Treatment of Brachial Plexus Injuries




How to proceed for the treatment ?


A. Open Brachial Plexus Injury

       Sharp Objects , Missiles injury



  Associated vascular and mediastinal injuries are treated first. Tag plexus nerves with suture.


  Document deficits

   EMG after 3 -6 weeks .


    Then Surgery.

      For  Low velocity injury

         wait and follow up in 3 and 6 weeks ,

          if no improvement then surgery .


B. Closed Injuries

       Traction injuries

        1.C5-6

        2. C 5-7

        3. C7 ,8,T1

  Observe , Physical Therapy  for 6 - 8 weeks.


    Myelography , axonal reflex evlauation

  Explore at 3- 6 weeks

                      if no functional recovery

                      if only distal recovery

                      post- ganglionic injury




Surgical Goals

     1. Restore elbow Flexion

     2. Shoulder Abduction

      3. Restore sensation to medial border of forearm and hand


Techniques


 Neurorraphy

 Primary Repair

 Neurolysis

Nerve Grafting

Neurotization






Direct intraoperative nerve stimulation of nerve axon potential obtained and Neurolysis  done.

If no nerve action potential obtained across damaged part , excision and grafting done.

If avulsion and no proximal stump found

          Intercostal nerve anastomosed with Musculocutaneous Nerve for Elbow Flexion .

          Takes 12-18 months  for nerve regeneration.



If patient presents late

Shoulder


            Tendon transfer

                         Trapezius to Deltoid transfer for Shoulder Abduction .


                L EPISCOPO Tendon Transfer

                              Latissimus Dorsi transfer for External Rotation of shoulder



                 Shoulder Arthrodesis if active scapulothoracic movement preserved.


   Elbow

                Flexion - Latissimus Dorsi , Pectoralis Major , Triceps , Sternocleidomastoid , Flexor   

                               Pronator mass tendon transfer .



Amputation -rarely for painful functionless limb.


 
       


















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