Brachial plexus injuries by Dr. Rashi Goel PT

Rashi Goel
MPT Orthopedics in Hand Rehabilitation
Manipal University
Manipal, Karnataka
25/01/2014 1rashigoelphysio@gmail.com

STUDY OBJECTIVES
• Anatomy review
• Classification of nerve injury
• Formation of Brachial Plexus
• Causes
• Classification
• Clinical Features
• Special Features
• Pathomechanics
• Mechanism of different injuries

• Assessment
• Management
• OBPI
• PNI management

ANATOMY REVIEW
• A typical peripheral nerve consists of
-several axon bundles/fascicles

PATHOPHYSIOLOGY OF INJURY
• Nerve response to injury

Classification of nerve injuries
• Seddon- 1 to 3
• Sunderland- 1 to 5
• Mackinnon- 6th

Classification of
Peripheral Nerve injury
Seddon Process Sunderland
Neurapraxia Segmental demyelination First degree
Axonotmesis Axon severed but endoneurium intact
(optimal circumstances for regeneration)
Second degree
Axonotmesis Axon discontinuity, endoneurial tube
discontinuity, perineurium and fascicular
arrangement preserved
Third degree
Axonotmesis Loss of continuity of axons, endoneurial
tubes, perineurium and fasciculi;
epineurium intact (neuroma in continuity)
Fourth degree
Neurotmesis Loss of continuity of entire nerve trunk Fifth degree

Neuropraxia
• conduction block at the site of injury
• no macroscopic injury to the nerve
• Physical examination will not show a Tinel’s sign
• Electrodiagnostic studies will show no
conduction across the area of injury but normal
conduction distal to the area of injury

Second-degree injury
• involves a rupture of the axon
• endoneurium remains intact
• possibility of recovery following Wallerian
degeneration
• A Tinel’s sign will be noted on examination

Third-degree lesions
• injury to the endoneurium
• preservation of the perineurium
• scarring will occur
• Full recovery is unlikely

Fourth-degree injury
• Rupture of the fasciculi
• Disruption of the perineurium
• The nerve is in continuity
• scarring will likely prevent regeneration
• A Tinel’s sign will be present at the site of
injury but will not advance

Neurotmesis
• Entire nerve trunk is ruptured
• Axonal continuity cannot be re-stored

Pathology Motor Sensory Treatment Recovery
Neuropraxia
First degree
Anatomic & axonal
continuity
Complete
paralysis
Minimal
loss
Observation Complete
Second degree Transection axon
but endoneurium
intact
Complete
paralysis
Complete
loss
Observation Complete
Axonotmesis
Third degree
Perineurium intact Complete
paralysis
Complete
loss
Surgical
intervention
Complete
Fourth degree Epineurium intact Complete
paralysis
Complete
loss
Surgical
intervention
Complete
Neurotmesis
Fifth degree
Loss of nerve trunk
continuity,
complete
disorganization
Complete
paralysis
Complete
loss
Surgical
intervention
Complete

Mackinnon
• 6th degree injury
• Mixed pattern

1. Nerve trunks cross the flexor aspect of joints
• Extension ROM < flexion so less tension during
limb movements
• Exceptions- ulnar n. at elbow & sciatic n. at hip
2. Nerve Trunk runs an undulating course in its
bed, fasciculi in epineurium & nerve fibers
inside fasciculi
So length between any two fixed points >
distance between these two points

3. During tension, perineurium because of
elastic fibres imparts greater elasticity tan
endoneurium & epineurium
4. Epineurial connective tissue cushions te
nerve fibres against deforming forces

Nerve roots
Over stretching of nerve roots by transmitted
forces during repetitive stress and traction
injury is prevented by:
1. Dura mater is adherant to intervertebral
foramen so resists displacement of the nerve
when traction pulls the entire system outward

2. 4th
, 5th
, 6th
, & 7th
nerve roots securely
attached to vertebral column
so more prone for traction injuries
Rest- more prone for avulsion

BRACHIAL PLEXUS INJURY

Incidence
• 15- 25 years
• 70%- secondary to motor vehicle accidents

Anatomy of the Brachial Plexus
• Ventral rami of spinal nerve roots C5 to T1
Pre fixed- Post fixed-
C4 large C4 small/absent
C5 reduced
T1 reduced T1 larger
T2 absent T2 present
more vertical arrangement more horizontal

Formation
Typical arrangement
• Ant rami of C5 + C6 = SPT (unite near lateral
border of middle scalene)
• C7 = MPT
• C8 + T1 unite behind scalene anterior = IPT

• At the lateral border of the ﬁrst rib
• just above or behind the middle third of the
clavicle
• trunks undergo
anterior division
posterior divisions

