Brachial plexus in Adults and Children Senario

Question 1

Onset

Answer 1

MOI

1. Blunt vs penetrating vs birth
2. Open or closed
3. High velocity
4. Low velocity
5. Traction injury with fall
   
   1. onto tip of shoulder and head extended away from arm
      
      1. C5-6, upper trunk
   2. arm abducted away from body
      
      1. C8-1, lower trunk

Question 2

Symptoms associated

Answer 2

1. Neurologic
   
   1. Which dermatomes/myotomes
2. Mechanical
3. Constitutional
4. Local

Question 3

Perinatal Hx

Answer 3

Pregnancy, presentation, delivery method, and apgars

1. Risk factors for obstetrical brachial plexus palsy
   
   1. Macrosomia (> 4 kg)
   2. Maternal diabetes
   3. Prior child with BPP
   4. Prolonged 2^nd stage of labour
   5. Forceps delivery
   6. Shoulder dystocia
   7. Breech delivery

Question 4

Developmental Hx

Answer 4

growth ht/wt, milestones

Question 5

ROS

Answer 5

1. Associated injuries
   
   1. Clavicle #
   2. Humerus fracture
   3. C-spine
   4. Beware of axillary/ subclavian artery injury
   5. Ribs
   6. AC and SC
   7. Rotator cuff

Question 7

Adult Physical Exam

Look

Deformity

Skin changes

Answer 7

Position of limb

1. Erb’s (C5, C6, ~C7)
   
   1. Shoulder
      
      1. Adducted and IR
   2. Elbow
      
      1. Extended
   3. Forearm
      
      1. Pronated
   4. Wrist
      
      1. Flexed
2. Klumpke’s (C8, T1, ~C7)
   
   1. Elbow
      
      1. Flexed
   2. Forearm
      
      1. Supinated
   3. Hand
      
      1. Intrinsic minus

Skin changes

Open or closed injury

Question 8

NV Exam

Answer 8

1. do vascular exam first so you don’t forget
2. check for long track signs to make sure there is no concomitant cord injury
3. cranial nerve exam
4. C5
   
   1. Motor: deltoid (axillary)
   2. Sensory: lateral arm
5. C5-6
   
   1. Motor= biceps (MCN)
   2. Sensory= lateral forearm
   3. Reflex= biceps
6. C6
   
   1. Motor= no pure motor either 5-6 biceps (MCN) or 6-7 wrist extensors (radial)
   2. Sensory= thumb and index
   3. Reflex= brachioradialis
7. C7
   
   1. Motor= triceps (radial)
   2. Sensory= middle finger
   3. Reflex= triceps
8. C8
   
   1. Motor= finger flexion , fds (median) and fdp (median and ulnar)
   2. Sensory= ring and little finger, also medial forearm from MACN
9. T1
   
   1. Motor= finger abduction (ulnar)

Sensory= medial arm (MBCN)

Question 9

Special Tests

Answer 9

1. Horner’s syndrome – bad
2. Scapular winging
3. Chest auscultation
4. Tinel’s sign
5. NB

Question 10

Special Tests

Answer 10

1. Horner’s syndrome – bad
   
   1. b/c preganglionic meaning no spontaneous recovery
   2. Myosis - constriction of the pupil
   3. Ptosis - drooping of the eyelids
   4. Enophthalmos - sinking of the eye into the socket
   5. Anhydrosis - Dry
2. Scapular winging
   
   1. Bad sign - preganglionic
3. Chest auscultation
   
   1. Decreased breath sounds on ipsilateral side due to diaphragmatic palsy (phrenic nerve = preganglionic)
   2. Get CXR
4. Tinel’s sign
   
   1. presence = rupture
   2. absence + neuro deficit = avulsion
   3. advancing Tinel’s may be indicative of recovering lesion
5. NB
   
   1. dorsal scapular and long thoracic are only nerves to arises from roots before they form trunks!!!
   2. only one branch arises from trunk = suprascapular
   3. no branches from divisions

Question 11

Patterns

Answer 11

1. Upper plexus injury = Erb
   
   1. Involves segments innervated by C5 and 6
   2. Extended elbow, adducted and internally rotated
      
      1. No active abduction or external rotation of shoulder nor flexion of the elbow
   3. If serratus anterior, levator scapulae, rhomboids are affected
      
      1. root injury and surgical repair will be impossible
2. Lower plexus injury = Klumpke
   
   1. Deficits involving C8 and T1 +/- C7
   2. Affects intrinsics of hand, finger and wrist flexors
   3. Associated horner syndrome is sign of root avulsion
3. Injuries can be at any level from R,T,(D),C,B
   
   1. Lateral cord
      
      1. MCN deficit and lateral root of median nerve (PT and FCR) and lateral pectoral (clavicular head of pect)
   2. Posterior cord
      
      1. subscapular, thoracodorsal, axillary, radial
   3. Medial cord
      
      1. ulnar and median nerve except FCR and PT

Question 12

Paeds Physical Exam

Question 13

Paeds

Look

Answer 13

1. Swelling

Associated fracture

2. ​Deformity

Resting posture of the limb

​​

Question 14

Move

Answer 14

1. Spontaneous shoulder, elbow, wrist, finger motion
2. Shoulder abduction
3. Elbow flexion
4. Wrist extension
5. Finger extension
6. Thumb extension

Question 15

Special Tests

Answer 15

1. Horner’s (avulsion of T1 sympathetic ganglion – pre-ganglionic)
   
   1. Myosis
   2. Ptosis
   3. Enophthalmos
   4. anhydrosis
2. Neonatal reflexes
   
   1. watch for elbow flexion, wrist and finger extension
   2. Moro
   3. Asymmetric tonic neck
   4. Votja

Question 16

Pediatric Brachial plexus classification

Answer 16

1. Mallet
   
   1. descriptive-good for physical exam
   2. Grade 1 – 5
      
      1. 1=no function
      2. 5=normal
   3. Global ABD
      
      1. 2 = < 30 degrees
      2. 3 = 30 – 90 deg
      3. 4 = > 90
   4. Global ER
      
      1. 2 = < 0
      2. 3 = 0 – 20
      3. 4 = >20
   5. Hand to neck
      
      1. 2 = not possible
      2. 3 = difficult
      3. 4 = easy
   6. Hand to spine
      
      1. 2 = not possible
      2. 3 = S1
      3. 4 = T12
   7. Hand to mouth
      
      1. 2 = marked trumpet sign
      2. 3 = partial trumpet sign
      3. 4 = < 40 deg abduction
2. Toronto** **score
   
   1. good for management
   2. Scored 0 – 2 (0=no function, 1=partial, 2=normal)
      
      1. Shoulder abduction
      2. Elbow flexion
      3. Wrist extension
      4. Finger extension
      5. Thumb extension
   3. Total of < 3.5 at 3 months

indication for microsurgery