Brachial plexus Injury and Surgery

Question 1

Axillary nerve reconstruction

Answer 1

Ant dectopectoral approach
Cephalica lateralt
Deltopect grove

Question 2

Somsak transfer

Answer 2

Radial to axillary nerve

Both post cord last branches
Anterior branch to medial triceps head usually used.
(The post branch gives
T minor branch and superior lateral cut nerv branch)

Question 3

Supraclavicular approach

Answer 3

2cm above clavicle
Platysma
Directly Supraclavicular nerves (retract with vessel loops)
Fat pad
External jugular vein (retract or divide with double ligatures)
Omohyoid divide
Identify phrenic nerve on anterior scalene with nerve stimulator, mark with pen (no vessel loops)
Identify long thoracic nerve (in or behind middle scalene)
Upper and middle trunks visualized

Question 4

Most common brachial plexus injury (category)

Answer 4

Supraclavicular injury 75%

50% of these are 5 level (C5-T1) injury

Question 5

3 types of 5 level Supraclavicular brachial plexus injury

Answer 5

60% upper trunk ruptur (C5-6/7) + lover trunk avulsion (C8-T1)
30% true 5 lvl avulsion
10% 6 lvl avulsion C4-T1

Question 6

Most common partial brachial plexus injury

Answer 6

Upper trunk rupture 35% of all Supraclavicular injuries

Question 7

How common is C6-C8 injury among Supraclavicular injuries? Sparing C5 and T1

Answer 7

8%

Question 8

How common is isolated C8-T1 Supraclavicular injuries?

Answer 8

3%

Question 9

Which peripheral nerves av particularly vulnerable to traction injury?

Answer 9

Musculocutaneous, axillary and suprascapular nerve

15% of all Supraclavicular injuries have concomitant segmental injuries at or below the clavicle.

Question 10

How common are Infraclavicular injuries?

Subtypes?

Answer 10

25% of all brachial plexus injuries

whole limb injury (45%)
single/combined cord injury (30%)
isolated periferal nerve injury (25%)

Question 11

Signs of root avulsion?

Pre or postganglionic

Answer 11

No Tinell´s sign

Elevated hemidiaphragm

Lost sensation above clavicle

Horner syndrome
Fracture to C7 transvere process or 1st rib (C8-T1 avulsion)

Paraspinal muscles (dorsal rami)
Rhomboid (Dorsal scap C5)
Scapular winging (Long thorasic nerve)

Pseudomeningocele

Question 12

TOS tests

Answer 12

Roos EAST - Elevated Arm Stress Test (3min pumpa hand 90/90 Adson - arm 45gr o titta mot den o dra bakåt puls? Costoclqvicular manouver - tryck Axel ner som ryggsäck o samtidigt dra arm bakåt puls? Allens test 90-90 o titta bort - puls?

Question 13

Predict prognosis and need of surgical intervention in pediatric brachial plexus injury?

Answer 13

God prognosis if biceps recovers fully (antigravity) by 4 months in:
- Narakas group I (Erbs) and
- II (Erbs + C7 wrist/digital extension - waiters tip)

Bad pronosis: Group III (flail limb, no horner) Group IV (Horner)

Question 14

Mallet score for global motor function

Opposed to MRC isolated muscle testing

Answer 14

Modification ads 6th category internal rotation

Question 15

Radiography in pediatric plexus

Answer 15

X-ray fractures?
MRI for preop planning

CT myelography but onlyintraforaminal assesment

Question 16

Role of EMG/NCV in pediatric plexus injury

nerve conduction velocity

Answer 16

Unreliable: Can underestimate injuries due to plasticity in infantile nervous system

Presence of normal sensory NCV but no motor nerve conduction is diagnostic for root abulsion

No reinnervation at 3m suggests uvlsion

Question 17

What type of delivery can give lover root avulsion

Answer 17

Breech delivery (säte)
Otherwise uncommon
Bad prognosis with hand involvment

Question 18

Timing of surgery in pediatric plexus injury

Answer 18

Narakas I and II: 5-6m if bad antigravity biceps recovery
Narakas III and IV: 2-3m
Surgery 3-9m at varius centers

Question 19

Nerve transfers in C5-7 pediatric plexus injury

Answer 19

1. Intercostals to biceps or Oberlin
2. Partial spinal sccessory to suprascapular nerve
3. Somsak Radial long head triceps motor brans to axillary

Question 20

Prognosis of most pediatric plexus injuries in general

Answer 20

Majority ar transient - up to 40% have permanent neurological deficit

If recover partial antigravit upper trunk muscle strenth in 2m - usually complete recovery 1-2y
But partial recovery 3-6m will have some permanent deficit

Question 21

Major clinical dilemma in pediatric plexus injuries

Answer 21

If infants without antigravity return C5-7 function 3-6m warrant surgical exploration and reconstruction.

No comparison is done between microsurgical + tendon transfer later vs tendon transfer only

Question 22

Pediatric C5 only viable root

Answer 22

Nervtransfer
Ass ->Suprascap
Intercost-> musculocut + median
C5->lower trunc

Question 23

2 paradoxal contractures in pediatric plxus injury

Answer 23

Elbow flexion contracture secondary to impaired flexors (contracture of brachialis)
Shoulder abduction contracture sec to impaired abductors

Question 24

Putti sign

Answer 24

Superior protrusion fo the superior-medial angle of the scapula

Secondary to shoulder abduction contracture

Becouse of abduction muscle atrophy with tightness of denervated muscle

Question 25

Shoulder internal rotation treatment

Answer 25

Fidn eraly by palpation + MRI when needed. 6-12m surgery or Botox. Subscapularis lengthening or slide, capsule release. Severe cases with luxation only rotation osteotomy. If no active external rotation: Muscle transfer LD, TMajor - rotator cuff.

Goal is to reach mouth/head, but still reach genitals/contrallat hand..

Question 26

Elbow problems

Answer 26

Weak flexor: nerve transfer, vascularied muscle, tendon transfer (PM, LD, triceps, Steindler)

Flexor-extensor cocontraction: Botox (relearn muscles)

Contracture: Physio in most cases (mild)
serial casting, surgical releas, ex-fix distraction, flexor ->ext transf, humeral osteotomy