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Plastic Surgery( Grabb)Ali jasim > Brachial Plexus Injuries > Flashcards

Brachial Plexus Injuries Flashcards

1
Q

Surgery is undertaken for closed injuries when physical
examination and diagnostic modalities show a plateau or
absence of functional recovery (ideally 3-5 months post
trauma)

A

T

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2
Q

fibrosis of the neuromuscular junctions occurs in

A

approximately 12 to 18 months after
denervation

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3
Q

the time elapsed since trauma is the most important factor to consider when determining which surgical intervention is appropriate

A

T

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4
Q

The treatment course for these injuries can span a lifetime,

A

T

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5
Q

Permanent functional disability is certain

A

T

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6
Q

Lower-energy mechanisms
tend to produce postganglionic nerve ruptures

A

T

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7
Q

higher-energy mechanisms tend to produce tearing of the rootlets of the peripheral nerve directly from the spinal cord, proximal to the dorsal root ganglion

A

T

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8
Q

adult brachia!
plexus trauma mostly affects young males worldwide (>90%

A

T

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9
Q

CS to Tl.
The dorsal root, which contributes sensory nerves only, is thicker and
more resistant to avulsion forces

A

T

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10
Q

The spinal nerves coalesce
into the upper (CS and C6), middle (C7), and lower (C8 and Tl)
trunks which are contained between the anterior and posterior scalene muscles

A

F which are contained between the anterior and middle scalene muscles

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11
Q

Each trunk then splits into anterior and posterior divisions within the area deep to the clavicle

A

T

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12
Q

inferior to the clavicle, they become the lateral, posterior, and medial
cords in the area deep to the pectoralis minor

A

T

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13
Q

The axillary and radial nerve are separable at the region of the posterior cord deep to the lateral border of the pectoralis minor

A

T

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14
Q

The musculocutaneous nerve can be located at the proximal arm in
the plane between the coracobrachialis and biceps brachialis

A

T

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15
Q

The median and ulnar nerves are most easily found in the mid-distal arm
deep to the brachia! veins as they wrap around the brachia! artery

A

T

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16
Q

the posterior
division of lower trunk is quite small

A

T

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17
Q

At the cord level, the
axillary artery is sandwiched between the three cords

A

T

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18
Q

classification systems :Terzis’

A

root, supraclavicular postganglionic, and infraclavicular injuries

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19
Q

the Alnot classification

A

preganglionic root, postganglionic root,
supraclavicular and retroclavicular, and infraclavicular injuries

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20
Q

Chuang’s level 1 to 4 classification separates injuries into preganglionic (root avulsion), postganglionic, pre- and retroclavicular, and
infraclavicular injuries

A

T

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21
Q

The frequency of the nerve root injury

A

■ C5-C6: 15%
■ C5-C7: 20%-35%
■ C8-Tl: IO%
■ CS-Tl: 50%-70%

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22
Q

Cephalic traction upon the
arm with consequent lower trunk injuries much more rarely encountered

A

T

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23
Q

Most closed injuries of the brachia!
plexus are actually mixed in nature {Mackinnon’s sixth degree
injury)

A

T

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24
Q

Mackinnon’s first through third degrees of nerve
injury severity will recover spontaneously

A

T

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25
Q

Exploration after 2 weeks should be accompanied by preparation for nerve grafting

A

T

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26
Q

low-velocity gunshot injuries inflicted by handguns only have a small shock wave and zone
of temporary cavitation

A

T

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27
Q

most civilian gunshot wounds
(handguns) are managed conservatively for the first 3 to 5 months
in a manner similar to closed injuries

A

T

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28
Q

High-velocity gunshot injuries cause a large
shock wave and permanent cavitation usually inflicting greater
than Mackinnon’s fourth degree nerve injury.

A

T

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29
Q

The prognosis for
spontaneous recovery after a high-velocity gunshot wound is poor

A

T

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30
Q

exploration of these injuries is advisable at 2 to 3 months post-injury if clinical and electrodiagnostic evidence of recovery are still absent in high-velocity gunshot

A

T

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31
Q

Anterior shoulder
dislocation and scapular fracture are associated with posterior cord
damage.

