brachial plexus palsies

Question 1

Plexus brachialis

Anatomy

Answer 1

Summary:

1. 5 Zones: spinal nerve roots, trunks, divisions, cords and terminal branches
2. C5-6 upper trunk, C7 middle trunk, C8-Th1, lower trunk
3. anterior division of upper and middle trunk - lateral chord
4. posterior division of all trunks - posterior chord
5. anterior division of the lower trunk - medial chord
6. lateral and medial chord - n. medianus
7. lateral chord terminates into the n. musculocutaneus
8. medial chord terminates into the n. ulnaris
9. posterior chord terminates into n. axillaris and the n. radialis
10. omohyoid muscle separates the posterior triangle into a superior, omotrapzial triangle and an inferior, omoclavicular triangle
11. upper and middle trunk and their divisions lies in the omotrapzial triangle
12. lower trunk lie in the omoclavicular triangle
13. upper, middle and lower trunk ramify into their respective divisions posterior to the clavicle
14. divisions form chords which lies around the a. axillaris with name based on the relationship to the a. axillaris

convergence of C5 and C6 called Erb’s point

Question 2

Clinical examination

Answer 2

after 3 weeks - complete Wallersche degeneration - no changing of the injury

after 6 Month - end of the golden period of the primary brachial plexus surgery (primary repair, grafting, nerve transfer) - at this point muscle or tendon transfers are the treatment options

Question 3

History of plexus brachialis injury

Answer 3

1. the energy and thus the severity of the injury
2. nature and radiation of pain
3. presence of reinnervation
4. patient’s social circumstances

motorcycle accidents are the most cause for brachial plexus injury in 82%, sport too, 50% football players - traction to the arm,

Question 4

Physical examination

Answer 4

4 questions:

1. what is the extend of the injury (partial or complete)
2. level of injury (proximal musculature preserved
3. what is the severity of the injury (avulsion or a rupture)
4. what are the time related changes (recovery)

C5 - supraspinatus, infraspinatus, deltoideus

C6 - biceps

C7 - triceps and the forearm extensors

C8 and T1 - flail hand - digital flexors and intrinsic function is absent

Question 5

Inspection

Answer 5

root avulsion:

C5,6, and maybe 7 - scapula winging and wasting trapezius

C8 and T1 - Horner syndrome

cervical scoliosis - ruptur of the posterior branches of the spinal nerves innervating the neck musculature

dry skin in an anaestetic area - suggest a post-ganglionic lesion, normal moisture pre-ganglionic lesion

Question 6

Palpation

Answer 6

important is the testing of dermatomes

C7 - middle finger

C6 - supplies the thumb

C5 - the lateral arm

C8 - the little finger

T1 - the medial forearm

testing the muscles:

avulsion or rupture? avulsion can only treated with nerve transfers, whereas ruptures can be treated with nerve repair with grafting

1. (C4) phrenic nerve - diaphragma
2. (C5) long throcic nerve - serratus anterior muscle (C5, C6, C7 and maybe C8) - scapula winging with margo inferior pulls backwards to the spine (trapezius winging - margo inferior moves laterally) - when both muscles are paralysed the inferior margo goes up
3. (C5) - dorsal scapular nerve innervates the rhomboid and the levator scapulae - both muscles moves the scapula medial to the spine (antagonist of the serratus anterior)

Question 7

BPI facts

Answer 7

• open, closed or caused by a gunshot
• 2 weeks are required for both antegrade and retrograde Wallerian degeneration
• another 2 weeks for sprouding of the proxima stump
• growth 1mm per day
• options for neural reconstruction include external and internal neurolysis, direct nerve repair, repair with cable grafts and neurotization

Question 8

anatomy and basis science

Answer 8

• differnce between preganlionic and postganglionic avulsions/ruptures - with preganglionic lesion the nerve keep alive because of the fact that the cell body is still alive
• roots are located in the posterior triangle of the neck between the anterior and the middle scalene, underneath the deep cervical fascia
• omohyoid subdivides the posterior cervical triangle into superior/occipital and inferior/subclavian triangles
• upper and middle trunk - superior/occipital
• lower trunk - inferior/subclavian
• most common are the roots C5-Th1 - about 71%
• upper trunk - C5-C6
• middle trunk - C7
• lower trunk - C8-Th1
• each trunk divides into anterior and posterior divisions
• coalesce into the posterior, medial and lateral cord
• cords branches into peripheral nerves
• injuries are classified based on the anatomic level
• roots and trunks are superior to the clavicle
• divisions are deep under the clavicle
• cords and branches are distal to the clavicle
• anatomy is very important to rule out the height of BPI lesion

