BPI due to trauma, in details. hope you guys understand

1. TRAUMATIC BRACHIAL
PLEXUS INJURY
HAND DIVISION
TM / MC
SUPERVISOR : DR. DHEDIE PRASATIA SHAM, M.KES, SP.OT

2. Case report
53 years old right handed female, fell from a flight of stairs on her right arm.
She fell on a stretched out – wide open arm. She was unable to move her
arm after the incident.
On clinical examination there was an asymmetric profile of pain and
neurological deficit in right upper limb
Sensations were reduced on :
 lateral aspect of arm
 dorsal and ulnar aspext of forearm
 volar and dorsal aspect of wrist and
hand
Motor deficit was found on :
 Extensor of wrist and fingers
 Other area was not able to be
evaluated due to fracture
dislocation of shoulder (at initial
examination)

3. Case report
Open reduction and internal fixation of proximal humerus were done after
pre-anaesthetic evaluation
Exploration of nerve lesion was not attempted during fracture fixation,
because it was presumed to be probably neuropraxia/axonotmesis

4. Case report
Detailed motor examination was done after 3 days, and examination
revealed the following
 shoulder abduction was 2/5
 elbow extension was 0/5, flexion was 4/5
 wrist extension and finger extension was 0/5
 wrist and finger flexion was 0/5
 fingers adduction and abduction was 0/5
 thumb abduction and extension was 0/5
Electromyography (EMG) and nerve conduction velocity test (NCV) were
performed after 3 weeks and results were infraclavicular brachial plexus palsy
with denervation of extensor of elbow, wrist, and fingers and flexors of wrist.

5. Case report
Patient was admitted for conservative therapy in the form of :
 Physiotherapy
 Stretching of muscles to prevent contractures
 Strengthening of functional muscles
 Sensory reeducation
 Dynamic cock up splinting
 Electrical stimulation twice A day
 Range of motion exercises
At follow up of 6 months, median and radial nerve function were found to be
improving with power improving in supinator, flexors, and extensors of wrist
and fingers

6. Case report
By 12 months it was found that :
 Abduction of shoulder was 4/5, with range of 0-130 degrees
 triceps power was 5/5
 wrist and finger extension and flexion power being 4/5
 adduction and abduction of fingers was 3/5
 thumb abduction and extension was 3/5
At 18 months, the patient regained near-normal power of the limb with
complete recovery of shoulder abduction; elbow, wrist, and finger extension
and flexion
Only adduction and abduction power of fingers, abduction and extension of
thumb was limited to 3/5

7. On to the discussions..

8. ANATOMY
The brachial plexus most commonly (77% of cases)
receives contributions contiguously from the
anterior spinal nerve roots of C5 to T1.
Prefixed cords (22% of cases) receive an
additional contribution from C4.
Postfixed cords (1% of cases) receive a
contribution from T2.
Journal of the American Academy Orthopaedic Surgeons;Adult traumatic Brachial Plexus injury;2005

9. Anatomy of Brachial Plexus
 Rob Taylor Drinks Cold Beer
1. Five roots
2. Three trunks (upper,
middle , lower
3. Six Divisions (two from
each trunk
4. Three Cords (posterior,
lateral, medial)
5. Multiple Branches
 The roots lie between scalenus
anterior and medius mucle
 The trunks lie in posterior triangle
of neck
 The divisisions lie behind clavicle
and at outer border of rib
 The cords lie in upper axilla

10. 2 2 0 7 5
Supraclavicular Retroclavicular Infraclavicular

11. Relationship of brachial plexus and axillary artery

12. Epidemiology
 Global increase of BPI cases worldwide due to increase participation in
extreme sports and increase number of MVA survivor
 Significant predilection in MALE gender, with ages between 15-25 years old
 Narakas et al stated that 70% of BPI are due to traffic accident, and 70% of
them involve use of motorcycles.
 Of all types of BPI, 75% involve total plexus lesions (C5-T1)
 20-25% of all lesions are C5-C6 root injuries
 2-3.5% of lesions are isolated C8-T1 root lesions

13. Mechanism of injury
 In general, supraclavicular area is most commonly affected
 Roots and trunks get affected more compared to cords and terminal
branches
 Injury may be due to :
 Stretching of nerve at time of trauma
 Compression of hematoma
 Direct trauma by proximal humerus
 Entrapment of nerve (after reduction of dislocation)

14. Upper Brachial plexus injury
 Avulsion injury often is a result of a violent lateral head and neck turn away
from ipsilateral shoulder, as shown in pictures, with disruption in C5-7 root
or upper trunk

15. Lower brachial plexus injury
 Avulsion can also occur in cases of forceful traction of upper limb above the
level of head with considerable force, causing avulsion injury of C8-T1 roots
or lower trunk.

