Brachial Plexus Injury

Brachial plexus
injury
The principles and philosophy behind the early
treatment and management of Nerve graft, repairs and
Tendon transfers.
Tony Betts - Addenbooke's T&O conference 2013
Brachial plexus injury
Prevalence and epidemiology
• 70% Brachial Plexus injuries in Adults caused by Motor vehicle
injuries
• 70% Motorcycle Injuries
• Men and Boys between 15-25 years old
• In one study/ series, the rate of incidence to the local
population was 1.75/100000/year.
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Adult Brachial Plexus Injuries: Mechanism, Patterns of Injury and \physical Diagnosis: Morgan SL et al : Hand Clinic
21 (2005) 13-24 2005
• Flores LPr. [Epidemiological study of the traumatic brachial plexus injuries in adults]. Neuropsiquiat 2006
Mar;64(1):88-94. Epub 2006 Apr 5.
[Article in Portuguese]
Prevalence and epidemiology
• Most of the lesions were supraclavicular (62%).
• Twenty-one cases occurred due to traction (60%), 9 to gun shot wound
(25%), 3 to compression (8.5%) and two perforation/laceration (5.7%).
• Motorcycle accidents were the cause of trauma in 54% of patients.
• CT myelography demonstrated root avulsion in 16 cases (76%).
• Partial spontaneous neurological recovery was observed in 43% of the
patients.
• Neuropathic pain occurred in 25 (71%) cases, and the use of some oral
intake drugs (as amitriptyline or carbamazepine) controlled it in 64% of
times
• Flores LPr. [Epidemiological study of the traumatic brachial plexus injuries in adults]. Neuropsiquiat; 2006 Mar;64(1):8894. Epub 2006 Apr 5.
[Article in Portuguese)(PubMed-Google scholar Search)
Brachial plexus injury
• Immediately after a serious nerve injury it is essential to get a
quick diagnosis and protect the injured site to prevent further
damage and retraction of the nerve.
• Nerve injuries can be classified according to the Sunderland
classification of nerve pathology starting with a mild
neuropraxia and progressing to full severance of the affected
nerve.
Sunderland classification
Classification
• Grade 1: Neuropraxia
• Conduction disruption with intact axon and preserved supportive structures
• Prognosis: Normally full recovery in days to weeks without surgical intervention
• Grade 2: Axonotmesis
• Disrupted axon with intact endoneurium; Wallerian degeneration takes place after 1-2
weeks
• Prognosis: Variable recovery, worse prognosis for proximal injuries and injuries that
do not successfully re-implant in the muscle within 18 months
• Grade 3: Neurotmesis with preservation of perineurium
• Endoneurium is disrupted
• Prognosis: 60-80% recovery
• Grade 4: Neurotmesis with preservation of epineurium
• Prognosis: Nerve grafting is required
• Grade 5: Neurotmesis with complete transection of nerve trunk
• Prognosis: Bypass/jump grafting is required
• Explanation
Brachial plexus injury
Classification
• Tidy vs. untidy wounds
Classical neuropraxia.
least severe injury, is characterized by a conduction block (focal conduction block);
- conduction across the zone of nerve injury is inhibited, however, conduction within the nerve both
proximal and distal to the lesion remains intact;
- continuity of all structures is preserved;
- (no axonal loss) but there is focal demyelination;
- complete recovery is evident in 3 to 6 weeks;
- after a simple crush injury function may return within days;
- w/ neuropraxia there is immediate conduction block across the site of injury with normal
conduction distally;
Brachial plexus injury
Neurotmesis
Arises from severe nerve injury .
