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BRACHIAL PLEXUS INJURY ANATOMY MECHANISMS CAUSE Dx XR SURGERY ORTHOTICS REHAB AFRM UL P+O VIDEOCONF 2009

ANATOMY-Brachial Plexus Arises: lower cervical and upper thoracic spinal nerve roots C5,6,7,8 + T1. Courses: between anterior and middle scalene muscles and adjacent to the subclavian artery. AFRM UL P+O VIDEOCONF 2009

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NERVE

ROOTS: PRE AND POST FIXED TRUNKS: SUPRA/SUBCLAVICULAR ARTERY DIVISIONS: AXILLARY ARTERY / PECTORALIS MINOR CORDS: AXILLARY ARTERY

INDIVIDUAL VARIATIONS COMMON AFRM UL P+O VIDEOCONF 2009

MECHANISMS OF INJURY

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MECHANISMS OF INJURY 1. CLOSED TRAUMA: 1a) TRACTION TRIANGULAR SHAPE DOWNWARD FORCE X UPPER ROOTS UPWARDS FORCE X LOWER ROOTS i.e:

HYPER ABDUCTION/ SHOULDER = FALL, BREECH SUDDEN DEPRESSION/SHOULDER = BLOW WRENCHING = TRACTION DISPLACEMENT OVER FIXED SHOULDER = MBA

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1b) DIRECT INSULT SPORTS = RUGBY FIREARM RECOIL RUCKSACK PALSY FRACTURES + SH DISLOCATION PEOPLE AT RISK: ie HAEMOPHILIACS RADIATION: ie BREAST TUMOUR

AFRM UL P+O VIDEOCONF 2009

1c) BIRTH PALSY (ERB’S PALSY) COMPRESSION TRACTION UPPER = ERBS: LOWER = KLUMPKE

eg

WAITERS TIP

2. OPEN TRAUMA: OPEN WOUNDS IATROGENIC AXILLARY ARTERY PUNCTURE RECONSTRUCTION ABDUCTION SPLINTING OPEN HEART SURGERY RADIATION

AFRM UL P+O VIDEOCONF 2009

CONGENITAL / OBSTETRIC ACQUIRED TRAUMA - multi-system injury Young physically based males (15 - 25) 70 % PREGANGLIONIC 30 % POSTGANGLIONIC

ALSO TUMOR + Inflammatory processes AFRM UL P+O VIDEOCONF 2009

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BPI’s are often with Multi-Trauma eg MBA:clarify mechanisms of accident may explain injury ie. thrown over handlebars, abd-ext rotation shoulder with traction heavy crash helmets implicated although reduce death # = clavicle, ribs,cervical spine,upper limb, combined neuro vascular damage, diaphram x cupola movement upper limb damage BEWARE OF CLOSED HEAD INJURY OR SCI 









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? SPINAL TRAUMA

-

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SCI BPL

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NARAKUS’ LAW OF 7/ 70 ‘ S FOR BPI’s

70% TRAUMATIC ARE MVAs 70% MVAs are MBAs 70% MBAs HAVE ASSOC INJURY 70% SUPRA CLAVICULAR LESION 70% SUPRA CLAVICULAR LESIONs - 1 ROOTAVULSED 70% LOWER ( C78 T1 ) AVULSED 70% LOWER ROOT AVULSIONS HAVE PAIN ROOT AVULSIONS

AFRM UL P+O VIDEOCONF 2009

SYMPTOMS paralysis of the shoulder arm, and/or hand with parasthesias and altered sensation. Temperature and color of the limb may be altered because of damage to the autonomic nervous system

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DIAGNOSIS Hx:  DETAILS LABOUR DELIVERY  ? HIGH VELOCITY INJURY  LOCALISE LESION/S  Symptoms of a brachial plexopathy commonly are nonlocalizing  SOMETIMES COMBINATIONS

AFRM UL P+O VIDEOCONF 2009

Dx CLINICAL EXAMINATION EXCLUDE ROOT AVULSION = PREGANGLIONIC

---C345 DIAPHRAM

---DORSAL SCAPULAR C5 RHOMBOIDS

---LONG THORACIC C567 SERRATUS ANT (WINGING SCAPULA)

