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Trauma pada Pleksus Brakialis

ANATOMI PLEKSUS BRAKIALIS


Ramus anterior saraf spinal C5 sampai T1 bergabung membentuk pleksus brakialis. C5 dan C6 berbgabung
membentuk trunk superior, C7 membentuk trunk medial, dan C8 dan T1 bergabung membentuk trunk inferior.
Cord medial merupakan divisi anterior dari trunk inferior. Divisi anterior yang berasal dari upper dan middle
trunk membentuk cord lateral.Divisi posterior berasal 3 trunk membentuk posterior cord. Dari ketiga cord
tersebut keluar cabang saraf yang menginervasi anggota gerak atas antara lain n muskulokutaneus berasal dari
cord lateral, n medianus berasal dari cord lateral dan medial, n radialis dari cord posterior, n aksilaris dari cord
posterior dan n ulnaris dari cord medial.
Long thorasic dan dorsal scapular berasal langsung dari root saraf spinal. Hanya n suprascapular (C5 C6) yang
berasal dari trunk.
Saraf spinal keluar dari foramina vertebralis dan melewati scalenus anterior dan medial, kemudian antara
klavikula dan rusuk pertama didekat coracoid dan caput humerus. Pleksus pada bagian praosimal bergabung di
prevertebral dan oleh axillary sheath di mid arm.
PENYEBAB
Ada banyak kemungkinan penyebab lesi pleksus brakialis. Trauma adalah penyebab yang paling sering, selain
itu juga kompresi lokal seperti pada tumor, idiopatik, radiasi, post operasi dan cedera saat lahir.
PATOFISIOLOGI
Bagian cord akar saraf dapat terjadi avulsi atau pleksus mengalami traksi atau kompresi. Setiap trauma yang
meningkatkan jarak antara titik yang relatif fixed pada prevertebral fascia dan mid fore arm akan melukai
pleksus.
Traksi dan kompresi dapat juga menyebabkan iskemi, yang akan merusak pembuluh darah. Kompresi yang berat
dapat menyebabkan hematome intraneural, dimana akan menjepit jaringan saraf sekitarnya.
KLASIFIKASI LESI
1. Lesi Upper Plexus
Erb-Duchenne Paralysis (C5 C6)
Kelemahan atau paralisis pada bahu dan bicep, kadang disertai trauma pada root C7 yang menyebabkan
paralisa lengan bawah.
2. Lesi Lower Plexus
Dejerine-Klumpkes Paralysis (C8 T1)
Kadang disertai kerusakan root C7, paralisis pada otot intrisik tangan dan fleksor jari yang menyebabkan
kehilangan fungsi tangan dan lengan bawah. Sering terjadi sympathetic palsy Horners syndrome
3. Lesi Total Brachial
Erb-Klumpke Paralysis (C5 T1)
Komplet paralisis dan anestesi dari lengan
4. Lesi Posterior Cord
Mengenai root C5 C6 C7 C8, paralisis pada deltoid, ekstensor elbow, ekstensor wrist, extensor fingers.
GAMBARAN KLINIS

Terdapat riwayat trauma yang melibatkan ekstensi servikal, rotasi, lateral bending, dan depresi atau
hiperabduksi dari bahu. Pasien juga mengeluhkan kelemahan, kehilangan sensori, parasetesia pada lengan.
Mekanisme trauma dapat berupa tarikan, luka tembus, hantaman atau kompresi
Pemeriksaan dilakukan pada tulang leher, bahu, kalvikula, skapula serta sendi untuk luas gerak sendi, alignment,
dan tender point.
Pemeriksaan neurologis meliputi pemeriksaan motorik, pemeriksaan sensorik dan reflek tendon dalam
Pemeriksaan sensorik dapat berupa light touch sensation, pinprick sensation, 2-point discrimination, vibrasi dan
proprioseptif
Evaluasi juga dilakukan untuk memeriksa joint instability, dan winging skapula, pola atrofi otot dibandingkan
dengan sisi yang sehat, tanda-tanda sindrom Horner, serta pemeriksaan untuk spinal cord dan brain injury.
DIAGNOSA BANDING
Guilain-Barre Syndrome
Multiple Sclerosis
Spinal Cord Injury
Traumatic Brain Injury
PEMERIKSAAN PENUNJANG
Pemeriksaan Radiografi
1. Foto vertebra servikal untuk mengetahui apakah ada fraktur pada vertebra servikal
2. Foto bahu untuk mengetahui apakah ada fraktur skapula, klavikula atau humerus.
3. Foto thorak untuk melihat disosiasi skapulothorak serta tinggi diafragma pada kasus paralisa saraf
phrenicus.
EMG NVC
1. Pemeriksaan NCV untuk mengetahui system motorik dan sensorik, kecepatan hantar saraf serta latensi
distal.
SNAPs (sensory nerve action potentials) berguna untuk membedakan lesi preganglionic atau lesi
postganglionic. Pada lesi postganglionic, SNAPs tidak didapatkan tetapi positif pada lesi preganglionic.
2. Pemeriksaan EMG dengan jarum pada otot dapat tampak fibrilasi, positive sharp wave (pada lesi
axonal), amplitudo dan durasi.
SSEP (Somatosensory evoked potensials)
Berguna untuk membedakan lesi proksimal misalnya pada root avulsion
MRI dan CT SCAN
Untuk melihat detail struktur anatomi dan jaringan lunak saraf perifer.
PENATALAKSANAAN
BEDAH
Regangan dan memar pada pleksus brakialis diamati selama 4 bulan, bila tidak ada perbaikan, pleksus harus
dieksplor. Nerve transfer (neurotization) atau tendon transfer diperlukan bila perbaikan saraf gagal.1
1. Pembedahan Primer
Pembedahan dengan standart microsurgery dengan tujuan memperbaiki injury pada plexus serta
membantu reinervasi. Teknik yang digunakan tergantung berat ringan lesi.
1. Neurolysis : Melepaskan constrictive scar tissue disekitar saraf.
2. Neuroma excision : Bila neuroma besar, harus dieksisi dan saraf dilekatkan kembali dengan teknik
end-to-end atau nerve grafts
3. Nerve grafting: Bila gap antara saraf terlalu besar, sehingga tidak mungkin dilakukan tarikan. Saraf yang
sering dipakai adalah n suralis, n lateral dan medial antebrachial cutaneous, dan cabang terminal sensoris
pada n interosseus posterior

