Brachial plexus injury The principles and philosophy behind the early treatment and management of Nerve graft, repairs and Tendon transfers.

Brachial plexus injury

Prevalence and epidemiology

• 70% Brachial Plexus injuries in Adults caused by Motor vehicle injuries

• 70% Motorcycle Injuries

• Men and Boys between 15-25 years old

• In one study/ series, the rate of incidence to the local population was 1.75/100000/year.

• Adult Brachial Plexus Injuries: Mechanism, Patterns of Injury and \physical Diagnosis: Morgan SL et al : Hand Clinic

21 (2005) 13-24 2005

• Flores LPr. [Epidemiological study of the traumatic brachial plexus injuries in adults]. Neuropsiquiat 2006 Mar;64(1):88-94. Epub 2006 Apr 5.

[Article in Portuguese]

Prevalence and epidemiology

• Most of the lesions were supraclavicular (62%).

• Twenty-one cases occurred due to traction (60%), 9 to gun shot wound (25%), 3 to compression (8.5%) and two perforation/laceration (5.7%).

• Motorcycle accidents were the cause of trauma in 54% of patients.

• CT myelography demonstrated root avulsion in 16 cases (76%).

• Partial spontaneous neurological recovery was observed in 43% of the patients.

• Neuropathic pain occurred in 25 (71%) cases, and the use of some oral intake drugs (as amitriptyline or carbamazepine) controlled it in 64% of times

• Flores LPr. [Epidemiological study of the traumatic brachial plexus injuries in adults]. Neuropsiquiat; 2006 Mar;64(1):88-

94. Epub 2006 Apr 5. [Article in Portuguese)(PubMed-Google scholar Search)

Brachial plexus injury

• Immediately after a serious nerve injury it is essential to get a quick diagnosis and protect the injured site to prevent further damage and retraction of the nerve.

• Nerve injuries can be classified according to the Sunderland classification of nerve pathology starting with a mild neuropraxia and progressing to full severance of the affected nerve.

Sunderland classification Classification

• Grade 1: Neuropraxia • Conduction disruption with intact axon and preserved supportive structures • Prognosis: Normally full recovery in days to weeks without surgical intervention • Grade 2: Axonotmesis • Disrupted axon with intact endoneurium; Wallerian degeneration takes place after 1-2

weeks • Prognosis: Variable recovery, worse prognosis for proximal injuries and injuries that

do not successfully re-implant in the muscle within 18 months • Grade 3: Neurotmesis with preservation of perineurium • Endoneurium is disrupted • Prognosis: 60-80% recovery • Grade 4: Neurotmesis with preservation of epineurium • Prognosis: Nerve grafting is required • Grade 5: Neurotmesis with complete transection of nerve trunk • Prognosis: Bypass/jump grafting is required • Explanation

Brachial plexus injury Classification • Tidy vs. untidy wounds

Classical neuropraxia. least severe injury, is characterized by a conduction block (focal conduction block);

- conduction across the zone of nerve injury is inhibited, however, conduction within the nerve both proximal and distal to the lesion remains intact; - continuity of all structures is preserved; - (no axonal loss) but there is focal demyelination; - complete recovery is evident in 3 to 6 weeks; - after a simple crush injury function may return within days; - w/ neuropraxia there is immediate conduction block across the site of injury with normal conduction distally;

Brachial plexus injury

Neurotmesis

Arises from severe nerve injury .

- characterized by axonal enlargement into an amorphorous mass,

breakdown of the axons, and schwann cell ingestion of fragmented

myelin to provide clean endoneural tubes for advancement of

regenerating axons;

- axonal sprouting begins within 96 hours;

distally the entire axonal material is phagocytosed from the site

of injury to the endplates-

with severe trauma, there is focal demyelination w/o disruption of

axons, and slowing of the conduction velocity can be demonstrated

across the lesion;

- conduction block is restored once myelin regeneration is

restored (taking weeks to months);

Isolated Nerve injuries of BP

• Long thoracic Nerve of Bell

• Spinal accessory nerve (Cranial nerve XI)

• Dorsal scapular Nerve

• Suprascapular Nerve Palsy

• The Axillary Nerve

• Isolated peripheral Nerve Lesions of the Brachial Plexus affecting the Shoulder joint. Ernest J Genthochos : The

University of Pennsylvania Orthopaedic Journal 1999 :12 ;40-44

Injury and repair mechanism

• Injured nerve response to injury (<24 hours)

• Macrophage recruitment; wallerian degeneration (one week)

• Scwann cell alignment; axon regeneration (weeks to months)

• Successful Target reinnervation (weeks to years)

