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● “Waiter’s tip” positioning of arm suggests upper plexus injury, with arm
adducted, shoulder internally rotated, elbow extended, forearm pronated,
with wrist/fingers flexed
● Winged scapula indicates injury to long thoracic nerve (C5, C6, C7)
● Elbow flexed posture indicates injury to C7 root in isolation
● Flail limb with no motor function suggests pan-brachial plexus injury
(including roots C5-C8, with or without T1)
● Horner syndrome (eyelid ptosis, pupillary miosis, and anhidrosis) indicates
injury to lower plexus with injury to the T1 root proximal to sympathetic and
somatic motor fiber separation.
THINGS TO REMEMBER:
● Erb’s Palsy, or Erb’s Duchenne Palsy: involves cervical nerve roots C5, C6,
and sometimes C7. These nerves are at the top of the brachial plexus, and
send electrical impulses to the shoulder and upper arm. a common injury of
the upper brachial plexus nerves, causing numbness and loss of motion
around the shoulder and an inability to flex the elbow, lift an arm or bring
objects to the mouth.
● This group of nerves work on reaching, lifting, and bringing the arm above
the head (for tasks such as dressing, assisting in feeding, and of course
playing). When C7 is involved, the ability to extend the elbow against
gravity is limited as well as picking up wrist (to give high five, throw a ball,
etc).
●
● 2) Klumpke’s Palsy: impacts the lower nerve roots (C8-T1), in which the
shoulder is spared and the elbow is functional, but the wrist and hand are
paralyzed. a less common injury that affects the lower brachial plexus,
leading to loss of motion and/or sensation in the wrist and hand, such as
being unable to move fingers.
OTHER injuries:
● 3) Total Plexus Palsy: involves the entire brachial plexus and results in a
flaccid or paralyzed arm. It can also be seen in conjunction with a Horner’s
sign, which presents as drooping of the eye on the same side of the
affected arm. Additionally, the phrenic nerve can be affected causing some
diaphragmatic paralysis on the affected side.
● One type of brachial plexus injury is called a "stinger" or "burner." Stingers
occur with compression or overstretching of the nerves that run from the
neck to the arm, usually during collisions in contact sports.
● Avulsion. In this most severe brachial plexus injury, the nerve root has been
torn from the spinal cord. These types of injuries may not be repairable
with surgery. EX: Horner’s syndrome
● Stretch (Neuropraxia). When the nerve is mildly stretched, it may heal on
its own or require simple, nonsurgical treatment methods to return to
normal function.
● Rupture. A more forceful stretch of the nerve may cause it to tear partially
or fully. These types of injuries can sometimes be repaired with surgery.
● Upper-Trunk Palsy Injury- Upper-trunk palsy occurs when the angle
between the shoulder and the neck forcibly widens, such as when a fall
forces the shoulder down and the head to the opposite side.
● Lower-Trunk Palsy Injury
● Lower-trunk palsy occurs when the angle between the arm and the chest
wall forcibly widens. This may damage the lower nerves and the lower
trunks.
● Pan-Plexus Palsy Injury
● Pan-plexus palsy may occur if the force of the injury is extreme. In
pan-plexus palsy, all levels of the nerves and trunk are damaged. This
results in complete paralysis of the arm and hand, which is often referred
to as "flail limb."
NERVE INJURY
● The long thoracic nerve is a proximal branch of the brachial plexus, arising
from the proximal C5, C6, and C7 spinal nerves, that innervates the
serratus anterior muscle. This muscle originates on the lateral surfaces of
the upper 8 ribs and inserts on the entire medial border of the scapula. It
pulls the scapula away from the midline and forward around the thorax
(scapular abduction). It also rotates the lateral angle of the scapula
upward. this muscle fixes and stabilizes the scapula so that muscles
originating from it can function properly. Injury to the long thoracic nerve
causes winging of the scapula
● The dorsal scapular nerve is a very proximal branch from the C5 spinal root.
This nerve innervates both the major and minor rhomboid muscles.
rhomboids connect the medial edge of the scapulae to the spinal column.
