Brachial plexus and peripheral nerve injuryinjury.pptx

Peripheral nerve injury presentation slide

1. BRACHIAL PLEXUS AND PERIPHERAL NERVE INJURY SYAZWANI SAEDI BINTI IDRIS SAEDI TAJUL ‘ATIQAH BINTI ZAULKAFALI NUR FATIHAH BINTI ZULKAFLI NUR DIYANA SAKINAH BINTI MUHAMAD RUSDI

2. OVERVIEW Introduction Pathogenesis Classification Examination techniques Ulnar nerve paradox Double crush syndrome Investigation Treatment

3. INTRODUCTION

4. PERIPHERAL NERVE MYELIN AXON NEURON SCHWANN CELL ENDONEURIUM FASCICLE EPINEURIUM PERINEURIUM BLOOD VESSEL NODES OF RANVIER

5. FUNCTION: Myelin: coating axon Axon: serving touch, pain, proprioception Schwann cell: producing myelin Nodes of Ranvier : where nerve impulses leap on

6. PATHOGENESIS

7. TRANSIENT ISCHEMIA Acute nerve compression Within: 15 min: numbness + tingling 30 min: Loss pain sensibility 45 min: Muscle weakness Relief of compression: Intense paraesthesiae (5 min) Restored sensation( 30 sec) Full muscle power (10 min)

8. N EUROPRAXIA Reversible Nerve conduction block Loss of some types of sensation and muscle power Spontaneous recovery ( days – weeks)

9. AXONOTMESIS Closed fracture and dislocations Conduction loss ( axon ruptured, intact neural tubes) Axonal regeneration within hours of nerve damage by Schwann cells New axon grow  join to end-organs  can function

10. NEUROTMESIS Nerve trunk ruptured, axonal continuity cannot be restored Jumbled knot/ neuroma produced Fail to reach end-organs Surgical intervention Function adequate but never normal

11. CLASSIFICATION

12. * Based on Apley’s System of Orthopaedics and Fractures, 9 th edition

13. SUNDERLAND CLASSIFICATION

14. WHY CLASSIFY?

15. BRACHIAL PLEXUS INJURY

16. MECHANISM INJURY Affect movement & cutaneous sensation in upper limb ~ 95% due to traction/compression Mechanism: Stab wound Traction (closed wound) Supraclavicular (65%) Infraclavicular (25%) Combined (10%) Others : - Obstetrics – Erb & Klumpke Postanaesthetic Radiation Tumour Iatrogenic

17. TRACTION INJURY Upper brachial plexus injury ( C5, C6, C7) -d/t forcible widening of shoulder-neck angle Lower brachial plexus injury (C8, T1) -when upper limb is suddenly pulled superiorly

18. CLINICAL FEATURES Based on: Level of lesion Pre or postganglionic lesion? Type of lesion

19. LEVEL OF LESION

20. PRE OR POSTGANGLIONIC LESION?

21. Features of root avulsion: Crushing/burning ( anaesthetic hand) Scapular muscle/ diapragm paralysed Horner’s syndrome: Ptosis Miosis Enophthalmos A nhidrosis Severe vascular injury Associated cervical spine fractures Spinal cord dysfunction

22. TYPE OF LESION To identify the severity of damage Mild (1 st /2 nd degree injury)  recover by 6/8 weeks Severe (3 rd /4 th degree injury) Neurotmesis  early operative exploration needed Based on: Mechanism injury Impact velocity

23. OBSTETRICAL BRACHIAL PLEXUS PALSY

24. SPECIFIC NERVE INJURY

25. Axillary Nerve Injury

26. Causes: Anterior-inferior shoulder dislocation Fracture of humeral head Clinical features: Cannot abduct the shoulder due to deltoid weakness Numbness over deltoid (C5 dermatomes) Treatment: Recovers spontaneously (If no sign of recovery by 8 weeks, nerve should explored and grafted) If operation fails, consider shoulder arthrodesis or tendon transfer

27. Radial Nerve Injury Radial nerve All muscles of posterior compartments of arm & forearm Skin of posterior & inferolateral arm, posterior forearm & dorsum of hand Branches: Superficial branch (innervate dorsum of hand) Deep branch which become posterior interosseous nerve

28. Can injured at elbow, upper arm and in axilla If there is no sign of recovery, nerve should be explored and repaired/grafted

29. Compression of the radial nerve at the upper arm while sleeping (Saturday night palsy) Compression of the radial nerve at axilla (crutch palsy)

