Sexy Call Girl Tiruvannamalai Arshi 💚9058824046💚 Tiruvannamalai Escort Service
Brachial plexus injuries by Dr. Rashi Goel PT
1. Rashi Goel
MPT Orthopedics in Hand Rehabilitation
Manipal University
Manipal, Karnataka
25/01/2014 1rashigoelphysio@gmail.com
2. STUDY OBJECTIVES
• Anatomy review
• Classification of nerve injury
• Formation of Brachial Plexus
• Causes
• Classification
• Clinical Features
• Special Features
• Pathomechanics
• Mechanism of different injuries
25/01/2014 2rashigoelphysio@gmail.com
7. Classification of nerve injuries
• Seddon- 1 to 3
• Sunderland- 1 to 5
• Mackinnon- 6th
25/01/2014 7rashigoelphysio@gmail.com
8. Classification of
Peripheral Nerve injury
Seddon Process Sunderland
Neurapraxia Segmental demyelination First degree
Axonotmesis Axon severed but endoneurium intact
(optimal circumstances for regeneration)
Second degree
Axonotmesis Axon discontinuity, endoneurial tube
discontinuity, perineurium and fascicular
arrangement preserved
Third degree
Axonotmesis Loss of continuity of axons, endoneurial
tubes, perineurium and fasciculi;
epineurium intact (neuroma in continuity)
Fourth degree
Neurotmesis Loss of continuity of entire nerve trunk Fifth degree
25/01/2014 8rashigoelphysio@gmail.com
10. Neuropraxia
• conduction block at the site of injury
• no macroscopic injury to the nerve
• Physical examination will not show a Tinel’s sign
• Electrodiagnostic studies will show no
conduction across the area of injury but normal
conduction distal to the area of injury
25/01/2014 10rashigoelphysio@gmail.com
11. Second-degree injury
• involves a rupture of the axon
• endoneurium remains intact
• possibility of recovery following Wallerian
degeneration
• A Tinel’s sign will be noted on examination
25/01/2014 11rashigoelphysio@gmail.com
12. Third-degree lesions
• injury to the endoneurium
• preservation of the perineurium
• scarring will occur
• Full recovery is unlikely
25/01/2014 12rashigoelphysio@gmail.com
13. Fourth-degree injury
• Rupture of the fasciculi
• Disruption of the perineurium
• The nerve is in continuity
• scarring will likely prevent regeneration
• A Tinel’s sign will be present at the site of
injury but will not advance
25/01/2014 13rashigoelphysio@gmail.com
14. Neurotmesis
• Entire nerve trunk is ruptured
• Axonal continuity cannot be re-stored
25/01/2014 14rashigoelphysio@gmail.com
15. Pathology Motor Sensory Treatment Recovery
Neuropraxia
First degree
Anatomic & axonal
continuity
Complete
paralysis
Minimal
loss
Observation Complete
Second degree Transection axon
but endoneurium
intact
Complete
paralysis
Complete
loss
Observation Complete
Axonotmesis
Third degree
Perineurium intact Complete
paralysis
Complete
loss
Surgical
intervention
Complete
Fourth degree Epineurium intact Complete
paralysis
Complete
loss
Surgical
intervention
Complete
Neurotmesis
Fifth degree
Loss of nerve trunk
continuity,
complete
disorganization
Complete
paralysis
Complete
loss
Surgical
intervention
Complete
25/01/2014 15rashigoelphysio@gmail.com
18. 1. Nerve trunks cross the flexor aspect of joints
• Extension ROM < flexion so less tension during
limb movements
• Exceptions- ulnar n. at elbow & sciatic n. at hip
2. Nerve Trunk runs an undulating course in its
bed, fasciculi in epineurium & nerve fibers
inside fasciculi
So length between any two fixed points >
distance between these two points
25/01/2014 18rashigoelphysio@gmail.com
19. 3. During tension, perineurium because of
elastic fibres imparts greater elasticity tan
endoneurium & epineurium
4. Epineurial connective tissue cushions te
nerve fibres against deforming forces
25/01/2014 19rashigoelphysio@gmail.com
20. Nerve roots
Over stretching of nerve roots by transmitted
forces during repetitive stress and traction
injury is prevented by:
1. Dura mater is adherant to intervertebral
foramen so resists displacement of the nerve
when traction pulls the entire system outward