4. Neurotization : Neurotization pleksus brachialis digunakan umumnya pada kasus avulsi pada akar saraf
spinal cord. Saraf donor yang dapat digunakan : hypoglossal nerve, spinal accessory nerve, phrenic
nerve, intercostal nerve, long thoracic nerve dan ipsilateral C7 nerve. Intraplexual neurotization
menggunakan bagian dari root yang masih melekat pada spinal cord sebagai donor untuk saraf yang
avulsi.
2. Pembedahan Sekunder
Tujuan untuk meningkatkan seluruh fungsi extremitas yang terkena. Ini tergantung saraf yang terkena.
Prosedurnya berupa tendon transfer, pedicled muscle transfers, free muscle transfers, joint fusions and
rotational, wedge or sliding osteotomies.
REHABILITASI PASKA TRAUMA PLEKSUS BRAKIALIS
Paska operasi Nerve repair dan graft.
Setelah pembedahan immobilisasi bahu dilakukan selama 3-4 minggu. Terapi rehabilitasi dilakukan setelah 4
minggu paska operasi dengan gerakan pasif pada semua sendi anggota gerak atas untuk mempertahankan luas
gerak sendi. Stimulasi elektrik diberikan pada minggu ketiga sampai ada perbaikan motorik. Pasien secara terus
menerus diobservasi dan apabila terdapat tanda-tanda perbaikan motorik, latihan aktif bisa segera dimulai.
Latihan biofeedback bermanfaat bagi pasien agar otot-otot yang mengalami reinnervasi bisa mempunyai kontrol
yang lebih baik.
Paska operasi free muscle transfer
Setelah transfer otot, ekstremitas atas diimobilisasi dengan bahu abduksi 30, fleksi 60 dan rotasi internal, siku
fleksi 100. Pergelangan tangan posisi neutral, jari-jari dalam posisi fleksi atau ekstensi tergantung jenis
rekonstruksinya.
Ekstremitas dibantu dengan arm brace dan cast selama 8 minggu, selanjutnya dengan sling untuk mencegah
subluksasi sendi glenohumeral sampai pulihnya otot gelang bahu.
Statik splint pada pergelangan tangan dengan posisi netral dan ketiga sendi-sendi dalam posisi intrinsik plus
untuk mencegah deformitas intrinsik minus selama rehabilitasi. Dilakukan juga latihan gerak sendi gentle pasif
pada sendi bahu, siku dan semua jari-jari, kecuali pada pergelangan tangan.
Pemberian elektro stimulasi pada transfer otot dan saraf yang di repair dilakukan pada target otot yg paralisa
seperti pada otot gracilis, tricep brachii, supraspinatus dan infraspinatus.
Elektro stimulasi intensitas rendah diberikan mulai pada minggu ketiga paska operasi dan tetap dilanjutkan
sampai EMG menunjukkan adanya reinervasi.
Enam minggu paska operasi selama menjaga regangan berlebihan dari jahitan otot dan tendon, dilakukan
ekstensi pergelangan tangan dan mulai dilatih pasif ekstensi siku. Sendi metacarpal juga digerakkan pasif untuk
mencegah deformitas claw hand.
Ortesa fungsional digunakan untuk mengimobilisasi ekstremitas atas. Dapat digunakan tipe airbag (nakamura
brace) untuk imobilisasi sendi bahu dan siku.
Sembilan minggu paska operasi, ortesa airbag dilepas dan ortesa elbow sling dipakai untuk mencegah subluksasi
bahu.
Setelah Reinervasi
Setelah EMG menunjukkan reinervasi pada transfer otot, biasanya 3 - 8 bulan paska operasi, EMG biofeedback
dimulai untuk melatih transfer otot menggerakkan siku dan jari.
Teknik elektromiografi feedback di mulai untuk melatih otot yang ditransfer untuk menggerakkan siku dan jari
dimana pasien biasanya kesulitan mengkontraksikan ototnya secara efektif.
Pada alat biofeedback terdapat level nilai ambang yang dapat diatur oleh terapis atau pasien sendiri. Saat otot
berkontraksi pada level ini, suatu nada berbunyi, layar osciloskop akan merekam respons ini. Level ini dapat
diatur sesuai tujuan yang akan dicapai.
Lempeng elektroda ditempelkan pada otot, kemudian pasien diminta untuk mengkontraksikan ototnya. Pada saat
permulaan biasanya EMG discharge sulit didapatkan, tetapi dengan latihan yang kontinu, EMG discharge otot
akan mulai tampak.
Latihan EMG biofeedback dilakukan 4 kali seminggu dan tiap sesi selama 10 - 70 menit, dan latihan segera
dihentikan bila ada tanda-tanda kelelahan..
Efektivitas latihan biofeedback tidak dapat dicapai bila pasien tidak mempunyai motivasi dan konsentrasi yang

cukup.

