Brachial plexus anatomy, diagnosis and orthopaedic treatment

PRESENTED BY : Harjot singh gurudatta

MODERATOR : Dr. Rohit Sharma

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Formed by ventral rami of spinal nerves C5-T1

Pre and post fixed

Five ventral rami form three trunks that separate into

six divisions that then form

cords that give rise to nerves

Major nerves

Axillary

Radial

Musculocutaneous

Ulnar

Median

1) Root value of lateral cord & all its branches is

C5,6,7 with NO EXCEPTION.

2) Root value of medial cord & all its branches is C8 &

T1 with ONE EXCEPTION; Ulnar nerve; whose

root value is C7,8 & T1.

3) Root value of posterior cord branches is C5,6 with

TWO EXCEPTIONS :

@ Thoracodorsal nerve; C6,7,8.

@ Radial nerve; C5,6,7,8 & T1.

4) Root value of upper trunk & its branches is C5,6.

*Things to Notice*

Some mnemonics for remembering the branches: Posterior Cord Branches

STAR - Subscapular (upper and lower), Thoracodorsal, Axillary, Radial

ULTRA or ULNAR- Upper subscapular, Lower subscapular, Thoracodorsal, Radial, Axillary

Lateral Cord Branches LML or LLM "Lucy Loves Me" - Lateral pectoral, Lateral

root of the median nerve, Musculocutaneous

Medial Cord Branches M4U or MMMUM "Most Medical Men Use Morphine" -

Medial pectoral, Medial cutaneous nerve of arm, Medial cutaneous nerve of forearm, Ulnar, Medial root of the median nerve

M shape

formed by

1. Musculocutaneous N.

2. Lat. & Med. Root of

median N. of both lat. &

med. Cords.

3. Ulnar N.

1

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DERMATOMES OF UPPER LIMB

ERB’S PARALYSIS

• Erb’s point

• Causes Downward traction

• Nerve roots involved

• Muscles Paralysed

• Deformity

• Disability

•deltoid –supraspinatus–

infraspinatus–biceps -brachialis

LEFT SIDE PARALYSIS

Klumpke’s paralysis-

Site of injury

Cause of injury

Nerve roots involved

Muscles paralysed

Deformity

Disability

CLAW HAND HORNER SYNDROME

High-energy trauma to the upper extremity and neck causes a variety of lesions to the brachial plexus.

The common mechanism is violent distraction of the entire forequarter from the rest of the body ie motorcycle accident or a high-speed motor vehicle accident. A fall from a significant height may also result in brachial plexus injury. DIRECT BLOW AND TRACTION.

Sports most commonly associated with brachial plexus injuries include: Am football, baseball, basketball, volleyball, fencing, wrestling, and gymnastics

Nerve injuries can result from blunt force trauma, poor posture, or chronic repetitive stress

Patients generally present with pain and/or muscle weakness

Over time, some patients may experience muscle atrophy

Loss of useful function of the upper extremity is common

Millesi classification*

Supraganglionic

Infraganglionic

Trunk

Cord

Anatomical Classification

C5-6 waiters tip (Erbspalsy)

C5-7 as above, elbow slightly flexed

C5-T1 flail limb, claw hand, vasomotor changes, +/- Hornerssyndrome

Nerve root avulsion

dorsal & ventral rootlets

invested by pia mater / dural funnel

etiology: traction (occasionally missile, knife)

Significant traction causes dural rupture / root vulnerability

ventral > dorsal root (esp C8-T1) at higher risk

POOR Prognosis!

Grade 1 – Neuropraxia Disruption in nerve function that produces numbness and tingling

Most common grade within athletics

Symptoms usually resolve within several minutes

Grade 2 – Axonotmesis Damage to the nerve’s axon

Symptoms = numbness, tingling, and affected function (may last several days)

Long nerves have a greater healing time than short nerves

Rare within athletics

Motor march, Tinel sign

Grade 3 – Neurotmesis Permanent nerve damage occurs

Very rare within athletics

“Occurs with high-energy trauma, fractures, and penetrating injuries”

How do you Rx the patient knocked off his motorcycle with clavicle # and flail arm?

Manage acute injury according to ATLS principles; look for concomitant injury ie c-spine.

History Age, handedness, occupation, special skills

Cause of injury: arm hyperabducted vs neck laterally flexed

Immediate or delayed arm weakness

Concomitant injury

General health: PMH, DH, Smoker

Examination (use pre-printed brachial plexus diagrams): determine level Look at face: does he have Horner’s? (=lower root lesion C8 T1) Undress upper torso Look from front at posture of arm, scars, muscle wasting,

asymmetry/swelling Look at back again for scars, muscle wasting, asymmetry

Test sp. Accessory n (shrug shoulders) Supraspinatus responsible for 1st 20 of shoulder abduction (resisted arm

abduction) Rhomboids (touch back of head) Lat dorsi (press both hands into hips and cough)

Look at vascularity of arm Check sensation both upper limbs (root levels) Check movement both upper limbs from shoulder to fingers (AROM +

PROM) Reflexes Function of phrenic nerve

Wall test for serratus ant (winging scapula)