Question 9

epidemiology

Answer 9

• incidence about 0,6 per 100.000 persons
• usually high energy traumata or penetrating injuries (stap wound or gun shots)
• men women = 9:1
• age about 30
• most common cause are traffic accidents - mototrcycle, all-terrain vehicle or snowmobile, penetrating trauma or sudden impact of the shoulder girdle
• pull to the upper extremity - upper BPI
• sudden hyperabduction - lower BPI

Question 10

pathophysiology of nerve injury and nerve repair

Answer 10

seddon classification

• conduction block - neuroproxia
• lesion in continuity - axonotmesis
• complete division - neurotmesis

sunderland classification

• expanded for axonotmesis - which part is transected
• sunderland’s classification directly correlates with the histologic findings
• injured nerve undergo morphological changes decribed by August Waller - called Wallerian degeneration of the nerve
• begins 24 to 48h after the injury - distinctive loss of fascicular elements are lossed with a microscope
• process (degradation of axoplasm and axolemma) is fascilitated by a calcium influx accompanied by proteases at the time of the injury
• Myelin is phagocytosed
• Schwann cell’s de-differentiate into Büngner’s bands that align along the basal lamina
• bands span the gap between the injured nerve ends to help organize the reperative response and outgrowth of the healthy end
• this response is further mediated by a host of inflammatory cytokines which recruit macrophages to the site of the injury
• common neutrophic factors include nerve growth factor (neurotropin 3-5, epidermal growth factors, insulin-like growth factors I and II, glial-derived neurotropic factor and brain-derived neurotropic factors) - advancement of the growing cone
• neurotropism describes the ability of the regenrating growth cone to preferentially select its correct destination (motor Schwann cell tubes for motor fascicles and sensory tubes for sensory fascicles)

Question 11

evaluation

Answer 11

• more than one associated injury
• initial evaluation of the plexus begins normally at the trauma day with triage and effective management of the severly injured patient
• mostly head injuries, shoulder girdle fracture dislocations and chest wall trauma occur most frequently
• cervical spine injuries and/or spinal cord injury also should be noted (preganglionic injury)
• vascular injury in about 20% of cases
• normally the plexus treatment is done subacutely when the injury zone has declared itself
• common injury patterns: C5-C8 (pan plexus), C5-C6 upper plexus and C5-C7 upper plexus (isolated lower plexus injuries are seldom)
• pan plexus about 40% of BPIs with combination of preganglionic and postganglionic trauma
• high likelihood of a graftable spinal nerve (usually C5) in pan plexus injury is important - because of limited intraplexal and extraplexal nerve transfers
• informations from clinical history, physical examination, electrodiagnostic studies and advanced imaging must answer the following questions

1. which elements are injured and how does this effect the patiens function
2. is it a nerve root avulsion, rupture or both
3. what is the anticipated natural history of the neurologic deficits given from the time of the injury

Question 12

History

Answer 12

1970 - 1980 - Millesi - first grafts for birth and traumatic injuries of the Plexus brachialis

1980 - 1990 - more diagnostic and advanced surgical techniques

2005 - nerve transfer becomes more and more important

Question 13

Traction injury

Answer 13

caused by traction or stretch injury -

low energy cause traction and streching without avulsion or rupture - (Sunderland I) or lower degress of axonotmesis (Sunderland II) maybe ischemic injury

high-energy cause - ruptur of plexal elements (Sunderland V)

shoulder neck angle widening - mostly C5, C6 and mabe C7 are involved - have a good fixation to the bone - mostly disruption

scapulo-humeral angle is widening - mostly C8 and Th1 are involved - no good fixation to the bone - mostly avulsion injuries

most patient show a variable and mixed type of injury with avulsion and rupture or stretching

mostly accompanied injuries - the whole shoulder girdle - the chest wall - the lung - the spine - the head - 20% have vascular traum

Question 14

gunshot wounds

Answer 14

plexal elements usually in continuity but some elements are transected

low- and high-velocitiy damage - direct damage or by second condition (shockwave only with high-velocitiy)

good oberservation - often a spontaneous recovery - if not surgical repair is required