---T1 HORNERS SYNDROME

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X X X X X

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BPI CLINICAL PICTURES 







C5 + C6 C5 , C6 + C7 C7 , C8 + T1 COMPLETE

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CERVICAL MYOTOMES

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C5 AND C6

UPPER TRUNK

MOTOR SUPRA/ INFRA SPINATUS, PECT MAJ (CLAV ) ,DELTOID ,LAT DORSI ,BICEPS ,BRACHIALIS ,BRACHIORADIALIS ,RAD WRIST EXT

SENSORY LAT UPPER LIMB

FUNCTION POOR HAND PLACEMENT AND ELBOW FLEX BUT GOOD GRASP AND RELEASE PROGNOSIS: BEST RCOVERY IF < 12/12 AFRM UL P+O VIDEOCONF 2009

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AFRM UL P+O VIDEOCONF 2009

C5,C6 AND C7 MOTOR C5 C6 + X FLEX EXT ELBOW,WRIST,FINGERS

SENSORY ALSO MIDDLE FINGER

FUNCTION + POOR GRASP AND RELEASE

PROGNOSIS: SPONTANEOUS RECOVERY POOR OFTEN SH FUSION AND TENDON TRANSFER AFRM UL P+O VIDEOCONF 2009

C7,C8 AND T1 SMALLEST GROUP MOTOR INTACT SH,ELBOW +WRIST EXT LOSS LONG FLEX/EXT FINGERS + INTRINSICS

SENSORY MEDIAL ASPECT FOREARM,ULNAR HAND,4TH + 5TH FINGERS

FUNCTION INTACT PLACEMENT OF HAND

PROGNOSIS: ABSENT HAND FUNCTION

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THE COMPLETE LESION MOTOR FLAIL

SENSORY FUNCTION HORNERS, WINGED SCAPULA (SERRATUS ANTERIOR)

PROGNOSIS: EXTREMELY POOR,PERMANENT LOSS ,

SEVERE PAIN AFRM UL P+O VIDEOCONF 2009

ROOT AVULSION

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AVULSION C 7-8 + T1

DON’T USUALLY SEE AVULSION OF UPPER WITHOUT LOWER AFRM UL P+O VIDEOCONF 2009

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TI LESION EVIDENCED BY PTOSIS ASSOCIATED ROOT AVULSION PAIN PAIN in avulsion lesions of the brachial plexus represents the most significant impediment to rehabilitation.

MX “GET BACK TO WORK “ WYN PARRY

AFRM UL P+O VIDEOCONF 2009

PROFOUND LOSS

PAIN AFRM UL P+O VIDEOCONF 2009

PREGANGLIONIC Proximal

to dorsal root ganglion complete motor + sensory loss of root denervation of deep paraspinal muscles no tinels assoc # = cervical transverse process AFRM UL P+O VIDEOCONF 2009

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AFRM UL P+O VIDEOCONF 2009

POOR PROGNOSIS WITH

PREGANGLIONIC = INTACT SAP WITH ANAESTHESIA COMPLETE HORNER’S SYNDROME SENSORY C2/C2 DYSAESTHESIA PROX NERVES ie: SUPRA CLAVICULAR ROOT AVULSION PAIN AFRM UL P+O VIDEOCONF 2009

X-RAY EXAMINATION CERVICAL

SPINE AVULSION #S DISPLACED # CLAVICLE = HYPERMOBILITY # SH ? INFRACLAVICULAR DAMAGE ONLY PARALYSIS DIAPHRAM (C3,4,5) AFRM UL P+O VIDEOCONF 2009

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IX

MRI and CT Scans: Myelography previously myelogram

EMG ETC NERVE

CONDUCTION SAP / MOTOR CONDUCTION TESTS AUTONOMIC FUNCTION SWEAT TESTS HISTAMINE RESPONSE AFRM UL P+O VIDEOCONF 2009

MRI

-

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RIGHT

normal

MIDLINE SCI

LEFT outpouching

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POST GANGLIONIC Distal

to spinal ganglia divide into trunk + cord better prognosis for spontaneous and post surgical recovery AFRM UL P+O VIDEOCONF 2009

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Mx The treatment of brachial plexus injuries varies depending on the mechanism and the time the injury is discovered in relation to the inciting trauma. Current treatment includes assessing function with physical examination, preoperative electromyogram, and then repair of viable nerve roots and associated vascular injuries

AFRM UL P+O VIDEOCONF 2009

NON-OPERATIVE MX OVERALL

APPROACH PREVENTION PAIN MX OPTIMISE REMAINING FUNCTIONS ORTHOTICS AFRM UL P+O VIDEOCONF 2009

SURGERY NEUROSURGERY NERVE Salvage: USUALLY LONG AND COMPLEX PROCEDURES

? Exploration ?can perform neurolysis or an interpositional graft. pre and intraoperative neurophysiological tests are valuable with diagnosis and functional evaluation AMPUTATION NEEDS TO BE CAREFULLY CONSIDERED, + SHOULDER FUSION? AFRM UL P+O VIDEOCONF 2009

