BRACHIAL PLEXUS INJURY

5 weeks of gestation

Afferent fibers from neuroblast located alongside neural tube

Efferent fibers from neuroblast in the basal plate

of tube from where they grow outside

EMBRYOLOGY

Afferent and efferent fibers join to form the nerve

Nerves divide into anterior and posterior divisions

There are connections between these nerves in the brachial plexus

RELATIONS OF BRACHIAL PLEXUS

Branches of lateral and medial cords

Branches of posterior cord

There are few terminal branches of the roots trunks and cords.

ROOTS: a)dorsal scapular nerve b)branch to phrenic nerve c)Long thoracic nerve

TRUNKS: a)nerve to subclavius b) suprascapular nerve

CORDS: a) Lateral cord gives lateral pectoral nerve b)Posterior cord gives upper subscapular, lower subscapular and thoracodorsal nerve.

Branches of roots and trunks

Found in around 50% Most commonly pre-fixed(28-62%) and

post-fixed(16-73%)

Variations

PREFIXED BRACHIAL PLEXUS

Post-fixed plexus

Anatomy of rootlets, roots and vertebral foramen contribute to the type of injury

Rootlets forming the cervical roots are intraspinal and lack connective tissue or meningeal envelope.

Vulnerable to traction and susceptibility to avulsion at the level of cord.

Patho-anatomy

Fibrous attachment of spinal nerves to the transverse process seen in the 4th through 7th cervical roots

This explains the high incidence of root avulsions in C8-T1 roots

The spinal nerve able to move freely in the foramina due to non attachment to it

Common :Birth injuries, motor vehicle trauma, sports injuries

Rare :Gunshot wound, Stab injury Irradiation, Pancoast tumor

Chronic microtrauma : Backpacker’s palsy, Painters

Aetiology

Narakus' "law of seven seventies," based on experience with more than 1,000 patients over an 18-year span, estimates the current demographics:

70% of traumatic brachial plexus injuries (BPIs) are due to motor vehicle accidents.

70% of the vehicle accidents involve motorcycles or bicycles. 70% of the cycle riders have associated multiple injuries. 70% have a supraclavicular lesion. 70% of those with supraclavicular lesions have at least one

root avulsed. 70% of patients with root avulsions have the lower roots (C7,

C8, Tl or C8, Tl) avulsed. 70% of patients with lower-root avulsions experience

persistent pain

Usually closed injuries 95% traction injuries, 5% compression injuries Supraclavicular more common than

infraclavicular involvement Roots and trunks most commonly involved Root avulsions: 2 mechanisms peripheral- common central- rare

Infraclavicular injuries occur at cords or peripheral nerves and usually incomplete

Caused by shoulder fracture or dislocation

5- 25% of infraclavicular injuries are associated with axillary artery injury

Penetrating injuries are usually infraclavicular

Infraclavicular lesions

MECHANISM OF INJURY

MECHANISM OF INJURY

in as many as one in 250 births

High birth weight, prolonged labor,breech presentation, and shoulder dystocia

Produced by traction on the neural elements for example, stretching of the brachial plexus with forced lateral flexion of the head and neck or excessive pull of limbs over head

Obstetrical or birth palsy of the brachial plexus

Pain, especially of the neck and shoulder Pain over a nerve common with rupture, as

opposed to lack of percussion tenderness with avulsion

Paresthesias and dysesthesias

Weakness or heaviness in the extremity

Diminished pulses, as vascular injury may accompany traction injury

symptoms

Sensory examination extremely important

Deep pressure sensation may be the only clue to continuity in a nerve with no motor function or other sensation

Apply full pinch to the nail base and pull the patient's finger outward ;any burning suggests continuity of the tested nerve

According to the location of injury, extension throughout the plexus, and the degree of the damage

Based on a thorough physical examination, BPI divided into preganglionic and postganglionic injuries.