- characterized by axonal enlargement into an amorphorous mass,
breakdown of the axons, and schwann cell ingestion of fragmented
myelin to provide clean endoneural tubes for advancement of
regenerating axons;
- axonal sprouting begins within 96 hours;
distally the entire axonal material is phagocytosed from the site
of injury to the endplateswith severe trauma, there is focal demyelination w/o disruption of
axons, and slowing of the conduction velocity can be demonstrated
across the lesion;
- conduction block is restored once myelin regeneration is
restored (taking weeks to months);
Isolated Nerve injuries of BP
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Long thoracic Nerve of Bell
Spinal accessory nerve (Cranial nerve XI)
Dorsal scapular Nerve
Suprascapular Nerve Palsy
The Axillary Nerve
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Isolated peripheral Nerve Lesions of the Brachial Plexus affecting the Shoulder joint. Ernest J Genthochos : The
University of Pennsylvania Orthopaedic Journal 1999 :12 ;40-44
Injury and repair mechanism
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Injured nerve response to injury (<24 hours)
Macrophage recruitment; wallerian degeneration (one week)
Scwann cell alignment; axon regeneration (weeks to months)
Successful Target reinnervation (weeks to years)
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Wallerian degeneration: Gaining perspective on inflammatory events after peripheral nerve injury: AD Gaudet, P G
Popovich, and M S Ramer Journal of Neuroinflammation 2011 8:110
Nerve Injuries
Mechanism of Injury
Mechanism of Injury
Mechanism of Injury
Central mechanism of avulsion. Central avulsions occur from direst cervical trauma. The spinal cord
is moved transversely or longitudinally, causing a sheering and spinal bending that results in an
avulsion of nerve rootlets
Investigations
MyelographyandCTmyelographycanbeinstrumentalindeterminingthelevelofnerveinjury.Ifapseudomeningocele(*)ispresent,thereisagreaterlikelihoodofanerverootavulsion.(A)Multipleroot
avulsions(*)areclearlyseenbyCTmyelogram.(B).The
arrowsontheoppositesideoftheavulsion(*)showthenormaldorsalandventralrootletoutlineoftheuninjuredside.Noticehowtheseoutlinesaremissingontheinjuredside.(CourtesyoftheMayo
Foundation)
Rochester,MN;withpermission.)CT/
Brachial plexus injury
• A thorough neurological examination is required, followed by
a transfer to a specialist service for exploration and nerve
conduction test.
• Following a diagnosis of the nerve injury a treatment
approach can be instigated which includes nerve release,
grafting and or exploration.
Investigations:
Neurophysiology
• Grade A: NAP( nerve action potentials) normal or near normal. EMG
normal units, no spontaneous activity.
• Grade B favourable: NAP > 50% of normal. EMG mild Axon injury
with copious recruitment
• Grade B unfavourable: NAP absent or <50%. Limited EMG
recruitment, moderate axonal injury. Collateral reinnervation
present
• Grade C: NAP present in some cases but more often absent. EMG
poor recruitment, fibrillations, nascent units. Severe axonal injury
Prevalence and epidemiology
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• “During this exploration, recording of the spinal cord evoked potential (ESCP) or the
somatosensory evoked potential (SEP) is mandatory to determine the site of injury.
Nerve grafting is indicated for a rupture in the root demonstrating a positive ESCP or
SEP potential, in the trunk or in the cord. Exploration of the brachial plexus should be
extended distally as far as possible to achieve good results after nerve grafting; when
this was done more than M3 (MRC grading) power of the infraspinatus, deltoid, and
biceps was achieved in more than 70% of our 32, 30, 33 patients, respectively”
Nagano AJ: Treatment of brachial plexus injury. Orthop Sci. 1998;3(1):71-80
Brachial plexus injury
Nerve repair requires a period of immobilisation to protect
the repairing nerve.
• This is usually for 6 weeks. Following the period of
immobilisation, a gentle mobilisation phase is allowed.
• Clinical test include; muscle contraction test,
sensitisation test and the tinels sign.
• Care is taken to ensure no excessive loading force or
traction (stretch force) is allowed upon the nerve
Pre operative Assessment
Please assess:
Strength (Manual Muscle Test)
Sensation (ASIA Points)
Pain (VAS)
Oedema
Avoid:
Functional use
Full PROM
Adverse neural dynamics
Contraindications:
Unstable fractures (clavicle, humerus, scapula).
Cervical Spine Injures
• Haemotoma / vascular injury
• N.B. Please note if the patient is experiencing pain on movement at time of initial assessment (PROM or AROM)
aim to protect the arm in a sling. Advise no gleno-humeral joint ROM, but retain hand, wrist forearm rotation
PROM.
Assessment of the Motor system
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Observation of posture and Limb
Muscle atrophy
Skin changes
Palpation of the limb/skin
Manual muscle testing
Neural tension test-single nerve
Palpation of the nerve trunk
Peripheral Nerve injuries:
Assessment of the Motor system
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Mixed nerves-definite distribution, Parasthesia and hypoesthesia
Motor nerves pain is poorly localised
Weakness
Muscular atrophy prior to subjective perception of weakness
Local tenderness
Distribution of symptoms= spinal dermatome or peripheral nerve
path, or vascular projection of stress.
Therapist Guidelines for patients referred to the RNOHT for Brachial Plexus
Exploration +/- Repair.
Post Operative Treatment :Exploration,Decompression/Neurolysis ofBrachialPlexus.
Time post operation
0-6/52
For infraclavicular explorations PROM of hand,
wrist, forearm rotators, elbow and gleno-humeral joint
ER(N), Abduction 40 degrees (to protect pec. major
repair).
For Supraclavicular explorations PROM of hand,
wrist, forearm rotators, elbow, gleno-humeral joint
ER(N) Forward flexion to 90 degrees Abduction to 40
degrees.
Sling for comfort.
Avoid resistance and/ load upon operated limb.