16. Preganglionic injury & Postganglionic injury

17. Preganglionic VS postganglionic
lesions
Postganglionic lesions
 Both sensory and motoric roots are
ruptured
 May restore spontaneously (in cases
of axonotmesis)
 May be repaired surgically
Preganglionic lesions
 Motor neurons are separated
from motor centers in ventral
horns
 Sensory neurons remain intact at
dorsal root ganglion
 Sensory nerve remains
undamaged
 Can not be repaired
 Transfer of functioning motor
nerve required to restore
function

18. Chapter 5: Shoulder and elbow clinical cases. Section 3: The clinicals. Postgraduate Orthopaedic

19. Horner’s Syndrome
 Lower plexus root avulsion  correlates with C8 or T1
root avulsion
 Interuption to sympathetic supply to the eye from
damage to the stellate ganglion at level of T1
 Partial ptosis of upper eyelid + miosis of pupil +
anhidrosis (loss of sweating on one half of face) +
enophtalmus
 Usually appears 3-4 days after injury
Chapter 19: Hand oral core topics. Section 5: The hand oral. Postgraduate Orthopaedic

20. Horner Syndrome
A
P
E
M
nhidrosis
tosis
nophtalmus
yosis

21. Pre-Ganglionic Injury
 Horner’s syndrome
 Winged scapula medially
 Abscence of Tinel sign or tenderness to percussion in
the neck
 Normal histamine test
 Elevated hemidiaphragma
 Rhomboid paralysis
Brachial plexus injuries. Orthobullets

22. Factors affecting prognosis of peripheral nerve injury

23. Systematic examination is in
order..

25. Physical examination
 BPIs are often accompanied by other severe injuries, which may hinder
diagnosis of nerve injury until patient’s recovery
 Have suspicion of there are injuries to :
 Shoulder girdle
 First rib
 Rupture of axillary artery
 According to the location :
1. upper plexus (erb’s palsy)
2. lower plexus (klumpke’s palsy)

26. Supraclavicular injuries :
 Shoulder is adducted and internally rotated
 Tenderness over the notch of clavicle
 Muscle weakness during shoulder abduction
 External rotation of arm
Infraclavicular injuries :
 Due to high energy trauma mechanism at shoulder level
 May be associated with rupture of axillary artery
 Axillary, suprascapular and musculocutganeous nerves most likely affected

27. BPI SKEMA
 Injury to different part of brachial plexus may show different types of
weakness / dysfunction
 To better understand the weakness of muscles and origin of the palsy /
lesions, a better understanding of muscle innervation which originate from
brachial plexus is needed
 Apart from motor dysfunction, sensory deficit is an additional sign to
examine.

29. Patient interview
observation
 Note the overall position or posture with respect to
the alignment of upper extremities
 Note the patient’s preferences to use injured
extremity, or supporting 1 arm
 Check shoulder position  fracture / dislocation
 Observe the patient’s facial expression  pain

30. Patient interview
observation
Examples of questions that should be asked to the patient
1. What is your problem?
2. Describe the painful symptoms associated with the injury, including the location (remember the
shoulder is a common area forreferred pain), character, and intensity of the pain (on a scale of 1 to
10). What makes it better or worse? Grading the intensity of the pain gives the athletic trainer an
objective measurement for future evaluations.
3. Describe the mechanism of the injury regarding the position of the head, neck, and arms.
4. Describe the neurological symptoms of numbness, burning, weakness, or tingling. Exactly where
and when do symptoms occur?
5. Did you experience any unusual symptoms such as snapping, popping, locking, tightness, or
crepitation?
6. When did the symptoms first occur?
7. Was the onset of symptoms sudden or gradual?
8. Describe the past history of similar episodes, if any, including: assessment, treatment,
rehabilitation, and other diagnostic testing