Prognostic and therapeutic implications

Diagnosis

Avulsion of the nerve root proximal to the spinal ganglion

Dorsal rami interrupted, denervation of dorsal neck muscles ( rhomboids, serratus anterior, ) Changes in EMG

Preganglionic Injury

No proximal stump or neuroma formation, No Tinel sign present

Meningocele formation due to dural and arachnoid lesion with avulsed roots

Myelographic leak

Roots not visible on CT

Pantopaque myelogram showing pseudomeningocele produced by avulsion of roots of C7 and C8; C5 and C6, which also were avulsed, did not fill. T1 still functions.

Associated Horner's syndrome or a fracture of the transverse process of the adjacent cervical vertebra

Nerve fibres to skin in continuity with neurons in the spinal ganglion

No wallerian degeneration of sensory nerve fibres

Positive nerve conduction

Depending on the number of roots avulsed, Preganglionic BPI generally falls into one of three categories:

A completely flail arm with avulsion of all roots (C5-T1)

A lower avulsion of the C8-T1 roots

An upper lesion in which only the C5 and C6 roots avulsed

Limb extended at the elbow, flaccid at the side of the trunk, and adducted and internally rotated

Paralysis of the supinator muscle causes pronation deformity of the forearm and inability to supinate the forearm.

Sensation absent over the deltoid muscle and the lateral aspect of the forearm and hand.

Upper plexus injury (Erb, C5 and C6 roots )

Segmental sensory and motor deficits involving C8 and T1

The primary dysfunction : apparent in the

intrinsic musculature of the hand along with paralysis of the wrist and finger flexors

The sensory deficit along the medial aspect of the arm, forearm, and hand

Lower plexus injury (Klumpke )

Distal to the spinal ganglia (proximal stump with neuroma formation)

Tinel’s sign positive, myelography negative, EMG normal, roots visible on CT, Nerve conduction abnormal

Postganglionic injuries further subdivided into trunk and cord injuries

Postganglionic injuries

Elicited by placing a drop of histamine on the skin along the distribution of the nerve being examined

Skin scratched through the drop of histamine : cutaneous vasodilation, wheal formation, and flare response

Nerve interrupted proximal to the ganglion :anesthesia along its cutaneous course, normal axon response

Injury is distal to the ganglion : anesthesia along the course of the nerve, and vasodilation and wheal formation seen, flare response absent

Cutaneous axon reflex

Long thoracic nerve ( serratus anterior muscle) intact

Suprascapular nerve involved

Upper trunk lesions ( paralysis of shoulder muscles & biceps brachii)

Middle trunk lesions :Radial nerve palsy Lower trunk lesions: ulnar & median nerve palsy

Trunk lesions

Long thoracic nerve, Suprascapular nerve & pectoral nerve intact

Posterior, lateral cord & medial cord lesions

Cord lesions

Motor and sensory deficits in the distribution of :

musculocutaneous nerve (paralysis of the biceps)

lateral root of the median nerve (paralysis of the flexor carpi radialis and pronator teres)

lateral pectoral nerve (clavicular head of the pectoralis major).

Sensory deficit over the anterolateral aspect of the forearm in the relatively small autonomous zone of the musculocutaneous nerve

Injuries of the lateral cord

Subscapular (paralysis of the subscapularis and teres major)

Thoracodorsal (paralysis of the latissimus dorsi)

Axillary (paralysis of the deltoid and teres minor) Radial (paralysis of extension of the elbow, wrist,

and fingers)

Sensory loss in the autonomous zone of the axillary nerve overlying the deltoid muscle

Injuries of the posterior cord

Motor deficit of a combined ulnar and median nerve lesion (except for the flexor carpi radialis and pronator teres)

Extensive sensory loss along the medial aspect of the arm and hand

Injuries of the medial cord

Upper plexus lesions (C5, C6)

Extended upper plexus (C5,C6,C7 )

C7 Lesions

Lower plexus lesions (C8, T1 )

Peripheral lesions

Extent of lesions

Seddon’s classification:

Neurapraxia ( traction/ compression, recovery is rule )

Axonotmesis ( section of nerve with intact sheath, wallerian degeneration, recovery in 6/8 weeks)

Neurotmesis (complete section, surgical repair)

