8. NARAKAS CLASSIFICATION
GROUPS NERVE ROOT DYSFUNCTION PROGNOSIS
I C5 C6 (ERBs) SHOULDER
ABDUCTION AND
EXTERNAL
ROTATION
ELBOW FLEXION
AND FOREARM
SUPINATION
SPONTANEOUS
RECOVERY IN 90%
II C5 C6 C7 WITH ABSENCE OF
WRIST EXTENSION
(WAITERS TIP)
POOR
III C5—T1 FLIAL EXTREMITY
WITHOUT
HORNERS
POOR
IV C5—T1 WITH
PREGANGLIONIC
AVULSION
HORNERS WITH
PHRENIC NERVE
POOR
15. Upper plexus
• Physical Exam
• Most common obstetric brachial plexopathy
• Best prognosis
• Clinically, arm will be adducted, internally
rotated, at shoulder; pronated, extended at
elbow (“waiter’s tip”)
• C5 deficiency
– axillary nerve deficiency
– suprascapular nerve deficiency
– musculocutaneous nerve deficiency
• C6 deficiency
– radial nerve deficiency
Lower plexus
•Rare in obstetric
palsy
•Usually avulsion
injuries
•Frequently
associated with a
preganglion injury
and Horner's
Syndrome
•Poor prognosis
Deficit of all of the
small muscles of
the hand (ulnar and
median nerves)
•Clinically, presents
as “claw hand
16. 2)IMAGING
• Plain X ray of shoulder: clavicle and humerus #
and chest : Diaphragm palsy
• CT/MRI: Not indicated
20. TREATMENT PROTOCOL
CLINICALLY
ASSESS
Discuss with
parents and
reassurance
No mobilisation for 3
weeks
Gentle
manipulation Baseline EMG at
6 weeks and
Reasses at 6
weeks
3 Months Re
examine
EMG MUST
BICEPS FUCTION MUST
RETURN TO NORMAL
(If Not)
IF NOT OPERATE
21. WHY 3 MONTHS?
• Muscle Survives Denervation For 1.5 years
• Nerve Grows at 3cm/month
32. Post op Care
• Splinting for 4 weeks
• Passive ROM of Elbow 4 times a day with
supination and pronation
• Night times A Plastic Splint Maintaining
Forearm in Full Pronation and Elbow in 30 deg
Flexion
49. BURNER-STINGER SYNDROME
• Also known as "dead
arm syndrome" or
brachial plexopathy
– refers to transient
brachial plexus
neuropraxi
50. • Presentation
• Symptoms
– unilateral tingling in arm not typically isolated to a single
dermatome
– usually resolve quickly in 1-2 minutes
• Physical exam
– full cervical ROM
– no tenderness
– unilateral transient weakness in C5, C6 muscles (deltoid,
biceps)
• Investigations:
• Xray : C spine
• MRI: Only in Bilateral cases
• Treatment:
• Conservative
55. Indications for Surgical management
• Pre ganglionic Avulsion at 6 weeks
• Post Ganglionic after 3 months
56. AIMS OF SURGERY
• Shoulder Stability : Abduction and External
rotation
• Elbow Flexion
• Median Nerve Sensations
• Finger Flexion
57. • C5 6 7 –can repair
• C8 T1 – Inaccessible,close to Major vessels
very short and direct repair is difficult
58. Primary Nerve Reconstruction
• Neurolysis:Neuroma In Continuity
• Direct Nerve repair-Rarely Possible
• Nerve Grafting
• Nerve Transfer
• Functioning Free Muscle transfer (FFMT)
60. Nerve Grafting
• Indications : Post ganglionic rupture
• Prerequisites : Proximal nerve available
Muscle targets Not Distal
Graft Length (<10cm)
61.
62. Nerve Transfer
• Def: Transfer of normal fascicle or nerve
branch to a important motor/sensory that has
sustained irreparable damage
• Indications:
• Irreparable preganglionic
• Selected post ganglionic
• Reinnervation of FFMTs
63. Spinal Accessory to Suprascapular
• Indications:C5 6 7 and Complete plexus injury
<6-9 months
Post op care:
Shoulder immobilsation 3 weeks
EMG at 6 months
64.
65.
66. Ulnar to Musculocutaneous
• Indications:Elbow flexion with C5 6
Occassionally for C5-7 with
preserved ulnar/median nerve
Post op care:Immobilisation for 3 weeks
Reinnervation at 6 months
67.
68.
69. Intercostal Nerve Transfer to
Musculocutaneous
• Indications:C5-7
• 3-6 intercostal nerves
• Risk of pleural tear
70.
71. FFMT(Functioning Free Muscle
transfer)
• Definition:Microvascular transfer of muscle with
its nerve to restore function
• Prerequisites:
• First 3-6 months
• Restoration of Shoulder stability
• Antagonist muscle—Normal (eg;In elbow Triceps
should be Normal)
72. Selection of Donor Muscle
• Must have Vascular
Pedicle
• Sufficient Length
• Sufficient Excursion
• Adequate Force
• Expendable
• GRACILIS
• Latissimus Dorsi
• Rectus Femoris
75. Post op Protocol
• Elbow immobilised in 100 deg flexion and
neutral supination for 6 weeks
• After 6 weeks—Passive Mobilisation
• Extension avoided beyond 30 deg for 3
months
76. SAHA TRAPEZIUS TRANSFER
• Indications for trapezius transfer:
Failure of nerve repair
• Late brachial plexus injuries
• Trapezius full strength against resistance
• A normal glenohumeral joint and Passive abduction of at
least 80°
Contraindications for trapezius transfer:
Trapezius strength less than M4 on MRC scale
• Advanced degenerative arthritis of glenohumeral joint
• Old unreduced shoulder dislocation
79. SHOULDER ARTHRODESIS
Indications
• Neglected/Failed cases with Gleno-humeral
instability.
• Total/upper Plexus Palsy
• Good strength of Trapezius/Rhomboid
Complications
Post op Fracture of Humerus
Risk of Non-union
