1. Traumatic Brachial Plexus Injury: Assessment and Management
Mohamed Khalid MCh.Orth, FRCS.Orth, Diplomate European Board of Hand Surgery
With inputs from Dominic Power, Peripheral Nerve Surgeon, Queen Elizabeth Hospital, Birmingham.

2. Objectives Anatomy Pathomechanics Pathoanatomy Pathophysiology
Common clinical patterns
BPI Classification
Key examination points
BPI investigation
Early management
Timing of surgery
Reconstruction priorities
Reconstruction ladder
Evolution of modern techniques
Reconstruction algorithm
Additional procedures
Results
Prognosis in BPI
Research areas
Clinical cases

3. Brachial Plexus Anatomy
Anterior primary rami of C5-T1
Phrenic nerve C3/4/5
3 important nerves originate above the clavicle
C5 root-dorsal scapular
C5/6/7 roots-long thoracic nerve (Bell)
C5/6 upper trunk-suprascapular nerve
T1 contributes preganglionic sympathetic fibres to stellate ganglion

4. Pathomechanics of BPI

6. Pathoanatomy

7. Pathophysiology Seddon 1943
Neuropraxia
Focal demyelination
Axonal continuity
Axonotomesis
Axonal loss
Wallerian degeneration
Neurotmesis
Transection of a nerve
Complex spectrum with several patho-physiological processes co-existing:
Focal ischaemia and oedema
Demyelination
Intraneural bleeding
Axonal loss
Nerve avulsions (post-ganglionic)
Root avulsions (pre-ganglionic)
Spinal cord oedema and haemorrhage
Intra- and peri-neural fibrosis
Anterior horn cell death

8. Common Clinical Patterns
Supraclavicular lesions
Preganglionic or postganglionic
Myotome / dermatome distribution
Infraclavicular lesions
Postganglionic
Proximal peripheral nerve distribution
Upper, Intermediate, Lower or TBPI
Upper roots injured most frequently
80% patients are likely to have at least some complete injury
Upper roots (C5/C6) often postganglionic
Branches and interscalene ligaments protect roots from avulsion
60% ruptures
40% avulsions
Lower roots (C8/T1) usually preganglionic
Direct line of pull to spinal cord
85% avulsions
15% ruptures

9. Upper Plexus - C5/6 “Bad shoulder, good hand”
Affects shoulder girdle muscles
“Waiters tip”
Erb’s palsy
Adducted and internally rotated shoulder
Root lesion
Serratus anterior, Rhomboids, Suprapsinatus, Infraspinatus, Deltoid, Biceps brachii, Brachialis, Brachioradialis
More distal lesion
Rhomboids spared (dorsal scapular nerve)
Serratus anterior spared (long thoracic nerve)

10. Intermediate Plexus - C7
Rare in isolation
Tumour
Iatrogenic injury
Co-exists with upper and lower plexus injuries
C5/6/7
C7/8/T1
Minor impact
Weakness of wrist extensors
Can be used as ipsilateral intraplexal donor or contralateral donor for reconstruction

11. Lower Plexus – C8/T1 “Good shoulder, bad hand” Klumpke’s palsy
Weakness FCU, FDP to ulnar digits
Loss of hand intrinsics
Loss of EIP
Loss of EPL
Medial forearm and hand sensory loss
Horner’s syndrome (loss of sympathetic outflow)

12. Classification of Brachial Plexus Palsy
Age
Pathological
Anatomical
Combination

13. Classification of Brachial Plexus Palsy
Age
Pathological
Anatomical
Combination
Obstetric
Adult

14. Classification of Brachial Plexus Palsy
Age
Pathological
Anatomical
Combination
Traumatic
Traction, avulsion, penetrating wounds
Infective
Cervical amyotrophy
Parsonage-Turner (viral brachial neuritis)
Radiation induced
Malignant
Pancoast tumour of the lung
Primary nerve tumours
Iatrogenic
CVLs
Invasive angiography
Neck dissection

15. Classification of Brachial Plexus Palsy
Age
Pathological
Anatomical
Combination
Supraclavicular
Infraclavicular

16. Classification of Brachial Plexus Palsy
Age
Pathological
Anatomical
Combination
Preganglionic
Postganglionic

17. Classification of Brachial Plexus Palsy
Age
Pathological
Anatomical
Combination
Upper plexus
C5/6
C5/6/7
Lower plexus
C8/T1
Panplexus
C5-T1