Reedukasi otot diindikasikan saat pasien menunjukkan kontraksi aktif minimal yang tampak pada otot dan
group otot. Tujuan reedukasi otot untuk pasien adalah mengaktifkan kembali kontrol volunter otot. Ketika
pasien bekerja dengan otot yang lemah, intensitas aktivitas motor unit dan frekuensi kontraksi otot akan
meningkat. Waktu sesi terapi seharusnya pendek dan dihentikan saat terjadi kelelahan dengan ditandai
penurunan kemampuan pasien mencapai tingkat yang diinginkan.
Pemanasan, ultrasound diatermi, TENS, interferensial stimulasi, elektro stimulasi dapat dipergunakan sesuai
indikasi. Dilakukan juga penguatan otot-otot leher dan koreksi imbalans otot-otot ekstremitas atas.
Terapi Okupasi
Terapi okupasi terutama diperlukan untuk :
Memelihara luas gerak sendi bahu, membuat ortesa yg tepat untuk membantu fungsi tangan, siku dan lengan,
mengontrol edema defisit sensoris.
Melatih kemampuan untuk menulis, mengetik, komunikasi.
Menggunakan teknik-teknik untuk aktivitas sehari-hari, termasuk teknik menggunakan satu lengan,
menggunakan peralatan bantu serta latihan penguatan dengan mandiri.
Terapi Rekreasi
Terapi ini sebagai strategi dan aktivitas kompensasi sehingga dapat menggantikan berkurang dan hilangnya
fungsi ekstremitas.
Ortesa pada paska Trauma Pleksus Brakialis
Pada umumnya penderita dengan injury pleksus brakialis akan menggunakan lengan disisi kontralateral untuk
beraktivitas. Pada beberapa kasus, penderita memerlukan kedua tangan untuk melakukan aktivitas yang lebih
kompleks. Untuk itu orthosis didesain sesuai kebutuhan penderita
Orthosis untuk penderita injury pleksus brakialis dibuat terutama untuk mensuport bagian bahu dan siku

Sedangkan untuk prehension tangan, umumnya terbatas pada metode kontrolnya sehingga tidak banyak
didesain. Beberapa orthosis digerakkan menggunakan sistem myoelektrik, sehingga penderita mampu
melakukan gerakan pada pergelangan tangan dan pinch pada jari-jarinya

Orthosis ini dapat membantu penderita paska trauma untuk melakukan aktivitas sehari-hari seperti makan dan
minum dari gelas atau botol, menyisir rambut, menggosok gigi, menulis menggambar, membuka dan menutup
pintu, membawa barang-barang.

Brachial Plexus Injury (BPI)


What is the brachial plexus?
The brachial plexus is a network of nerves that originate in the neck region and branch off to
form most of the other nerves that control movement and sensation in the upper limbs,
including the shoulder, arm, forearm, and hand. The radial, median, and ulnar nerves
originate in the brachial plexus.

Causes of a brachial plexus injury


Brachial plexus injury (BPI) is an umbrella term for a variety of conditions that may impair
function of the brachial plexus nerve network. The majority of pediatric and adult brachial
plexus injuries are caused by trauma. The most common inciting events may include:

High-speed vehicular accidents, especially motorcycle accidents

Blunt trauma

Stab or gunshot wounds

Inflammatory processes (brachial plexitis)

Compression (for example caused by a growing tumor)

Neuropathies

A brachial plexus injury occurring during birth is called birth related brachial plexus palsy
or obstetric brachial plexus palsy.

What is obstetric brachial plexus palsy?


Obstetric brachial plexus palsy occurs in less than 1% of live births. It is most common when
there is difficulty delivering the baby's shoulder. During delivery, the baby's shoulder may
become impacted on the mothers pubic bone causing the brachial plexus nerves to stretch or
tear (shoulder dystocia). The prognosis for recovery depends on the pattern, complexity, and
severity of injury. Erb's Palsy refers to an injury of the upper brachial plexus nerves leading
to loss of motion around the shoulder and ability to flex the elbow. Klumpke's palsy refers to
an injury of the lower brachial plexus leading to loss of motion in the wrist and hand.

Types of brachial plexus injuries


Brachial plexus injuries are categorized according to the type of trauma experienced by the
nerve. The following are the types of brachial plexus injuries:

Avulsion this means the nerve has been pulled out from the spinal cord and has no
chance to recover.

Rupture this means the nerve has been stretched and at least partially torn, but not
at the spinal cord.

Neurapraxia this means the nerve has been gently stretched or compressed but is
still attached (not torn) and has excellent prognosis for rapid recovery

Axonotemesis this means the axons (equivalents of the copper filaments in an


electric cable) have been severed. The prognosis is moderate.