Question 15

laceration injury

Answer 15

sharp - with knifes or glasses

blunt - with fan, motor blade, chain saws or animal bites

immidiate surgical exploration - 30% required vascular surgery - maybe development associated hematoma, pseudoaneurysm fistula (as with gunshots or traction)

Question 16

common patterns of BPI

Question 17

preoperative evaluation

Answer 17

no further recovery - surgery should be achieved in the first 2-3 month -

preganglionic - no graft repair possible- often early surgery is necessary

each patient needs an individual approach - multidisciplinary clinic

History:

understand the mechanism of the injury - more severe trauma have a less potential of spontaneous recovery - severe pain in an anesthetic extremity could be a root avulsion

Question 18

Physical examination

Answer 18

special documentation sheets

serial examinations over the first month may help to determine the presence or absence of ongoing nerve degeneration or prognosis for recovery

injury of rhomboid and serratus anterior indicates a proximal preganglionic nerve root avulsion

Horner Syndrome indicates a lower preganglionic low plexus injury (T1 sympathetic ganlion is closed to the T1 root)

absence of tinel sign suggests a preganglionic root avulsion

later on muscular artrophy of the paraspinal muscles indicates a preganglionic root avulsion with shifting the head to the contralateral side

postganglionic: precence of tenderness supra- and infraclaviculary region - absence of sweating and minimal preservation of movement - advancing Tinel sign is suggestive of a recovering lesion

Question 19

Imaging Evaluation

Answer 19

normal x-rays for treatment of trauma patients - elevated diaphragma indicates a preganglionic nerve root avulsion of C3-5 - fractures of the transversal process of the spine - especially with good fixation with the nerve root (C5-C6) - rib fractures are important for later nerve transfer (10% of nerves are damaged with fractures)

later on - Myelography and CT-Myelography - in the modern times also the MRI for a lot of centres

classification of Nagano and collegues

N, normal

Al, slightly abnormal root sleeve shadow

A2, obliteration of the tip of the root sleeve with shadow of root or rootlets showing

A3, obliteration of the tip of the root sleeve with no root and rootlets shadow visible

D, defect instead of root sleeve shadow

M, traumatic meningocele

Myelography is normally performed after 3-4 weeks - blood clot wil be dissolve and the pseudomenigocele to form and visualize

MRI can see more peripheral findings

maybe a angiography and CT angiography is performed to achieve the blood supply especially for free functional muscle transfer (FFMT)

pulmonary function test

special case of diaphragma involvement and the possibility to harvest intercostal nerves - normally a good patient tolarates the four or five intercostal nerve transfers even if concomitant phrenic nerve dysfunction becomes present

electrodiagnostic evaluation

can diagnose, localize and characterize the nerve lesion and gives evidence of potential recovery

baseline 3-4 weeks after trauma to allow the complete wallarian degeneration

should include EMG and nerve conduction studies (NCS)

EMG

fibrillation at rest and absence (complete injury)

fibrillation reduced (partial injury)

nascent motor unit potentials (low in amplitude, polyphasic in configuration and of variable duration) signs of reinnervation

e.g. rhomboids, seraratus anterior and cervical spine muscle with an abnormal EMG may suggest a high proximal preganglionic injury

trapezius should be evluated for potential nerve transfer of the spinal accessory nerve

NCS are helpful for differentation of injury level

SNAP - sensory nerve action potentials - preganglionic SNAP are preserved because of the viable cell body - if postganglionic injury the SNAP will be lost. - MNAP (motor nerve action potenials) will be lost with both kinds of injury

the electrodiagnosis is repeated 2 month after the first baseline to determine changes of recovery - although there is a recovery (advancin tinel sign, presence of nascent units and the improvement of function) all findings can not necessarily eliminate the need for surgery

Question 20

Indications for surgery

Answer 20

no hope of spontaneous recovery or for further recovery

patients with any traumatic mechanism

laceration immidiate

gunshots delayed

traction injuries normally delayed with a observation of about 2-3 month

if a patient could clearify identified with a preganglionic nerve root avulsion surgery can done earlier because there is no possibility for spontaneous recovery

every operation should be indicated by the individual situation of the patient the examinations in the context of time

