superascapular nerve
 ICN 4
Musclocutaneus n
ICN 5

ICN 6
Oberlin nerve transfer

Biceps m.
Anastamosis
Ulnar n.
Radial to axillary transfer
Tendon Transfer

Triceps to Biceps
Latismus dorsi m.
Latismus dorsi transfer
to flexion elbow
and extension finger
Trapezius to Deltoid
Arthrodesis
Functional muscle flaps

Gracillis harvest
 Summary

Brachial plexus injury

y rgy
Open sharp injuryenerg Shot gun w
e
Tractional
en injury
gh o
Hi L

Immediate exploration Under observation

Exploration No improvement in 2-3 m

Exploration In 12 m. Non-anatomic improvement

Peripheral reconstruction > 12m .

Gradual improvement
THANK YOU!!!