1. Undivided anterior primary rami
2. Trunks—upper, middle, lower
3. Divisions of the trunks—anterior & posterior
4. Cords—lateral, posterior, and medial
5. Branches—peripheral nerves derived from
the cords

A. Branches of Roots
• 1. N. to serratus anterior- long thoracic n./
Nerve of Bell- C5,6,7
• 2. N. to rhomboideus- dorsal scapular n.- C5
– Also supplies levator scapulae
– Rhomboideus major
– Rhomboideus minor

B. Branches of trunks
• Upper trunk-
1.suprascapular n.-
– Supraspinatus
– Infraspinatus
2. Nerve to subclavius

C. Braches of cords
• A. Lateral Cord: C5,6,7
1. Lateral pectoral
2.Musculocutaneous
3.Lateral root of median

• B. Medial Cord: C8,T1
1. Medial Pectoral
2. Medial cut. N. of arm
3. Medial cut. N. of forearm
4. Ulnar n. – C7 from communicating branch
from lat root of median n.
5. Medial root of median

• Posterior cord:
1. Upper & lower Subscapular- subscapularis
& teres major- C5,6
2. Thoracodorsal N.- lattisimus dorsi- C6,7,8
3. Axillary/ Circumflex n.- deltoid & teres
minor- C5,6
4. Radial n.- C5 to T1

Horner’s syndrome
Avulsion of T1 root
Interruption of T1 Sympathetic ganglion
• miosis (small pupil)
• enophthalmos (sinking of the orbit)
• ptosis (lid droop)
• anhydrosis (dry eyes)

Horner’s syndrome

Two anatomical triangles
1. The interscalene triangle
contains the roots of the plexus
between
• anterior and middle scalene muscles
superiorly
• ﬁrst rib inferiorly

2. The posterior triangle of the neck
contains the trunks of the plexus
formed by
• sternocleidomastoid muscle anteriorly
• trapezius laterally
• clavicle inferiorly

• Roots and trunks- supraclavicular plexus.
• Cords and branches- Infraclavicular plexus
subjected to individual variations

Rotator cuffs
• Supraspinatus-
• Infraspinatus-
• Teres minor-
• Subscapularis-

Causes
• Traumatic traction/ crush lesions
• TOS
• Obstetrical lesions
• Lesions due to irradiation-post anaesthetic
palsy, needle puncture & after tumor excision
around neck or shoulder
• Iatrogenic lesions
• Tumors
• Gunshots wounds25/01/2014 45rashigoelphysio@gmail.com

• 20
compression after trauma as clavicular
malunion
• Personage turner syndrome or brachial
neuritis
• Vascular lesions- aneurysm of subclavian
artery or vein

Five possible levels where nerve
can get injured
1. Root
2. Trunks
3. Divisions
4. Cords
5. Branches / Peripheral nerve
4725/01/2014 rashigoelphysio@gmail.com

Classification

Preganglionic and Postganglionic
nerve lesions

Postganglionic Preganglionic
Location Distal to DRG Proximal to DRG
Preservation SNAPs
Abnormalities SNAPs & MAPs MAPs
Repair Surgical repair/
Grafting
Neurotization

• Traumatic injuries-
• Brachial plexus stretched b/w 2 points of
attachment
1.Transverse processes proximally
2.Clavipectoral fascia junction distally
51
Pathomechanics

Traction apparatus with neutral axis at the C7
vertebra when arm is horizontal
BP = Single cord with 5 separate points of
attachment

• When traction force falls through C7, traction
is equally borne by all parts C5 - T1
• Deviation from neutral axis creates an unequal
pull to one side or the other5325/01/2014 rashigoelphysio@gmail.com

• Traction imparted to arm elevated above
horizontal- stress increased to lower roots of BP
• Traction imparted to arm depressed below the
horizontal- stress increased to upper roots of BP

Mechanism
• Closed trauma
• Traction or compression
• Traction- 95% of the injuries

Root avulsions

Root avulsions
• 75% of supraclavicular lesions
• Common at C7- T1 nerve roots
• 2 Mechanisms-
• 1.Peripheral - common
• 2.Central - rare

Peripheral Central
when there is a traction
force to the arm and the
ﬁbrous supports around
the rootlets are avulsed
occur from direct cervical
trauma
The epidural sleeve may be
pulled out of the spinal
canal, creating a
pseudomeningocele
The spinal cord is moved
transversely or
longitudinally, causing a
sheering and spinal
bending that results in an
avulsion of nerve rootlets