30. Ulnar Nerve Injury Ulnar nerve Flexor carpi ulnaris & ulnar half of flexor digitorum profundus (forearm) Most intrinsic muscles of hand Skin of hand both dorsum and palmar of 5 th and half of 4 th digit Branches: Superficial branch of ulnar nerve Deep branch of ulnar nerve

31. Flexor carpi ulnaris Flexor digitorum profundus

32. Usually near the wrist or near the elbow

33. Ulnar Nerve Paradox Ulnar paradox – More proximal the lesion, less is the claw.  This is due to paralysis of flexor digitorum profundus which reduces flexion of the interphalangeal joint. If the lesion of the ulnar nerve occurs at the level of the wrist, the innervation of the medial half of the flexor digitorum profundus muscle (FDP), which is responsible for flexing the IP  joints (the two distal joints of the fingers), is unaffected . However, there will be paralysis of medial two lumbricals which function as to flex the MCP and to extend the IPJ. Thus creating the hyperextension of MCP joint in little and ring finger and flexion of IPJ forming the ‘claw hand’.

34. Median Nerve Injury Median nerve Muscles of anterior compartment of forearm (except for flexor carpi ulnaris & half of flexor digitorum profundus ) 5 intrinsic muscles in thenar , half of palm and palmar skin Branches: anterior interosseous palmar cutaneous

35. Commonly injured near the wrist or high up the forearm

36. Nerve Entrapment Syndromes When peripheral nerves tranverse fibro-osseous tunnels, they are at risk of compression if soft tissue increase in bulk. Condition increase in bulk: Pregnancy Myxodema Rheumatoid arthritis Local obstruction

37. Carpal Tunnel Syndrome The most common site for nerve compression O ccur in median nerve compression

38. Causes: Rheumatoid arthritis, diabetes,menopause , obesity,thyroid disorder, kidney failure, carpal fractures or dislocation Signs and Symptoms: R educe sensation and tingling over the distribution. Occur when wrist is held still in flexion or hyperextension (often at night when patient asleep) Relief by changing posture or shaking hand to get the circulation going P ositive Tinel or Phalen sign

39. Double Crush Syndrome Refers to a situation in which the compression of a peripheral nerve occurs at two sites at the same time If a nerve is impaired at one location it makes that patient more susceptible to other entrapments along the same course Examples: thoracic outlet syndrome and carpal tunnel syndrome

40. EXAMINATION OF PERIPHERAL NERVES OF UPPER LIMB AND LOWER LIMB Axillary nerve Radial nerve Median nerve Ulnar nerve Sciatic nerve Common peroneal nerve

41. Axillary nerve (C5,C6) Commonly damaged during shoulder dislocations and displaced fractures of the proximal humerus . Flattening over the lateral aspect of the shoulder result from muscle wasting. Examination: Deltoid contraction Sensation over the “regimental badge” area

42. Radial nerve : innervates muscle of the posterior compartment of arm and forearm and the overlying skin Deep radial (became Posterior interosseous )-extensors of fingers and wrist except extensor carpi radialis longus Superficial radial -sensory/ cutaneous

43. Radial nerve injury Sites of radial nerve injury Common mechanism of injury Motor deficit Sensory deficit Very high lesion ( at the axilla ) Crutch palsy Saturday night palsy Forearm extension, Extension of finger and wrist, Wrist drop Weakness of supination Lateral Arm Posterior Forearm Dorsum aspect of hand at the base of the thumb. high lesion (at the mid-arm) Mid shaft humeral fracture Extension of finger and wrist, Wrist drop Weakness of supination Posterior Forearm Dorsum aspect of hand at the base of the thumb. Low lesion (at the elbow) * Involved post.interosseous nerve, superficial intact Fracture or dislocation at the elbow Extension of finger at MCP joints Weakness of wrist extension Finger drop and partial wrist drop None as it supplied by superficial radial nerve

44. Examination Inspection : Wrist drop Wasting of forearm muscle Wasting of triceps

45. Muscle activity : test the extensors of the wrist and fingers the supinator muscle the brachioradialis the triceps (extension of elbow)

46. Sensory : Test sensory loss in the areas supplied by the nerve

47. Median nerve : Principle nerve of the anterior compartment of forearm. Anterior interosseous is its major branch

48. Median nerve injury sites of median nerve injury Common mechanism of injury Motor deficit Sensory deficit High median (forearm) Forearm fracture or elbow dislocation, tight cast Wasting of thenar eminence Thumb abduction Thumb opposition Flexion of thumb, index and middle fingers Pronation of forearm Radial three and half and of digits and the lateral palmar surface Low median (wrist) or in the carpal tunnel Cuts in fro nt of the wrist or carpal dislocation Wasting of thenar eminence Thumb abduction Thumb opposition Radial three and half and of digits and the lateral palmar surface Anterior interosseous (proximal forearm) Tight cast, forearm bone fracture Pronation of forearm Flexion of thumb, index and middle fingers none