Question 21

contraindications for surgery

Answer 21

absolute contraindications are rare

stiffness, contracture, medical comorbidity, associated traumatic brain injury or spinal cord injury should be considered

no surgery to patients with a good recovery - outcomes in literature are seen to be better without surgery

C8-Th1 is a relative contraindication for surgery because the nerve cannot reach the hand - forearm nerve transfers or secondary reconstruction (tendon transfers) should be achieved

if more than one year has passed primary plexus surgery is contraindicates, maybe in special cases distal nerve transfers can be considered up to 18 month after trauma

Question 22

Timing of surgery

Answer 22

based on three principles:

1. better functional outcome in patients with spontaneous recovery
2. surgical intervention for patients with no hope for spontaneous recovery
3. surgical outcome is better with early performance

Immediate surgery

sharp open injury - immediate injury

blount laceration - maybe delayed within 3-4 weeks - better definition of the injury zone

occassionally the nerve surgeon could join the operation when the vascular surgeon reconstructed the vessels - than the nerve surgeon could explore the plexus in the same time for later surgery planning - sharp devisions can repair immediately, blunt devision are coapted loosely and marked with radiopaque vascular clips - than exploration 3-4 weeks later with a good surgery plan

avulsed roots can be perform immediately or at a second setting depending on the patiens condition

nerve are stretched but in continuity - this should be observed

delayed surgery

gunshot wounds and traction injury is usually observed if there is any sign of spontaneous recovery

the surgeon have to determine the probability of spontaneous recovery

root avulsions should be explored earlier

pan plexus - after 2-3 month

no suspicion of root avulsion could wait 3 to 6 month

is there a high rate of spontaneous recovery you can wait 5-6 month

no surgery after 6 month - bad outcome

intraoperative monitoring for NAPs will help to determine the grade of sponataneous recovery for intraoperative decisions

secondary reconstruction

FFMT, tendon transfers, bony or soft tissue procedures should be used for patients seen after 12 month

algorith in surgery treatment of adult BPI by Millesi

tinel consistently negative, no MUAP - supect preganglionic 5-level injury - do surgery

tinel positive but stationary, no MUAP - suspect postganglionic injury leve IV/V - do surgery

tinel positve and advancing MUAP present - suspect postganglionic injury leve II/III - continue oberservation for 4-6 weeks with reassessment

is there ongoing clincal recovery

yes - level II injury - no surgery

yes - level III - but plateaued - do surgery when recovery do not progress

no - level III injury with external or internal compression - do surgery

Question 23

approach

Answer 23

different types - maybe 2 incisions to prevent scar forming - want to see the whole than zigzag incision from the proximal lateral border of the SCM to clavicle ongoing to the coracoid process and than through the deltapectoral groove to the medial arm

divide the m. omohyodius in the lateral neck triangle - the underlaying fat patty has to be mobilized - now the subclavian artery and vene can be seen medially -

plexus lays between the anterior and medial scalene muscle - the anterior scalene can be resected for better overview of the plexus - identify the n. phrenicus and carefully hold is medially - now the upper plexus can be seen -

superficial cervical artery over the upper trunk

transverse cervical artery over the middle trunk

the pectoralis major is mobilized medially, the pectoralis minor is divided hold proximal and distal - now the infraclavican plexus can be carefully preparated

Question 24

intraoperative assessment

Answer 24

inspection and palpation is not as reliable as in other surgeries, intraoperative assessment is very important

using of electrodiagnosis with:

SSEP (somatosensory evoked potentials), MEP (motor evoked potentials) from the contralateral skulp to proofe nerve roots in continuitiy and NAP (nerve action potentials)

Choline acetyltransferase activity - more in motor than in sensory nerves - CAT has a good qualitiy with higher than 2000 cpm

Question 25

intraoperative decisions and priorities in repair

Answer 25

decisions intraoperative depends on:

• functional significance
• likelihood of regaining function after nerve reconstruction
• degree of difficulty in restoriing the function by secondary reconstructive surgery

Question 26

C5-6 injury

Answer 26

goal:

shoulder stability with abduction and (internal) and external rotation

reinnervation of the deltoid (via the posterior division of the upper trunk, the axillary proper nerve or the anterior division of the axillary nerve) and suprascapular nerve for the supraspinatus and infraspinatus

elbow flexion

anterior division of the upper trunk, musculocutaneus nerve in proper or the motor branches of the brachialis and biceps