25/01/2014 20rashigoelphysio@gmail.com
21. 2. 4th
, 5th
, 6th
, & 7th
nerve roots securely
attached to vertebral column
so more prone for traction injuries
Rest- more prone for avulsion
25/01/2014 21rashigoelphysio@gmail.com
23. Incidence
• 15- 25 years
• 70%- secondary to motor vehicle accidents
25/01/2014 23rashigoelphysio@gmail.com
24. Anatomy of the Brachial Plexus
• Ventral rami of spinal nerve roots C5 to T1
Pre fixed- Post fixed-
C4 large C4 small/absent
C5 reduced
T1 reduced T1 larger
T2 absent T2 present
more vertical arrangement more horizontal
25/01/2014 24rashigoelphysio@gmail.com
26. Formation
Typical arrangement
• Ant rami of C5 + C6 = SPT (unite near lateral
border of middle scalene)
• C7 = MPT
• C8 + T1 unite behind scalene anterior = IPT
25/01/2014 26rashigoelphysio@gmail.com
27. • At the lateral border of the first rib
• just above or behind the middle third of the
clavicle
• trunks undergo
anterior division
posterior divisions
25/01/2014 27rashigoelphysio@gmail.com
30. 1. Undivided anterior primary rami
2. Trunks—upper, middle, lower
3. Divisions of the trunks—anterior & posterior
4. Cords—lateral, posterior, and medial
5. Branches—peripheral nerves derived from
the cords
25/01/2014 30rashigoelphysio@gmail.com
31. A. Branches of Roots
• 1. N. to serratus anterior- long thoracic n./
Nerve of Bell- C5,6,7
• 2. N. to rhomboideus- dorsal scapular n.- C5
– Also supplies levator scapulae
– Rhomboideus major
– Rhomboideus minor
25/01/2014 31rashigoelphysio@gmail.com
32. B. Branches of trunks
• Upper trunk-
1.suprascapular n.-
– Supraspinatus
– Infraspinatus
2. Nerve to subclavius
25/01/2014 32rashigoelphysio@gmail.com
33. C. Braches of cords
• A. Lateral Cord: C5,6,7
1. Lateral pectoral
2.Musculocutaneous
3.Lateral root of median
25/01/2014 33rashigoelphysio@gmail.com
34. • B. Medial Cord: C8,T1
1. Medial Pectoral
2. Medial cut. N. of arm
3. Medial cut. N. of forearm
4. Ulnar n. – C7 from communicating branch
from lat root of median n.
5. Medial root of median
25/01/2014 34rashigoelphysio@gmail.com
39. Two anatomical triangles
1. The interscalene triangle
contains the roots of the plexus
between
• anterior and middle scalene muscles
superiorly
• first rib inferiorly
25/01/2014 39rashigoelphysio@gmail.com
41. 2. The posterior triangle of the neck
contains the trunks of the plexus
formed by
• sternocleidomastoid muscle anteriorly
• trapezius laterally
• clavicle inferiorly
25/01/2014 41rashigoelphysio@gmail.com
45. Causes
• Traumatic traction/ crush lesions
• TOS
• Obstetrical lesions
• Lesions due to irradiation-post anaesthetic
palsy, needle puncture & after tumor excision
around neck or shoulder
• Iatrogenic lesions
• Tumors
• Gunshots wounds25/01/2014 45rashigoelphysio@gmail.com
46. • 20
compression after trauma as clavicular
malunion
• Personage turner syndrome or brachial
neuritis
• Vascular lesions- aneurysm of subclavian
artery or vein
25/01/2014 46rashigoelphysio@gmail.com
47. Five possible levels where nerve
can get injured
1. Root
2. Trunks
3. Divisions
4. Cords
5. Branches / Peripheral nerve
4725/01/2014 rashigoelphysio@gmail.com
52. Traction apparatus with neutral axis at the C7
vertebra when arm is horizontal
BP = Single cord with 5 separate points of
attachment
5225/01/2014 rashigoelphysio@gmail.com
53. • When traction force falls through C7, traction
is equally borne by all parts C5 - T1
• Deviation from neutral axis creates an unequal
pull to one side or the other5325/01/2014 rashigoelphysio@gmail.com
54. • Traction imparted to arm elevated above
horizontal- stress increased to lower roots of BP
• Traction imparted to arm depressed below the
horizontal- stress increased to upper roots of BP
5425/01/2014 rashigoelphysio@gmail.com
55. Mechanism
• Closed trauma
• Traction or compression
• Traction- 95% of the injuries
25/01/2014 55rashigoelphysio@gmail.com
57. Root avulsions
• 75% of supraclavicular lesions
