brachial plexus injury
TRANSCRIPT
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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