THE WAY OF THINKING IN

BRACHIAL PLEXUS INJURY

FOR
ALL DEAR UNHAS ORTHOPAEDIC
RESIDENT
 Diagnosis?
Incomplete Left Brachial Plexus injury post
ganglioner
Complete Right Brachial Plexus Injury Preganglionic
Type at Trunk Level
IncompleteRight Brachial plexus injury post
ganglionic type at level cords
Complete Right Brachial Plexus Injury Post ganglionic
type C5-C7at Trunk level and Pre ganglionic C8-T1
Obelin Procedure
Saha Procedure
Early Treatment
In case of Brachial Plexus Injury :
1. Determine whether Obstetric / Trauma
2. In case of trauma determine Open or
Close case
3. In case of trauma determine Pre or Post
Ganglion Type
4. In case of trauma determine Complete or
Incomplete lession
5. In Case of Post Ganglionic Type determine
Level of Injury (RTDCB)
 Obstetric Case
1. Erb type (C5-C6)
2. Klumke type (C7-Th1)
 Trauma Setting
Meticulous history taking: 1.
(name/age/occupation/hand dominant) with 2.
Mechanisme Of Injury and 3. Physical
Examination are needed
Dont forget Live saving in acute setting (ATLS)
PHYSICAL EXAMINATION
Always remember ATLS
HEAD TO TOE
- eye : horners syndrome
- neck : C-spine evaluation
- chest : asymetri , other injury
- abdomen
- extremity
 Local status :
L : skin colour, bruising, soft tissue
swelling, scar, muscle wasting,
deformity
F : warm/not, skin dry/wet,
tenderness, muscle tone, pulse
M : A/P ROM
SPINAL CORD WITH MOTOR AND
SENSORY CELL BODIES
 Pre Ganglion Type
1. Horner Syndrome (APEM) only
shown if Th1 is involved
2. Winging scapula (+)
3. Vascular Injury (+/-)
4. X ray Cervical Fracture
5. MRI
6. Histamine Test (+) flare reaction
Muscle chart (Pre-operative)
Level Nerve Muscle Strength
Root Dorsalscapular Rhomboid +++
Long Thoracic Serratus Anterior +++

Trunk Suprascapular Supraspinatus 0

Infraspinatus 0
Cord Thoracodorsal Lattisimus Dorsi 0
Lateral/Medial Pectoral Pectoralis 0
Branch Axilla Deltoid 0
Musculocutaneous Biceps 0
Radial Tricep,ECRL,ECRB,EDC, 0
ECU,APL,EPB, EPL
Median FCR,FDS,FPL,Thenar 0
Ulnar FCU, FDP 34 ,Adductor Policis, 0
Interosseus
 Muscle chart (Post-
Level
operative)
Nerve Muscle Strength
Root Dorsalscapula Rhomboid +++
Long Thoracic Serratus Anterior +++

Trunk Suprascapular Supraspinatus 0

Infraspinatus 0
Cord Thoracodorsal Lattisimus Dorsi 0
Lateral/Medial Pectoral Pectoralis 0
Branch Axilla Deltoid 0
Musculocutaneous Biceps 0
Radial Tricep,ECRL,ECRB,EDC, 0
ECU,APL,EPB, EPL
Median FCR,FDS,FPL,Thenar 0
Ulnar FCU, FDP 34 ,Adductor Policis, 0
Interosseus
ROM
Remember Do Passive ROM first in order to exclude possibility of joint
contracture

Fig. 1 Trapezius (Spinal accessory

nerve and C3, C4)
The patient is elevating the shoulder
against resistance.
Arrow: the thick upper part of the
muscle can be seen and felt.
 Post Ganglionic Type
Anatomy
Roots
Rhomboids Prefixed C4
Dorsal Scapular
Levator Scapulae C5
C6
C7

C8
T1

Postfixed T2
ROOT

Fig. 2 Rhomboids (Dorsal scapular nerve; C4,

C5)
The patient is pressing the palm of his hand
backwards against the examiner's hand.
Arrow: the muscle bellies can be felt and sometimes
seen.
ROOT

Fig. 3 Serratus anterior (Long thoracic nerve;

C5, C6, C7)
The patient is pushing against a wall. The left
serratus anterior is paralysed and there is winging of
the scapula
 Post Ganglionic Type
Anatomy
Trunks

Supraspinatus
Suprascapular nn.
Infraspinatus Nerve to
subclavius
TRUNK

Fig. 4 Supraspinatus (Suprascapular nerve;

C5, C6)
The patient is abducting the upper arm against
resistance.
Arrow: the muscle belly can be felt and
sometimes seen
TRUNK

Fig. 5 Infraspinatus {Suprascapular

nerve; C5, C6)
 Anatomy
Usu. No nerves Divisions

Anterior divisions =
flexors

Posterior divisions =
extensors
X FOR DIVISION LESSION
IS NONE
 Anatomy
Cords

Pect major Lateral pectoral n.