• Common at C7- T1 nerve roots
• 2 Mechanisms-
• 1.Peripheral - common
• 2.Central - rare
25/01/2014 57rashigoelphysio@gmail.com
58. Peripheral Central
when there is a traction
force to the arm and the
fibrous supports around
the rootlets are avulsed
occur from direct cervical
trauma
The epidural sleeve may be
pulled out of the spinal
canal, creating a
pseudomeningocele
The spinal cord is moved
transversely or
longitudinally, causing a
sheering and spinal
bending that results in an
avulsion of nerve rootlets
25/01/2014 58rashigoelphysio@gmail.com
63. Physical Examination
(1) Posture
(2) ROM of the cervical spine, shoulder, and upper
extremity
(3) motor strength
(4) sensation
(5) palpation
(6) special tests
(7) activities of daily living
(8) vocational and avocational pursuits
25/01/2014 63rashigoelphysio@gmail.com
64. ROM
• Active & Passive
• Reflexes
• Rule out Spinal Cord Injury-
1. Lower limb strength
2. Sensory
3. increased reflexes
4. pathological reflexes
25/01/2014 64rashigoelphysio@gmail.com
65. Motor testing
• Spinal accessory- check trapezius
• To be used for nerve transfer
25/01/2014 65rashigoelphysio@gmail.com
67. • Lattisimus dorsi- palpate in post axillary fold
and ask to cough
• Pectoralis major- palpate as patient adducts
his arm against resistance
• Suprascapular nerve- shoulder ER and
elevation- atrophy of infraspinatus
• shoulder flexion, rotation, and abduction-
rotator cuff or deltoid injury
25/01/2014 67rashigoelphysio@gmail.com
68. • preganglionic injury
• long thoracic nerve C5-C7= scapular winging
as the patient at-tempts to forward elevate
the arm
• dorsal scapular nerve C4-C5= atrophy of
rhomboids and parascapular muscles
25/01/2014 68rashigoelphysio@gmail.com
69. Sensory Examination
• Autonomous Zones
• Deep pressure
• light touch
• Temperature
• stereognosis
• two-point discrimination
25/01/2014 69rashigoelphysio@gmail.com
72. Radiographic Evaluation
• Cervical spine and shoulder
• Chest X- Ray
• Transverse process # of cervical vertebrae-
root avulsion
• Clavicle #, ribs #
• Old rib #- intercostal nerves- for nerve
transfer
• Phrenic nerve- paralysis of diaphragm
25/01/2014 72rashigoelphysio@gmail.com
73. CT
• Level of nerve root injury
• 3 to 4 weeks after injury- pseudomeningocele
for root avulsion
• In acute trauma, CT/myelography remains
the gold standard
25/01/2014 73rashigoelphysio@gmail.com
74. MRI
• Adv. Over CT
Non invasive
non traumatic neuropathy-
Tumours
Radiation injury
Idiopathic BP neuritis
Vasculitic conditions
• Oedema on T2 scan- zone of injury
25/01/2014 74rashigoelphysio@gmail.com
75. Histamine Test
To differentiate pre & post ganglionic injuries
Intact skin- triple response
Preganglionic- normal response in area of skin
that is anaesthetic
Postganglionic- vasodilation, wheal formation
but no flare response as this requires functioning
axon in continuation with its cell body
25/01/2014 75rashigoelphysio@gmail.com
77. Neurolysis
• Neurolysis is the surgical technique of freeing
intact nerves from scar tissue
25/01/2014 77rashigoelphysio@gmail.com
78. Nerve Grafting
• To bridge ruptured nerves
25/01/2014 78rashigoelphysio@gmail.com
79. Most frequently used donor nerve
• Sural nerve- yield up to 30 cm of nerve
• Antebrachial cutaneous
• Radial sensory
• Ulnar
• Ant. tibial
• Superficial peroneal
• Saphenous
25/01/2014 79rashigoelphysio@gmail.com
80. 1. Attachment of a donor nerve to the
ruptured distal stump, sacrificing the original
function of the nerve for a more beneficial
result in the upper limb
2. Restoration of motor or sensory function
can be accomplished by neurotization
Nerve transfer/ Neurotization
25/01/2014 80rashigoelphysio@gmail.com
81. • used in pre-ganglionic
injuries
• reinnervation of a
denervated motor or
sensory end Organ
25/01/2014 81rashigoelphysio@gmail.com
83. 1. Intercostal n.- combinations of musculocut.,
long thoracic, radial, or median n.