Neurotemesis this means the entire nerve has been divided. The prognosis is very
poor.

Neuroma this refers to a type of tumor that grows from a tangle of divided axons
(nerve endings), which fail to regenerate. The prognosis will depend on what
percentage of axons do regenerate.

Symptoms of a brachial plexus injury


BPI may result in some of the following symptoms:

Pain

Loss of sensation

Muscle weakness

Paralysis of some or all of the muscles of the shoulder and upper limb

Some patients may experience avulsion pain (a burning, crushing type of pain) in the
distribution of the injured nerves.

Podcast: Brachial Plexus Injury and Treatment

Dr Allan Belzberg describes the brachial plexus nerve system and how to treat an injury ...
Date: 11/26/2010
More Podcasts

Diagnosis of brachial plexus injury


Due to the complex spectrum of brachial plexus injuries, a detailed and comprehensive
understanding of the exact nature of injury in each patient is required for proper management.
Multiple modalities are utilized to diagnose a brachial plexus injury including:

History taking and clinical examination

Electrodiagnostic studies (EMG, NCV, SNAP, SSEP)

Imaging studies (CT, MRI)

Some of these evaluations may need to be repeated on a regular basis to track the progression
of recovery of function. Used in combination, these modalities provide valuable insights into
the elements of the brachial plexus that have been injured including information about the
severity of the injury and prognosis.

Treatment for a brachial plexus injury


Due to the broad spectrum of brachial plexus injuries, it is difficult to estimate the rate of
spontaneous recovery. The potential for spontaneous recovery depends on the type and
severity of injury. Therefore, prognosis must be assessed for each patient individually based
on the type and severity of their injury, and the progression of any spontaneous recovery that
may be occurring.

Nonsurgical treatment options for brachial plexus injuries


Depending on the degree of severity, some nerve injuries are able to heal on their own. If this
is not a viable option for a particular patient, a surgical option may be recommended by the
physician. Physical rehabilitation therapy is always part of the recovery process for a brachial
plexus injury.

Surgical treatment options for brachial plexus injuries


The degree of functional impairment and potential for recovery depend on the mechanism,
type, complexity of the brachial plexus injury, and time from injury. The most important
decision your surgeons will make is determining if and when surgical intervention should
occur. Learn more about surgery for a brachial plexus injury.

Brachial plexus injury

The brachial plexus is a network of nerves that conducts signals from the spinal cord, which
is housed in the spinal canal of the vertebral column (or spine), to the shoulder, arm and hand.
These nerves originate in the fifth, sixth, seventh and eighth cervical (C5-C8), and first
thoracic (T1) spinal nerves, and innervate the muscles and skin of the chest, shoulder, arm
and hand. Brachial plexus injuries, or lesions, are caused by damage to those nerves.[1][2][3]
Brachial plexus injuries, or lesions, can occur as a result of shoulder trauma, tumours, or
inflammation. The rare Parsonage-Turner Syndrome causes brachial plexus inflammation
without obvious injury, but with nevertheless disabling symptoms.[1][4] But in general, brachial
plexus lesions can be classified as either traumatic or obstetric. Obstetric injuries may occur
from mechanical injury involving shoulder dystocia during difficult childbirth.[5] Traumatic
injury may arise from several causes. "The brachial plexus may be injured by falls from a
height on to the side of the head and shoulder, whereby the nerves of the plexus are violently
stretched....The brachial plexus may also be injured by direct violence or gunshot wounds, by
violent traction on the arm, or by efforts at reducing a dislocation of the shoulder joint".[6]

Anatomy

This image shows the anterior view of the 5 brachial plexus nerves on the human arm.
Axillary,Median,Musculocutaneous,Radial,Ulnar.
The brachial plexus is made up of spinal nerves that are part of the peripheral nervous
system. It includes sensory and motor nerves that innervate the upper limbs. The brachial
plexus includes the last 4 cervical nerves (C5-C8) and the 1st thoracic nerve (T1). Each of
those nerves splits into smaller trunks, divisions, and cords. The lateral cord includes the
musculocutaneous nerve and lateral branch of the median nerve. The medial cord includes the
medial branch of the median nerve and the ulnar nerve. The posterior cord includes the
axillary nerve and radial nerve.[7]

Epidemiology

Adults
The epidemiology of brachial plexus injury also known as BPI is found in both children and
adults, but there is a difference between children and adults with BPI.[8] The occurrence of
adult brachial plexus injuries in the 1900s multiple traumatic injuries for North America
population is with a prevalence of about 1.2%.[8] BPI is most commonly found with young
healthy adults, from ages 14 to 63 years old, along with 50% of patients between the ages of
19 and 34 years old, and with male patients being 89% at risk[8]

Figure 2. BPI Traumatic event

Children
As for the epidemiology of brachial plexus injury in children OBPP also known, as
obstetrical brachial plexus palsy occurred the most for young children ranging from 0.38 to
1.56 per 1000 live births due to the type of care and the average birth weight of infants in
different regions of the world.[8] For example a study was done for the incidence of OBPP
where USA is about 1.51 cases per 1000 live births, a Canadian study, where the incidence
was between 0.5 and 3 injuries per 1000 live Birth, and European countries, such as a Dutch
study reported an incidence of 4.6 per 1000 births.[8] Newborns with brachial plexus injury
was most commonly found in Diabetic women whose babies weighed more than 4.5 kg at
birth along with different types of deliveries.[9] Brachial plexus injury risks for newborns are
increased with gained birth weight, birth delivery where a vacuum is assisted, and not being
able to handle glucose.[10] Brachial plexus injury is a traumatic event and that has been shown
to increase over the years.[11]