C5 root is intact:

grafting between the C5 and the suprascapular nerve and posterior devision of the upper trunk

grafing between the C5 and the posterior division of the upper trunk and the spinal accessory nerve to the suprascapular nerve

C5 root is not intact:

spinal accessory nerve to the suprascapular nerve and the triceps motor branch to the anterior part of the axillary nerve

elbow flexion

double oberlin procedure with a branch of the median to the brachialis muscle and the ulnar nerve to the biceps motor branch (grafting with intact C6 root to the anterior division of the upper trunk is possible)

Question 27

C5-7 injuries

Answer 27

same problems similar to the C5-6 injury with problems in elbow extension and wrist and finger extension in variable clinic findings

additional:

elbow extension and wrist extension should be adressed

combination of grafting (if roots intact) and nerve transfer could be achieved (spinal acessory, intercostals, ulnar and median nerve fascicles)

Question 28

C8-Th1 injury

Answer 28

extrinsic and intrinsic muscles of the hand are weak, and variable wrist weakness

long distance of reinnervation - so nerve transfers are not favorable

individualized approach is required

• reconstruction of thumb flexion
• finger flexion
• opposition
• intrinsic-minus claw deformity
• finger and thumb extension

if C7 is affected too - tendon transfers are limited than FFMT are used

Question 29

Pan plexus injury

Answer 29

priorities of repair in order of importance

1. elbow flexion by reinnervation of the biceps/brachialis muscle
2. shoulder stabilization, abduction and external rotation by reinnervation of the suprascapular and axillary nerves
3. hand sensation by innervation of the lateral cord
4. wrist and finger flexion: when performed reinnervation of the triceps muscle because it is a antagonist of the elbow flexion and maybe potentiates the strength of an FFMT
5. wrist and finger extension
6. intrinsic hand muscle function

complete root avulsions there is no proximal intact nerve root - in this case only spinal acessory, intercostal and C3 and C4 roots can be used

mostly only one intact root is find intraoperatively - than target for axillary and suprascapular nerve.

flexion of the elbow should be restored with a neurotization from intercostal nerves to the biceps and FFMT neurotized from the intercostal nerve

maybe let the spinal accessory nerve intact to perform a delayed lower trapezius transfer for external rotation

if more than one root is viable than also serratus anterior or pectoralis major could be achieved

hand reinnervation - single stage gracilis FFMT is used for both elbow and finger flexion

maybe spinal accessory nerve to the triceps for elbow extension

sensation for the hand (median nerve) - intercostal nerves to the lateral cord

secondary surgeries with wrist fusion, thumb CMC, MCP and IP fusion in palmar abduction and pronation, soft tissue balancing with flexor superficial lasso procedures

others are two-staged FFMT and contralateral C7 transfer to the median nerve

Question 30

primary nerve reconstruction

Answer 30

neurolysis

neuroma with positive NAP

direct nerve repair

only with small gaps - some surgeons prefer nerve transfer before grafting - it can be used with postganlionic ruptures or after neuroma with different targets

often:

C5 to suprascapular nerve and posterior devision of upper trunk

C6 to anterior division of the upper trunk

C7 to posterior division of the middle trunk or radial nerve

nonvascularized for gaps with 10cm and vascularized grafts for longer gaps such as 15-20cm

normally the sural nerve is harvest of both sides

other nerves:

• superficial nerve of the radial nerve
• medial brachial and antebrachial nerve
• lateral antebrachial cutaneous nerve
• dorsal ulnar nerve

nerve conduits are more used for peripheral nerve repair or for grouping grafts in the plexus surgery

Question 31

nerve transfer

Answer 31

nerve transfer, neurotization, nerve crossing

indications:

irreparable preganglionic injury

selected postganglionic injury

reinnervation of FFMTs

important attributes

• closer to the end-organ
• delivery of a large number of “pure axons”
• repair outside the injured and scarred zone
• avoidance of nerve graft and their two repair sites
• ease of relearning, especially with synergistic transfers

Question 32

spinal accessory nerve to suprascapular nerve

Answer 32

spinal accessory nerve

lateral portion of a supraclavicular incision on the anterior surface of the trapezius muscle

targets:

• suprascapular nerve (with an anterior or posterior approach) -
• can be use for all injuries, sparing of the most proximal branches of the spinal accessory nerve is important, good for injuries less than 6-9 month old
• outcome is less favorable in C5-7 and pan plexus injury
• shoulder immobilization for about 3 weeks
• EMG documented reinnervation begins 6 months postop.