Degree of damage

Radiographic evaluation◦ In anteroposterior (AP) chest radiography,

specific attention directed to the distance between the spinous processes of the thoracic spine and the scapula

◦ If the radiograph not malrotated, an increase in this distance compared with the contralateral side may indicate scapulothoracic dissociation 

Imaging Studies

Gold standard

The most reliable indicator of root avulsion : an absent root shadow on plain myelography

A common sign of a root avulsion: meningocele at the affected level

Delayed for 4 weeks so that any blood clot will not be dislodged by the study and the meningocele can be allowed to form

CT Myelography

Fast spin echo (FSE-MR)

Useful in infants with obstetric palsy

Noninvasive and can be performed under sedation

Postmyelography MRI and CT : mainstays of imaging brachial plexus injuries

Confirm a diagnosis

Localize lesions

Define severity of axon loss and completeness of lesion

Serve as an important adjunct to thorough history, physical exam and imaging study

ELECTRODIAGNOSTIC STUDIES

For closed injuries EMG and NCV best performed 3 to 4 weeks after the injury because wallerian degeneration will occur by this time

Denervation changes(fibrillation potentials) seen in proximal muscles 10 to 14 days and 3 to 6 weeks post injury in most distal muscles

Reduced MUP(motor unit potential) recruitment shown immediately after weakness from LMN injury

Presence of active motor units with voluntary effort and few fibrillations at rest good prognosis

Distinguishing preganglionic from postganglionic lesions

EMG

NAP (nerve action potential )

SEP (somatosensory evoked potential)

CMAP (compound muscle action potential)

INTRA OP TESTING

Differentiates preganglionic from postganglionic injuries

If the injury proximal to the dorsal root ganglion (DRG), no Wallerian degeneration; a SNAP observed in a nerve with an anesthetic dermatome confirms a preganglionic lesion

SNAPs not useful for C5 evaluation, C5 does not provide a significant contribution to a major peripheral sensory nerve

Sensory nerve action potentials (SNAPs)

Intraoperative SSEPs are useful in brachial plexus surgery.

The presence of suggests continuity between the peripheral nervous system and the CNS via the DRG.

Absent in postganglionic or combined pre- and postganglionic lesions.

Somatosensory evoked potentials (SSEPs):

PREOPERATIVE PLANNING

A - acute exploration• concomitant vascular injury• open injury by sharp laceration• crush or contaminated wound

Open injury with low-velocity missile • Early exploration not indicated, unless injuries to

adjacent vessels or viscera make immediate treatment necessary

• Condition of the patient prevents extensive repair or grafting of the plexus

• Injury inspected, its extent documented & observed

Timing of intervention

A correct diagnosis of the amount of damage to the plexus established only by exploration.

Functional assessment of the nerve made by

intra-operative nerve stimulation

A non-conducting neuroma resected and the gap reconstructed with nerve grafts

B - early exploration (1- 2 weeks)

• Unequivocal complete C5- T1 avulsion injuries• Facilities not available at initial exploration• Concomitant injuries requiring early care

Complete injuries with no recovery by clinical examination or EMG at 12 weeks post injury

Distal recovery without regaining clinical or electrical evidence of proximal muscle function

Any return has ceased

Patient shows non-anatomical return of function with isolated lack of proximal function in the presence of good distal nerve recovery

Delayed exploration > 3 months

Evidence that the lesions at the postganglionic level

Anaesthetic limb, severe deafferentation pain, Horner’s syndrome and pseudomeningoceles on imaging

Postganglionic lesions :follow patients conservatively for up to 3 months to watch for spontaneous motor recovery. In upper-plexus injuries, if the biceps muscle not recovered within 3 months, then surgical exploration

Stretch neurapraxia may regenerate healthy nerve tissue

Observation & physical therapy up to 8-10 weeks for spontaneous recovery

After 4 weeks a baseline electromyography and CT/MR myelography should be performed.