Figure 3. Incidence of OBPP

Traumatic Injuries
BPI has shown to occur 44% through 70% with traumatic injuries, such as motorcycle
accidents, sporting activities, or even at the work places.[8] With 22% being motorcycle
injuries and about 4.2% having plexus damage.[8] People that have accidents with riding
motorcycles and snowmobiles, have higher risks of getting BPI.[12]

Figure 4. Motorcycles and BPI

Causes
In most cases the nerve roots are stretched or torn from their origin, since the meningeal
covering of a nerve root is thinner than the sheath enclosing the nerve. The epineurium of the
nerve is contiguous with the dura mater, providing extra support to the nerve.
Brachial plexus lesions typically result from excessive stretching; from rupture injury where
the nerve is torn but not at the spinal cord; or from avulsion injuries, where the nerve is torn
from its attachment at the spinal cord. A build-up of scar tissue around a brachial plexus
injury site can also put pressure on the injured nerve, disrupting innervation of the muscles.
Although injuries can occur at any time, many brachial plexus injuries happen during birth:
the baby's shoulders may become impacted during the birth process causing the brachial
plexus nerves to stretch or tear. Obstetric injuries may occur from mechanical injury
involving shoulder dystocia during difficult childbirth, the most common of which result
from injurious stretching of the child's brachial plexus during birth, mostly vaginal, but
occasionally Caesarean section. The excessive stretch results in incomplete sensory and/or
motor function of the injured nerve.[2][5]
Injuries to the brachial plexus result from excessive stretching or tearing of the C5-T1 nerve
fibers. These injuries can be located in front of or behind the clavicle, nerve disruptions, or
root avulsions from the spinal cord. These injuries are diagnosed based on clinical exams,
axon reflex testing, and electrophysiological testing.[13] Brachial plexus injuries require quick
treatment in order for the patient to make a full functional recovery (Tung, 2003). These types
of injuries are most common in young adult males.[14]
Traumatic brachial plexus injuries may arise from several causes, including sports, highvelocity motor vehicle accidents, especially in motorcyclists, but also all-terrain-vehicle
(ATV) accidents. Injury from a direct blow to the lateral side of the scapula is also possible.
The severity of nerve injuries may vary from a mild stretch to the nerve root tearing away
from the spinal cord (avulsion). "The brachial plexus may be injured by falls from a height on
to the side of the head and shoulder, whereby the nerves of the plexus are violently
stretched...The brachial plexus may also be injured by direct violence or gunshot wounds, by
violent traction on the arm, or by efforts at reducing a dislocation of the shoulder joint".[6]
Brachial plexus lesions can be divided into three types:
1. An upper brachial plexus lesion, which occurs from excessive lateral neck flexion
away from the shoulder. Most commonly, forceps delivery or falling on the neck at an
angle causes upper plexus lesions leading to Erb's palsy.[6] This type of injury

produces a very characteristic sign called Waiter's tip deformity due to loss of the
lateral rotators of the shoulder, arm flexors, and hand extensor muscles.[2][15]
2. Less frequently, the whole brachial plexus lesion occurs;[16]
3. most infrequently, sudden upward pulling on an abducted arm (as when someone
breaks a fall by grasping a tree branch) produces a lower brachial plexus lesion, in
which the eighth cervical (C8) and first thoracic (T1) nerves are injured "either before
or after they have joined to form the lower trunk. The subsequent paralysis affects,
principally, the intrinsic muscles of the hand and the flexors of the wrist and fingers".
[6]
This results in a form of paralysis known as Klumpke's paralysis.[6][17]

Injury Mechanism of Brachial Plexus


Injury to the brachial plexus can happen in numerous environments. These may include
contact sports, motor vehicle accidents and birth.[18] Although these are but a common few
events, there is one of two mechanisms of injury that remain constant during the point of
injury. The two mechanisms that can occur are traction and heavy impact.[19] These two
methods disturb the nerves of the brachial plexus and cause the injury.[20]

Traction, also known as stretch injury, is one of the mechanisms that cause brachial plexus
injury. The nerves of the brachial plexus are damaged due to the forced pull by the widening
of the shoulder and neck. This is a closer look at the traction mechanism at the cervical spine.
The arrowed red line represents the stretch of the nerves. Depending on the force, lesions
may occur.