Medial pectoral n.
Teres major Medial brachial cutaneous
Upper & lower subscapular n Medial antebrach. Cutan.
subscapularis
Thoracodorsal n Lat dorsi
CORDS

Fig. 6 Pectoralis Major; Clavicular Head (Lateral pectoral

nerve; C5, C6)
The upper arm is above the horizontal and the patient is
pushing forward against the examiner's hand,
Arrow, the clavicular head of pectoralis major can be seen
and felt.
CORDS

Fig. 7 Pectoralis Major: Sternocostal Head {Lateral and medial

pectoral nerves; C6, C7,C8)
The patient is adducting the upper arm against resistance.
Arrow: the sterno-costal head can be seen and felt.
CORDS

Fig. 8 Latissimus Dorsi (Thoracodorsal nerve; C6, C7,

C8)
The upper arm is horizontal and the patient is adducting it
against resistance. Lower
arrow: the muscle belly can be seen and felt. The upper
arrow points to teres major.
 Anatomy
Branches

Biceps

Brachialis (lat cut n of forearm)

coracobrachialis

musculocutaneous
radi
almedian
Ulnar
Deltoid, teres minor
Axillary
BRANCHES

Fig. 9 Biceps (Muscuiocutaneous

nerve; C5, C6)
The patient is flexing the supinated
forearm against resistance.
Arrow: the muscle belly can be seen and
BRANCHES

Fig. 10 Deltoid (Axillary nerve; C5, C6)

The patient is abducting the upper arm against
resistance.
Arrow: the anterior and middle fibres of the
muscle can be seen and felt.
BRANCHES

Fig. 11 Triceps (Radial nerve; C6, C7. C8)

The patient is extending the forearm at the
elbow against resistance.
Arrows: the long and lateral heads of the muscle
can be seen and felt.
BRANCHES

Fig. 12 First Dorsal Interosseous Muscle

(Ulnar nerve; C8, T1)
The patient is abducting the index finger
against resistance.
Arrow: the muscle belly can be felt and usually
seen
BRANCHES

Fig. 13 Flexor Digitorium

Superficialis (Median nerve; C7,
C8, T1)
 Remember Sensoric function and
autonom function
Further Examination
Chest x-ray inspiration-expiration
view
Cervical x-ray
MRI C-spine
EMG/NCV
Arteriografi if vascular injury (+)
 Treatment
Depend on time of presentation :
1. Emergency Treatment
2. Immediate Treatment (3 weeks 6
months)
3. Late Treatment ( more than 6
months)
 Type of treatment
1. Soft Tissue
- Emergency presentation Nerve repair
(neuroraphy)
- Immediate presentation nerve procedure
(neurolisis, neurotisasi, nerve graft)
- Late Presentation muscle or bony procedure
( Tendon transfer, muscle transfer, Free
vascularized muscle transfer, arthrodesis)
2. Bony Procedure
- Commonly in Late case presentation by
Arthrodesis procedure
 Nerve, Muscle or Bony
Procedure ?
Nerve Procedure if 3 weeks 6
months of presentation
Muscle or Bony Procedure if more
than 6 months of presentation
 Priority of Treatment
1. Elbow Flexion Reconstruction
a.Soft tissue procedure :
- Nerve (ex. Nerve transfer of N
Intercostal or N Accesorius spinalis into
Musculocutaneous or Oberlin procedure)
- muscle procedure (ex. Steindler
flexorplasty or Free gracilis muscle transfer
wich is innervated by N Intercostal)
b. Bony procedure
OBERLIN
PROCEDURE
Free gracilis muscle transfer, yang
diinervasi oleh N Intercostal
2. Shoulder Reconstruction
Goal : Shoulder abduction, external rotation
and shoulder stability.
a. Soft tissue :
1) nerve transfer (ex. transfer distal part of N
Accesorius Spinalis into N Suprascapularis or
triceps branch of N Radialis transferred into N
Axillaris, nerve transfer by using N Phrenicus )
2) Muscle transfer (Saha Procedure)
b. Bony Procedure (Arthrodesis Glenohumeral
Joint)
3. Wrist and Hand Function
- Soft tissue procedure : muscle
procedure(ex.Jones Procedure and gracilis free
functioning muscle transfer ) actually hand
function is difficult to be achieved by nerve
transfer.
- Bony Procedure for wrist joint
 Notes
Steindler Flexorplasty (by re-route position of
common flexor muscle origin into anterior distal
humerus)

Saha Procedure (Transfer of Trapezius muscle

into Greater Tuberosity of Humerus)

Jones procedure consist of :

PL into APL (Extention thumb)
PT into ECRL (Extention wrist joint)
FCU / FCR into EDC (Extention MCP)
ABBREVIATE OF SPINE INJURY
PROCEDURE

ATTENTION CHEST
CARE!!
A : ATLS for live saving first
T : Traction and Reduction
T : Turn and change position
E : Early rehabilitation with Emotional and
psychological care
N : Nursing care
T : Team multidisiplinary approach
I : Instability treatment
O : Operation for Instability and
Decompression
N : Nutrition care
C : Chest care
H : Heart rate
E : Empty Bladder, early Bladder Training
S : Skin care
T : Temperature

C : Complete
A : Assesment
R : Repeat
E : Examination