A

T

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32
Q

Spine fractures indicate a more proximal focus of energy

A

T

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33
Q

Examination should proceed in a distal to proximal fashion

A

T

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34
Q

Horner syndrome indicates disruption of the sympathetic pathways likely the presence of a root
avulsion involving the upper plexus

A

F likely presence of a root
avulsion involving the lower plexus

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35
Q

Deafferentation pain (a.k.a. phantom
limb pain and sensation) is a sign that root avulsion has occurred

A

T

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36
Q

Sequence of examination of Brachial plexus injury

A

History
Tinnel sign
Horner syndrome
Deafferentation pain(Root avulsion)

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37
Q

diaphragmatic muscle paralysis (hemidiaphragmatic elevation the injured side) suggests alikelyinvolvement
of the upper plexus

A

T

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38
Q

diaphragmatic innervation (C3, C4, and
CS) that is involved in the zone of injury is located near the lower trunk

A

F diaphragmatic innervation (C3, C4, and
CS) that is involved in the zone of injury is located near the upper
trunk

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39
Q

presence of pseudo meningocele adjacent to the vertebrae with MRI
and CT myelography indicates what?

A

which develop when the dura tears
in conjunction with avulsion spinal nerve roots

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40
Q

using the phrenic donor nerve
is safe in lower-BM! patients

A

T

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41
Q

MRI has not yet been proven as a reliable modality for delineating nerve rupture or injury within the plexus

A

T

42
Q

The baseline nerve conduction study and EMG should be
performed no earlier than 3 to 4 weeks after trauma, why?

A

certain acute
phase injury changes take that amount of time to become detectable

43
Q

Follow-up electrodiagnostic study should be repeated at 2-month intervals

A

T

44
Q

Contraindications to surgery

A

Traumatic brain or spinal cord injuries that may prevent productive participation in a rehabilitative protocol
medical
comorbidities prohibitive of a prolonged general anesthetic session
Joint contractures
patient’s willingness and ability to comply with postoperative
rehabilitation

45
Q

sensory nerve action potential (sensory nerve)-begins to decrease at day 6

A

T

46
Q

sensory NCS tends to overestimate severity ofinjury

A

T

47
Q

compound muscle action potential (motor nerve)-begin to decrease at day 2 or 3 after injury

A

T

48
Q

CMAP amplitudes are the most useful for quantifying the amount of axon loss

A

T

49
Q

Amplitude reflects the total number of conducting axons

A

T

50
Q

at least 50% of the motor nerve must be disrupted before these MUAP changes can be discernible

A

T

51
Q

If muscle is innervated, there are no spontaneous discharges

A

T

52
Q

PSW (positive sharp waves)-acute phase injury sign (should subside by I y post injury

A

T

53
Q

Fibrillations-acute phase injury sign (does not appear until 2-3 wk after injury

A

T

54
Q

Fibrillations-acute phase injury sign (does not appear until 2-3 wk after injury

A

T

55
Q

Complete denervation show no spontaneous discharge

A

T

56
Q

completely reinnervated muscle will also return to the state of
no spontaneous discharge

A

T

57
Q

Polyphasic waves are a pathologic finding, but the nerve is still
alive

A

T

58
Q

Fasciculations indicative of upper motor neuron disorders

A

F. Lower motor

59
Q

Ifmotor nerve conduction (amplitude) is absent at 4 months after injury, this as a bad prognostic indicator

A

T

60
Q

The incision can be carried infraclavicular onto the chest for access this approach allows for both
diagnostic and therapeutic objectives

A

T

61
Q

Options for nerve graft

A

sural, saphenous, median antebrachial cutaneous, or lateral
antebrachial cutaneous nerves

62
Q

Allografts
cant be used

A

Allografts
should not be used

63
Q

proximal stumps that are too short to
support coaptation how you can mange ?

A

by nerve transfers using intraplexus transfer from proximal stumps of neighboring spinal nerves
or from extra plexus donors (e.g., CN XI, contralateral C7, intercostal nerves, phrenic, or cervical motor branches of C3/C4)

64
Q

Exploration of the lower trunk can be risky in this regard, as adhesions
to the pleural cavity and the proximity to great vessels in this case can
sometimes also lead to pneumothorax or vessel injury.