31. Physical Examination
Inspection
Look the upper limb from the shoulder to fingertips:
 Deltoid wasting
 Supraspinatus/infraspinatus wasting
 Forearm wasting of mobile wad, extensor, flexor
compartment
 Hand’s intrinsic muscle , thenar, hypothenar muscle
wasting
 Clawing hand

32. Physical Examination
Palpation
 The chest, back, and upper limb musculature are felt
to assess muscle bulk/tone
 Skin temperature
 Skin texture (dry/wet)
 Any tenderness / hyperaesthesia

33. Physical Examination
Palpation
The following structures need to be palpated and
checked for a suspected BPI
1. the cervical spine, clavicle, humerus, scapula,
sternum, and ribs
2. 2. the sternoclavicular, acromio-clavicular, and
glenohumeral joints
3. 3. the musculature around the shoulder and neck.

34. Physical Examination
Range of Motion
 Assess passive ROM to check for any fixed
contracture
 Shoulder
 Elbow
 Wrist
 Hand

35. Physical Examination
Test for Sensation
 Assess any areas of numbness
 Assess any area of pain
 Assess any areas of abnormal sensation

36. Physical Examination
Test for Muscle Power
 The joint involved must have a full range of passive
movement
 Each muscle must be assessed individually  one test for
one muscle function
 Systematized manner from proximal to distal direction
 A system based on anatomical knowledge of brachial
plexus is necessary to avoid missing any lesions and to
assess fully the extent of involvement at each level of the
plexus

37. Muscle innervation of brachial plexus

38. From behind the patient
1. Trapezius (XI cranial nerve)
 Shrug shoulders up
2. Serratus anterior (long thoracic nerve C5,C6,C7)
 Push into a wall
3. Rhomboid (dorsal scapular nerve C5)
 Squeeze shoulder blades together
 Patient place hands on hip, asked to stop
examiner pushing their arms forward
Chapter 5: Shoulder and elbow clinical cases. Section 3: The clinicals. Postgraduate Orthopaedic

39. From behind the patient
4. Supraspinatus (suprascapular nerve C5,C6)
 Jobe’s empty can test
5. Infraspinatus (suprascapular nerve C5,C6)
 Shoulder external rotation movement
6. Deltoid (axillary nerve C5 C6 posterior cord)
 Shoulder abduction with elbow flexed 90 degree
Chapter 5: Shoulder and elbow clinical cases. Section 3: The clinicals. Postgraduate Orthopaedic

40. 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.

41. Serratus anterior (Long thoracic
nerve; C5, C6, C7)
The patient is pushing against a wall. The left serratus anterior is
paralysed and there is medial winging of the scapula

43. Rhomboids (Dorsal scapular
nerve;C5)

44. Supraspinatus (Suprascapular
nerve; C5, C6)
The patient is abducting the upper arm against resistance.
Arrow: the muscle belly can be felt and sometimes seen

45. Infraspinatus (Suprascapular
nerve; C5, C6)

46. 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.

47. From behind the patient
1. Biceps (musculocutaneus nerve C5 C6 lateral
cord)
 Patient’s shoulder adducted, forearm supinated,
elbow flexed against resistance
2. Triceps (radial nerve C6 C7 C8 posterior cord)
 Patient’s forearm is pronated, shoulder flexed 450
, elbow extended against resistance
3. ECRL (radial nerve C5 C6)
 Patient’s elbow is flexed 900 , extend wrist against
resitance
Chapter 5: Shoulder and elbow clinical cases. Section 3: The clinicals. Postgraduate Orthopaedic

48. From behind the patient
4. Supinator (radial nerve C6 C7)
 Extend the elbow to eliminate biceps
 With forearm pronated, ask the patient to supinate against
resistance
5. Extensor digitorum communis (PIN C7 C8)
 Support palm of patient’s hand to eliminate effects of gravity
 Extend fingers against resistance
Chapter 5: Shoulder and elbow clinical cases. Section 3: The clinicals. Postgraduate Orthopaedic

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

50. 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.

51. 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.

52. 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.

53. 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.

