Practical Approach to examination of Brachial Plexus

Brachial Plexus

Its a complex structure . Rembering all of its branches is difficult. Rembering further down to all

muscles supplied by each nerve is even more difficult.Finally the Brachial plexus site of injury can

be pin pointed just by examination .  Best way is to reharse with friends in the same order mentioned

as below. It makes examination fast , easy and simple.




Look

 Front
             Head at centre
 
             no ptosis , myosis , anhydrosis on forehead

             Shoulders - any scars  on shoulder ?
                           
            normal axillary folds

            Chest - wasting of Pectoralis Major

             No any fixed attitude of Upper extremities

 Side -     Normal overlying skin on shoulder, describe scars if present , UE
 
               Normal Deltoid contour , Biceps , triceps , forearm muscles ,

               no guttering on dorsum of hand , normal thenar and hypothenar muscles

              axilla clear


Back - Normal alignment of head , vertebrae

            both scpaula at same level ,

            normal posterior axillary fold ,
             
            describe scars which might be present on shoulder

            winging of scapula


Feel - Temperature , an mass on suprascapular region , soft tissue tenderness , deep bony tenderness ,

           scar - size , mobility , tenderness ,

Movement

             
        C- spine - flexion / extension


        Shoudler - Active / Passive

        Elbow - Supination / Pronation

                    flexion / extension

        Wrist - Flexion / extension

        Fingers - MCP joints - Active / Passive

                        IP joints - Active / Passive

  Lymph nodes

  Pulsation - radial and ulnar arteries

 Power

Back - shrugging for trapezius ,

           serratus anterior

            rhomboids

            subscapularis - Gerber's test

             Latissimus Dorsi


Front
          Pectoralis Major

          Supraspinatus

          Infraspinatus / Teres Minor (External rotator)



Sides - Deltoid , Biceps , Triceps , Supinator, Pronator  , Wrist extensor , Finger flexor



Your impression

Deficits - Pectoralis Major

                Deltoid

                 Rotator Cuff
   
                Latissimus Dorsi

                Elbow / wrist finger extensor

                Impaired C5-6 Sensation

Diagnosis is C 5-6 injury.

What level ?
 Posterior to clavicle .
Cause Pectoralis Major exits  below Clavicle.




Next Scenario

3 years old girl by birth

Deficits - Rhomboids ,
                 
                 rotator cuff muscles
             
               pectoralis major

                deltoid

                wrist and finger extensors

                 C 5-6 impaired sensation

Diagnosis is Erb's palsy


Erb's point
  C 5 nerve root

   C6 nerve root

    two divisions of uppper trunk

    dorsal scapular nerve

     nerve to subclavius


How to investigate ?

 X-ray Shoulder - AP / Lat . to see joint in position or not ?

CXR to see involvement of diaphragms

Electrophysiologic studies

                                                 NCS and EMGs
CT scan of Glenoid to see glenoid retroversion


Treatment

Early Presentation - Neurolysis for  lesion in continuity

Primary Repair

 Nerve Grafting

Neurotization with oberlin transfer

Late Presentaion

 tendon transfer

            Shah - Trapezius to Supraspinatus

            Release - Steindler

Osteotomy

            derotational osteotomy of humerus


NCS and EMG in Brachial plexus role - to be studied .







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