49. Inspection: Thenar wasting Atrophy pulp of index Cracking of the nails

50. Muscles: Pronator teres Test power of flexor pollicis longus in the thumb Flexor digitorum profundus in index finger Ask patient to form circle with index and thumb and press their tips tightly Test abductor pollicis brevis

51. Sensory : Test sensory loss in the areas supplied by the nerve

52. Carpal tunnel syndrome Median nerve, sensitive structure in the carpel tunnel Inflammation of the synovial sheaths Wasting of thenar muscle Loss of coordination and strength in thumb Loss of sensory at radial three and half and of digits except central palm. (* palmar cutaneous branch of the median nerve)

53. Examination: Apply very firm, steady pressure with both thumbs for 30 sec. over the median nerve in the carpal tunnel Note the onset of numbness, pain or paraesthesia Phalen test Hold both wrists fully flexed for 1-2 min Noted exacerbation of paraesthesia

54. Low ulnar injury Injury to the nerve in the distal part of the forearm, denervates most intrinsic hand muscles . Hypothenar wasting Weak finger abduction Loss of thumb adduction ( froment’s sign ) Loss of sensation

55. Claw hand , the person cannot extend the interphalangeal joints when trying to straighten the fingers. This results from atrophy of the interosseous muscles of the hand. The claw is produced by the unopposed action of the extensors and FDP

56. Common peroneal nerves Motor distribution: Muscles of anterior compartment of the leg: Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus tertius Muscle of peroneal (lateral) compartment of the leg: Peroneus brevis and longus On the foot, extensor digitorum brevis

57. Sensory distribution the first web space (deep peroneal ) the dorsum of the foot and the front and lateral half of the leg (superficial peroneal )

58. Common peroneal nerve injury At the fibular neck, trauma in lateral ligament injuries of the knee or pressure from a splint or plaster cast.

59. Examination: Look for deformity of foot drop and abnormal gait. (either leg lifted high or foot slid along the ground) Test the dorsiflexion of the foot (deep peroneal ) Evert the foot (superficial peroneal ) Test the sensation in the area of distribution Note muscle wasting of the anterior and lateral half of the leg

60. Sciatic nerve(L4-S3) Losses include those seen in both tibial and common peroneal nerve palsies

61. Sciatic nerve injury Common mechanism of Injury Sensory loss Muscle deficit Posterior hip dislocation Entire sole of the foot Dorsum of the foot Lateral aspect of the leg and lateral half of the calf Wasting of muscle : The posterior thigh The calf Sole of the foot Drop foot Trophic ulceration Absent ankle jerk Loss of muscle power: Hamstring muscles of the calf Muscles of anterior and lateral compartment of the leg

62. Investigation and management of Brachial Plexus Injury

63. INVESTIGATIONS Radiography Chest x-ray : - Fracture of 1 st and 2 nd ribs Cervical spine - transverse process fracture indicate root avulsion Shoulder x-ray - Fracture of clavicle - Dislocation of shoulder

64. MRI Standard imaging for non-traumatic brachial plexopathies . Can differentiate pre/post-ganglionic injury Non-invasive, no radiation Diagnostic accuracy is relatively high Able to detect tumors that are invading the plexus from the area adjacent to it but difficult to distinguish the tumors since their features are non-specific. MRI has been shown to be less accurate in detecting nerve root avulsions compared to CTM and MRM

65. Magnetic Resonance M yelography (MRM) Diagnosis of traumatic meningoceles and nerve root avulsion N on-invasive, does not employ radiation, and is superior in the assessment of psuedomeningoceles compared to CTM. D iagnostic accuracy of 92% in root avulsion Figures 2 & 3:  CT myelogram showing a normal brachial plexus (left) and injured brachial plexus (right)

66. Electrodiagnostic studies Electromyography (EMG) Diagnostic procedure to assess the health of muscles and the nerve that control the muscles. EMG results can reveal nerve dysfunction, muscle dysfunction or problems with nerve-to-muscle signal transmission. For closed injuries can best be performed 4 to 6 weeks after the injury because to look for spontaneous recovery

67. 2) Nerve conduction study Measures sensory nerve action potential (SNAPs) Use electrode to detect nerve conduction Only reliable after one week Can distinguish between pre/ postganglionic