Note weak trapezius (asymmetric shrug)

Brachial Plexus Cervical Compression

Test

Cervical Distraction Test

Spurling’s Test

Brachial Plexus Traction Test

Thoracic Outlet Syndrome

Adson’s Test

Allen’s Test

Axillary N. Sensory – Lateral arm Motor – Shoulder

abductionMusculocutaneous N. Sensory – Anterior arm Motor – Elbow flexion

Radial N. Sensory – 1st Dorsal web

space Motor – Wrist extension

and thumb extensionMedian N. Sensory – Pad of Index

finger Motor – Thumb pinch

and abductionUlnar N. Sensory – Pad of little

finger Motor – Finger

abduction

C5 – Biceps brachii reflex (anterior arm near antecubital fossa)

C6 – Supinator reflex (lateral aspect of forearm)

C7 – Triceps brachii reflex (at insertion of tricepbrachii)

C8 and T1 do not have reflex tests

Imaging: Xray: AP chest (look for teeth and fractures ), AP + lat views shoulder, C-Spine (AP, lat, odontoid peg), Fine-cut CT,

MRI

Sensory nerve action potentials (SNAPs): differentiate preganglionic from postganglionic injuries. …histamine..

Electromyography (EMG): In the first week after injury, EMG cannot be used to exclude a complete disruption unless voluntary motor unit action potentials are observed. If no signs of denervationare present in a paralyzed muscle by 3 weeks after injury, EMG can be used to confirm a neuropraxia.

Somatosensory evoked potentials (SSEPs): In general, SNAPs are more reliable than SSEPs. Many difficulties exist with SSEPs, and they are not widely used.

Medical: MDT physio: maintain supple joints with FROM

Orthoptists / splinting

Pain control

Surgical options: nerve transfers

nerve grafting

muscle transfers

free muscle transfers

neurolysis of scar in incomplete lesions

Arthrodesis to stabilise joints

Open wounds

Sharp injury

Bullet injury

Closed injuries

Chest tube

Bullet woundClavicle osteotomy

Junction of trunk and cords

Laceration

Nerve repair and graft

Laceration

Nerve graft

Closed injury, (tractional injuries)

Closed injury, (tractional injuries)

Early exploration

Underobservation

Decision for the time of delay exploration

Decision for the type of the treatment

Late recostruction

Closed injury, (tractional injuries)

Early exploration

Underobservation

Decision for the time of delay exploration

Decision for the type of the treatment

Late recostructionPeripheral reconstruction

Closed injury, (tractional injuries)

Early exploration vascular reconstruction

Closed injury, (tractional injuries)

Early exploration

Underobservation

First 6-12 weeks

Stabilization of the patient

Stabilization of the injury

Evaluation of the improvement

After 2-3 monthsNo improvement; exploration

Progressive improve; wait & watch

Non-anatomic recovery; explor.

Based on severity

Closed injury, (tractional injuries)

Early exploration

Underobservation

Decision for the time of delay exploration

No recovery

After 6-12 weeks (based on the severity of the trauma)

Progressive improvement

Wait for further improvement

Non-anatomic recovery

Exploration before 9-12 months

Closed injury, (tractional injuries)

Early exploration

Underobservation

Decision for the time of delay exploration

Decision for the type of the treatment

Neurolysis

Nerve repair

Nerve graft

Nerve transfer

Tendon transfer

Arthrodesis

Functional muscle flaps

Straight on Brachial Plexus

Early exploration

Delay exploration

Peripheral reconstruction

Late reconstruction

Danger of more damage

Failure is obvious

Neurolysis….check…potential

Nerve repair

Nerve graft

Nerve transfer

Tendon transfer

Arthrodesis

Functional muscle flaps

Gun shot injury

After neurolysis from scar tissue

Neurolysis

Nerve repair…

Nerve graft

Nerve transfer

Tendon transfer

Arthrodesis

Functional muscle flaps

Neurolysis

Nerve repair

Nerve graft

Nerve transfer

Tendon transfer

Arthrodesis

Functional muscle flaps

Suralmedial cutaneous forearmulnar (vascularised)

Self transfer (i.e. Sural

Nerve)

Manufactured Nerve

Processed Nerve

Cadaver Transplant

Living Related Transplant

Neurolysis

Nerve repair

Nerve graft

Nerve transfer..neurotization

Tendon transfer

Arthrodesis

Functional muscle flaps

Accessory nerveCervical plexusPhrenic nerveIntercostal nervesUlnar ECU nerveCrossed C7Hypoglossal nerve

Motor cycle accident open wound

C5

C6

Vertebral foramen

Accessory to suprascapular

Accessory Injured upper trunk

Superascapular nerve

Oberlin nerve transfer

Oberlin nerve transfer

Biceps m.

Ulnar n.

Anastamosis

Radial to axillary transfer

Axillary n

(inverted)

Radial n.

ICN 4

ICN 5

ICN 6

Musclocutaneus n

Neurolysis

Nerve repair

Nerve graft

Nerve transfer

Tendon transfer

Arthrodesis

Functional muscle flaps

Triceps to Biceps

Latismus dorsi m.