18. Classification of Brachial Plexus Palsy
Age
Pathological
Anatomical
Combination
Leffert
I open
II closed
IIA Supra-clavicular
Pre-, Post-ganglionic
IIB Infra-clavicular
III radiation
IV obstetric
IVA Erb’s
IVB Klumpke’s
IVC Mixed

19. Key Examination Points
ATLS
Serial clinical examination
Flaccid paralysis of involved limb
Associated fractures and dislocations
First rib, clavicle, cervical transverse processes, ipselateral limb fractures
Shoulder, ACJ , SCJ and scapulo-thoracic dislocations
De-afferentiation pain
Long tract signs in lower limbs
Asymmetry of reflexes, clonus, up-going plantar
Horner’s syndrome
Miosis, ptosis, anhydrosis, enopthalmos
Phrenic nerve palsy
Loss of dorsal scapular nerve
Cervical plexus involvement
Sensory loss proximal to clavicles
Paralysis of strap muscles
Cervical scoliosis

20. BPI Investigation Imaging CXR, C spine, shoulder radiographs MRI
Myelography + CT
Neurophysiology tests
Somatosensory Evoked Potentials
NCS
6/52 neuropraxia resolution
Normal SNCVs and absent MNCVs in preganglionic lesions
Absent SNCVs and MNVCs in postganglionic lesions
EMG
Fibrillation potentials
Spontaneous muscle depolarisations due to ACh receptor upregulation in target muscles
Histamine Test
Is it pre-ganglionic?
Historical interest only

21. CXR: Phrenic Nerve Palsy

22. CT Myelogram: C5/6 root avulsions

23. Early Management of BPI
Open injury:
Early exploration
Debridement
Nerve repair, graft and transfers
Closed injury:
Physiotherapy
Shoulder abduction
Shoulder external rotation
Elbow ROM
ROM fingers
Occupational therapy
Wrist splints
Resting intrinsic plus splints
Skin care for trophic areas
Education
Regular clinical reassessment
Advancing Tinel test for regeneration in zones of axonotmesis
Deep muscle pain for early sign of reinnervation

24. Early Management of BPI
Open injury:
Early exploration
Debridement
Nerve repair, graft and transfers
Closed injury:
Physiotherapy
Shoulder abduction
Shoulder external rotation
Elbow ROM
ROM fingers
Occupational therapy
Wrist splints
Resting intrinsic plus splints
Skin care for trophic areas
Education
Regular clinical reassessment
Advancing Tinel test for regeneration in zones of axonotmesis
Deep muscle pain for early sign of reinnervation

25. Case 1: Open root avulsions

26. Case 1: Open root avulsions

27. Case 2: Stab injury C5/C6

28. Case 2: Stab injury C5/C6

29. Case 2: Stab injury C5/C6

30. Case 2: Stab injury C5/C6

31. Early Management of BPI
Open injury:
Early exploration
Debridement
Nerve repair, graft and transfers
Closed injury:
Physiotherapy
Shoulder abduction
Shoulder external rotation
Elbow ROM
ROM fingers
Occupational therapy
Wrist splints
Resting intrinsic plus splints
Skin care for trophic areas
Education
Regular clinical reassessment
Advancing Tinel test for regeneration in zones of axonotmesis
Deep muscle pain for early sign of reinnervation

32. Early Management of BPI
Open injury:
Early exploration
Debridement
Nerve repair, graft and transfers
Closed injury:
Physiotherapy
Shoulder abduction
Shoulder external rotation
Elbow ROM
ROM fingers
Occupational therapy
Wrist splints
Resting intrinsic plus splints
Skin care for trophic areas
Education
Regular clinical reassessment
Advancing Tinel test for regeneration in zones of axonotmesis
Deep muscle pain for early sign of reinnervation

