1. Brachial Plexus injuries (Obstetric)
Dr Kannan K Kumar
Consultant Hand and Brachial Plexus surgeon
Hosmat hospital

2. Dr Paul Brand fellow in Hand surgery and brachial plexus, Christian medical college, Vellore
Kleinert fellow in hand and microsurgery, University of Louisville, Kentucky, USA
Fellow in brachial plexus surgery, OGDH, Yamaguchi, Japan

3. CONTENTS Anatomy Origin and formation of brachial plexus
Obstetric Brachial Plexus injuries
Treatment
Salvage procedures

4. ANATOMY
Ventral rami, of the lower cervical and upper thoracic nerve roots

5. Components of brachial plexus
It includes – From above the fifth cervical vertebra to underneath the first thoracic vertebra(C5-T1).

6. The trunks pass laterally and lies around the subclavian artery
Behind the clavicle, each trunk splits into anterior and posterior divisions.

8. FORMATION OF THE BRACHIAL PLEXUS

9. Cadaver

10. FORMATION OF THE BRACHIAL PLEXUS
Roots
The ventral rami of spinal nerves C5 to T1 are referred to as the roots of the plexus.
Trunks
Shortly after emerging from the intervertebral foramina , these 5 roots unite to form three trunks. –The ventral rami of C5 & C6 unite to form the Upper Trunk. –The ventral ramus of C 7 continues as the Middle Trunk. –The ventral rami of C 8 & T 1 unite to form the Lower Trunk.

12. Divisions Each trunk splits into an anterior division and a posterior division.
Cords
– Upper and Middle trunks - lateral cord.
– Lower trunk - medial cord.
– Posterior divisions - posterior cord.
– Position relative to the axillary artery

13. III. BRANCHES :
From the Roots
Dorsal Scapular nerve Derived from C5 root Motor nerve to the Rhomboideus major and minor muscles
Long Thoracic nerve Derived from C 5,6,7 Innervates the serratus anterior muscle

14. FORMATION OF THE BRACHIAL PLEXUS

15. Nerve to subclavius muscle Suprascapular nerve From the Lateral Cord
From the Upper Trunk
Nerve to subclavius muscle
Suprascapular nerve
From the Lateral Cord
Lateral Pectoral nerve
Innervates the clavicular head of the pectoralis major muscle
From the Medial Cord
Medial Pectoral nerve Innervates the sternocostal head of the pectoralis major muscle Innervates the pectoralis minor muscle
Innervates supra and infraspinatus muscles
Innervates the clavicular head of the pectoralis major muscle
Innervates the sternocostal head of the pectoralis major muscle Innervates the pectoralis minor muscle

16. FORMATION OF THE BRACHIAL PLEXUS

17. Cutaneous distribution

18. ANATOMIC VARIATIONS
The plexus may include ventral rami from C4 or T2 and these are designated as
Pre fixed- C4 added
Post fixed- T2 added.

19. OBSTETRIC BRACHIAL PLEXUS PALSY

20. HISTORY Early days – congenital deformity.
Smillie [1768] – Obstetric origin
Danyau [1851] – Autopsy – lesion
Duchenne [1861]- traction injury, OBPI
ERB [1875]- pointed lesion at upper trunk
Kennedy [1903]- early surgical repair
Narakas [1981]- microsurgical results.

21. Incidence: 0.13 - 4/1000 live births
Spectrum
Difficult to diagnose early on – Pseudoparalysis

22. Erb’s palsy
Erb's palsy (Erb-Duchenne Palsy) is a paralysis of the arm caused by injury to the upper trunk C5-C6.
Signs of Erb's Palsy
Deltoid, biceps, and brachialis muscles.
The arm hangs by the side and is rotated medially; the forearm is extended and pronated. commonly called "waiter's tip hand."

24. Erb’s Palsy – Nerves Affected

25. Left Erb’s point

26. Klumpke s palsy Variant involving the lower roots. C8 and T1 nerves.
Affects, principally, the intrinsic muscles of the hand and the flexors of the wrist and fingers.
The classic presentation of Klumpke's palsy is the “claw hand” where the forearm is supinated and the wrist and fingers are hyperextended with flexion at interphalangeal and metatarso phalangeal joints.

