branchial plexus nerve injuries ppt presentation.pptx

Injuries of the Brachial Plexus

1. AXILLA SSALI JULIUS

2. INTRODUCTION The axilla is a pyramid-shaped space between the upper part of the arm and the side of the chest. It forms an important passage for nerves, blood, and lymph vessels as they travel from the root of the neck to the upper limb.

3. BORDERS OF THE AXILLA Superior [clavicle, scapula, and first rib] Anterior [ pectoralis major and minor muscles] posterior [teres major, subscapularis , latissimus dorsi muscles] lateral [ humerus , the coracobrachialis,short head of the biceps ] medial [ serratus anterior and the first four ribs]

4. CONTENTS Axillary artery (and branches) Axillary vein (and tributaries)  Brachial plexus (and branches) Axillary lymph nodes Biceps brachii (short head) and coracobrachialis

5. NERVES The nerves entering the upper limb provide: sensory innervation to the skin and deep structures motor innervation to the muscles influence over the diameters of the blood vessels by the sympathetic vasomotor nerves sympathetic secretomotor supply to the sweat glands.

6. BRANCHIAL PLEXUS AND NERVE INJURIES PRESENTER: SSALI JULIUS SUPERVISOR: DR SSENYONJO, ORTHOPEDIC SURGEON

7. BRACHIAL PLEXUS It is formed in posterior triangle of the neck by the union of the anterior rami of the 5th, 6th, 7th , and 8th cervical and the 1st thoracic spinal nerves The plexus can be divided into roots (6), trunks(3), divisions(6), and cords(3)

8. Prefixed and postfixed A prefixed brachial plexus has been described as having a contribution to the plexus from C4 without a significant contribution from T1, while a postfixed brachial plexus has been described as having a T2 contribution without a significant contribution from C5.

9. THE BRANCHIAL PLEXUS

10. BRANCHIAL PLEXUS The roots of C5 and 6 unite to form the upper trunk T he root of C7 continues as the middle trunk T he roots of C8 and T1 unite to form the lower trunk Each trunk then divides into anterior and posterior divisions The anterior divisions of the upper and middle trunks unite to form the lateral cord T he anterior division of the lower trunk continues as the medial cord the posterior divisions of all three trunks join to form the posterior cord.

11. NERVES OF THE PLEXUS Roots Dorsal scapular nerve (C5) Long thoracic nerve (C5, 6, and 7) Upper trunk Nerve to subclavius (C5 and 6) Suprascapular nerve Lateral cord Lateral pectoral nerve Musculocutaneous nerve Lateral root of median nerve

12. NERVES OF THE PLEXUS Medial cord Medial pectoral nerve Medial cutaneous nerve of arm and medial cutaneous nerve of forearm Ulnar nerve Medial root of median nerve Posterior cord Upper and lower subscapular nerves Thoracodorsal nerve Axillary nerve Radial nerve

13. NERVE INJURIES These may follow trauma or nontrauma Trauma Sport injury Surgery Blunt or penetrating trauma Nontrauma Inflammatory Infectious Tomour traction

14. Winging of the scapular The three important muscles and their innervation Serratus anterior : Long thoracic nerve Trapezius: spinal accessory nerve rhomboids: Dorsal scapula nerve They stabilize the scapular during the action of other muscles Causes can be trauma or non trauma

15. LONG THORACIC NERVE INJURY I njury causes weakness and paralysis to serratus anterior. Causes medial winging of the scapular due to failed scapula abduction Boxer’s or swimmer’s palsy

16. SPINAL ACCESSORY NERVE INJURY Commonly damaged because of its long route and superficial. Injury is usually iatrogenic during surgical procedures in the posterior neck triangle clinically: Shoulder dropping Lateral winging of the scapular Shoulder pain, radiating to the upper back and ipsilateral arm

17. Suprascapular Nerve Entrapment Entrapment may occur as it passes through suprascapular notch or in spinoglenoid notch . S uprascapular notch entrapment leads to decreased shoulder abduction and loss of external rotation Spinoglenoid notch entrapment causes loss of external rotation