33. Timing of Surgery Acute closed BPI <6/52
CT myelography 3-6/52 post injury
Pseudomeningocoeles, myelomalacia and root avulsions
Unequivocal total BPI (C5-T1 avulsion)
Explore 1-2/12
All others repeated clinical assessment
Consider EMG and NCS at 6-8/52
Planned exploration at 3/12 for grafting and nerve transfers
Delayed presentation <6/12
Consider NCS /EMG / CT myelography
Explore for neurolysis, grafting and nerve transfers
Delayed presentation >6/12
Consider selective distal neurotisations , arthrodeses, tendon transfers and functioning free muscle transfers

34. Reconstruction Priorities
Shoulder and elbow control to enable positioning of a sensate hand for prehension
Shoulder abduction SSN (AxN)
Elbow flexion MCN
Sensate hand (MN / lateral cord)
Finger flexion (MN)
Elbow extension (RN)
Release (RN / PIN)
(Intrinsic function)

35. Reconstruction Priorities
Shoulder and elbow control to enable positioning of a sensate hand for prehension
Shoulder abduction SSN (AxN)
Elbow flexion MCN
Sensate hand (MN / lateral cord)
Finger flexion (MN)
Elbow extension (RN)
Release (RN / PIN)
(Intrinsic function)

36. Reconstruction Ladder in BPI
Neurolysis
External / internal
Nerve grafts
Sural, LCNF, MCNF
Plexo-plexal (anatomic)
Neurotisation
Reinnervation of a denervated motor or sensory end organ
Extraplexal donors for specific functions
Nerve transfers
Ipselateral C7 or contralateral hemi C7 transfer to median nerve using a vascularised ulnar nerve graft (in cases of preganglionic C8/T1 lesions) based on superior ulnar collateral vessels
Arthrodeses
Osteotomies
Tendon transfers
Amputations
Functioning Free Muscle Transfers

37. Evolution of modern techniques 1
Early exploration <6/52
Haemorrhage is often problematic
Potential for early recovery of neuropraxic injury
Unreliable intra-operative nerve stimulation
Poor historical results of late exploration (>6/12)
Distal reinnervation is unsatisfactory
Long grafts
End plate response diminishes with time
Move towards earlier exploration in closed injuries (6/52-3/12)
Referrals are often delayed
Associated injuries (eg IPPV for HI)
BPI is frequently missed
Trauma surgeon education
Supra-regional referrals

38. Evolution of modern techniques 2
Neurotise rather than plexo-plexal grafting
“One nerve, one function”
Uncertain condition of root (SSEPs poor predictors)
Co-contraction of reinnervated antagonists
Importance of reinnervation of the deltoid
Leechavenvongs: Long Head Triceps to anterior axillary nerve
Distally based transfers more rapid and reliable recovery
Oberlin 1 and Oberlin 2 transfers for elbow flexion
FCR, PL, redundant FDS branches to ECRB, PIN and PT
Avoid grafts
Longer reinnervation times and less predictable outcomes
End to side techniques (“Something for nothing”)
FFM transfer when >6/12 since injury
Muscle reinnervation MRC 3+ not possible after 12/12
Contralateral C7 to provide sensation
Hemi C7 transfer minimises donor morbidity
Poor motor reinnervation, reasonable sensory to median nerve
Selective use of osteotomies, arthrodeses, tendon and muscle transfers

39. Selective neurotisation: Phrenic to SSN

40. Selective neurotisation: XI to SSN

41. Selective neurotisation: XI to MCN

42. Selective neurotisation: ICNs to MCN

43. Leechavengvongs: Triceps branch to axillary transfer

44. Leechavengvongs: Triceps branch to axillary transfer

45. Oberlin 1: Selective distal neurotisation for elbow flexion

46. Oberlin 1 and 2: Selective distal neurotisations for elbow flexion

47. Oberlin 1 and 2: Selective distal neurotisations for elbow flexion

48. Doi: Functioning free gracilis for elbow flexion and finger extension

49. Contralateral Hemi C7 Transfer

50. Osteotomy TBPI Some C5/6/7 recovery No wrist extension
Supinated forearm
Poor cosmesis and function

51. Osteotomy TBPI Some C5/6/7 recovery No wrist extension
Supinated forearm
Poor cosmesis and function

52. Osteotomy Plan Derotation osteotomy of forearm Wrist fusion
Wrist flexor to digital extensor transfer

53. Arthrodeses
Glenohumeral fusion
Wrist fusion
CMCJ fusion to thumb

54. Glenohumeral Arthrodesis 1
TBPI post XI to SSN and ICNs to MCN
Poor shoulder recovery
GHJ instability with “pistoning” with elbow flexion
Shoulder internal rotation with elbow flexion