• Wallerian degeneration: Gaining perspective on inflammatory events after peripheral nerve injury: AD Gaudet, P G

Popovich, and M S Ramer Journal of Neuroinflammation 2011 8:110

Nerve Injuries

Mechanism of Injury

Mechanism of Injury

Mechanism of Injury

Central mechanism of avulsion. Central avulsions occur from direst cervical trauma. The spinal cord is moved transversely or longitudinally, causing a sheering and spinal bending that results in an

avulsion of nerve rootlets

Investigations

Myelography and CT myelography can be instrumental in determining the level of nerve injury. If a pseudomeningocele (*) is present, there is a greater likelihood of a nerve root avulsion. (A) Multiple root

avulsions (*) are clearly seen by CT myelogram. (B). The arrows on the opposite side of the avulsion (*) show the normal dorsal and ventral rootlet outline of the uninjured side. Notice how these outlines are missing on the injured side. (Courtesy of the Mayo Foundation) Rochester, MN; with permission.)CT/

Brachial plexus injury

• A thorough neurological examination is required, followed by a transfer to a specialist service for exploration and nerve conduction test.

• Following a diagnosis of the nerve injury a treatment approach can be instigated which includes nerve release, grafting and or exploration.

Investigations: Neurophysiology • Grade A: NAP( nerve action potentials) normal or near normal. EMG

normal units, no spontaneous activity.

• Grade B favourable: NAP > 50% of normal. EMG mild Axon injury with copious recruitment

• Grade B unfavourable: NAP absent or <50%. Limited EMG recruitment, moderate axonal injury. Collateral reinnervation present

• Grade C: NAP present in some cases but more often absent. EMG poor recruitment, fibrillations, nascent units. Severe axonal injury

Prevalence and epidemiology

.

• “During this exploration, recording of the spinal cord evoked potential (ESCP) or the somatosensory evoked potential (SEP) is mandatory to determine the site of injury. Nerve grafting is indicated for a rupture in the root demonstrating a positive ESCP or SEP potential, in the trunk or in the cord. Exploration of the brachial plexus should be extended distally as far as possible to achieve good results after nerve grafting; when this was done more than M3 (MRC grading) power of the infraspinatus, deltoid, and biceps was achieved in more than 70% of our 32, 30, 33 patients, respectively”

Nagano AJ: Treatment of brachial plexus injury. Orthop Sci. 1998;3(1):71-80

Brachial plexus injury

Nerve repair requires a period of immobilisation to protect the repairing nerve.

• This is usually for 6 weeks. Following the period of immobilisation, a gentle mobilisation phase is allowed.

• Clinical test include; muscle contraction test, sensitisation test and the tinels sign.

• Care is taken to ensure no excessive loading force or traction (stretch force) is allowed upon the nerve

Pre operative Assessment

Please assess:

Strength (Manual Muscle Test)

Sensation (ASIA Points)

Pain (VAS)

Oedema

Avoid:

Functional use

Full PROM

Adverse neural dynamics

Contraindications:

Unstable fractures (clavicle, humerus, scapula).

Cervical Spine Injures

• Haemotoma / vascular injury

• N.B. Please note if the patient is experiencing pain on movement at time of initial assessment (PROM or AROM) aim to protect the arm in a sling. Advise no gleno-humeral joint ROM, but retain hand, wrist forearm rotation PROM.

Assessment of the Motor system

• Observation of posture and Limb

• Muscle atrophy

• Skin changes

• Palpation of the limb/skin

• Manual muscle testing

• Neural tension test-single nerve

• Palpation of the nerve trunk

Peripheral Nerve injuries: Assessment of the Motor system • Mixed nerves-definite distribution, Parasthesia and hypoesthesia

• Motor nerves pain is poorly localised

• Weakness

• Muscular atrophy prior to subjective perception of weakness

• Local tenderness

• Distribution of symptoms= spinal dermatome or peripheral nerve path, or vascular projection of stress.

Therapist Guidelines for patients referred to the RNOHT for Brachial Plexus

Exploration +/- Repair.

Post Operative Treatment : Exploration, Decompression / Neurolysis of Brachial Plexus.

Time post operation

0-6/52 For infraclavicular explorations PROM of hand,

wrist, forearm rotators, elbow and gleno-humeral joint

ER(N), Abduction 40 degrees (to protect pec. major

repair).

For Supraclavicular explorations PROM of hand,

wrist, forearm rotators, elbow, gleno-humeral joint

ER(N) Forward flexion to 90 degrees Abduction to 40

degrees.

Sling for comfort.

Avoid resistance and/ load upon operated limb.

Keep the limb supported while dressing.

Be mindful of scar healing for 4/52. Scar management

programme if needed.