Keep the limb supported while dressing.
Be mindful of scar healing for 4/52. Scar management
programme if needed.
2/52
Oedema management please monitor.
Wound check at Bolsover Street by SHO/ Register.
Re-enforcement of post operative precautions.
6/52
Start full PROM programme with Physiotherapist at
Bolsover Street PNI Clinic.
Nerve repair graft of Brachial Plexus
Post operative Treatment
Pleasenotecontradictionscouldbe:
Trauma
Reconstructivesurgery
VascularInjury
Time post operation
0-6/52
Arm is immobilised in the sling (ie Lancaster)
No gleno-humeral joint movement.
Maintain AROM/PROM of hand, wrist and forearm rotation. No elbow movement if infraclavicular repair.
Advise strip washing for the 6/52 period. Advise use of baby wipe for axilla hygiene.
Be mindful of scar healing for 4/52. Scar management programme if needed.
Oedema management please monitor
2/52
Wound check at Bolsover Street by SHO/ Register. Re-enforcement of post operative precautions.
6-12/52
Aim to have either:
In patient Rehabilitation at Stanmore
Initial physiotherapy assessment at Bolsover Street post PNI clinic review.
This plan is at the surgeon’s discretion.
Inpatient Rehabilitation: Please use BPL assessment form.
Strength (Manual Muscle Test)
Sensation (ASIA Points
Pain (VAS)
Oedema
Functional / ADL’s
Full PROM
Psychological / Emotional
Orthotic referral
Postural education
Balance/gait retraining.
Set patient Goals
12+/52
Begin resistive exercise if appropriate recovery of muscle (grade 3/5)
Continue progressive strengthing regimes, avoiding trick movements and substitute muscle patterning.
Discharge when optimised muscle strength, nerve mobility and maximised functional recovery.
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Inpatient Rehabilitation
This plan is at the surgeon’s discretion.
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Strength (Manual Muscle Test)
Sensation (ASIA Points)
Pain (VAS)
Oedema
Functional / ADL’s
Full PROM
Psychological / Emotional support
Postural education
Balance/gait retraining.
Occupational Therapy – Splints, supports etc.
Pain management
Orthotic referral
Social services
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Set patient Goals
Nerve transfers to regain function.
Oberlins Nerve transfer
• Ulnar nerve fascicle rerouted into the bicep muscle belly.
• 3/12 before any activation of bicep.
• Possible 3/5 MMT functional achievable
Nerve transfers to regain function.
Somsak Axillary Nerve Transfer
• Radial nerve from long head of triceps rerouted to the axillary
nerve.
• 3/12 before any activation of the posterior deltoid.
• Possible 4/5 MMT function achievable.
Nerve transfers to regain function.
Spinal Accessory Nerve to Supraclavicular Nerve Transfer
• Spinal accessory taken from Upper Traps rerouted to the
supraclavicular nerve for re-Innervation of Supraspinatus and
Infraspinatus.
• 3/12 before any activation of the Supraspinatus and Infraspinatus .
• Possible 4/5 MMT function achievable.
Nerve Repairs
• Treatment involves assisted joint movements,
gentle muscle exercises, it may be necessary to
use muscle stimulation techniques and/or
biofeedback techniques to encourage muscle
recovery.
• if pain is an issue then nerve desensitisation
techniques can also be used. Nerve repairs can
take 12-36 months to complete during this time
the therapist can monitor the progress of the
nerve recovery and muscle performance and add
appropriate levels of exercises
Nerve Repairs
• During the recovery phase it is essential to maintain the
mobility of the affected joints.
• joint mobilisation using accessory techniques
• Self stretches
• Self joint mobilisation are all encouraged to prevent joint
contractures and joint stiffness.
Nerve Repairs
• Functional exercises are encouraged at late stage
rehabilitation to promote normal movement mechanics and
the return to ADL functions.
• Normal strengthening techniques with resistance can be
instigated once power has returned.
• Continuous reassessment is necessary whilst also recording of
joint mobility, nerve mobility and muscle strength.
Key points
• Do not excessively stretch a recently repaired nerve.
• in the presence of nerve damage associated with joint
fracture the return of joint mobility is compromised by the
irritability and sensitivity of the repairing nerves
Tendon transfers
Tendon transfers are usually instigated after normal nerve recovery has
not occurred and muscle function remains absent with associated joint
contractures and stiffness.
The Initial presentation
Six weeks post operative immobilisation to protect the graft...
Early stage rehabilitation:
1. Explain the operation, which muscles have been transferred, the
previous function of the muscle and the expected change in
direction of the muscle pull
2. Start with active assisted joint movements,
3. Encourage cognitive exercise with training of new direction of
muscle pull.