Non surgical management

Restoration of elbow flexion

Restoration of shoulder abduction

Restoration of sensation to the medial border of the forearm and hand

Surgical Goals

Neurolysis Nerve repair• Neurorrhaphy• End to side coaptation Nerve graft Nerve transfer or neurotization Functional free muscle transfer Carlstedt et al :reimplantation of avulsed roots

Surgical options

Direct intraoperative nerve stimulation and recording required across damaged elements

• If nerve action potentials are obtained, simple neurolysis indicated.

• If neural integrity completely lost, or if no nerve action potentials recorded across a damaged element, excision and nerve grafting are required

In root avulsions of the upper plexus in which no proximal neural stump is available for nerve grafting, neurotization between the intercostal nerves and the musculocutaneous nerve to restore elbow flexion

Effective only if scar tissue seen around nerve or inside epineurium, preventing recovery or causing pain

Pre and post neurolysis direct nerve stimulation is mandatory to evaluate improvement in nerve conduction

Neurolysis

Sharp transection with excellent fascicular pattern and minimal scar

Lesions of the C5 and C6 nerve roots, the upper trunk, and the lateral cord proximal to the origin of the musculocutaneous nerve can be treated with some success

Neurorrhaphy

Excellent in small nerves with one function Viterbo :BR J Plast surg 1994

Denervated nerve brought with its cross section end to side with innervated nerve with creation of epineural/perineural windows

End to side coaptation

Indicated for well defined nerve ends without segmental injuries

Intraoperatively a good fascicular pattern should be seen after the neuroma excision

Possible sources: sural, brachial cutaneous nerve, radial sensory and possibly ulnar nerve

Before implantation graft orientation reversed to minimize axonal branch loss

Surgical technique the most important factor in nerve graft

Nerve graft

A tension free nerve graft better than a primary repair under tension

Thin cutaneous grafts (e.g. sural nerve) prepared

Graft should be 20% longer than the length of the nerve defect

Endoscopic harvesting of the sural nerve graft devise to overcome the potential drawbacks of the open technique

Mackinnon et all

Act as a temporary scaffold across which axons regenerate

Ultimately, the allograft tissue completely replaced with host material

Tacrolimus, greater potential and fewer side effects than other immunosuppressants, neuroregenerative and neuroprotective effects

NERVE ALLOGRAFTS

Nerve repairs performed with fibrin sealants produced less inflammatory response and fibrosis, better axonal regeneration, and better fiber alignment than the nerve repairs performed with microsutures alone

Fibrin sealant techniques were quicker and easier to use

* J oint Reconstr Microsurg 2006

Nerve fibrin glue *

Help in directing axonal sprouts from the proximal stump to the distal nerve stump

Provide a channel for diffusion of neurotropic and neurotrophic factors and minimize infiltration of fibrous tissue

Tubes made of biological materials such as collagen have been used with more success for distances of less than 3 cm

*PS Bhandari, LP Sadhotra, P Bhargava, AS Bath, MK Mukherjee, Pauline Babu Indian Journal of Neurotrauma (IJNT), Vol. 5, No. 1, 2008

NERVE CONDUITS *

For repair of severe brachial plexus injury, in which the proximal spinal nerve roots have been avulsed from the spinal cord

Ideally performed before 6 months post injury but may be better suited than grafting in situation after the preferred 6 months time frame

A proximal healthy nerve coapted to the denervated nerve to reinnervate the latter by the donated axons

Neurotizations

The concept is to sacrifice the function of a lesser valued donor muscle to revive the function in the recipient nerve and muscle that will undergo reinnervation

Transferring a pure motor donor nerve to a motor recipient nerve gives the best result of motor neurotization, for example, spinal accessory to suprascapular neurotization

contd…..

Recipient site at the peripheral part of the plexus such as the musculocutaneous nerve, the suprascapular nerve, or the axillary nerve more effective than a recipient in the central part such as the posterior cord or the lower trunk

Reinnervate the recipient nerve as close to the target muscle as possible; ex. transfer of an ulnar nerve fascicle directly to the biceps branch of the musculocutaneous nerve in close proximity to its entry into the muscle Frederic et all

contd….

