Approach

• Ensure both limbs fully exposed
• May have mixed picture of upper and lower brachial plexus injuries

1. Formed by anterior rami of C5, 6, 7,8 T1
2. 3 trunks: upper, middle, lower (posterior triangle of neck)
3. 6 divisions
4. 3 cords: lateral, medial, posterior (named in relation to axillary artery)
5. Branches

Vital points

1. Mechanism of injury
   • Traction injury: suspect lower brachial plexus
   • Fall onto tip of shoulder: suspect upper brachial plexus
2. Clinical consequences
   • Pain / sensory loss / parasthesia / weakness
3. Functional consequences
   • Use of limb for ADLs
4. Treatments
   • Contracture release
   • Nerve repair
   • Tendon transfers
5. Effect on quality of life

Examination

1. Inspect
   • Waiter's tip: Erb-Duchenne palsy: adducted shoulder, extended elbow, forarm pronation and internally rotated
   • Claw hand: Klumpe-Dejerne palsy: paralysis of small / intrinsic muscles of the hand
   • Scars
   • Muscle wasting
   • Fasciulations
   • Inspect face
2. Tone
   • Flaccid and hypotonic

3. Power
   • Shoulder abduction@ c5
   • Shoulder adductio: c5-7
   • Elbow flexion: c5-6
   • Elbow extension c7
   • Wrist flexion: c7-8
   • wrist extension: c7
   • Finger flexion: c7-8
   • Finger extension: c7-8
   • Finger abduction: T1

     MRC (Medical research council grading of muscle power)

     M0 - no contraction
     M1 - flicker
     M2 - movement with gravity eliminated
     M3 - active movement against gravity
     M4 - Active movement against gravity and resistance
     M5 - normal

4. Sensation
   • Light touch (dorsal columns)
   • Pain / temperature (spinothalamic)
5. Co-ordination
6. Reflexes

   S1/2: Ankle
   L3/4: Knee
   C5/6: Biceps / supinator
   C7/8: Triceps jerk

Completion

1. Examination of neck

Features of a preganglionic and post ganglionic injury

• Bruising in posterior triangle
• Pain in an insensate hand
• Loss of sensation above clavicle
• Ipsilateral Horner's
• Loss of muscle function
• Worse prognosis in pre ganglionic as no peripheral nerve tissue to repair

Assessment of prognosis of brachial plexus injury

Pattern of injury

1. Root avulsion
   • Not amenable to repair
2. Rupture
   • of plexus outside vertebral column
   • Unlikely to heal spontaneously, surgery may be of benefit
3. Nerve damage without rupture
   • Improvement likely to occur spontaneously

Management of Brachial plexus injuries

1. Closed: staged
   1. Stage I (3 months) - treat expectantly, assess clinically and electrophysiologically
   2. Stage II (3-6motnhs): if improvement, treat expectantly, if not - nerve exploration
   3. Stage III: nerve exploration and repair
   4. Stage IV: active therapy (after repair)
   5. Stage V (2 years): final assessment of recovery made and adjucnt procedures considered, such as tendon transfer
2. Open
   1. Primary epineural repair