Question 33

spinal accessory nerve to the motor branch of the musculocutaneus nerve

Answer 33

• used from some groups
• mostly preferred is intercostal nerve or double oberlin procedure to musculocutaneous
• interpose a graft between the spinal accessory nerve and the musculocutaneus after the branch for of the coracobrachialis
• M3 force patients similar to intercostal nerve transfer, M4 force patients are seen more in incostal nerve transfer (no use of graft and only 1 coaptation)

Question 34

triceps motor branch to the axillary nerve

Answer 34

usually with C5-C6 patients with a strong triceps function

triceps long head motor branch to the anterior division ot the axillary nerve (Leechanvengvongs procedure)

contraindication

triceps - with muscle strength grade less M4

all three heads of the triceps should be studied especially with C7-injury

results

6 month after surgery a arc of 124° degree could achieved with patiens with cocomitant transfer of the spinal accessory nerve to the suprascapular nerve

results are better with less injury C5-C6

postop.

shoulder immobilization for 3 weeks

reinnervation needs 6 month postop.

Question 35

Ulnar nerve fascicular transfer to the biceps motor branch

Answer 35

ulnar nerve at the brachium in special topography

posteromedial fascicles for the forearm muscles

anterolateral fascicles for the intrinsic muscles

intraoperative testing for the fascicles for the flexor carpi ulnaris

this fascicles are harvested and coaptated to the motor branch of the biceps brachii

contraindication:

weakness of the ulnar nerve

complications:

sensory changes will improve over a period of time

outcome

90% of patients achieve M3 muscle strength - better with C5-C6 injury than in C5-C7 injuries

double oberlin procedure

can be combinated with the transfer of a fascicle of the median nerve to achieve more strength for elbow flexion - same approach and coaptation of the motor branch of the brachialis muscle to a portion of the median nerve (usually innervating the superficial flexor or the flexor carpi radialis)

postop management

shoulder immobilization for 3 weeks

reinnervation about 3-6 month after surgery

Question 36

intercostal nerve transfer

Answer 36

used for reinnervation of the musculocutaneous nerve

than reinnervation to the triceps, deltoid, serratus anterior muscles, FFMT and hand sensation

3. to 6. intercostal nerve have the great length for the musculocutaneus nerve
4. intercostal nerve for long thoracic nerve transfer
5. intercostal nerve for suprascapular nerve (seldom - no study just case reports)

musculocutaneus

3 or 4 intercostal nerves are used or coaptation directly to the biceps motor branch

no graft should be used because of worse outcome

coaptation is done with the arm in abduction to perform a tension free coaptation and for see if movement is possible

dissection of the nerve at the costochondral junction

postop.

shoulder immobiliziation for 3 weeks

reinnervation started 6 to 9 month postop. (positive squeeze test - chest pain when the biceps is pinched - about 4-5 month after procedure) - long period - elbow flexion against gravidity needs about 12 to 18 month - biceps movement with breathing rhythm - this resolves after 32 month

Question 37

contralateral C7 nerve transfer

Answer 37

controversial method over years

3 potentiala issues:

whether it can be done safely

whether it works well enough to justify the risk

whether indepent function can be learned in adults

based on a period of time in studies in asia over several decades it become accepted more and more

target for shoulder, elbow, hand and FFMT

C7 innervated muscles are innervated from all roots over the plexus

intraop stimulation of the C7 contralateral

nerve is transected at the level of the middle trunk or at the anterior or posterior divisions - mostly the fibers which innervates the pectoralis major

than a tunnel is prepared anterior chest, supraspinal or intraspinal

is used to neurotize the median nerve in a pan-plexus injury - the ipsilateral ulnar nerve can be used as pedicled graft for grafting (superior ulnar collateral arteria from the brachial artery is the pedicle)

harvest the ulnar nerve most distal and proximal of the superior ulnar collateral arteria

can be used as a pedicled graft without anastomosis - than distal end goes to contralateral pedicle and proximal and to median nerve

if used as a free pedicled graft it has to anastomosis with local vessels on the contralateral side - than goes through the tunnel to coaptated with the suprascapular nerve or the posterior cord

outcome

despite many authors it is disappointing - can be used in children for pan-plexus birth injuries

