Brachial Plexus Injuries

Question 1

What is an avulsion injury?

Answer 1

The nerve root is torn off the spinal cord at its origin

Question 2

What is neurapraxia?

Answer 2

The nerve is stretched and damaged but not torn

Question 3

What is a nerve rupture?

Answer 3

The nerve is torn at a point along its length

Question 4

What is axonotmesis?

Answer 4

The nerve is partially severed

The axon and myelin sheath are torn but the surrounding epineurium, perineurium, and connective tissue are preserved

Question 5

What is a post traumatic neuroma?

Answer 5

A growth of scar tissue at the site of previous nerve injury that leads to compression of the nerve

Question 6

What is the injury mechanism that results in Erb’s palsy?

Answer 6

A traction injury due to excessive lateral neck flexion to the contralateral side or excessive shoulder depression causing violent stretching (+/- tearing) of the upper portion of the brachial plexus

Question 7

What could cause Erb’s palsy?

Answer 7

Falls onto neck/shoulder

Motorcycling accidents

Direct trauma (clavicle fracture, gun shot wound, stab injury)

Attempts to reduce a shoulder dislocation

Traction injury during difficult/obstructed labour (breech with arms above head, shoulder dystopia + emergency forceps)

Excessive traction on the arm e.g. in sports

Question 8

Where would a patient with Erb’s palsy experience loss of sensation?

Answer 8

The skin over the ‘sergeants patch’, lateral arm, and lateral forearm

Question 9

In what muscles would you see wasting in a patient with Erb’s palsy?

Answer 9

The deltoid, supraspinatus and the anterior compartment of the arm

Question 10

Which movements are preserved in patients with Erb’s palsy?

Answer 10

Wrist flexion and extension, and finger movements

Question 11

Which movements are lost in a patient with Erb’s palsy?

Answer 11

Shoulder abduction
External rotation
Elbow flexion
Wrist supination

Question 12

Which arm position do patients with Erb’s palsy typically present with?

Answer 12

Waiters tip

Limb adducted , internally rotated shoulder, extended elbow and pronated wrist

Question 13

What reflex is absent in a patient with Erb’s palsy?

Answer 13

The bicep reflex is absent

Question 14

What is the location an Erb’s palsy injury?

Answer 14

The superior trunk of the brachial plexus

That affects the suprascapular nerve, the nerve to subclavius, the musculocutaneous nerve and the auxiliary nerve

Question 15

Is Erb’s palsy an upper brachial plexus injury?

Answer 15

Yes Erb’s palsy is an upper brachial plexus injury (injury to the superior trunk)

Question 16

Is Klumpke’s palsy an upper brachial plexus injury?

Answer 16

No Klumpke’s palsy is a lower brachial plexus injury

Question 17

What is the mechanism of injury that leads to Klumpke’s palsy?

Answer 17

A traction injury due to excessive force placed on an abducted shoulder resulting in violent stretching (+/- tearing) of the lower portion of the brachial plexus

Question 18

What is the site of injury in the brachial plexus that results in Klumpke’s palsy?

Answer 18

The inferior frank of the brachial plexus

Affecting the median and ulnar nerves

Question 19

Which is the rarest brachial plexus syndrome?

Answer 19

Klumpke’s palsy

Question 20

What sensation is lost in a patient with Klumpke’s palsy?

Answer 20

Loas of skin sensation in the median and ulnar distributions of the hand and in the medial forearm and arm

Question 21

What sensation is preserved in patients with Klumpke’s palsy?

Answer 21

Sensory supply to the lateral dorsum of the hand

Question 22

What muscles would show wastage in patient with Klumpke’s palsy?

Answer 22

The muscles of the hand

Question 23

What movements would be lost in a patient with Klumpke’s palsy?

Answer 23

Loss of movement in the hand, loss of wrist flexion

Question 24

Which position would a patient with Klumpke’s palsy typically present with?

Answer 24

Claw hand

Question 25

What movement is usually preserved in a patient with Klumpke’s palsy?

Answer 25

Shoulder movement is usually preserved

Question 26

What injuries could lead to Klumpke’s palsy?

