Brachial Plexus Injury Clinical Examination and Surgical Management in a capsule
I found students really lost when doing a Brachial Plexus Injury clinical examination. If it is done in a sequence then it won't be. I have explained it in a simplified manner. Go from the front , then side and observe on the back on inspection. Then again do the 2nd round from front, sides and to back on palation along with movement of joints. Then on third round i would do tinel's sign , sensory exam and muscle power testing on third round. And at last i would complete the examination measuring scars, if there is descrepancy of limb length and finally pulsation of brachial / radial and ulnar arteries / lymhp nodes
To pass any PG exam , a good history along with a comprehensive physical examination is a minimum criteria to be appreciated and be asked for treatment which allows you to pass the exam. All questions after that will help you be get extra.
i wish you all the best.
Please support me giving comments sothat i can work more on topics like these.
Look -
(Front ) Head -
Alignment
Horner's Syndrome
Shoulder - Scars, axillary folds , muscles wasting
Chest - Wasting of Pectoralis Major
Extremities- Any particular attitude of UL
Look (side )
see the attitude of extremities and arm and back
comment on skin color , deltoid contour , biceps , triceps ,forearm muscles, guttering on dorusm of hand, thenar and hypothenar muscles
see axilla and boundaries
Look (Back )
comment on alignment of head and vertebrae
both scapula at same level or not
normal posterior axillary fold
describe if there are any scars present
is there winging of scapula ?
Feel
temperature , any palplable swelling on supraclavicular region
soft tissue tenderness
deep bony tenderness
scar - size , mobility , tenderness,
Movement
C- spine - Flexion, Extension , bending and rotation
Shoulder - Active and Passive
Elbow - Supination and Pronation
Wrist - Flexion and Extension
Fingers - MCP and IP Joints
Measurement - if there is shortening of upper extremities
Pulsation of Arteries on UE/ Appley's test if any procedure to be done on hands and Wrist
Sensation - Dermatomes
Tinel's Sign
Reflexes
Power of Muscles
Back - Shrugging of Shoulder - to see Trapzius Muscles
Serratus Anterior - Push the wall and see the winging of scapula
Palpate muscles on medial border of scapula - on attention position
Subscapularis muscle - Gerber's test
Latissimus Dorsi - see the power of muscle in extension , internal shouder rotation and adduction of shoulder joint
Front - Check power of Pectoralis Major Muscles
Supraspinatus / Infraspinatus / Teres Minor Muscles - Resisted External Rotation
Sides
Deltoid
Biceps
Triceps
Supinator
Pronator
Wrist Extensor
Finger Flexors
Give an Impression at last
Assess deficits
deficits in C5,6 Dermatome
Muscles Weakness
Pectoralis Major
Deltoid
Rotator Cuff
Latissimus Dorsi
Elbow / Finger / Wrist Extensor
These help to conclude the C5, 6 Injury
Viva
Q : At what level did the injury occur ?
A: Posterior to Clavicle because Pectoralis Major is involved , nerve to Pectoralis Major exits below clavicle.
Next scenario , a 3 years old girl by birth has following deficits :
C5 , 6 Sensory Deficit
Muscles weakness
Rhomboids
Rotator cuff muscles
Pectoralis Major
Deltoid
Wrist Extensor
Finger Extensor
Q : What is your Diagnosis ?
A: Erb's Palsy
Q: Tell more about Erb's Point ?
A: C 5 Nerve root
C 6 Nerve root
two divisions of upper trunk
dorsal scapular nerve
nerve to suvclavius
Q: How do you investigate ?
X-ray of shoulder joint - AP/ LAT - to assess joint position
CXR - to see involvement of Diaphragm
Electrophysiology - NCS and EMG
CT scan of shoulder joint to see glenoid retroversion
Q: What are different treatment options ?
Early Presenter
Neurolysis - lesion in continuity ( action potentials along nerve )
Primary Repair
Nerve Grafting
Neurotization - Oberlin
Later Presentation
Tendon transfer
Saha - Trapezius to Supraspinatus
Release (steindler )
Derotational Osteotoy of Humerus is important if there is excess retroversion and shoulder dislocation.
Please see the role of NCS and EMGs in Brachials Plexus Injury.
Also check
https://orthonp.blogspot.com/2020/04/algorithm-6-for-osteonecrosis-of.html
Please give comments what were missing and how can I improve .
I will be thankful.
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