54. 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

55. BRANCHES
Fig. 13 Flexor Digitorium Superficialis (Median
nerve; C7, C8, T1)

57. Diagnostic approach..

58. Imaging Studies
X rays of Cervical spine, shoulder girdle, Humerus and Chest should be
obtained
 Cervical spine x ray
 Fracture  spinal cord trauma
 Transverse process fracture  possible root avulsion
 Shoulder Girdle x ray
 Clavicle fracture  possible brachial plexus injury
 1st and 2nd rib fracture  injury to overlying part of brachial plexus
 Chest x ray
 Past rib fracture may injure corresponding intercostal nerves
 Elevated and paralyzed hemidiaphragm  phrenic nerve injury

59.  CT / computed tomography & CT myelography
 Usually performed 3 – 4 weeks after trauma to ensure blood clot is absorbed
 Evaluation of level of nerve injury
 Pseudomeningocele in case of cervical root avulsion  as overshadowing at
point of lesion and around

60.  MRI (up to 3.0-T) may show 3D high resolution views of fine structures 
viewing detailed anatomic nerve depiction

61.  In preganglionic BPI, MRI shows
 Pseudomeningocele, shown as high density cystic shadowns inside and outside
intervertebral foramen, has varied morphology with basic shape is triangular
 In postganglionic BPI MRI shows
 Nerve discontinuity, retraction of distal nerve after rupture, disappearance of local
nerve structure, replacement by scar tissue or hematoma

62.  In postganglionic BPI MRI shows
 Abnormal neural signals often manifested as hyperintensities T2-weighted
images, significant neural thickening, and unclear boundaries between thickened
nerves

63.  In postganglionic BPI MRI shows
 Abnormal shapes in neural pathways, loss of normal smooth neural pathways,
meandering or even curling pathways
 Abnormal signals from soft tissues surrounding the damaged nerve, including (1)
scarring of the anterior scalene muscle, (2) local scarring around damage nerves,
appeared as hyperintensities in T2 images.

64. What to do…

65. Management
 Modern series reveal reverse relationship between
time from injury to operative intervention and clinical
outcome.1
 Immediate surgical exploration may be indicated in
certain cases of penetrating trauma or iatrogenic
injury.1
 Reasonable to observe for 3 months in the absence
of major vascular injury2
 Early surgical intervention (3 weeks to 3 months after
injury) is indicated in patients with complete or near-
complete injuries resulting from a high energy
mechanism.2
1. Chapter 19: Hand oral core topics. Section 5: The hand oral. Postgraduate Orthopaedic
2. Traumatic brachial plexus injury. Hand, Upper extremity, and microvascular surgery. Miller’s Review 7th edition.p618

66. Management
 Low-energy closed injury  low probability of nerve disruption and
most cases will recover spontaneously  manage conservatively
initially1
 BPI resulting from low-energy mechanisms, especially in those with
an incomplete upper plexus lesion  best observed for at least 3
to 6 months for spontaneous recovery.
 If theres is no clear clinical evidence of improvement 
neurophysiology
 Only consider surgery if complete absence of function of
all/part of the plexus remains at 2-3 months
1. Chapter 19: Hand oral core topics. Section 5: The hand oral. Postgraduate Orthopaedic
2. Traumatic brachial plexus injury. Hand, Upper extremity, and microvascular surgery. Miller’s
Review 7th edition.p618

67. Priorities of Surgery
 Shoulder stability
 Shoulder external rotation
 Elbow flexion
 Wrist extension
Chapter 19: Hand oral core topics. Section 5: The hand oral. Postgraduate Orthopaedic

68. Priorities of Surgery (from
another source)
 Elbow flexion
 Shoulder stability
 Brachial-thoracic pinch
 C6-C7 sensory
 Wrist extension / finger flexion
 Wrist flexion / finger extension
 Intrinsic function
Brachial plexus injuries. Orthobullets

69. Surgical Technique
 Direct nerve repair
 Nerve graft
 Neurotization
 Muscle/tendon transfer
 Arthrodesis
Brachial plexus injuries. Orthobullets

