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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