2. Spinal accessory n.- suprascapular/
musculocutaneous n.
3. Phrenic n.- for axillary n.
4. Plexo-plexal transfers
5. Motor branches of C3- C4 cervical plexus
6. Contralateral C7 transfers- for median n.
7. N. to long head of triceps- Ant. Br. Of axillary n.
8. Fascicles or branch from ulnar,median and
radial nerves25/01/2014 83rashigoelphysio@gmail.com
86. Muscle Transplantation
• Indications-
1.Failed neurolysis or nerve grafting
2.Chronic root avulsion for >1 year with no
neural regeneration
3.To enhance function in addition to nerve
reconstruction
25/01/2014 86rashigoelphysio@gmail.com
88. Double free muscle transfer
• To restore elbow and hand function
• Advantage of length of gracilis muscle and
proximal location of its neurovascular bundle to
gain early reinnervation of the transferred
muscle while allowing wrist and hand function
25/01/2014 88rashigoelphysio@gmail.com
91. Pre- operative care
• Universal sling, envelope sling, or hemisling
patients who have an upper trunk or complete
• Prevent inferior glenohumeral subluxation,
which results from paralysis of deltoid,
supraspinatus, and infraspinatus muscles
• head of humerus be held in a normal or
slightly elevated position in the glenoid
25/01/2014 91rashigoelphysio@gmail.com
94. 1. Light weight
2. Inexpensive
3. Maintain elbow in flexion
4. Allow for a variety of elbow flexion positions
5. Independent application
6. Client will be able to perform bilateral,
midline tasks
7. Adjustable by user
8. Easy to clean and maintain
25/01/2014 94rashigoelphysio@gmail.com
95. • A long MCP extension splint for patient who
has weak wrist extension & trace finger
extension
25/01/2014 95rashigoelphysio@gmail.com
96. • Paralysis of wrist extensors
• Passive flexed resting stance of the wrist
• Resting hand splint to prevent overstretching
of weak and finger extensor muscles in night
20°dorsiflexion
25/01/2014 96rashigoelphysio@gmail.com
97. • Initial post injury period – PROM
• Digit mobility
• Self-ROM exercises
25/01/2014 97rashigoelphysio@gmail.com
98. Electrical stimulation
• for denervated muscles
– direct current
– Infinite duration (≥ 300 ms)
9825/01/2014 rashigoelphysio@gmail.com
99. Motor response
• Rheobase
The smallest amplitude of current flowing for
an infinite duration that produces a minimal
but perceptible response.
• Chronaxie
The shortest stimulus time at twice the
rheobase that will produce a minimal
perceptible response.
9925/01/2014 rashigoelphysio@gmail.com
100. • Denervated muscle
Chronaxie longer than 20 to 30 milliseconds,
most often closer to 100 milliseconds
• Normally innervated muscle
Less than 1 millisecond
10025/01/2014 rashigoelphysio@gmail.com
101. Immediate postoperative care
• Shoulder girdle is immobilized 3-6 weeks
• Cast / Splint for distal nerves or tendon
corrections
• Hemi-sling continued till evidence of
-reinnervation of the supraspinatus muscle
-restoration of the integrity of GH joint
-can be discontinued thereafter
10125/01/2014 rashigoelphysio@gmail.com
103. • PROM - 4 to 6 times a day , 10 to 20 reps
- within the ranges restricted by the surgeon
• Immediately if no functioning free muscle or
tendon transfers have been performed
• To minimize stiffness in these joints and to
promote neural mobility and gliding
10325/01/2014 rashigoelphysio@gmail.com
106. Electrical stimulation
• 3 to 6 weeks after surgery
• Allow time for the nerve transfers to heal with
considerably less danger of rupture
• Direct-current (galvanic) stimulator
• Electrodes placed over the muscle directly
• Current longer than chronaxie
10625/01/2014 rashigoelphysio@gmail.com
107. • As the muscle reinnervates, the chronaxie
slowly decreases
• The time at which muscle recovery begins is
thus detectable by changes in the stimulation
parameters When the chronaxie decreases to
20 milliseconds or shorter, voluntary
contractions of the muscle begin
• Stimulate for 30 to 60 moderately strong
contractions
• Visible contractions
25/01/2014 107rashigoelphysio@gmail.com
110. Extraplexal Re-education
• Voluntary MUPs on EMG / Visible contraction
• Successful contractions produced by
replicating nerve function
11025/01/2014 rashigoelphysio@gmail.com
111. Activation of muscles neurotized
• Intercostals / Phrenic nerve – can be activated
using breathing techniques
11125/01/2014 rashigoelphysio@gmail.com