18. Axillary Nerve damage Axillary nerve ( innervate deltoid ) usually damaged by fractures of surgical neck of humerus or due to an inferior dislocation of shoulder joint. Effect Loss or weakness of abduction of shoulder Loss of sensation at the shoulder

19. Erb-Duchenne Paralysis Erb’s palsy

20. Erb-Duchenne Paralysis (Erb’s Palsy) Brachial plexus injury at Erb’s point C5, C6 ( upper trunk) Maybe due to excessive lateral flexion of the neck ( birth trauma and falling on head and shoulder) Absent or impaired moro reflex may be diagnotic Upper limb assumes typical “waiter’s tip position” Shoulder adducted and medially rotated. Elbow extended Forearm pronated

21. Klumpke’s palsy Injury to the lower truck (C8 ,T1) Its due to hyperabduction of the arm ( birth injury, trauma) and compression of the trunk ( tumour )

22. Radial nerve injury Severity and symptoms depend on site of lesion Most common clinical finding is wrist drop

23. Radial nerve injury(axilla) Cause : Prolonged use of crutches (Crutch Paralysis) Loss of extension of elbow due to paralysis of triceps Loss of extension of wrist due to paralysis of extensor muscles of forearm (Wrist Drop). Supination of forearm in elbow extension not possible (paralysis of supinator) Loss of sensation over Posterior surface of lower part of arm and narrow strip over back of forearm Over lateral side of dorsum of hand and lateral 3½ fingers

24. Radial Nerve Injury (Radial Groove) Causes: Fracture of shaft of humerus Improper intramuscular injection Prolonged pressure Effects: Triceps brachii is spared (extension of elbow is possible) Other effects are similar as those of a lesion of radial nerve in axilla

25. Ulnar nerve Usually injured at following sites: Elbow Cubital tunnel Wrist Hand Effects depending on site of lesion

26. Ulnar nerve(elbow and cubital tunnel) Easily damaged (lies in ulnar groove behind medial epicondyle of humerus) Causes: Fracture of medial epicondyle Effects: Loss of flexion of terminal phalanges of ring and little finger due to paralysis of flexor digitorum profundus (medial half) Weakness of flexion and adduction of wrist due to paralysis of flexor carpi ulnaris Loss of adduction and abduction of fingers due to paralysis of Palmar (adductors) and dorsal (abductors) interossei Loss of adduction of thumb due to paralysis of adductor pollicis . Flattening of hypothenar eminence and depression of interosseous space due to atrophy of hypothenar and interosseous muscles

27. Median Nerve injury Injury usually injured at following sites: Axilla Wrist Carpal Tunnel Effects depending on site of lesion

28. Median nerve injury( axila ) Motor Effects : Weakness of pronation of forearm due to paralysis of pronators. Deviation of wrist to Ulnar side on wrist flexion due to unopposed action of flexor carpi ulnaris . Weakness of flexion of distal phalanx of thumb and index finger. Wasting of thenar muscles due to paralysis. Loss of opposition of thumb due to paralysis of opponens pollicis . Loss of flexion and weakness of abduction of thumb. Ape-hand deformity

29. Median nerve injury( axila ) Sensory Effects: Loss of cutaneous sensations over palmar surface of lateral 3½ digits and radial two-thirds of palm

30. Medial Nerve Injury at Carpal Tunnel (Carpal Tunnel Syndrome) Compression of medial nerve in carpal tunnel. Causes Tendosynovitis Bony encroachment (osteoarthritis/injury) Symptoms Painful paraesthesia and numbness affecting radial 3½ digits of hand Wasting and weakness of thenar muscles. Loss of sensation or hypoaesthesia to light touch and pin prick over palmar aspect of radial 3½ digits and corresponding part of hand except skin over thenar eminence

31. read Test for radial, median and the ulnar nerves