Traction
Traction occurs from severe movement and causes a pull or tension among the nerves. There
are two types of traction: downward traction and upward traction. In downward traction there
is tension of the arm which forces the angle of the neck and shoulder to become broader. This
tension is forced and can cause lesions of the upper roots and trunk of the nerves of the
brachial plexus. Upward traction also results in the broadening of the neck and shoulder angle
but this time the nerves of T1 and C8 are torn away.[21]

Impact
Heavy impact to the shoulder is the second common mechanism to causing injury to the
brachial plexus. Depending on the severity of the impact, lesions can occur at all nerves in the

brachial plexus. The location of impact also affects the severity of the injury and depending
on the location the nerves of the brachial plexus may be ruptured or avulsed. Some forms of
impact that affect the injury to the brachial plexus are shoulder dislocation, clavicle fractures,
hyperextension of the arm and sometimes delivery at birth.[22] During the delivery of a baby,
the shoulder of the baby may graze against the pelvic bone of the mother. During this process,
the brachial plexus can receive damage resulting in injury. The incidence of this happening at
birth is 1 in 1000.[23] This is very low compared to the other identified brachial plexus
injuries.[18]

impact injury of bpi

Injury Classification
The severity of brachial plexus injury is determined by the type of nerve damage.[1] There are
several different classification systems for grading the severity of nerve and brachial plexus
injuries. Most systems attempt to correlate the degree of injury with symptoms, pathology
and prognosis. Seddon's classification, devised in 1943, continues to be used, and is based on
three main types of nerve fiber injury, and whether there is continuity of the nerve.[24]
1. Neurapraxia: The mildest form of nerve injury. It involves an interruption of the nerve
conduction without loss of continuity of the axon. Recovery takes place without
wallerian degeneration.[24][25]
2. Axonotmesis: Involves axonal degeneration, with loss of the relative continuity of the
axon and its covering of myelin, but preservation of the connective tissue framework
of the nerve (the encapsulating tissue, the epineurium and perineurium, are
preserved).[24][26]
3. Neurotmesis: The most severe form of nerve injury, in which the nerve is completely
disrupted by contusion, traction or laceration. Not only the axon, but the
encapsulating connective tissue lose their continuity. The most extreme degree of
neurotmesis is transsection, although most neurotmetic injuries do not produce gross
loss of continuity of the nerve but rather, internal disruption of the nerve architecture

sufficient to involve perineurium and endoneurium as well as axons and their


covering. It requires surgery, with unpredictable recovery.[24][27]
A more recent and commonly used system described by the late Sir Sydney Sunderland,[28]
divides nerve injuries into five degrees: first degree or neurapraxia, following on from
Seddon, in which the insulation around the nerve called myelin is damaged but the nerve
itself is spared, and second through fifth degree, which denotes increasing severity of injury.
With fifth degree injuries, the nerve is completely divided.[24]

Presentation (Signs and Symptoms)


Signs and Symptoms may include a limp or paralyzed arm, lack of muscle control in the
arm, hand, or wrist, and lack of feeling or sensation in the arm or hand. Although several
mechanisms account for brachial plexus injuries, the most common is nerve compression or
stretch. Infants, in particular, may suffer brachial plexus injuries during delivery and these
present with typical patterns of weakness, depending on which portion of the brachial plexus
is involved. The most severe form of injury is nerve root avulsion, which results in complete
weakness in corresponding muscles. This usually accompanies high-velocity impacts that
occurs during motor vehicle or bicycle accidents.[2]

Disabilities
Based on the location of the nerve damage, brachial plexus injuries can affect part of or the
entire arm. For example, musculocutaneous nerve damage weakens elbow flexors, median
nerve damage causes proximal forearm pain, and paralysis of the ulnar nerve causes weak
grip and finger numbness.[29] In some cases, these injuries can cause total and irreversible
paralysis. In less severe cases, these injuries limit use of these limbs and cause pain.[30]

This image shows the anterior and posterior views of the torso and upper limb of the human
body.
The cardinal signs of brachial plexus injury then, are weakness in the arm, diminished
reflexes, and corresponding sensory deficits.
1. Erb's palsy. "The position of the limb, under such conditions, is characteristic: the
arm hangs by the side and is rotated medially; the forearm is extended and pronated.
The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is
also supination of the forearm".[6]

2. In Klumpke's paralysis, a form of paralysis involving the muscles of the forearm and
hand,[31] a characteristic sign is the clawed hand, due to loss of function of the ulnar
nerve and the intrinsic muscles of the hand it supplies.[15]

Diagnosis
The diagnosis may be confirmed by an EMG examination in 5 to 7 days. The evidence of
denervation will be evident. If there is no nerve conduction 72 hours after the injury, then
avulsion is most likely.[citation needed]. The most advanced diagnostic method is MR imaging of
the brachial plexus using a high Tesla MRI scanner like 1.5 T or more. MR help us in the
assessment of the injuries in specific context of site, extent and the nerve roots involved. in
addition, assessment of the cervical cord, post traumatic changes in soft tissues may also be
visualised.

Treatment
Treatment for brachial plexus injuries includes orthosis/splinting,occupational or physical
therapy and, in some cases, surgery. Some brachial plexus injuries may heal without
treatment. Many infants improve or recover within 6 months, but those that do not have a
very poor outlook and will need further surgery to try to compensate for the nerve deficits.[1][5]
The ability to bend the elbow (biceps function) by the third month of life is considered an
indicator of probable recovery, with additional upward movement of the wrist, as well as
straightening of thumb and fingers an even stronger indicator of excellent spontaneous
improvement. Gentle range of motion exercises performed by parents, accompanied by
repeated examinations by a physician, may be all that is necessary for patients with strong
indicators of recovery.[2]

Brachial Plexus Injury Rehabilitation


There are many treatments to facilitate the process of recovery in people who have brachial
plexus injuries. Improvements occur slowly and the Rehabilitation[disambiguation needed] process can
take up to many years. Many factors should be considered when estimating a time of
recovery. Factors such as initial diagnosis of the injury, severity of the injury, and type of
treatments used.[32] Some forms of treatment include nerve grafts, medication, surgical
decompression, nerve transfer, physical therapy, and occupational therapy.[32]