Oedema management please monitor.

2/52 Wound check at Bolsover Street by SHO/ Register.

Re-enforcement of post operative precautions.

6/52

Start full PROM programme with Physiotherapist at

Bolsover Street PNI Clinic.

Nerve repair graft of Brachial Plexus

Post operative Treatment

Please note contradictions could be:

Trauma

Reconstructive surgery

Vascular Injury

Time post operation

0-6/52 Arm is immobilised in the sling (ie Lancaster)

No gleno-humeral joint movement.

Maintain AROM/PROM of hand, wrist and forearm rotation. No elbow movement if infraclavicular repair.

Advise strip washing for the 6/52 period. Advise use of baby wipe for axilla hygiene.

Be mindful of scar healing for 4/52. Scar management programme if needed.

Oedema management please monitor

2/52 Wound check at Bolsover Street by SHO/ Register. Re-enforcement of post operative precautions.

6-12/52 Aim to have either:

In patient Rehabilitation at Stanmore

Initial physiotherapy assessment at Bolsover Street post PNI clinic review.

This plan is at the surgeon’s discretion.

Inpatient Rehabilitation: Please use BPL assessment form.

Strength (Manual Muscle Test)

Sensation (ASIA Points

Pain (VAS)

Oedema

Functional / ADL’s

Full PROM

Psychological / Emotional

Orthotic referral

Postural education

Balance/gait retraining.

Set patient Goals

12+/52 Begin resistive exercise if appropriate recovery of muscle (grade 3/5)

Continue progressive strengthing regimes, avoiding trick movements and substitute muscle patterning.

Discharge when optimised muscle strength, nerve mobility and maximised functional recovery.

:. Inpatient Rehabilitation This plan is at the surgeon’s discretion.

• • Strength (Manual Muscle Test)

• • Sensation (ASIA Points)

• • Pain (VAS)

• • Oedema

• • Functional / ADL’s

• • Full PROM

• • Psychological / Emotional support

• • Postural education

• • Balance/gait retraining.

Occupational Therapy – Splints, supports etc.

Pain management

Orthotic referral

Social services

• Set patient Goals

Nerve transfers to regain function. Oberlins Nerve transfer

• Ulnar nerve fascicle rerouted into the bicep muscle belly.

• 3/12 before any activation of bicep.

• Possible 3/5 MMT functional achievable

Nerve transfers to regain function. Somsak Axillary Nerve Transfer

• Radial nerve from long head of triceps rerouted to the axillary nerve.

• 3/12 before any activation of the posterior deltoid.

• Possible 4/5 MMT function achievable.

Nerve transfers to regain function.

Spinal Accessory Nerve to Supraclavicular Nerve Transfer

• Spinal accessory taken from Upper Traps rerouted to the supraclavicular nerve for re-Innervation of Supraspinatus and Infraspinatus.

• 3/12 before any activation of the Supraspinatus and Infraspinatus .

• Possible 4/5 MMT function achievable.

Nerve Repairs

• Treatment involves assisted joint movements, gentle muscle exercises, it may be necessary to use muscle stimulation techniques and/or biofeedback techniques to encourage muscle recovery.

• if pain is an issue then nerve desensitisation techniques can also be used. Nerve repairs can take 12-36 months to complete during this time the therapist can monitor the progress of the nerve recovery and muscle performance and add appropriate levels of exercises

Nerve Repairs

• During the recovery phase it is essential to maintain the mobility of the affected joints.

• joint mobilisation using accessory techniques

• Self stretches

• Self joint mobilisation are all encouraged to prevent joint contractures and joint stiffness.

Nerve Repairs

• Functional exercises are encouraged at late stage rehabilitation to promote normal movement mechanics and the return to ADL functions.

• Normal strengthening techniques with resistance can be instigated once power has returned.

• Continuous reassessment is necessary whilst also recording of joint mobility, nerve mobility and muscle strength.

Key points

• Do not excessively stretch a recently repaired nerve.

• in the presence of nerve damage associated with joint fracture the return of joint mobility is compromised by the irritability and sensitivity of the repairing nerves

Tendon transfers Tendon transfers are usually instigated after normal nerve recovery has not occurred and muscle function remains absent with associated joint contractures and stiffness. The Initial presentation Six weeks post operative immobilisation to protect the graft... Early stage rehabilitation: 1. Explain the operation, which muscles have been transferred, the

previous function of the muscle and the expected change in direction of the muscle pull

2. Start with active assisted joint movements, 3. Encourage cognitive exercise with training of new direction of

muscle pull. 4. Teach mental appreciation of muscle pull and tension. 5. Discourage excessive effort during exercises which encourage co-

contraction and substitute muscle activity. 6. Avoid excessive muscle load during early phase; avoid resistance,

fatigue and lengthening.

