frcs revision - brachial plexus & hands

Hands II & Brachial PlexusChye Yew Ng

MBChB(Hons) FRCS(Tr&Orth) British Diploma in Hand Surgery European Board of Hand Surgery Diploma

Consultant Hand & Peripheral Nerve SurgeonUpper Limb Fellowship Director

Wrightington Hospital

www.slideshare.net/ChyeYewNg

www.vumedi.com (search for chye yew ng)Clinical examination of brachial plexusExamination of a patient with upper roots BPINerve transfers for C5,C6 BPIExploration of infraclavicular brachial plexus

www.youtube.com (search for CY Ng or brachial plexus exam)

@CY_Hand @Nerve_Clinic

Overview

Peripheral nerve injuriesBrachial plexus injuriesCompression neuropathyCRPSTendon transfersDupuytren’s diseaseExtensor and flexor tendon injuriesSkin coverage

Hierarchical Approach to FRCS Revision

Why?(Indications)

What?(Treatment options)

When?(Timing of surgery)

How?(Technical details)

HOTHigher Order

Thinking

Peripheral Nerve Injuries

Cross Section of a Peripheral Nerve

Fascicle

Endoneurium

Epineurium

Perineurium

EpiPEn = Epi – Peri – Endo

Extrinsic & Intrinsic vascular supplyLongitudinal – Segmental -

Interconnected

Central Neuronal Death & Neuroprotection

Neuronal death after peripheral nerve injury

Acetyl-L-carnitineArrests sensory neuronal deathSpeeds up regeneration

N-acetyl-cysteineProvides sensory and motor neuronal protection Hart et al. Neurological Research 2008

MechanoreceptorsSlowly Adapting Rapidly

Adapting

Cutaneous

Low frequenc

y vibration

Merkeldiscs

Meissnercorpuscle

Subcutaneo

High frequenc

y vibration

Ruffiniterminals

Paciniancorpuscle

Mechanisms of Nerve Injuries

Crush / compressionStretch / tractionLaceration / transectionMetabolic disturbance

IschaemiaRadiationElectrical injuryThermal injury

Classification of Nerve Injuries

Seddon

BMJ1942

Neurapraxia(Transient Block)

Axonotmesis(Lesion in

Continuity)

Neurotmesis(Division of a

nerve)

Brain1943

• Localised degeneration of the myelin sheaths

• Complete interruption of axons

• Preservation of supporting structures (Schwann tubes, endoneurium, perineurium)

• All essential parts destroyed

• Interruption can occur without apparent loss of continuity

Neurapraxia Axonotmesis Neurotmesis

Motor - - -Sensory +/- - -Autonom

ic +/- - -NCS

Conduction block at the site

Distal conduction preserved

Loss of conduction both at and distal to the lesion

EMG No fibrillation Fibrillation ++ Fibrillation ++

Recovery

Days to weeks provided the cause is removed

Months provided the cause is removed

No recovery unless repaired

Nerve Conduction StudiesRecording electrode

Neurapraxia

Axonotmesis

Neurotmesis

Wallerian degeneration

Recording electrode

In clinical practice, how do you distinguish?

Axonotmesis versus NeurotmesisNature of injury

Serial observations

Exploration

Seddon BMJ 1942

(Imaging)

Sunderland

1951I II III IV V

Focalconduction

NO Wallerian

degeneration

AxonalDisruption

Endoneurium

Disruption

Axon +

Endoneurium+

Perineurium

Disruption

Axon +

Endoneurium+

Perineurium+

EpineuriumDisruption

Cross-innervation

Sunderland ‘VI’

Grabb & Smith’s Plastic Surgery 6th edition. Chapter 9

Physiological Conduction Block

Type AIntraneural circulatory arrestMetabolic block with no nerve fibre pathologyImmediately reversible

Type BIntraneural oedemaIncreased endoneurial fluid pressureReversible within days or weeks

Lundborg

Physiological

conduction block

Myelindamage

Axonal damage

Axon +

Endodamage

Axon +

Endo +

Peridamage

Axon +

Endoneurium+

Perineurium+

Epineurium

damage

Type A

Type B

Sunder

land1951

I II III IV V

Seddon

1942Neurapraxia

(Transient Block)

Axonotmesis

(Lesion in Continuity

Neurotmesis(Division of a nerve)

