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 .
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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