Tendon Transfers

Post operative intermediate phase:

• Add active exercises once the muscle action has reached oxford grade 3/5, against gravity.

• Ensure continuous assessment of the tendon strength and reduce effort of the exercises once trick activity is noted.

• Demonstrate home exercises which encourage isolated muscle activity and teach self monitoring to optimise the effectiveness of the exercises

Tendon Transfers

• Learning to “switch off” and reduce co-contraction of opposing muscles to the repaired tendon can be an important component of late stage rehabilitation.

• The key to rehabilitation is practice through repetition to encourage integration into normal movement patterns and not successive fast progressive overloading principles used to promote strength, in the absent of nerve damage.

• Avoid gym activities( and ADL activities which strengthen the muscles that oppose the recently transfer tendon> strengthening the opposing muscle increases the effort the new tendon has to use to overcome the tension. For example a tendon transfer to encourage better lateral rotation/abduction of the arm and promote gleno-humeral stability ; latisimus dorsi to infraspinatus is difficult if the pectoralis muscle( as a medial rotator and adductor) is over developed or is clearly stronger and more responsive than the new repair.

Case studies 1. Tendon transfer at the Shoulder.

Latissimus Dorsi to Infraspinatus

Aim:

• To restore shoulder Lateral rotation and abduction.

Case study 2. Tendon transfer at the forearm

• FCU and Palmaris Longus to wrist, finger and thumb extensors

• Aim:

• To restore hand opening and grip

Nerve repair and grafting Left: Brachial Plexus. Right Axillary Nerve Injury.

Nerve repair and grafting Normal Right arm. Axillary Nerve injury. ̀ Muscle atrophy and skin changes.

Case Study: C5-7 Root Avulsion: Multiple Nerve exploration and grafting.

Case Study: C5-7 Root Avulsion: Multiple Nerve exploration

and grafting.

Case Study: C5-7 Root Avulsion: Multiple Nerve exploration and grafting.

Case Study: C5-7 Root Avulsion: Multiple Nerve exploration and grafting.

Case study- The Hand

Case study- The Hand

Case study- The Hand

Case study FFMT

Facilitation and antigravity

The Physiotherapy Management of OBPP

• OBPP is distressing and potentially disabling injury to the shoulder and arm of a newly born child. • The injury occurs during birth and has several mechanisms of injury. • The aetiology and pathology of OBPP will be defined.

• Occurs: 0.42 per 1000 (live) births • 1 in 2300 • 90% resolve within 6 months • 10% suffer life-long disabilities • 30% Assisted delivery • 60% Shoulder dystocia • 4% Breech delivery • RR 3.4 • 1% Caesarian Section • ^ Heavy babies • ^ Diabetes • 4 Narakas Scale • 15 Mallet • 5 Gilbert Elbow • 5 Ramoundi Hand • NAP’s • SEP’s • EMG • 7 Toronto Active Movement scale • 5 MRC • ROM • 30 degrees L.R.

Summary and conclusions

Key points

• The shoulder movement tells us about the level of recovery in C5

• The elbow flexion tells us about the level of recovery in C6

• The wrist extension tells us about the level of recovery in C7

• The hand movement tells us about the level of recovery in C8/T1

• Early treatment; immobilise and protect.

• Intermediate; assist and guide.

• Late treatment; repetition, function and strengthening.

Questions

To compensate or not to compensate?

How long to continue treatment and/or management?

References • Surgical Disorders of the Peripheral Nerves; Rolfe Birch : 2010 • A classification of peripheral nerve injuries producing loss of function ; S Sunderland; Brain (1951)

74 (4): 491-516. • Central Nerve Plexus Injury, Volume 78; Thomas Carlstedt ; 2007

• Kendell and Kendell: Muscle; Testing and function; Williams & Wilkins, 1993

• Isolated peripheral Nerve Lesions of the Brachial Plexus affecting the Shoulder joint. Ernest J Genthochos : The University of Pennsylvania Orthopaedic Journal 1999 :12 ;40-44

• Wallerian degeneration: Gaining perspective on inflammatory events after peripheral nerve injury: AD Gaudet, P G Popovich, and M S Ramer Journal of Neuroinflammation 2011 8:110

• Adult Brachial Plexus Injuries: Mechanism, Patterns of Injury and \physical Diagnosis: Morgan SL et al : Hand Clinic 21 (2005) 13-24 2005

• Rehabilitation Of Brachial Plexus Injuries in Adults and Children : Smania et al; Eur J Phys Rehabil Med 2012 , 48 483-506.