Answer 26

A falling person grabbing onto something Motor biking accident Direct trauma (GSW, stab injury, clavicle fracture) Difficult childbirth = arm prevention requiring force on the arm to deliver the baby Compression of the lower plexus by a ,ass in the root of the neck e,g. Lymphoma or lung cancer

Question 27

What could cause total/complete brachial plexus injury?

Answer 27

Severe traction injuries sustained in difficult childbirth High speed road traffic accidents

Question 28

What is the clinical presentation of someone with a total complete brachial plexus injury?

Answer 28

Totally limp, dangling, atrophied, numb upper arm, with associated Horners syndrome

Question 29

What is the most common cause of Klumpke’s palsy?

Answer 29

Difficult childbirth

Question 30

What is the site of injury for Horners syndrome?

Answer 30

The T1 nerve root

Question 31

What could cause Horner’s syndrome?

Answer 31

Cerebral pathology Traction injury Direct trauma Extrinsic compression

Question 32

How does Hornerks syndrome present?

Answer 32

Ipsilateral partial ptsosis (drooping eyelid) Enophthalmos (eye appears sunken) Anhidrosis (loss of sweating on one side of the face) Constricted pupil Loss of sympathetic nerve supply of the face and neck

Question 33

In Horners syndrome caused by nerve root compression what symptoms are present?

Answer 33

Hand/arm pain Wasting of the intrinsic muscles of the hand

Question 34

In Horner’s syndrome caused by traction injuries what other palsy is associated with it?

Answer 34

Klumpke’s palsy

Question 35

What is the mechanism of injury that results in Horners syndrome?

Answer 35

Any injury to the T1 root that is associated with loss of sympathetic function

Question 36

Where does brachial neuritis/plexitis occur?

Answer 36

Any part of the brachial plexus

Question 37

What is the mechanism of brachial neuritis?

Answer 37

Inflammatory reaction against the nerves of the brachial plexus

Question 38

What can cause brachial neuritis

Answer 38

Brachial neuritis can be triggered by: Bacterial, viral, parasitic infections Trauma Childbirth Recent surgery Recent radiotherapy Systemic inflammation disorders e.g. lupus Can be idiopathic Can be part of a polyneuropathy

Question 39

What are the clinical feature of brachial neuritis?

Answer 39

Sudden onset of excruciating shoulder and arm pain Development of paralysis and atrophy of affected muscles

Question 40

How long after onset do patients tend to present for brachial neuritis?

Answer 40

Patients present acutely due to the pain

Question 41

In what position do patients with brachial neuritis tend to present?

Answer 41

Supporting arm in adducted, internally rotated position

Question 42

What is thoracic outlet syndrome?

Answer 42

Compression of the neurovascular structures at the level of the thoracic outlet

Question 43

What part of the brachial plexus does thoracic outlet syndrome affect?

Answer 43

The trunks of the brachial plexus Typically the inferior trunk but can be any and all of the trunks

Question 44

What borders the thoracic outlet?

Answer 44

The anterior scalene muscle, middle scalene muscle, clavicle and first rib

Question 45

What can cause thoracic outlet syndrome?

Answer 45

Trauma - whiplash Repetitive strain/sports injuries Underlying malignancy - lymphoma, lung cancer Malunion of a clavicular fracture Cervical rib Musculoskeletal abnormality Congenital fibrous tissue band

Question 46

What are the neurological features of thoracic outlet syndrome?

Answer 46

Wasting of intrinsic muscles of the hand Reduced grip strength Numbness of paraesthesia

Question 47

What are the vascular feature of thoracic outlet syndrome?

Answer 47

Subclavian artery compression leads to: Aching, painful claudication of the arm Pallor Extreme cold of the arm Ischaemia with ulceration and gangrene (in extreme cases) Subclavian vein compression leads to: Diffuse arm pain and swelling Venous distension Cyanosis

Question 48

Subclavian vein compression as a result of thoracic outlet syndrome leads to:

Answer 48

Diffuse arm pain and swelling Venous distension Cyanosis

Question 49

Subclavian artery compression as a result of thoracic outlet syndrome leads to:

Answer 49

Aching, painful claudication of the arm Pallor Extreme cold of the arm Ischaemia with ulceration and gangrene (in extreme cases)