Latismus dorsi transfer

to flexion elbow

and extension finger

Deltoid paralysis

Trapez to Deltoid

Neurolysis

Nerve repair

Nerve graft

Nerve transfer

Tendon transfer

Arthrodesis

Functional muscle flaps

Shoulder arthrodesis in BPI

Neurolysis

Nerve repair

Nerve graft

Nerve transfer

Tendon transfer

Arthrodesis

Functional muscle flaps

Gracillis harvest Accessory n.

First stage of Doi procedure

Partial ulnar n. as a donor nerve

Extra plexus donor

Brachial plexus injury

Open sharp injury Shot gun Tractional injury

Immediate exploration under observation

Exploration No improvement in 2-3 m

Explor. In 12 m. Non-anatomic improvement

Peripheral reanimation > 12m .

Gradual improvement

Root value- C5

Supply – Rhomboid major &

minor muscle

Posterior view

LONG THORACIC NERVE

Root value- C5,C6,C7

Supply – Serratus anterior

muscle

BRANCHES OF UPPER

TRUNK

NERVE TO SUBCLAVIUS

Root value – C5,C6

SUPRASCAPULAR NERVE

Root value – C5,C6

Root value-

C5,C6,C7

MEDIAL PECTORAL NERVE

Root value- C8,T1

MUSCULOCUTANEOUS

NERVE

Root value – C5,C6,C7

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MEDIAN NERVE

MEDIAL CUTANEOUS NERVE OF ARM

Root value- C8,T1

MEDIAL CUTANEOUS NERVE OF

FOREARM

Root value- C8,T1

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ULNAR NERVE

Root value-(C7),C8,T1

UPPER SUBSCAPULAR

Root value-C5,C6

LOWER SUBSCAPULAR

Root value- C5,C6

NERVE TO LATISSIMUS DORSI

Root value-C6,C7,C8

AXILLARY NERVE

RADIAL NERVE

Test for ulnar nerve

Card test

Froment’s sign

Egawa’s test

CONTENT

Axillary artery & its branches

Axillary vein & its tributaries

Infraclavicular part of brachial plexus

Axillary lymph nodes

Axillary fat

Carpal tunnel syndrome

Epidemiology

Signs &symptoms

Motor changes

Sensory changes

Vasomotor changes

Trophic changes

Tests done

Tinel sign Phalen’s

maneavure

Radial NerveInjury in axilla

• Causes of injury

Motor effects:paralysis of

triceps,anconeus

extensors of the wrist

Extensors of fingers.

Brachioradialis

supinator muscle

• Deformity: Wrist and finger drop

Sensory effects -small area of sensation loss at arm

andforearm

sensory loss over lateral part of the dorsum of the

hand (lat. 3.5 fingers without distal phalynges)

Injuries at Spiral Groove

Caused by fracture shaft of humerus.

• Motor effects: paralysis of

extensors of the wrist

Extensors of fingers

• Deformity:

Wrist and finger drop

• Sensory effects:

anesthesia is present over the dorsal

surface of the hand (lat. 3.5 fingers)

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Spinal nerves attach to the spinal cord via roots

Dorsal root Has only sensory neurons

Attached to cord via rootlets

Dorsal root ganglion

Bulge formed by cell bodies of unipolar sensory neurons

Ventral root Has only motor neurons

No ganglion - all cell bodies of motor neurons found in gray matter of spinal cord

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31 pair each contains thousands of nerve fibers

All are mixed nerves have both sensory and motor neurons)

Connect to the spinal cord

Named for point of issue from the spinal cord 8 pairs of cervical nerves (C1-C8)

12 pairs of thoracic nerves (T1-T12)

5 pairs of lumbar nerves (L1-L5)

5 pairs of sacral nerves (S1-S5)

1 pair of coccygeal nerves (Co1)

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Rami are lateral branches of a spinal nerve

Rami contain both sensory and motor neurons

Two major groups

Dorsal ramus

Neurons innervate the dorsal regions of the body

Ventral ramus

Larger

Neurons innervate the ventral regions of the body

Braid together to form plexuses (plexi)

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Spinal nerves indicated by capital letter and number Dermatomal map: skin area supplied with sensory

innervation by spinal nerves

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Nerve plexus A network of ventral rami

Ventral rami (except T2-T12) Branch and join with one another

Form nerve plexuses In cervical, brachial, lumbar, and sacral regions

No plexus formed in thoracic region of s.c.

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Dorsal Ramus Neurons within muscles of trunk and

back

Ventral Ramus (VR)

Braid together to form plexuses

Cervical plexus - VR of C1-C4

Brachial plexus - VR of C5-T1

Lumbar plexus - VR of of L1-L4

Sacral plexus - VR of L4-S4

Coccygeal plexus -VR of S4 and S5

Communicating Rami: communicate with sympathetic chain of ganglia Covered in ANS unit

12-111

Formed by ventral rami of spinal nerves C5-T1

Five ventral rami form three trunks that separate into

six divisions that then form

cords that give rise to nerves

Major nerves

Axillary

Radial

Musculocutaneous

Ulnar

Median