4. Teach mental appreciation of muscle pull and tension.
5. Discourage excessive effort during exercises which encourage cocontraction and substitute muscle activity.
6. Avoid excessive muscle load during early phase; avoid resistance,
fatigue and lengthening.
Tendon Transfers
Post operative intermediate phase:
• Add active exercises once the muscle action has reached
oxford grade 3/5, against gravity.
• Ensure continuous assessment of the tendon strength and
reduce effort of the exercises once trick activity is noted.
• Demonstrate home exercises which encourage isolated
muscle activity and teach self monitoring to optimise the
effectiveness of the exercises
Tendon Transfers
• Learning to “switch off” and reduce co-contraction of opposing
muscles to the repaired tendon can be an important component of
late stage rehabilitation.
• The key to rehabilitation is practice through repetition to encourage
integration into normal movement patterns and not successive fast
progressive overloading principles used to promote strength, in the
absent of nerve damage.
• Avoid gym activities( and ADL activities which strengthen the
muscles that oppose the recently transfer tendon> strengthening
the opposing muscle increases the effort the new tendon has to use
to overcome the tension. For example a tendon transfer to
encourage better lateral rotation/abduction of the arm and promote
gleno-humeral stability ; latisimus dorsi to infraspinatus is difficult if
the pectoralis muscle( as a medial rotator and adductor) is over
developed or is clearly stronger and more responsive than the new
repair.
Case studies 1.
Tendon transfer at the Shoulder.
Latissimus Dorsi to Infraspinatus
Aim:
• To restore shoulder Lateral rotation and abduction.
Case study 2.
Tendon transfer at the forearm
• FCU and Palmaris Longus to wrist, finger and thumb extensors
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Aim:
To restore hand opening and grip
Nerve repair and grafting
Left: Brachial Plexus.
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Right Axillary Nerve Injury
Nerve repair and grafting
Normal Right arm.
Axillary Nerve injury.
Muscle atrophy and skin changes.
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Case Study: C5-7 Root Avulsion: Multiple Nerve exploration
and grafting.
Case Study: C5-7 Root Avulsion: Multiple Nerve exploration
and grafting.
Case Study: C5-7 Root Avulsion: Multiple Nerve
exploration and grafting.
Case Study: C5-7 Root Avulsion: Multiple Nerve
exploration and grafting.
Case study- The Hand
Case study- The Hand
Case study- The Hand
Case study FFMT
Facilitation and antigravity
The Physiotherapy Management of
OBPP
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OBPP is distressing and potentially disabling injury to the shoulder and arm of a newly born child.
The injury occurs during birth and has several mechanisms of injury.
The aetiology and pathology of OBPP will be defined.
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Occurs: 0.42 per 1000 (live) births
1 in 2300
90% resolve within 6 months
10% suffer life-long disabilities
30% Assisted delivery
60% Shoulder dystocia
4% Breech delivery
RR 3.4
1% Caesarian Section
^ Heavy babies
^ Diabetes
4 Narakas Scale
15 Mallet
5 Gilbert Elbow
5 Ramoundi Hand
NAP’s
SEP’s
EMG
7 Toronto Active Movement scale
5 MRC
ROM
30 degrees L.R.
Summary and conclusions
Key points
• The shoulder movement tells us about the level of recovery in C5
• The elbow flexion tells us about the level of recovery in C6
• The wrist extension tells us about the level of recovery in C7
• The hand movement tells us about the level of recovery in C8/T1
• Early treatment; immobilise and protect.
• Intermediate; assist and guide.
• Late treatment; repetition, function and strengthening.
Questions
To compensate or not to compensate?
How long to continue treatment and/or management?
References
• Surgical Disorders of the Peripheral Nerves; Rolfe Birch : 2010
• A classification of peripheral nerve injuries producing loss of function ; S Sunderland; Brain (1951)
74 (4): 491-516.
• Central Nerve Plexus Injury, Volume 78; Thomas Carlstedt ; 2007
• Kendell and Kendell: Muscle; Testing and function; Williams & Wilkins, 1993
• Isolated peripheral Nerve Lesions of the Brachial Plexus affecting the Shoulder joint. Ernest
J Genthochos : The University of Pennsylvania Orthopaedic Journal 1999 :12 ;40-44
• Wallerian degeneration: Gaining perspective on inflammatory events after peripheral nerve
injury: AD Gaudet, P G Popovich, and M S Ramer Journal of Neuroinflammation 2011 8:110
• Adult Brachial Plexus Injuries: Mechanism, Patterns of Injury and \physical Diagnosis:
Morgan SL et al : Hand Clinic 21 (2005) 13-24 2005
• Rehabilitation Of Brachial Plexus Injuries in Adults and Children : Smania et al; Eur J Phys
Rehabil Med 2012 , 48 483-506.