Lundborg

Physiological

conduction block

Myelindamage

Axonal disruptio

Axon +

Endo +

Axon +

Endoneurium+

Perineurium+

Epineurium

Type A

Type B

Sunder

land1951

I II III IV V

Seddon

1942Neurapraxia

(Transient Block)

Axonotmesis

(Lesion in Continuity

Neurotmesis(Division of a nerve)

Non-degenerative

Degenerative

Nerve in Danger!Pain, Pain, Pain• Burning• Severe

Autonomic dysfunction• Absence of sweating• Smoothness & dryness of skin

Tinel sign• Distal to Proximal• Regenerating touch fibres

Nerve Surgery

Neurolysis

Nerve repair

Nerve grafting

Nerve transfer

Prerequisites for Nerve Repair

Skeletal stability

Healthy tissue bed

Healthy nerve ends

No undue tension

Adequate soft tissue coverage

Epineurial versus Group Fascicular Repairs

EpineurialLess exactSimple

Group FascicularBetter alignmentMore dissection (scarring)

The functional results of group fascicular repair has not been shown to be more superior than that of epineurial repair.

Lee & Wolfe. Peripheral nerve injury & repair. JAAOS 2000

Prognostic Factors of Outcomes

• Age• DM, alcohol

Patient factors

• Level of injury (distal vs proximal)

• Type of nerve (pure vs mixed)• Condition of nerve ends

Injury factors

• Delay to repair• Length of gap

Surgical factors

Which of the following is false regarding fibrin glue?

a) Fibrin glue is nontoxic and does not block axon regeneration

b) It may be used in combination with suture repair

c) The outcome of fibrin glue repair is inferior to that of suture repair

d) The common components of fibrin sealants include fibrinogen, thrombin and calcium chloride e) It has low tensile strength

Tse & Ko. Nerve glue for upper extremity reconstruction. Hand Clinics 2012

Nerve Grafts/ConduitsAutologous SourceNerve autograftVein (+/- muscle)

Off-the-shelfType I collagenCaprolactonePolyglycolic acid (PGA)Submucosal ECM Processed nerve allograft

Lin et al. Nerve Allografts & Conduits in Peripheral Nerve Repair. Hand Clinics 2013Kaushik & Hammert. Options for Digital Nerve Gap. JHSAm 2015

A 35 year-old male presented with numbness along the radial border of his right index finger 9 months after he sustained a cut in his first web. After surgical exploration and debridement, there is a 3.5cm nerve defect in the radial digital nerve.

What is the most appropriate surgical reconstructive option?

a) Flexion of digit to achieve primary repair before gradual distraction

b) Type I collagen nerve conduit

c) Autologous vein graft

d) Posterior interosseous nerve graft

e) Polyglycolic acid (PGA) conduit

Principles of Motor Nerve Transfers

Donor nerve near target motor end platesExpendable donor nervePure motor donor nerveDonor-recipient size matchDonor function synergy with recipient functionMotor re-education improves function

Mackinnon SE, Novak CB. Hand Clin 1999

Brachial Plexus Injuries

• Time• Breadth

• Length

• Depth

Severity

(Seddon, Sunderland)

Level(Supra vs

Infraclavicular)

Acutevs

Chronic

Number of

roots(C5-T1)

Leffert Classification

I OpenII Closed

IIA Supraclavicular Pre-ganglionic Post-ganglionic

IIB InfraclavicularIII Radiation inducedIV Obstetric

IVA Erb’s (upper root)IVB Klumpke’s (lower root)IVC Mixed

Objectives of Examination

Where is the lesion?

What functions are lost?

What functions are present?

How can you improve functions of the limb?

Draw the brachial plexus

MEDIAN

LPSSDS

MEDIAN

LPSSDS

USs TD LSs

MEDIAN

LPSSDS

USs TD LSs

MP MBC MABC

MEDIAN

LPSSDS

USs TD LSs

MP MBC MABC

MEDIAN

LPSSDS

USs TD LSs

MP MBC MABC

Roots Trunks Divisions Cords Terminal branches

MEDIAN

LPSSDS

USs TD LSs

MP MBC MABC

Roots Trunks Divisions Cords Terminal branches

Middle

Lateral

Medial

Posterior

PosteriorPosterior

Myotomes

Common Clinical Patterns

Closed traction BPI

Supraclavicular

Upper roots

Total palsy

Infraclavicular

Cord(s)