68. MANAGEMENT 1) Non-operative - observation alone waiting for recovery I ndications most managed with closed observation guns shot wounds (in absence of major vascular damage can observe for three months) S igns of neurologic recovery advancing Tinel sign

69. 2) Operative Immediate surgical exploration (< 1 week) I ndications sharp penetrating trauma Iatrogenic injuries open injuries progressive neurologic deficits expanding hematoma or vascular injury T echniques nerve repair nerve grafting neurotization

70. E arly surgical intervention (3-6 weeks) Indications - near total plexus involvement and with high mechanism of energy D elayed surgical intervention (3-6 months) I ndications partial upper plexus involvement and low energy mechanism plateau in neurologic recovery best not to delay surgery beyond 6 months T echniques usually involves tendon/muscle transfers to restore function

71. Surgical Technique for Brachial Plexus Injury Nerve exploration Primary repair Late repair Nerve guides Nerve graft Nerve transfer Tendon transfer

72. Nerve exploration Indications : To explore if there are any divided nerve that needs repair. To explore the causes of delayed recovery To explore when in doubt of diagnosis.

73. Nerve repair

74. Primary repair Performed within 7 days of injury Indications : sharp clean wound Delayed Repair weeks/months after the injury Indicated if i ) closed injury does not show any recovery ii) misdiagnosed, and patient presented late iii) failed primary repair

75. Nerve guide Give guides (tube) for nerve gaps to grow back Example silicone Simple way avoiding nerve graft as it is limited.  It is an artificial means of guiding axonal regrowth to facilitate nerve regeneration Prevent painful neuroma as nerve end goes hair-wired

76. Nerve graft When gaps too large for suturing Sural nerve most commonly used Attached by fine suture or fibrin glue

77. Nerve graft  Transplanting a nerve from the leg to reconnect damaged nerves Nerve transfer S ewing an adjacent, functioning nerve or part of a nerve into a non functioning nerve in an attempt to restore function in a paralyzed muscle

78. Tendon transfer   A functioning tendon is shifted from its original attachment to a new one To restore the action that has been lost. T he origin of the muscle is left in place ; the tendon insertion (attachment) onto bone is detached and re-sewn into a different place. Restore function

79. Investigation and Management : Peripheral Nerve Injury Investigation: EMG and nerve conduction study characteristic findings denervation of muscle neurogenic lesions

80. MANAGEMENT Non-operative Operative Observation with sequential EMG for 3 months Medication : NSAID, Physiotherapy -Developing gross and fine motor skills -Re-educating normal movement patterns -Stretching -Strengthening If there’s no progression of nerve healing After 3 months. -Surgical repair Indication : Neurotmesis (3 rd degree) Nerve grafting Indication : Nerve defects > 2.5 cm

81. Axillary nerve injury Investigation Radiography Electrodiagnostic study ( EMG, NCS) Management Non-operative : NSAIDs, arm sling, physiotherapy Usually recovers spontaneously Operative : If no sign of recovery by 8 weeks and investigation of electrodiagnostic study show denervation. Nerve should be explored and grafted. Good result if surgery done within 12 weeks. If surgery failed, consider tendon transfer.

82. Radial nerve injury Investigation : Radiography Electrodiagnostic study ( EMG, NCS) Management (depends on causes) Non-operative : NSAIDS, bracing and splinting, physiotherapy Operative : Open wounds : explored, nerve repaired or grafted Closed wounds : observe, if there is no sign of recovery by 8-12 weeks, nerve explored and repaired or grafted

83. Ulnar Nerve Injury Investigation Electrodiagnostic test (Electromyography, Nerve Conduction Study to locate the site of lesion) Imaging: radiography :  to look for bone spurs, arthritis, or other places that the bone may be compressing the nerve. Management Non Operative : NSAID , Bracing or splinting, Physiotherapy Operative : Exploration and suture of a divided nerve Transposing the nerve to the front of the elbow (due to cubital tunnel syndrome) Cubital tunnel release Medial epicondylectomy

84. Median Nerve Injury Investigation Electrodiagnostic test (Electromyography, nerve conduction study) Imaging: radiography (to look for fracture that cause impaired range of movement) Management Non Operative : NSAID , Bracing or splinting, Activity changes (use different hand, less burden on the hand, make way for healing process. Operative : Exploration and suture of a divided nerve Divide transverse ligament to make more space (decompression)

85. Musculocutaneous nerve injury Investigation Radiography Electrodiagnostic test (EMG, NCS) Management Spontaneous recovery is possible but may take several months Surgical decompression is indicated as first-line treatment if there is  paraesthesia , as this suggests that the affected nerve still has some function Repair and nerve grafts