70. QUESTIONS..

71. Q1
• A 26-year-old male sustains a traction injury to his left
arm after a motorcycle crash with resulting weakness
in this left upper extremity. An electromyography
(EMG) done shows normal cervical paraspinal muscle
activity. Which of the following statements is true
regarding this injury?
1. The injury has likely resulted in the avulsion of several nerve roots
2. Physical exam would likely reveal drooping of his left eyelid and
anhidrosis
3. Intact paraspinal musculature on EMG is suggestive of a post-ganglionic
lesion
4. Immediate surgical intervention with neurotization would eliminate
weakness and restore function
5. The patient would show a normal histamine test

72. PREFERRED RESPONSE 3
 Normal cervical paraspinal muscle activity on EMG is
characteristic of a post-ganglionic injury.
Determining whether a brachial plexus injury is pre- or post-
ganglionic has important treatment and prognostic implications.
Findings that suggest a pre-ganglionic lesion include Horner
syndrome (ptosis, miosis, anhidrosis), a medially winged scapula,
loss of paraspinal musculature activity on EMG, and a normal
histamine test. These injuries tend to have a worse prognosis
than post-ganglionic lesions, which show an abnormal histamine
test and intact cervical paraspinal activity on EMG.
Moran et al. review brachial plexus injuries. They recommend a
baseline EMG for non-operative injuries at 3-4 weeks time after
Wallerian degeneration has occurred.

73. Q2
• A patient sustains a transection of the posterior cord
of the brachial plexus from a knife injury. This injury
would affect all of the following muscles EXCEPT?
1. Subscapularis
2. Latissimus dorsi
3. Supraspinatus
4. Teres minor
5. Brachioradialis

74. PREFERRED RESPONSE 3
 The posterior cord of the brachial plexus gives rise to the
1) upper subscapular nerve 2) lower subscapular nerve 3)
thoracodorsal nerve 4) axillary nerves 5) radial nerve. The
upper subscapular nerve innervates the subscapularis. The
lower subscapular nerve innervates teres major and also
subscapularis. The thoracodorsal nerve innervates
latissimus dorsi. The axillary nerves innervates deltoid and
teres minor. The radial nerve innervates the triceps,
brachioradialis, wrist extensors, and finger extensors. The
supraspinatus is innervated by the suprascapular nerve off
the upper trunk and therefore would not be affected by
an injury to the posterior cord. The anatomy of the
brachial plexus is shown in Illustration A. A

75. Q3
• A 21-year-old collegiate football player has been
diagnosed with a left superior trunk brachial plexus
injury following a tackle. Which of the following would
most likely be normal on physical exam?
1. Sensation over the lateral aspect of shoulder
2. Biceps reflex
3. Shoulder abduction
4. Sensation over radial aspect of forearm
5. 2nd and 5th finger abduction

76. PREFERRED RESPONSE 5
 Examination of finger abduction would be normal in a patient
with an isolated superior trunk brachial plexus injury. Finger
abduction is performed by the ulnar nerve, which is supplied by
the inferior trunk of the brachial plexus.
Superior trunk brachial plexus injuries are thought to occur
secondary to traction when an athlete sustains a lateral flexion
injury of the neck. Transient injuries are often referred to as
"stingers" or a "burner." Symptoms of these injuries are referable
to the motor and sensory functions of the axillary,
musculocutaneous, and supra-scapular nerves.
Hershman reviewed the etiology of brachial plexus injuries. They
showed that superior trunk brachial plexus injuries are usually
transient, with 95% of people regaining full neurological
recovery with conservative management.

77. references
 Chapter 5: Shoulder and elbow clinical cases. Section 3: The clinicals.
Postgraduate Orthopaedic
 Brachial Plexus Injuries in Adults: Evaluation and Diagnostic Approach,
Vasileios et al. Hindawi publishing corporation, ISRN orthopaedics, 2014
 Fracture Dislocation of Shoulder with Brachial Plexus Palsy: A Case Report
and Review of Management Options, rathose et al, journal of
orthopaedic case reports 2017 Mar-Apr: 7(2):48-51
 Systematic Evaluation Of Brachial Plexus Injuries, Haynes Scott, Med, ATC
 Detection of nerve rootlet avulsion on CT myelography in Patients with
birth Palsy and Brachial Plexus Injury After Trauma, Walker et al. AJR:167
 orthobullets

78. THANK YOU