Terminal branch(es)

Motorcycle accident

Shoulder trauma

Common Clinical Patterns25yo RTA polytraumaNo shoulder motion

No elbow flexionGOOD HAND

25yo RTA polytraumaFLAIL UPPER LIMB

65yo anterior dislocation of shoulder

NO DELTOID

C5, C6

C5 – T1

Axillary nerve

Common Clinical Patterns

25yo RTA polytraumaNo shoulder motion

C5, C6XR neck chest

shoulderMRI cervical spine, BPNCS/EMG at 3 weeks

25yo RTA polytraumaFLAIL UPPER LIMB C5 – T1

NCS/EMG at 3 weeks

NO DELTOIDAxillary nerve

NCS/EMG at 6 weeks

if no recovery

Pre- versus Post-ganglionic?

ClinicalHorner’s syndromeRhomboid, serratus anterior, paraspinal muscles paralysisAbsent Tinel signHistamine test (historical)

RadiologyPhrenic nerve palsy (raised hemidiaphragm)Cervical transverse process /1st rib♯PseudomeningocelesRootlets abnormalities

NeurophysiologyPreserved SNAP (but insensate)

Intraoperative Assessment - Is there a graftable nerve

stump?• Direct inspection• PalpationSurgical

• Somatosensory Evoked Potentials (SSEP)

• Motor Evoked Potentials (MEP)Neurophysiolo

• Frozen section (fascicles / scar)• Choline acetyltransferase (CAT)

activity – identify motor fasciclesLaboratory

Timing of Surgery

Emergent- Open injury- Arterial injury- Deteriorating neurology

Early (<3months)- Closed injury- Complete/partial palsy- Neurolysis/grafts/ transfers

Late (>12months)- Muscle transfers- Bony procedures

Surgical Priorities1 – Restore elbow flexion2 – Restore shoulder abduction & ER (stability)3 – Restore hand function

Common Nerve TransfersPalsy Donor Recipient

C5, 6Spinal accessory Radial (long head of triceps) Ulnar fascicle Median fascicle

SuprascapularAxillary (anterior)Biceps branchBrachialis branch

C5, C6, C7Spinal accessory Intercostals Ulnar fascicle Median fascicle

SuprascapularAxillary (anterior)Biceps branchBrachialis branch

C8, T1Brachioradialis or brachialis branchSupinator branch

AINPIN

Common Clinical Patterns ?Prognosis

25yo RTA polytraumaNo shoulder motion

C5, C6Regain good elbow flexion, moderate shoulder movementReturn to work

25yo RTA polytraumaFLAIL UPPER LIMB C5 – T1 Poor-to-fair function

Long-term disability

NO DELTOIDAxillary nerve

Fair-to-good recovery

Compression Neuropathy

What do (I think) you need to learn?

Carpal tunnel syndromeCubital tunnel syndromeGuyon canal syndromeRadial tunnel syndrome / PIN palsyPronator syndrome / AIN palsy

Carpal Tunnel SyndromeA collection of symptoms and signs due to increased pressure within the carpal tunnel leading to compression of the median nerve

• Pins & needles or Tingling• Numbness• Pain• Weakness or clumsiness• Wasting of thenar muscles

What are the contents of the carpal tunnel?

Median nerveFDS x4FDP x4FPL

Anatomical variations of the recurrent motor branch of median

Who is affected? Risk Factors

Age: 45- 65Females > malesFamily historyPregnancyMedical conditions: Diabetes mellitus, Rheumatoid arthritis, HypothyroidismObesityVibrationAnatomical abnormalities of the wrist

What is the Gold Standard?

Signs Symptoms

Neurophysiology

Treatment Options Comments

Nocturnal neutral wrist splint • Those with night symptoms

Steroid injection • Consider in pregnancy-related CTS• 1 in 4-5 symptom-free at 1 year

Carpal tunnel release

• Complete division of transverse carpal ligament

• Open and endoscopic CTR both equally effective. Endoscopic CTR may offer earlier return to work but this may not be justifiable by its increased risks of nerve injury and costs (in the NHS).

Cubital tunnel syndromeWhat is your preferred surgical treatment for primary cubital tunnel syndrome?