Physical Therapy
Having an effective occupational and physical therapy program is important when dealing
with the unfortunate circumstances of brachial plexus injuries. One of the main goals of
rehabilitation is to prevent muscle atrophy until the nerves regain function. Electrical
stimulation is an effective treatment to help patients reach this fundamental goal. Exercises
that involve shoulder extension, flexion, elevation, depression, abduction and adduction
facilitate healing by engaging the nerves in the damaged sites as well as improve muscle
function. Stretching is done on a daily basis to improve or maintain range of motion.
Stretching is important in order to rehabilitate since it increases the blood flow to the injury
as well as facilitate nerves to function properly.[33]

Treatment
The exercises mentioned above can be done to help rehabilitate from mild cases of the injury.
However, in more serious brachial plexus injuries surgical interventions can be used.
Function can be restored by nerve repairs, nerve replacements, and surgery to remove tumors
causing the injury.[34] Another crucial factor to note is that psychological problems can hinder
the rehabilitation process due to a lack of motivation from the patient. On top of promoting a
lifetime process of physical healing, it is important to not overlook the psychological well
being of a patient. This is due to the possibility of depression or complications with head
injuries.[35]

Prognosis
The site and type of brachial plexus injury determine the prognosis. Avulsion and rupture
injuries require timely surgical intervention for any chance of recovery. For milder injuries
involving build-up of scar tissue and for neurapraxia, the potential for improvement varies,
but there is a fair prognosis for spontaneous recovery, with a 90 - 100% return of function.[1][2]

Trapezius transfer to treat flail shoulder


after brachial plexus palsy
Ricardo Monreal, 1 Luis Paredes,1 Humberto Diaz,1 and Pastor Leon1
Author information Article notes Copyright and License information
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Abstract
Background
After severe brachial palsy involving the shoulder, many different muscle transfers have been
advocated to restore movement and stability of the shoulder. Paralysis of the deltoid and
supraspinatus muscles can be treated by transfer of the trapezius.

Methods
We treated 10 patients, 8 males and 2 females, by transfer of the trapezius to the proximal
humerus. In 6 patients the C5 and C6 roots had been injuried; in one C5, C6 and C7 roots;
and 3 there were complete brachial plexus injuries. Eight of the 10 had had neurosurgical
repairs before muscle transfer. Their average age was 28.3 years (range 17 to 41), the mean
delay between injury and transfer was 3.1 years (range 14 months to 6.3 years) and the
average follow-up was 17.5 months (range 6 to 52), reporting the clinical and radiological
results. Evaluation included physical and radiographic examinations. A modification of
Mayer's transfer of the trapezius muscle was performed. The principal goal of this work was
to evaluate the results of the trapezius transfer for flail shoulder after brachial plexus injury.

Results

All 10 patients had improved function with a decrease in instability of the shoulder. The
average gain in shoulder abduction was 46.2; the gain in shoulder flexion average 37.4. All
patients had stable shoulder (no subluxation of the humeral head on radiographs).

Conclusion
Trapezius transfer for a flail shoulder after brachial plexus palsy can provide satisfactory
function and stability.
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Background
After severe brachial palsy involving the shoulder, secondary operations are sometimes
required to restore function. These include shoulder artrhodesis, rotational osteotomy, muscle
transfer or a combination of these techniques.
For paralysis of the deltoid and supraspinatus muscle many different muscle transfers have
been advocated to restore movement and stability of the shoulder. These include transfer of
the trapezius, pectoralis major and teres major, latissimus dorsi, and combined biceps and
triceps.
In a classic monograph; Saha [1] gave details of his experience with transfer of the trapezius,
using a modification of the technique originally described by Bateman [2]. However, the
absence of clear indications for the operation and expecting too much for this transfer alone
has led to its infrequent use.
We have evaluated the results of the trapezius transfer for flail shoulder after brachial plexus
injury.
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Methods
We treated 10 patients, 8 males and 2 females, by transfer of the trapezius to the proximal
humerus. In 6 patients the C5 and C6 roots had been injured; in one C5, C6 and C7 roots; and
in 3 there were complete brachial plexus injuries. Eight of the 10 had had neurosurgical
repairs before muscle transfer.
Their average age was 28.3 years (range 17 to 41), and the average follow-up was 17.5
months (range 6 to 52). The mean delay between injury and transfer was 3.1 years (range 14
months to 6.3 years).
All patients had elbow flexion (2 had had previous Steindler flexorplasties) and 6 patients had
good ipsilateral hand function.
Evaluation included physical and radiographic examinations. The active abduction/flexion
shoulder motion was recorded (power between 3 to 5 grades according to MRC scale).
Shoulder abduction was measured as the angle between the trunk and the arm. The pre-

