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PL30 Plastic Surgery
Brachial Plexus
Toronto Notes 2019
Brachial Plexus
Etiology
• commoncausesofbrachialplexusinjury:complicationofchildbirthandtrauma • othercausesofinjury:compressionfromtumours,ectopicribs
Common Palsies
Table 23. Named Neonatal Palsies of the Brachial Plexus
Palsy
Duchenne-Erb Palsy
Klumpke’s Palsy
Location of Injury
Upper brachial plexus (C5-C6)
Lower brachial plexus (C7-T1)
Mechanism of Injury
Head/shoulder distraction (e.g. motorcycle)
Traction on abducted arm
Features
“Waiter’s tip deformity” (shoulder internal rotation, elbow extension and pronation, wrist flexion)
“Claw hand”
May include Horner’s syndrome
Differential Diagnosis of Adult-Acquired Brachial Plexus Palsies
• trauma(blunt,penetrating) • thoracicoutletsyndrome
■ associated with large cervical rib, anomalous first rib, strenuous arm work, neck muscle hypertrophy ■ neurogenic: compression of brachial plexus, resulting in upper limb paresthesia, pain, and weakness ■ vascular: compression/thrombosis of subclavian artery/vein, resulting in pain; pallor and Raynaud’s
if arterial; swelling and cyanosis if venous • tumour
■ schwannoma: well-defined margins enable total resection ■ neurofibromas: associated with neurofibromatosis type I ■ other: e.g. Pancoast syndrome (apical lung tumour)
• neuropathy(compressive,post-irradiation,viral,diabetic,idiopathic)
Investigations
• EMG
• MRI:goldstandardforidentifyingsofttissuemassesandnerveroots
• CTmyelogram:controversial,althoughsomepeoplethinkthatitisbetterthanMRIforidentificationof
nerve root avulsion
• closedinjuries:ifavulsionsuspected,thenCTmyelogramorMRIinitially;otherwise,EMG/NCS6-12
wk post-injury to assess healing progress
• openinjuries:ORforexplorationwithinafewdayspost-injury(oncepatientstable)
Management
Table 24. Management of Brachial Plexus Injuries
Type
Closed Injuries Concussive/compressive Traction/stretch
Obstetric palsy
Open Injuries Sharp or vascular injury
Treatment
Usually improves (unless expanding mass, e.g. hematoma)
If no continued insult, follow for 3-4 mo for improvement
Surgery if no significant improvement and/or residual paresis at 6 mo of age Explore immediately in OR