I would perform in-situ decompression because meta-analyses have shown comparable clinical outcomes but lesser complications/morbidity when compared to anterior transposition.

Cubital tunnel syndromeWhat are the indications of anterior transposition?

• Revision• Subluxation/Instability of ulnar nerve• Poor tissue bed for the nerve• (Elbow trauma surgery)

Sensory branch (after PB)

Ulnar artery aneurysm or thrombosis

Guyon’s canalWhat you need to know?

MixedLEFT HAND

Superficial branch (sensory only after Palmaris brevis)

Ulnar artery aneurysm or thrombosis

Deep motor branch

Ganglion or hook of hamate fracture (zones 1 & 2)

MixedLEFT HAND

Posterior Interosseous Nerve

Radial tunnel syndrome

Pain syndromeEMG normal

PIN palsyMotor deficitEMG abnormal

Common Sites of Compression:Fibrous band btw brachialis & BRRecurrent leash of HenryExtensor carpi radialis brevis edgeArcade of FröhseSupinator muscle edge

Proximal Median NervePronator syndromePain (forearm) syndromeParaesthesiaEMG/NCS inconclusive

AIN palsyMotor deficit onlyEMG/NCS abnormal

Sites of Compression:Supracondylar processLigament of StruthersLacertus fibrosusBtw two heads of pronator teresFDS arch

Sites of Compression:Tendinous edge of deep head of PTLacertus fibrosusFDS archAccessory head of FPL (Gantzer’s muscle)Accessory muscle from FDS to FDPAberrant muscles (FCRB, palmaris profundus)Thrombosis of ulnar collateral vesselsAberrant radial arteryBicipital bursa

Complex Regional Pain Syndrome

Disproportionate PainSensory changesAbnormal skin color Temperature change Abnormal sudomotor activity OedemaJoint stiffness

EXCLUSION OF OTHER CAUSES!

International Association for Study of Pain

CRPS Type I

Reflex sympathetic dystrophy (RSD)

No definable nerve injury

CRPS Type II

Causalgia

Definable nerve injury

Symptoms NOT restricted to dermatome

CRPS – Budapest Criteria

Management of Suspect CPRS

Prevention (Vitamin C – distal radius fractures)

Treat any treatable cause

Physiotherapy (Desensitisation, mirror therapy)

Pain specialistMultimodal analgesicsRegional blockadeBisphosphonate infusion

Psychology

Tendon Transfers

IndicationsRestore function

Muscle paralysis/nerve injuriesIrreparable injuries to the musculotendinous units

Restore balanceStroke, cerebral palsy, tetraplegia

Decision makingWhat is missing

What needs reconstructing (think of FUNCTION)

What is available

What is appropriate

PrinciplesTissue equilibrium is achieved

Bony stability

Good soft tissue envelope/gliding plane

Full passive range of motion

Expendable donorMinimum 1 wrist extensor, 1 wrist flexor1 extrinsic flexor & extensor to each digit

Force proportional to cross-sectional area of muscle

Average fibre length proportional to potential excursion

Amplitude/Excursion (The 3-5-7 rule)Wrist flexors/extensors: 33mmFinger extensors, FPL, EPL: 50mmFinger flexors: 70mmTenodesis effect +20mm

Expect decrease of one MRC grade after transfer

PrinciplesHow?

Single line

Single joint

Single function

Synergy

Sensibility

PrinciplesHow?

Ideal principles but not obeyed all the times

Median Nerve Palsy

LowDonor Tendon

Camitz Palmaris longus

Burkhalter Extensor indicis proprius

Bunnell FDS IV

Huber Abductor digiti minimi

HighLost Function Donor Tendon

Opposition EIP APB

Thumb IPJ flexion

Brachioradialis FPL

Index finger flexion

FDP I Sutured to neighbour FDPs

Radial Nerve Palsy

PIN HighLost Function Donor Tendon

Wrist extension PT ECRB

Fingers extension

FCR EDC

Thumb extension

PL EPL

Lost Function Donor Tendon

Fingers extension

FCR EDC

Thumb extension

PL EPL

Ulnar Nerve Palsy

LowLost Function Donor TendonClawing (Grasp) FDS III slips

lateral bandsThumb adduction

ECRB + PL graft Adductor pollicis

Index finger abduction

Accessory APL 1st dorsal interosseous

Little finger adduction(Wartenberg sign)

EDM radial lateral band

HighLost Function Donor TendonIn addition to lowFDP IV/V DIPJ flexion

Side-to-side tenorrhaphy FDP III

Anti-clawing ProceduresStatic

Zancolli capsulodesisFasciodermadesisTenodeses

DynamicMCPJ flexionMCPJ flexion + IPJ extension

Bouvier manoeuvre?