When contracted, the rhomboids pull the scapula toward the midline
(scapular adduction and retraction) and superiorly (downward rotation of
the lateral angle). The rhomboids move the scapula in the opposite
direction to that of the serratus anterior muscles. With chronic
denervation, wasting of this muscle deep to the trapezius is evident. The
scapula may also be displaced laterally and inferiorly and rotated laterally.
● The suprascapular nerve (C5, C6) o riginates from the upper trunk of the
brachial plexus and passes the inferior belly of the omohyoid to the
suprascapular notch through which it passes to the posterior surface of
the scapula. The suprascapular nerve innervates the supraspinatus and
infraspinatus muscles. The supraspinatus attaches to the superior aspect of
the humeral head and mediates the initial 20-30 degrees of arm abduction.
The infraspinatus attaches to the posterior lateral aspect of the humeral
head and is the primary external rotator of the arm.
● The axillary nerve (C5, C6) arises from the p osterior cord deep to the
axillary artery and divides into an anterior and posterior division near the
humeral neck as it passes medially and posteriorly to it. The anterior
division innervates the anterior and lateral deltoid. The posterior division
gives a branch to the teres minor, innervates the posterior portion of the
deltoid, and gives a sensory branch to the lateral shoulder region.
● The initial 30 degrees of abduction is primarily controlled by the
supraspinatus, whereas abduction above 90 degrees has an important
trapezius and serratus component that tilts the shoulder girdle upward.
Mr Unlucky has never been the superstitious type, frequently crossing paths with
black cats and breaking mirrors for fun. Earlier this morning, however, he ducked
underneath a ladder in the street and unfortunately received a direct blow to the
middle portion of his clavicle from a paint tin from the sky.
Which part of the brachial plexus most commonly lies deep to the clavicle?
A. Divisions
B. Nerves
C. Cords
D. Roots
E. Trunks
Billy is a ten-year-old who has fallen from a tree. He’s been a fairly lucky
ten-year-old, as a primary survey in the emergency department has revealed no
issues with his airway, cervical spine, breathing, circulatory system or neurological
status. On examination of his limbs, however, he appears to have unfortunately
developed a rare deformity whereby the right wrist and metacarpophalangeal
joints are held in extension, the interphalangeal joints are flexed, and he has
abnormal sensation over the ulnar border of the hand.
Which roots of the brachial plexus do you suspect have been injured?
A. C4-C5
B. C5-C6
C. C8-T1
D. C6-C7
E. C7-C8
Which of the following muscles does NOT derive its motor innervation from the
posterior cord of the brachial plexus?
A. Latissimus Dorsi
B. Subscapularis
C. Triceps
D. Deltoid
E. Serratus Anterior
As part of your revision of the pathology of carpal tunnel syndrome, you thought
it might be a helpful exercise to follow the path of the implicated nerve from the
wrist all the way up to the spinal cord.
This particular nerve in question is derived from which two cords of the brachial
plexus?
At which level do you suspect his brachial plexus may have been compromised?
A. C4-C5
B. C5-C6
C. C7-C8
D. C8-T1
E. C6-C7
A. Biceps Brachii
B. Supinator
D. Brachialis
E. Coracobrachialis
Mr Bloggs has dislocated his shoulder in an ill-advised attempt to jump over a cow. You
remember hearing of a medicolegal case in which a doctor was sued for failing to
document axillary nerve sensation prior to reducing such a dislocation, and thus being
unable to demonstrate that he had not caused the axonotmesis when it was later
discovered. You find that Mr Bloggs, fortunately, has intact sensation in the distribution
of the axillary nerve.
From which cord of the brachial plexus does the axillary nerve arise?
A. Upper
B. Posterior
C. Medial
D. Lateral
E. Lower
You are observing Dr Gasser anaesthetise a patient prior to open rotator cuff repair
surgery. She intends to perform a regional nerve block affecting the brachial plexus and
asks you about the relevant anatomy.
Between which two muscles do the roots of the brachial plexus emerge?
Which of the following brachial plexus nerve roots continues alone as a trunk?
A. C5
B. C8
C. C7
D. T1
E. C6
B. Pickwickian syndrome
C. Holmes-Adie syndrome
E. Pickwickian Syndrome
F. Horner's syndrome
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