Mechanism of avulsion

Injury patterns
• Supraclavicular more involved- 75%
• Double level injuries

Mechanism

Traction and abduction- C8,T1

Physical Examination
(1) Posture
(2) ROM of the cervical spine, shoulder, and upper
extremity
(3) motor strength
(4) sensation
(5) palpation
(6) special tests
(7) activities of daily living
(8) vocational and avocational pursuits

ROM
• Active & Passive
• Reflexes
• Rule out Spinal Cord Injury-
1. Lower limb strength
2. Sensory
3. increased reflexes
4. pathological reflexes

Motor testing
• Spinal accessory- check trapezius
• To be used for nerve transfer

Motor strength
• Posterior cord-
Wrist extension
Elbow extension
Shoulder abduction

• Lattisimus dorsi- palpate in post axillary fold
and ask to cough
• Pectoralis major- palpate as patient adducts
his arm against resistance
• Suprascapular nerve- shoulder ER and
elevation- atrophy of infraspinatus
• shoulder ﬂexion, rotation, and abduction-
rotator cuff or deltoid injury

• preganglionic injury
• long thoracic nerve C5-C7= scapular winging
as the patient at-tempts to forward elevate
the arm
• dorsal scapular nerve C4-C5= atrophy of
rhomboids and parascapular muscles

Sensory Examination
• Autonomous Zones
• Deep pressure
• light touch
• Temperature
• stereognosis
• two-point discrimination

Vascular Examination
• Distal pulses
• Thrills
• Bruits
• Rupture of axillary artery

Special tests
• Tinel’s sign

Radiographic Evaluation
• Cervical spine and shoulder
• Chest X- Ray
• Transverse process # of cervical vertebrae-
root avulsion
• Clavicle #, ribs #
• Old rib #- intercostal nerves- for nerve
transfer
• Phrenic nerve- paralysis of diaphragm

CT
• Level of nerve root injury
• 3 to 4 weeks after injury- pseudomeningocele
for root avulsion
• In acute trauma, CT/myelography remains
the gold standard

MRI
• Adv. Over CT
 Non invasive
 non traumatic neuropathy-
 Tumours
 Radiation injury
 Idiopathic BP neuritis
 Vasculitic conditions
• Oedema on T2 scan- zone of injury

Histamine Test
To differentiate pre & post ganglionic injuries
Intact skin- triple response
Preganglionic- normal response in area of skin
that is anaesthetic
Postganglionic- vasodilation, wheal formation
but no flare response as this requires functioning
axon in continuation with its cell body

Management

Neurolysis
• Neurolysis is the surgical technique of freeing
intact nerves from scar tissue

Nerve Grafting
• To bridge ruptured nerves

Most frequently used donor nerve
• Sural nerve- yield up to 30 cm of nerve
• Antebrachial cutaneous
• Radial sensory
• Ulnar
• Ant. tibial
• Superficial peroneal
• Saphenous

1. Attachment of a donor nerve to the
ruptured distal stump, sacriﬁcing the original
function of the nerve for a more beneﬁcial
result in the upper limb
2. Restoration of motor or sensory function
can be accomplished by neurotization
Nerve transfer/ Neurotization

• used in pre-ganglionic
injuries
• reinnervation of a
denervated motor or
sensory end Organ

5 possibilities for neurotization
• Musculomuscular
• Cutaneocutaneous
• neurocutaneous
• Neuromuscular
• neuroneural
Traumatic BPI

1. Intercostal n.- combinations of musculocut.,
long thoracic, radial, or median n.
2. Spinal accessory n.- suprascapular/
musculocutaneous n.
3. Phrenic n.- for axillary n.
4. Plexo-plexal transfers
5. Motor branches of C3- C4 cervical plexus
6. Contralateral C7 transfers- for median n.
7. N. to long head of triceps- Ant. Br. Of axillary n.
8. Fascicles or branch from ulnar,median and
radial nerves25/01/2014 83rashigoelphysio@gmail.com

Muscle Transplantation
• Indications-
1.Failed neurolysis or nerve grafting
2.Chronic root avulsion for >1 year with no
neural regeneration
3.To enhance function in addition to nerve
reconstruction

• Muscles-
1.Lattisimus dorsi
2.Rectus femoris
3.Gracilis
4.Gastrocnemius

Double free muscle transfer
• To restore elbow and hand function
• Advantage of length of gracilis muscle and
proximal location of its neurovascular bundle to
gain early reinnervation of the transferred
muscle while allowing wrist and hand function

Pre- operative care
• Universal sling, envelope sling, or hemisling
patients who have an upper trunk or complete
• Prevent inferior glenohumeral subluxation,
which results from paralysis of deltoid,
supraspinatus, and infraspinatus muscles
• head of humerus be held in a normal or
slightly elevated position in the glenoid