1

Direct suture without tension always superior to indirect suture with a nerve graft

Especially true for the weak donor nerves such as intercostal nerves and the distal spinal accessory nerve

Ipsilateral nerve transfer always superior to the contralateral nerve transfer

Current trends in the management of brachial plexus injuries Indian Journal of Neurotrauma (IJNT), Vol. 5, No. 1, 2008

A- intraplexal

B- extraplexal

Plexoplexal options are undamaged roots

Neurotization

The transfer of a spinal nerve or more distal plexus component with intact spinal cord connections to a more important denervated nerve

Ruptured proximal nerve used

Examples include connecting the proximal stump of C5 or C6 to the distal aspect of C8, lower trunk, or median nerve, or the use of a portion of a functional ulnar nerve to the musculocutaneous nerve

Intraplexal neurotization

Transfer of a non brachial plexus component nerve to the brachial plexus

Sources commonly used include spinal accessory nerve, intercostal nerves, phrenic nerve, deep cervical motor branches, and contralateral C7 transfer

Extraplexal neurotization

Neuromuscular neurotization (direct implantation of motor nerve fascicles in to denervated muscle) from intraplexal sources

Spinal accessory to surprascapular or musculocutaneous

Phrenic to axillary nerve Intercostal to musculocutaneous long thoracic,

radial and median nerve Long head of triceps nerve to anterior branch of

axillary nerve Partial ulnar nerve transfer for elbow flexion The contralateral C7 transfer preferred for hand

flexors and sensation in global plexopathies

Realistic targets to reinnervation

Through a lateral fourth-rib thoracotomy the motor portion of the third, fourth, and fifth intercostal nerves transferred subcutane-ously into the axilla to be anastomosed to the musculocutaneous nerve

Neurotization with intercostal motor nerves

If the interval from BPI to reconstruction delayed beyond 12 months, the results of surgical reconstruction with the intercostal nerves alone have been poor

Attributed to fibrosis of the motor end plates of the biceps muscle.

Under these circumstances, a free innervated gracilis muscle to replace the biceps

Attachment is made proximally with the gracilis origin to the coracoid process and distally to the biceps tendon. After successful vascular anastomosis of the artery and vein, through an ipsilateral thoracotomy, intercostal motor nerves to the third, fourth, and fifth ribs are used to successfully reinnervate the gracilis

Result

For upper trunk injury with intact lower trunk: 1 to 2 fascicles of ulnar nerve anastomosed to biceps

Contra lateral C7 used in pan brachial plexopathy with multiple avulsions and limited donor possibility

Contra lateral C7 root extended by means of vascularised ulnar nerve graft in patient with C8 T1 avulsion and median nerve is the most frequent recipient

Another option is transferring nerve to long head of triceps to anterior branch of axillary nerve

Oberlin technique

After brachial plexus repair and reconstruction, 12 to 18 months required to determine the extent of neural regeneration

If recovery considered inadequate, peripheral reconstruction considered

The choice of the donor muscle-tendon unit or units not interfere with existing function

Adequate strength (a grade of at least 4 of 5) of the donor muscle must be confirmed

Avoid transferring a tendon when the muscle of that tendon was previously paralyzed and has now recovered.

The excursion of the donor muscle-tendon unit must be adequate

Tendon transfers

Each tendon perform only one function The transfer employs a straight line of pull When possible, synergism should be employed

such that the simultaneous contractions of different muscles combine to achieve a desired function

Manual or electrodiagnostic testing to check for inphase firing of planned donors with nearby, uninvolved motors should be performed preoperatively, to ensure that transferred motors and intact motors do not act as antagonists and prevent active motion

Contd…

Functional range of motion Joint contractures released The joint congruent and reduced Skin supple without constricting scars

Trapezius-to-deltoid transfer as described by Saha to improve abduction and latissimus dorsi transfer to improve external rotation as described by L'Episcopo

Tendon Transfers About the Shoulder

Deltoid and the clavicular head of the pectoralis major as prime movers for abduction; they also lift the humeral shaft

Subscapularis, supraspinatus and infraspinatus are a steering group which stabilise the humeral head in the glenoid.

The sternal head of pectoralis major, latissimus dorsi, teres major and teres minor form a depressor group which alsorotate the shaft and pull the humeral head downwards during the last few degrees of abduction.