operative average was 3.1 (range 0 to 30). The average shoulder forward flexion was 4.5
(range 0 to 45). In all patients, the deltoid, supraspinatus, teres minor, infraspinatus and
subscapularis were paralysed and the trapezius, levator scapulae were preserved. The
rhomboids were affected in 2 patients. Paralysis of deltoid and supraspinatus was confirmed
by EMG. All patients were unemployed at the time of trapezius transfer. Radiological
subluxation of the shoulder was present in all cases. The subjective assessment of the patients
was not considered.
Surgery can be considered if the patient presents flail shoulder at more than one year after the
accident without spontaneous recovery or when it is clear that recovery following
neurosurgical repair is not progressing any more. A simple trapezius transfer is compatible
with the later return of some function to other shoulder girdle muscles. Passive shoulder
abduction of 80 is an important pre-requisite before transfer. The only contra-indication is
advanced degeneration of the shoulder.
A modification of Mayer's [3] transfer of the trapezius muscle was performed in which a
portion of the acromion is removed to allow for a more straight-line pull. The lateral aspect of
the acromion and its attached trapezius is removed, and its undersurface is roughened with a
rasp. Fixation with one or two screws secures the acromion and trapezius transfer to the
proximal part of the humeral shaft.
The principal goal of this work was to evaluate the results of the trapezius transfer for flail
shoulder after brachial plexus injury.

Surgical technique
The patient is placed supine with a sand-bag under the shoulder. The shoulder, the neck, and
the whole arm are prepared and free.
A saber-cut incision is made from the inferior border of the anterior axillary fold over the
anterior aspect of the shoulder to a point a few centimetres lateral to the medial border of the
scapula and just distal to the scapular spine. The deltoid origin is then cut from the lateral
third of the clavicle, the acromion, and the lateral half of the spine of the scapula.
A Gigli wire saw is used to transect the root of the acromion, and then the lateral clavicle, so
as to separate the lateral 1 cm of the clavicle with the acromion. The remaining insertions of
the trapezius are elevated from the clavicle and the scapular spine to 2 cm from the vertebral
border of the scapula. Careful dissection is needed to define the interval between the
trapezius and the supraspinatus. Special attention is needed to preserve the neurovascular
bundle of the spinal accessory nerve and transverse cervical artery, which courses from deep
to superficial through the trapezius.
The partly detached deltoid is split longitudinally to expose the proximal humerus, which is
scored with an osteotome. The arm is then abducted to 90, and the acromiocalvicular
fragment with its trapezius insertion is fixed to the humerus with two screws, ensuring firm
bone-to-bone. The wound is thoroughly irrigated with saline solution, and the deltoid is
sutured on top of the new trapezius insertion. The skin is closed in two layers over suction
drains a shoulder spica applied with the shoulder in 90 of abduction.

Postoperative management. Drains are removed on the second or third day. The spica is worn
for six weeks or until union is seen between the acromion fragment and the humerus. The arm
is then allowed to adduct progressively and a vigorous physical therapy programme is started.
As strength improves, more resisted muscle strengthening exercises are added.
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Results
The transfer improved function of the shoulder (Figure (Figure1).1). Postoperatively, the
average gain in shoulder abduction was 46.2 (p < 0.001, Fisher exact test); the gain in
shoulder flexion average 37.4 (p < 0.001). All patients had stable shoulders (no subluxation
of the humeral head on radiographs, Figure Figure22).

Figure 1
A 18-year-old man 16 months after trapezius transfer on the left side, showing 90 of
abduction.

Figure 2
The radiograph shows that there is not downward subluxation of the humeral head.
Surgical time averaged 2 hours (range 1 to 4), and the estimated mean blood loss was 200 ml.
There were no postoperative complications.
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Discussion
Severe injuries to the brachial plexus cannot always be successfully repaired; even failures
are seen after the best repair. Unsatisfactory or incomplete results affect abduction, external
rotation and forward projection of the humerus at shoulder level.
Flail shoulder secondary to a brachial plexus injury is difficult to treat. After neurosurgical
treatment and adequate physiotherapy, reconstructive surgery may be needed to improve the
stability and function of the shoulder.
Deltoid and supraspinatus paralysis may be managed by shoulder fusion [4-6] or muscle
transfer [7]. Shoulder arthordesis has been considered the procedure of choice in patients with
flail shoulder after brachial plexus palsy, but is irreversible and has a high complication rate.
Cofield and Briggs [8] pointed out the disadvantages of arthrodesis (24% incidence of
fractures, 25% had no improvement and 15% had aggravation of pain).

Trapezius, levator scapulae and rhomboid muscles remain healthy or recover in 96% of cases,
therefore are available for transposition.
Several muscle transfers have been advocated to restore movement and stability of the
shoulder after poliomyelitis [7,9,10], and, more recently, the use of these procedures after
brachial plexus palsy has been reported. [11-14]
Aziz, Singer and Wolff [12] discuss trapezius transfer for flail shoulder after brachial plexus
palsy, finding it a simple procedure with minimal blood loss, which provided functional
improvement.
Passive shoulder abduction of 80 is an important pre-requisite, and requires intensive
physiotherapy before transfer. If 80 is not obtained, shoulder arthrodesis is recommended
[13].
Trapezius transfer to treat flail shoulder after a brachial plexus injury will allow the patient to
position the arm much better, even when functional recovery is not adequately strong to keep
the shoulder stable. The procedure is relatively simple with minimal blood loss and the only
contraindication is advanced degeneration of the shoulder. Trapezius transfer can be used
combined with other transfers to achieve optimal use of the upper limb.
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Conclusion
Trapezius transfer can provide satisfactory functional improvement and it is better than
arthrodesis for paralysis of the shoulder after brachial plexus injury.