55. Glenohumeral Arthrodesis 2

56. Glenohumeral Arthrodesis 3

57. Glenohumeral Arthrodesis 4
GHJ plate fusion
positioning

58. Tendon and Muscle Transfers
Trapezius to greater tuberosity
Latissimus dorsi to infraspinatus
Latissimus dorsi to Biceps
Pectoralis major rotationplasty to Biceps
Steindler flexorplasty for assisted elbow flexion
Pedicled Latissimus dorsi to finger flexors

59. Pectoralis to Biceps 1

60. Amputation: Scapulothoracic dissociation

61. Additional Procedures
Weak elbow flexion
If co-contraction biceps and triceps consider triceps to biceps transfer
If weak post Oberlin consider Steindler flexorplasty
Supination deformity after Biceps reinnervation
Derotation forearm osteotomy
Weak finger extension
Wrist arthrodesis and wrist flexor to finger extensor transfers

62. Prognosis in BPI Improved if young (<30 years)
Distal injuries do better (“Time Distance”)
Incomplete motor loss suggests a focal injury
Some neuropraxia likely
Partial plexus injury better than flaccid paralysis of whole arm
Pre-ganglionic signs do worse
Associated vascular injuries do worse

63. Research Areas in BPI Surgical Molecular Rehabilitation
Re-plantation of pre-ganglionic avulsions to the CNS
May reduce brachialgia
(Sciatic conduit to conus medullaris has been used to re-innervate glutei in paraplegics)
Molecular
Neural transmitters
Nerve growth factors
Neural tubes and neurotropism (Lundborg)
Rehabilitation
Sensory re-education
Neural plasticity
“Acoustic glove” Lundborg (Sweden)

64. Case1: Preganglionic C5/C6
Phrenic to MCN
XI to SSN

65. Case1: Preganglionic C5/C6
Phrenic to MCN
XI to SSN
Shoulder abduction 70
Biceps MRC 4
Returned to work as a soldier

66. Case1: Preganglionic C5/C6
Phrenic to MCN
XI to SSN
Shoulder abduction 70
Biceps MRC 4
Returned to work as a soldier
But scapular winging due to long thoracic palsy

67. Case 2: C5-T1 Avulsions
Poor results of shoulder & elbow neurotisations
>6/12 at presentation

68. Pediatric Brachial Plexus Palsy
Incidence 0.38 to 1.56 per 1000 LB
Perinatal risk factors:
- Macrosomia
- Maternal diabetes
- Multiparous pregnancy
- Previous deliveries resulting in PBPP
- Prolonged labor
- Breech delivery
- Shoulder dystocia
- Assisted and difficult deliveries

69. Pattern Most commonly involves the upper trunk (C5/6)
Rarest is insolated lower trunk
Upper trunk Extra-foraminal most common with vertex delivery and shoulder dystocia
Right upper limb involved most often because of most common LOA position in vertex delivery
C5-6 root avulsions most common with Breech delivery and at times bilateral
Mecahnical cause most common

70. Diagnosis Clinical diagnosis most important
Horner’s syndrome bad prognostic sign
Serial examinations over the first few weeks to months
Observation of spontaneous movements, neonatal reflexes, motor stimulation

71. Naraka’s Classification
I Classic Erb’s palsy. 46% cases. Successful spontaneous recovery in 90%
II Extended upper trunk (C5-7). Waiter’s tip. 29% cases
III Flail Extremity without Horner’s syndrome
IV Flail Extremity with Horner’s syndrome. May have associated phrenic nerve palsy and elevated hemi-diaphragm. Limited spontaneous recovery

72. Prognostic Indicators
Infants who recover anti-gravity biceps strength by 2-3 months have a complete recovery in 1-2 years
Infants who do not recover antigravity biceps strength by 5-6 months should undergo micro-surgical reconstruction
Infants with partial recovery of C5-7 anti-gravity strength will have permanent progressive limitations requiring extensive rehab and salvage surgery