Question 38

other nerve transfers

Answer 38

intraplexal:

ipsilateral C7

parts or the whole C7 is used for patiens with C5-6 injuries

medial pectoral nerve

for musculocutaneous, axillary and long thoracic nerve, controversial discussions - leaving the pectoral major for shoulder adduction

thoracodorsal nerve

some donors for transfer - C6-C8 as well as the musculocutaneous and the axillary nerve, good length about 8 - 19cm

extraplexal

phrenic nerve

has been used for the musculocutaneus, suprascapular and axillary nerve

techniques included:

• supraclavicular harvesting for direct coaptation (suprascapular nerve)
• supraclavicular harvesting with grafting to the musculocutaneus or axillary nerve
• video assisted thoracic harvesting for more length direct coaptated to the musculocutaneous or with graft to the median nerve

hypoglossus nerve

normally used for fascialis neurotization - poor results

platysma motor branch

good for the future - less datas

cervical plexus nerves

Question 39

FFMT - Functioning Free Muscle Transfer

Answer 39

good for late cases or with 4 or more root avulsions

gracilis is optimal with his long muscle belly and a proximal neurovascular pedicle

nerve transfer to this point at the shoulder will restrore the muscle in 6 month

after 3-6 month for finger and thumb flexion or finger and wrist extension

shoulder innervation most important to achieve the right potential excursion of the FFMT

latissimus and gracilis can achieve good function for biceps also it is less in strength

good reinnervation from the spinal accessory nerve or the intercostal nerves

anastomsis is performed to the thoracoacromial artery and cephalic vene (origin of the muscle is a branch from the profunda femoris - muscle is dissected between the adductor magnus and the adductor longus - fixed to the acromion - skin paddle for oberservation of the flap - resting tension in 30° elbow flexion

postop.

6 weeks of immobilization - in 100° of elbow flexion neutral supination

double FFMT in pan-plexus injuries

1. exploration of the brachial plexus and repair of the ruptured motor nerves is possible
2. performance of the FFMT neurotized be the spinal accessory nerve for elbow flexion and finger and wrist extension
3. performance to the second FFMT with neurotization of the 5. and 6. intercostal nerve sutured to the FDP and the FPL (passed under the deep flexors and pronator teres as a pulley)
4. use of the 3. and 4. intercostal nerve for nerve transfer to the triceps muscle
5. coaptation of the intercostal sensory rami to the medial cord of the plexus to restore sensibility of the hand
6. maybe secondary reconstruction with arthrodesis of the glenohumeral joint, CMC joint of the thumb and the wrist joint to increase stability

1 und 2 is first setting, 3-5 is second setting, 6 is third setting

mostly for patient no older than 40 and less than 6 month after trauma

proximal joint stability is imperative for achieve useful recovery

postop:

shoulder is immobilized in 30° ab ABD and FLX, 60 of IRO and 100° of Elbow FLX, wrist in neutral fingers in forced EXT or FLX depending on reconstruction - cast for 4 weeks

reinnervation begins 3 to 8 month postop.

electrical stimulation is good for the donors

single-stage FFMT for prehesion (Greifen)

1. sural grafts from roots to suprascapularis and axillaris
2. intercostal 5 and 6 to biceps
3. T3 and T4 to FFMT - distal end of the tendon is sutured to the FDP and FPL (pulley is the lacertus fibrosus)
4. spinal accessory nerve to triceps with graft
5. secondary a wrist and CMC-joint D1 is performed when motor function returns - accompanied Zancolli lasso OP to prevent intrinsic-minus claw deformity

Question 40

second procedures

Answer 40

shoulder function:

glenohumeral arthrodesis

no stability in shoulder, normal function trapezius

tendontransfer for shoulder function

upper trapezius

latissimus dorsi

pectoral muscle

lower trapzius

elbow function

modified steindler

no reconstruction of the elbow flexion, when there is good strength of pronator-flexor muscles,

triceps-to-biceps transfer

medial head of triceps is transfered

FFMT - Latissimus dorsi transfer

pectoralis major transfer

wrist arthrodesis

Question 41

birth brachial plexus palsy

Answer 41

upper trunk “Erbs palsy) - most common

C5-C7 extended Erbs palsy - second most common

C5-Th1 - total brachial plexus palsy

often treated with nerve grafts to restore the plexus