Muscles of shoulder

When any two of the steering group of muscles were paralysed a single muscle transfer to replace the deltoid would not provide abduction beyond 90°

Transfer of pectoralis minor, the upper two digitations of serratus anterior, latissimus dorsi and teres major in various combinations.

Transfers of the levator scapulae, sternocleidomastoid, scalenus anterior, scalenus medius and scalenus capitis

Saha

Saha’s logical modification of the trapezius transfer described by Bateman

Provides a more distal fixation of the transfer after a more proximal release.

Greater lever arm, and fracture of the bony insertion transferred from the acromion allows better fixation to the narrow cylindrical shaft of the humerus.

An important modification to consider transfer for paralysed musclesof the rotator cuff, to improve control of the humeral head and prevent subluxation

Adduction and internal rotation contracture :Release or recession of subscapularis muscle

Isolated abduction contracture: Release or recession of deltoid muscle

Abduction and external rotation contracture: Transfer of infraspinatus tendon to teres minor tendon;release or recession of infraspinatus and supraspinatus tendons with or without release of deltoid muscle

Shoulder

Dysfunction of anterior and middle parts of deltoid muscle (partial reinnervation of paralyzed deltoid muscle) :Anterior transfer of posterior part of deltoid muscle

Dysfunction of supraspinatus or infraspinatus muscle :Transfer of latissimus dorsi tendon to greater tuberosity

Dysfunction of deltoid muscle Transfer of trapezius muscle with bone to lateral aspect of humerus; bipolar transfer of latissimus dorsi muscle

Dysfunction of subscapularis muscle :Transfer of serratus anterior muscle; transfer of pectoralismajor tendon

Internal or external rotation deformity with incongruent glenohumeral joint :Humeral derotation osteotomy

Severe dysfunction of shoulder with pain or instability :Glenohumeral arthrodesis

Reviewed 26 patients treated by trapezius transfer for deltoid paralysis due to brachial plexus injury or old poliomyelitis.

Assessed the power of shoulder abduction and the tendency for subluxation.

Good results in 16 patients (60%); five were fair and five poor.

Trapezius transfer appears to give reasonable results in the salvage of abductor paralysis of the shoulder.

J Bone Joint Surg [Br] 1998;80-B:114-6.

Trapezius transfer for deltoid paralysisP. P. Kotwal, R. Mittal, R. Malhotra

Procedure Division of the clavicle

and the acromion to allow transfer of the insertion of the central part of the trapezius

The transfer unit is fixed to the humeral shaft with screws

Radiograph after operation

Active abduction before surgery.

Active abduction after surgery.

Failure due to persistent anterior subluxation after trapezius transfer

Transfer of the latissimus dorsi tendon to the greater tuberosity or the rotator cuff

Transfer of trapezius

Release of subscapularis

Severe combined lesions and the surgeon cannot reasonably expect to achieve glenohumeral stability with any of the described soft-tissue procedures

To enhance the power of weak elbow flexion or extension transfers by isolating the forces of the transfer to the elbow

Arthrodesis

Fusion in this attitude permits scapular motion, when combined with elbow motion, to allow the patient to reach all four major functional areas: face, midline, perineum, and rear trouser pocket

Restoration of elbow flexion primary importance

Elbow flexion restored by intercostal neurotization or tendon transfer.

When the pectoralis major and latissimus dorsi areavailable for transfer, superior results anticipated

Tendon Transfers About the Elbow

Dysfunction of biceps muscle :Unipolar or bipolar transposition of pectoralis major muscle; bipolar transposition of latissimus dorsi muscle; free microvascular transfer of gracilis rectus muscle;modified Steindler flexorplasty; anterior transfer of triceps tendon

Dysfunction of triceps muscle :Transfer of latissimus dorsi muscle

Contd..