Donor options to correct clawing

Dupuytren’s Disease

Dupuytren’s DiseaseA benign proliferative disease that occurs in the fascia of the palm and digits resulting in nodules, cords and contractures.

EpidemiologyCaucasian of northern European ancestry 5th-7th decades M>F until 70 then M=FAutosomal dominant pattern with variable penetrance

Ectopic manifestationsLedderhose disease (plantar fascia)Peyronie's disease (dartos fascia of penis)Garrod’s pads (knuckle pads)

Components of Spiral Cord?

4 – Grayson ligament

3 – Lateral digital sheet

2 – Spiral band

1 – Pretendinous band

Luck Stages of Dupuytren

Proliferative (Myofibroblasts predominate)

Involutional (Type III > I collagen)

Residual (Fibrocytes predominate)

Risk factors / associations

Hueston diathesisCaucasiansPositive family historyBilateral diseaseEctopic lesionMaleAge of onset < 50

Other conditionsDiabetes mellitusAlcoholismHIVAnti-epilepticsTrauma(Vibration)

Indications for Intervention

Tabletop testMCPJ 30°contracturePIPJ any contracture

Functional limitation

Traditional teaching

Treatment Options

5-year recurrence

Needle fasciotomy 85%

Collagenase 50%

Fasciectomy 20%

Dermofasciectomy 10%

Increasing downtime and

complexity

Collagenase clostridium histolyticum (CCH)

AUX-I AUX-II

Class I Class II

Cleaves terminal ends of collagen

Cleaves internal sections of collagen

Extensor & Flexor Tendon Injuries

Extensor Tendon Compartments

Compartment Tendons Conditions

1 APLEPB de Quervain’s tenovaginitis

2 ECRLECRB Intersection syndrome

3 EPL Attrition rupture post-distal radial fracture

4 EIPEDC Tenosynovitis

5 EDM Vaughan-Jackson syndrome

6 ECU Subluxation / Snapping

Zones Treatment

I (II)• Mallet injury• Open: repair and pin• Closed: splint 8/52• If chronic, risk of Swan-neck

III (IV)• Open: repair and splint• Closed: immobilise PIPJ for 3/52

& leave DIPJ free• If chronic, risk of Boutonniere

V VI• Watch out for fight bites!• Rehab: Static vs Dynamic vs

VII • Repair retinaculum• Splint wrist in extension for 4/52

VIII • Core suture-type tendon repair

IX • Muscle belly injury• Beware of PIN injury

Leddy-Packer Classification

Flexor Tendon Repair

ChallengesRupture, adhesion, joint stiffness, infection

Surgical AimTo restore continuity to the tendon with a repair that is robust for EAM

Philosophy/ConceptManaging a number of compromises according to a hierarchy of priorities

How do you manage a zone II flexor tendon injury?

Anaesthesia GA, regional, Wide-awake technique (LA + adrenaline)

Core suture At least 4 strands (Kessler, Cruciate, Adelaide)4-0 monofilament (Prolene)

Epitendinous suture

Continuous configuration6-0 monofilament (Prolene)

Rehabilitation Dorsal splint for 6 weeksEarly active mobilisation

Skin Coverage

Reconstructive LadderFree

Tissue

Transfer

Distant flap

Local & Regional flap

Skin graft

Primary closure

Healing by secondary intention

Summary• Most injuries are mixed• Pain, Autonomic dysfunction & Tinel

signPeripheral nerve

injuries

• 4 dimensionsBrachial plexus injuries

• Carpal & cubital tunnel syndromesCompression neuropathy

• Budapest criteriaCRPS

Summary• What is missing• What function needs reconstructing• What is available• What is appropriate

Tendon transfers

• Luck stages• Spiral cord • Collagenase (AUX-I & II)

Dupuytren disease

• Zone of injuriesExtensor and flexor tendon

injuries

• Reconstructive ladder & elevatorSkin coverage

Thank you and good luck!@CY_Hand

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