112. • Spinal accessory - Elevation of the scapula
• Contralateral C7 - mirroring motions
25/01/2014 112rashigoelphysio@gmail.com
113. • For all recovering muscles
• Start with short sessions to avoid
hyperventilation and fatigue
11325/01/2014 rashigoelphysio@gmail.com
115. Biofeedback
• Useful when active contractions appear
• Portable biofeedback for home use
• In later stages,
Visual & palpatory monitoring
Use of opposite hand or a mirror
• Neuromuscular reeducation
11525/01/2014 rashigoelphysio@gmail.com
116. • Neuromuscular electrical stimulation
• For visualization
• Sensation of contraction
• Start with strong amplitude of evoked
contraction to give sense of the muscle
contracting and then decrease the strength of
stimulus
11625/01/2014 rashigoelphysio@gmail.com
118. Gravity-eliminated exercise
• To attain maximum range possible in gravity
eliminated position
• Light weights can be used
11825/01/2014 rashigoelphysio@gmail.com
119. Strengthening
• Against gravity
• Biofeedback- to monitor improvement in
muscle contraction
• Starting weights - 0.1 to 0.25 kg
• Use isometric, concentric, or eccentric
contractions
• Motivate & Encourage
11925/01/2014 rashigoelphysio@gmail.com
121. Sensory re-education
• Surgical reconstruction of sensation using
1.Intercostal sensory
2.Contralateral C7
3.Cervical plexus branches
12125/01/2014 rashigoelphysio@gmail.com
122. Patient education
• Pressure sores , Injury from sharp objects,
heat & cold
• Routine inspection of the skin
• Re-education has a role only once some
perception starts
• Semmes-Weinstein monofilaments - 4.31
12225/01/2014 rashigoelphysio@gmail.com
123. References
1. Brachial Plexus Injuries by Robert D. Leffert
2. Brachial Plexus Palsy by H. kawai & H.
Kawabata
3. Physical Therapy of shoulder by Robert
Donatelli
4. The HAND Fundamentals of therapy by
Morrin & Conolly
5. Various research articles
25/01/2014 123rashigoelphysio@gmail.com
Notes de l'éditeur
Great degree of variability both b/w individuals and b/w right & left limbs of the same individual
Superior, Middle, Inferior Primary trunk. Earlier called as ant, middle & post trunks- give reference
the neural structures that will supply the ventral (flexor) portion of the upper extremity are separated from those that will supply the dorsal (extensor) aspect
Musculo- biceps, brachialis, coracobrachialis, Lat pectoral- pec major & minor
With avulsion of the left T1 root, the first thoracic sympathetic ganglion is injured. The result, shown on the patient’s right side, is miosis (constricted pupil), ptosis (drooped lid), anhydrosis (dry eyes), and enophthalmos (sinking of the eyeball).
This patient showed miosis and ptosis after a lower trunk avulsion injury.
30 different causes
C5, 6 have strong fascial attachments at the spine
Put figure
When there is an avulsion of a cervical root, dural sheath heals with development of a pseudomeningocele. Immediately after injury, a blood clot is often in the area of the nerve root avulsion and can displace dye from the myelogram. So CT/myelogram should be performed 3 to 4 weeks after injury to allow time for any blood clots to dissipate and for pseudomeningocele to fully form. If a pseudomeningocele is seen on CT/myelogram, a root avulsion is likely
MRI- can visualize much of the brachial plexus, whereas CT/myelography shows only nerve root injury
Triple response- vasodilation, wheal formation. Flare response
Axon reflex test- 0.1% histamine hydrochloride intracutaneous injection of a 5 mm wheal size in each dermatome.
As it requires a length of proximal nerve it cannot be used in pre-ganglionic injuries
other components of the brachial plexus, so called plexo-plexal transfers
The contralateral C7 is used, with an interposed nerve graft, to innervate the median nerve. It is perhaps surprising that sacrificing the function of C7 in the patient’s normal limb leads tolittle or no neurological deficit.
Phrenic nerve- pure motor nerve wid abundant axons but threat to diaphragm
Fascicles or branch from ulnar,median and radial nerves (in upper arm type brachial plexus
injury)
Short pulse durations not effective LMN injury with Wallerian degeneration
Scar me- to soften & flatten the scars
Re-education technique used depends on the type of surgery performed
Mirroring motion- grasp with the opposite hand will elicit a response in the opposite limb