When the medial epicondylar muscles a weak or full extension of the elbow essential for transfer or ambulation, an alternative procedure considered

Steindler's procedure when the elbow flexors reach only grade 2, contrarily contraindicated when the elbow flexors are classified as grade 0, when the wrist flexors are weak, or when wrist and finger extensors are paralyzed

Steindler Flexorplasty proximal transfer (4 –

5 cm) and fixation of a piece of the medial epicondyle with its attached origin of the flexor-pronator muscle group in the middle of the anterior aspect of the humerus.

Liu TK. Yang RS. Sun JS. Clinical Orthopaedics & Related Research. (296):104-8, 1993 Nov

Seventy-one consecutive patients treated with a modified Steindler flexorplasty from 1970 to 1987. Additional operative procedures included shoulder fusion (45 patients), tendon transfer (20 patients), and wrist tenodesis (3). Follow-up averaged 8.2 years. The outcome excellent in 32%, good in 47%, fair in 13%, and poor in 8%. Postoperatively, the mean arc of active elbow flexion 114 degrees; the average elbow extension loss, 28 degrees; the mean active pronation, 74 degrees; and supination, 30 degrees. Wire breakage found in two cases. Additional tendon transfer of flexor carpi ulnaris to extensor carpi radialis brevis improved the outcomes in the patients without active supination.

The modified Steindler flexorplasty provided predictable functional improvement in carefully selected patients with paralyzed upper extremities.

An early but cosmetically unacceptable procedure : transfer of the sternocleidomastoid muscle which involves detaching this muscle from its insertion and linking it to the insertion of the biceps muscle by means of a long strip of fascia lata

Transfer of the sternocleidomastoid muscle to the biceps tendon

Extension Flexion

Bipolar pectoralis major flexorplasty as described by Schottstaedt et al

Bipolar latissimus dorsi flexorplasty as described by Hovnanian

Result

Flexion Extension

Bipolar latissimus dorsi tricepsplasty as described by Hovnanian

In hands in which the superficial flexors of the fingers and thenar muscles of opposition denervated, usually as the result of high median-nerve or brachial plexus injury, thumb opposition restored by transfer of the superficial flexor of the ring finger to the thumb through a dynamic pulley made from the distal segment of flexor carpi ulnaris which is attached to the extensor carpi ulnaris, combined with transfer of the proximal segment of flexor carpi ulnaris to the transferred paralyzed superficial ring-finger flexor tendon

C5-6 type :

complete loss of voluntary shoulder and elbow control, although many can still extend the wrist by using finger extensors and the extensor carpi ulnaris. Thumb and index finger sensation impaired

Figure-of-8 harness and Bowden cable a used to provide body-powered elbow flexion, sometimes with an elbow hinge that can be locked in several positions; Shoulder subluxation also reduced by su

Orthosis

C5-7 type 

adds radial palsy to the above picture, sensory loss in the hand increase, but all active extension at the wrist, hand, and fingers lost

Possible to add either static or spring-assisted wrist, hand, and finger extension to the previous orthosis.

c7- 8 Tl type

Good shoulder and elbow function but loses finger flexors, extensors, and intrinsics

Surgical reconstruction often of particular value

Those who sustain a concomitant traumatic transradial amputation : body-powered or switch-controlled terminal device

C8, Tl type

 Enjoys the greatest percentage of orthotic success since motor rather than sensory loss significant

Although finger flexors and intrinsics are paralyzed, sensory loss is limited to the ring and small digits, which are not involved in pinch prehension

FLAIL ARM ORTHOSES

In view of the substantial percentage of BPI amputees who reject prosthetic devices, it has been argued that orthotic restoration is an equally plausible alternative. Wynn Parry has reported his experience with a series of over 200 cases and states that 70% continue to use a full-arm orthosis for work or hobby activities after 1 year

Wynn Parry CB: Rehabilitation of patients following traction lesions of the brachial plexus. Clin Plast Surg 1984

 A thorough physical examination including manual and EMG muscle testing required to assess rehabilitation potential.

The patient actively involved in all prescription decisions from the outset; without a motivated and cooperative individual, even heroic prosthetic/orthotic interventions are doomed to failure.

Full-arm orthosis during the recovery period, beginning as soon as the patient has come to terms with the serious and potentially permanent nature of his injuries.

