Professional Documents
Culture Documents
INJURY
13th Post Graduate Intensive Course in Orthopaedics
4th April 2007 - HUKM
C5/C6
C7
C8/T1
Upper trunk
Middle trunk
Lower trunk
&finger extensors
C8
T1
finger flexors
intrinsic mucsles of hand
C5 (rhomboids)
C5,C6 ( ss,is)
C5,C6,C7 (sa)
C5
C5,C6 (subclavian)
Lateral cord
musculocutaneous
lateral root of median
lateral pectoral
Medial cord
ulnar
medial root of median
medial cut. n of arm & f/arm
medial pectoral
Posterior cord
axillary
radial
thoracodorsal
subscapular
Axillary
Musculocutaneous
Radial
Median
Ulnar
Magnitude
Rate
SSEP
Open injuries
Closed injuries
Supra, infra, sub clavicular
Combined
Postanaesthetic palsy
Radiation injury
Obstetric palsy
Site of lesion
preganglionic or
postganglionic
Severity of lesion
eg. rupture or
lesion-in-continuity
Sunderland class
Sunderland1978
Upper Trunk(C5,C6)
shoulder control
elbow flexion
Lower Trunk(C8,T1)
thumb & finger flexion, finger extension
Intrinsic
Global
Open injury
Upper roots- C5 & C6
Postganglionic
Sunderland 5 (Neurotmesis)
Clinical evaluation of BP
Clinical evaluation of BP
General examination
Manual muscle testing
Sensory dermatome
Pain & psycho-social evaluation
Clinical Examination
Posture
Torticolis
tilting away from the affected side
due to neck muscle paralysis
preganglionic
Clinical Examination
Horners
Sign
Supraclavicular
fullness, tenderness
Squeeze test
Tinels sign
Absence of SSEP
Absence of Tinels sign
Tinels sign
Infraclavicular and supraclavicular
percussion (distal to proximal)
Paraesthesia radiates distally
proximal axons available
location of neuroma or regenerating axons
does not exclude another distal lesion
TINELS positive
in
Reasons
1.
2.
Spontaneous recovery
Types of recovery
Sensory
Motor
Autonomic
EMG/NCV
questionable value
probably not useful
CT Myelography
Pseudomeningocele
PPV 50%
NPV 93%
MRI
Pseudomeningocele
empty root sleeve
shift of cord
Routine (3m-6m)
Secondary(>1y)
EARLY
LATE
Complete BPI
FFMT
LATE
Partial BPI
Tendon Transfer
12
18
24 months
Shoulder
arthrodesis shoulder
trapezius transfer
Elbow flexoplasty
steindlers transfer
bipolar latissimus dorsi transfer
bipolar pect major transfer
triceps to biceps transfer
Hand reconstruction
transfers, tenodesis, fusion
Steindler Flexorplasty
Proximal transfer of flexor insertion
Move insertion from medial epicondyle to
3 - 4 finger breadths proximally and
anteriorly to humerus
MANAGEMENT STRATEGY
GOALS
ELBOW FLEXION
SHOULDER STABILITY
WRIST / HAND PREHENSION
SENSORY
MANAGEMENT STRATEGY
GOALS
Basic reconstruction
Total reconstruction
What is a realistic
standard?
For global paralysis
- restore elbow flexion
- shoulder control
Only after that we may go further for hand prehension