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SURGICAL EXPLORATION If spontaneous recovery not expected in reasonable time

1 OBSTETRIC PALSY NO IMPROVEMENT 2/12 2 PENETRATING INJURIES 3 HIGH VELOCITY AVULSION INJURIES 4 ASSOCIATED VASCULAR DAMAGE 5 TO CLARIFY DX TIMING - LATER PROBLEM OF SCAR AFRM UL P+O VIDEOCONF 2009

PREGANGLIONIC NERVE SURGERY

3 groups - : upper avulsion C5 + C6 lower avulsion C8-T1 completely flail with avulsion all roots

AFRM UL P+O VIDEOCONF 2009

POST GANGLIONIC NERVE SURGERY

Exploration and direct reconstruction if no recovery 3 /12 recovery plateau and nerve grafting if complete transection upper trunk better < distance to grow 



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NERVE RECONSTRUCTION 1 DIRECT NEURAL REPAIR ?????? 2 CABLE NERVE GRAFTS 3 NEUROTISATION POST RECONSTRUCTION FUNCTION > 30 % SUPRACLAVICULAR (75%) 70 % INFRA CLAVICULAR (25%)

AFRM UL P+O VIDEOCONF 2009

WITH OR WITHOUT LIMB NEED TO KEEP MOBILE Malessy MJ Direct coaptation was achieved in 95% of ICNs, and functional elbow flexion was regained in 64% of the patients. AFRM UL P+O VIDEOCONF 2009

RECONSTRUCTIVE PROCEDURES SHOULDER ? Leave flail if no traction pain more cosmetic ?fusion if good scapular control needed ABD 20 FLEX 30 IR 40 prosthetic use ie occupation ELBOW ? Tendon transfer ? Intercostal neurotisation 









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FUNCTIONAL LOSS

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LIMB FUNCTION PROXIMAL

STABILITY

PLACEMENT

FUNCTIONAL

GRASP

AFRM UL P+O VIDEOCONF 2009

ORTHOTICS v Clinical Patterns C5-6 MOTOR X sh = elb,? Ext fingers + ext carp ulnaris SENSORY X thumb + finger sensation P+O ? Support Sh + Fig 8 cable ---Elb Flex

C5-7 MOTOR X adds radial n = Ext wrist hand + fingers SENSORY X adds hand P+O add static /spring assisted hand/finger Ext AFRM UL P+O VIDEOCONF 2009

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C7-8 T1

MOTOR X finger Flex,Ext + intrinsics SENSORY P+O Good Sh + Elb TRA body/switched control 

C8 T1

MOTOR X Finger Flex + Intrinsics SENSORY X Ring + Little Finger Less P+O 

COMPLETE

MOTOR Complete SENSORY Complete P+O Stanmore etc AFRM UL P+O VIDEOCONF 2009

REHAB 









ASAP SURGERY CAN CONFUSE ISSUE ? FULL ARM ORTHOSIS ?Dx PROSTHOSIS AMPUTATION ?

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SUB LUXATION

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SHOULDER FUSION ?

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A M P U T A T I O N

?

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EARLY TOLERANCE

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MOVE EARLY

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POSTURE,ATROPHY

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TRAUMA POSTURE ATROPHY

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EXTERNAL POWER ? FUTURE

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EP Brachial Plexus Orthosis 2005

INTRO -EPIDEMIOLOGY- INITIAL Mx -SURGERY- PAIN -INTERIM DEFINITIVE -FUTURE

AFRM UL P+O VIDEOCONF 2009

REVIEW LIKE AMPUTEE

ALTHOUGH NO DEVICE NECESSARILY NEEDED MAY GET LOST AS WITH UL AMPS MANY OTHER AND CHANGING NEEDS

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PROGNOSIS often UNCLEAR PROLONGED PERIOD OF UNCERTAINTY NEWER SURGERY: Ie NERVE GRAFTS, TRANSFERS LIMB RECONSTRUCTION Ie. MUSCLE TRANSFERS OFTEN LIMITED RECOVERY + FUNCTIONAL OUTCOMES Complete vs Incomplete AFRM UL P+O VIDEOCONF 2009

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Upper limb prosthesis  

Upper limb prosthesis

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