Once surgical reconstruction and spontaneous recovery are complete, amputation and trial with a prosthesis can be considered.

Psychological and social work consultation may be useful to help the patient discuss the altered body image and employment possibilities that will follow amputation.

REHABILITATION

Most of these injuries resolve without operative intervention

Joint mobilization and range-of-motion exercises performed by the parents and guided by a physical or occupational therapist can help to maintain a congruent glenohumeral joint and to minimize contractures

For severely affected, however, a variety of procedures are available

Management of obstetric palsy

3-9 mnths : Exploration and repair of brachial plexus

12-24 nths : Release of contractures

24-60 mnths : Tendon and muscle transfers >60 (and incongruent joint) :Osseous procedures

TIMING OF OPERATIVE PROCEDURES IN PATIENTSWHO HAVE OBSTETRICAL PLEXUS PALSY

As long as the glenohumeral joint is congruent, tendon and muscle transfers may be performed at a later date, but they should be considered at these earlier times to maximize functional recovery

Joint incongruity increase with the patient’s age

Patients with incomplete recovery who are seen more than six months after birth frequently have muscle contractures due to unopposed muscle forces and are no longer candidates for direct repair of the plexus

Performed in patients first seen when they are older than five years of age

Humeral rotational osteotomy for persistent internal rotation contracture and glenohumeral arthrodesis in the setting of severe pain, instability, or arthritic changes

For posterior dislocation of the humeral head :posterior capsular plication

Osseous procedures

Highly dependent on pattern of injury Complete C4 to T1 injuries a considered most

severe and virtually irreparable

Avulsion injuries from C5 toT1 amenable to restoration of shoulder and elbow function only

Ideal candidate for surgery are patients with proximal rupture or avulsion and sparing of lower trunk

PROGNOSIS

Since 1995 to 2002 , 505 patients studied for functional and occupational outcome after surgery for BPI

In India BPI most common due to RTA with Rt side involved in 2/3

40% cases have pan BPI 85% of cable graft yielded improvement in motor

power compared 68% in neurotized nerve and 66% in patients undergoing neurolysis

AIIMS STUDY

Most effective donor nerve for musculocutaneous neurotization was medial pectoral nerve (63.6%) patient improved

Accessory nerve was most effective for neurotization of suprascapular nerve (100%)

Thoracodorsal axillary neurotization gave (66.7% improvement)

50% patients either remained unemployed or had to change there jobs

Sedel reported results of surgical treatment of 63 traumatic brachial plexus palsies, 32 complete and 31 partial.

Of the 32 complete palsies, 26 had repair procedures; 21 were improved.

Of the 31 partial palsies, 23 had repair procedures, and 20 were improved.

Results of nerve transfer were disappointing

Solonen et al. reviewed 52 brachial plexus injuries treated surgically :Grafts used in 24 avulsions, neurolyses in 14, direct suture in 2, and intercostal neurotization in 12.

Good results seen in 19 patients after fascicular grafting with return of function of the biceps muscle.

Neurotization produced function in 4 of 12 patients.

Narakas reported surgical treatment by repair, grafting, or neurolysis in 164 patients with traction injuries and found that 85% of 20 patients with infraclavicular injuries improved after surgery, and that only 55% of 58 patients with supraclavicular injuries improved

Barnes found that 13 patients with plexus injuries but without EMG evidence of degenerative changes at 3 weeks recovered rapidly and completely.

Of 33 patients with upper plexus injuries, 22 spontaneously regained significant function of the muscles of the shoulder, elbow, and wrist. Of 26 with lower plexus injuries, 18 regained some proximal muscle function.

In 1977, Millesi, using the interfascicular autogenous nerve grafting technique, reported return of M3 or better power (Highet) in 38 (70%) of 54 patients

In 1984, Millesi :134 patients with complete brachial plexus lesions treated with neurolysis, nerve grafting, and neurotization. Useful function was regained in 47 of 65 patients (72%) after nerve grafting. In 72 patients with injury to the upper plexus only, useful function returned in 21 of 28 patients (75%) after nerve grafting

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