A

t

65
Q

Postoperative
neck immobilization is crucial

A

T

66
Q

Proximal exploration should be done within the posttrauma 3- to 5-month timeframe, to ensure opportunity for reinnervation
before the time of motor endplate fibrosis at the neuromuscular
junction

A

T

67
Q

Contralateral C7 can be used with five root injuries without other suitable
donors.

A

t

68
Q

Phrenic for shoulder abduction Suprascapular/posterior division
ofC5/C6 is strong enough
to use alone

A

T

69
Q

For median nerve we can used c6-c7 as donor

A

T

70
Q

The
option of tendon transfer or functioning free muscle transplantation
is often used as the lifeboat or
for augmentation of function after previous reconstruction

A

T

71
Q

tendon transfers are only viable options for incomplete brachia! plexus injury,

A

T

72
Q

Tendon transfers are often paired with arthrodeses (shoulder
or wrist) for an enhanced functional result.

A

T

73
Q

The gracilis myocutaneous flap is the most popular option for the FFMT for the upper
extremity

A

T

74
Q

Distal transfer is more safe than proximal exploration

A

T

75
Q

FFMTs also require a
donor nerve for neurotization

A

T

76
Q

reconstructive intervention is contraindicated if joints are ankylotic

A

T

77
Q

Upper trapezius transfer-Shoulder abduction

A

T

78
Q

Lower trapezius transfer-External rotation

A

T

79
Q

he strongest risk factor is undoubtedly shoulder dystocia for OBPP

A

T

80
Q

The most commonly encountered OBPP injury overall (46% of all OBPP) is a classic Erb palsy
(CS and C6 palsy)

A

T

81
Q

Fortunately, OBPP has a high frequency of
spontaneous resolution (77% to 90%)

A

T

82
Q

The most common pattern
of injury that necessitates operative exploration in pediatric

A

is a combination of
root avulsions and extraforaminal ruptures of CS, C6, and C7

83
Q

Test for OBPP

A

The tickle test
The towel test

84
Q

Terzis advocated surgical exploration
if total palsy with Horner syndrome was present at 2 months of age

A

T

85
Q

Gilbert’s threshold was 3 months of age without elbow flexion

A

T

86
Q

Clarke and Curtis described 9 months as the limit for recovery of motor function in response to the “cookie test

A

T

87
Q

Chuang
found no difference in the recovery of elbow and shoulder function
when surgical intervention was carried out at 2 versus 11 months

A

T

88
Q

Chuang’s threshold for surgical intervention was at 3 months if there was little to no wrist extension and finger flexion

A

T

89
Q

persistent lack or stagnation of improvement
in elbow or shoulder function warranted intervention at 6 to
12 months(Chuang’s)

A

T

90
Q

Electrodiagnosis in infants is notoriously unreliable
because of its tendency to overestimate the axonal function that is
present

A

T

91
Q

the phrenic nerve is generally not used
for OBPP

A

T

92
Q

Options for nerve graft of pediatric

A

saphenous, median antebrachial cutaneous , or lateral antebrachial
cutaneous nerves in addition to the sural nerves, given the short
length of the sural nerve in an infant

93
Q

What is the trumpet sign

A

cross-innervation between elbow flexors and shoulder abductors

94
Q

The development of aberrant reinnervation ultimately leads to muscle imbalance that often causes joint
deformities.

A

T

95
Q

Elbow reconstruction should prioritize restoration of elbow extension first

A

T

96
Q

Both shoulder and elbow reconstructions are typically done in the range of 4 to 6 years of age

A

T

97
Q

Hand and forearm function until age 6 to 13 years

A

T

98
Q

A Zancolli
procedure might be used for supination contracture

A

T

99
Q

joint contractures will
recur without diligent therapy and continuous lifelong maintenance
exercises

A

T

100
Q

Latissimus dorsi transfer

A

Shoulder abduction, external rotation / Shoulder arthrodesis

Plastic Surgery( Grabb)Ali jasim (92 decks)

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