27. MECHANISM Stretching Overweight babies with cephalic presentations
Underweight babies with breech
Forceful widening of angle between the neck & shoulder.
Vacuum pump
Forceps

32. Associated injuries C-spine fracture Torticollis Clavicle fracture
Shoulder dislocation
Humerus fracture
Facial nerve palsy
Phrenic nerve palsy

33. PATHOLOGY
Lesions range from degree I[neuropraxia] – V [neurotmesis or root avulsions].
Upper trunk –1st affected, most vulnerable part.
Upper trunk – mostly stretched
Lower trunks – mostly ruptured

39. Clinical assessment Limb is flail & dangling
Arm is held in IR, adduction, active abd not possible, elbow extended, forearm pronated, thumb flexed.
Complete paralysis- vasomotor impairment, pale & marble like color
Horner’s sign
Associated # [clavicle,humerus,]

40. Prognosis
Complete Recovery (80%)
Partial recovery
No improvement.

47. EMG
Performed at 3-4 wks- confirm neuropraxia or axonotmesis (difficult to perform)
At 2 months, signs of re-innervation.

48. Fluoroscopy- phrenic nerve injury.
Lumbar puncture- xanthochromic CSF- in root avulsions.
C.T myelogram
Fast spin Echo MRI: preganglionic nerve root injuries. (only if necessary)
Large diverticulae and meningoceles are indicative of root avulsions

50. DD Fracture of clavicle or humerus shaft or physeal separation
Septic arthritis / osteomyelitis
Congenital malformation of plexus
Postinfectious [varicella] plexopathy of muscles

51. Prognostic signs Nature of injury Lower plexus paralysis,
Global involvement,
Persistence of Horner’s and phrenic nerve palsy
Presence of Torticollis

52. Treatment Physiotherapy
ROM ex, facilitation of active movt, promotion of sensory awareness.
Avoid abduction & posterior projection of shoulder. Limb to be supported when holding baby
Goals: minimizing bony deformities, Jt contractues.
Weight bearing activity-skeletal growth

53. SURGICAL Early nerve repair Indications:
Failure of recovery of biceps or deltoid at 3 months
Group III& IV lesions
Presence of Horners sign.

54. Cookie sign
Failure to flex the elbow, so as to take the hand to the mouth.
3-6months.

55. Advantages of nerve repair
Diminishing potential for axon regeneration with age
Cross innervation & muscle imbalance aborted
Provide better condition for tendon transfer
Nerve repair is superior to spontaneous recovery.

57. Timing of surgery 5 months – 1 year TYPE OF SURGERY Neurolysis
Direct repair
Nerve grafting
Nerve transfers
Free functioning muscle transfers

58. Neurolysis

59. Direct Repair

60. Direct Repair

61. Direct Repair

65. Nerve Grafting

66. Nerve grafting

73. Free functioning muscle transfer

74. Common donors Spinal accessory (XIth) nerve.
Intercostal nerves (commonly 3rd to 6th)
Fascicles of the median and ulnar nerves
Opposite C7.

75. Common recipient nerves
Order of priority of restoration of function
Elbow flexion(Musculocutaneous nerve)
Shoulder stability (suprascapular nerve and axillary nerve)
Hand prehension

76. Late OBPP
Nerve regeneration: some muscles recover earlier, others paretic  muscle imbalance
Recovery results from misdirection of regenerated axons  cross innervation

77. Cross innervation Co-contraction of synergestic & antagonistic muscles
Diminishing functional recovery
Muscle contracture  deformity

79. HAND DEFORMITY In flaccid paralysis of complete lesion
Difficult to manage & difficult to rehabilitate
If no active wrist extension & no possible transfers – W. fusion with comb inter-metacarpal arthrodesis.

80. Take home points
Obstetric brachial plexus injuries may be avoidable if timely C-section is performed.
Early referral to a brachial plexus surgeon once the diagnosis is made.
All is not lost – Nerve surgery or other secondary procedures can improve function drastically.

81. Thank you