Completed Universal Arm Splint

1. Light weight
2. Inexpensive
3. Maintain elbow in flexion
4. Allow for a variety of elbow flexion positions
5. Independent application
6. Client will be able to perform bilateral,
midline tasks
7. Adjustable by user
8. Easy to clean and maintain

• A long MCP extension splint for patient who
has weak wrist extension & trace ﬁnger
extension

• Paralysis of wrist extensors
• Passive flexed resting stance of the wrist
• Resting hand splint to prevent overstretching
of weak and finger extensor muscles in night
20°dorsiflexion

• Initial post injury period – PROM
• Digit mobility
• Self-ROM exercises

Electrical stimulation
• for denervated muscles
– direct current
– Inﬁnite duration (≥ 300 ms)

Motor response
• Rheobase
The smallest amplitude of current ﬂowing for
an inﬁnite duration that produces a minimal
but perceptible response.
• Chronaxie
The shortest stimulus time at twice the
rheobase that will produce a minimal
perceptible response.

• Denervated muscle
Chronaxie longer than 20 to 30 milliseconds,
most often closer to 100 milliseconds
• Normally innervated muscle
Less than 1 millisecond

Immediate postoperative care
• Shoulder girdle is immobilized 3-6 weeks
• Cast / Splint for distal nerves or tendon
corrections
• Hemi-sling continued till evidence of
-reinnervation of the supraspinatus muscle
-restoration of the integrity of GH joint
-can be discontinued thereafter

• PROM - 4 to 6 times a day , 10 to 20 reps
- within the ranges restricted by the surgeon
• Immediately if no functioning free muscle or
tendon transfers have been performed
• To minimize stiﬀness in these joints and to
promote neural mobility and gliding

Edema control
• Decongestive massage
• Compression sleeves / garments
• Elevation

Scar management
• Scar massage
• Elastomer pads
• Gel sheeting

Electrical stimulation
• 3 to 6 weeks after surgery
• Allow time for the nerve transfers to heal with
considerably less danger of rupture
• Direct-current (galvanic) stimulator
• Electrodes placed over the muscle directly
• Current longer than chronaxie

• As the muscle reinnervates, the chronaxie
slowly decreases
• The time at which muscle recovery begins is
thus detectable by changes in the stimulation
parameters When the chronaxie decreases to
20 milliseconds or shorter, voluntary
contractions of the muscle begin
• Stimulate for 30 to 60 moderately strong
contractions
• Visible contractions

108
Stimulation unit for home use

Re-education of muscle

Extraplexal Re-education
• Voluntary MUPs on EMG / Visible contraction
• Successful contractions produced by
replicating nerve function

Activation of muscles neurotized
• Intercostals / Phrenic nerve – can be activated
using breathing techniques

• Spinal accessory - Elevation of the scapula
• Contralateral C7 - mirroring motions

• For all recovering muscles
• Start with short sessions to avoid
hyperventilation and fatigue

Methods
1.Biofeedback using visual/ tactile clues
2.Gravity-eliminated exercises
3.Progressive strengthening techniques

Biofeedback
• Useful when active contractions appear
• Portable biofeedback for home use
• In later stages,
Visual & palpatory monitoring
Use of opposite hand or a mirror
• Neuromuscular reeducation

• Neuromuscular electrical stimulation
• For visualization
• Sensation of contraction
• Start with strong amplitude of evoked
contraction to give sense of the muscle
contracting and then decrease the strength of
stimulus

Gravity-eliminated exercise
• To attain maximum range possible in gravity
eliminated position
• Light weights can be used

Strengthening
• Against gravity
• Biofeedback- to monitor improvement in
muscle contraction
• Starting weights - 0.1 to 0.25 kg
• Use isometric, concentric, or eccentric
contractions
• Motivate & Encourage

Pain management
• Diﬃcult areas
• Nerve pain

Sensory re-education
• Surgical reconstruction of sensation using
1.Intercostal sensory
2.Contralateral C7
3.Cervical plexus branches

Patient education
• Pressure sores , Injury from sharp objects,
heat & cold
• Routine inspection of the skin
• Re-education has a role only once some
perception starts
• Semmes-Weinstein monoﬁlaments - 4.31

References
1. Brachial Plexus Injuries by Robert D. Leffert
2. Brachial Plexus Palsy by H. kawai & H.
Kawabata
3. Physical Therapy of shoulder by Robert
Donatelli
4. The HAND Fundamentals of therapy by
Morrin & Conolly
5. Various research articles

Brachial plexus injuries by Dr. Rashi Goel PT

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