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BRACHIAL PLEXUS INJURIES, (Surgical Measures), Quick facts About FAS •…

- - - - It is a rare injury and could be due to
        penetrating or gunshot injuries.
      - Note: Other less important causes of brachial
        plexus injuries:
        
        Traction injuries
        
        Tumor removal
        
        Abnormal pressures due to faculty postures
        
        Post irradiation scenario
        
        Surgical excision of cervical ribs
        
        Shoulder dislocations.
  - - - Pre-ganglionic Lesion
        
        This is an unfortunate situation wherein the nerve
        roots are avulsed from the spinal cord.
        .
        
        The cause could be either birth or bike trauma as mentioned earlier.
        .
        
        The characteristic feature of this lesion is the
        presence of Horner’s syndrome
        
        About Horner’s syndrome
        What constitutes a Horner’s syndrome? (All P’s)
        
        Ptosis of the eyelid.
        
        Pupils, which are small and constricted.
        
        Protrusion of the eyeball, which is slight.
        
        Pain even at rest.
        
        Positive sensory action potentials.
        
        Poor prognosis
      - Postganglionic Lesions
        
        Here there is no Horner’s syndrome
        .
        
        The prognosis is slightly better than the preganglionic lesion
        .
        
        A positive Tinel’s sign may be elicited in this lesion.
    - - In preganglionic lesions
        
        Horner’s syndrome is present.
        .
        
        The patient is unable to elevate the scapula (due to the disruption in the nerve supply to the Rhomboids and L scapulae).
        .
        
        The patient may present with flail upper limb
      - In postganglionic lesions
        
        No Horner’s syndrome.
        .
        
        The patient is able to elevate the scapula.
        .
        
        Tinel’s sign is present in the later stages.
        (Tapping above the clavicle, produces tingling sensation in the anesthetic limb).
      - Investigations
        
        X-ray to rule out neck fractures,
        
        CT scan to study the crosssection anatomy,
        
        MRI to study the soft tissue damages,
        
        myelogram (shows meningocele in avulsion, but hazardous)
        
        and electrical studies
        are some of the investigations which give useful information during a brachial plexus injury.
        
        The electrodiagnostic tests include
        
        EMG,
        
        nerve conduction study,
        
        SEP (somatosensory-evoked potential),
        
        percutaneous electrical stimulation, etc.
        
        EMG is by far the most reliable
        and effective test, which successfully identifies the roots, involved.
        
        Treatment
        
        During the initial stages
        
        Splinting
        
        For complete paralysis:
        
        A flail arm splint (FAS)
        designed by Framton is advised.
        
        For incomplete lesions
        
        Here splints with necessary
        modifications as per the situations can be used.
        
        For pain control
        
        TENS is best suited
        
        To prevent contractures
        and deformities,
        
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        During the Later Stages
        
        Measures to strengthen the muscles
        
        : If there are movements,
        efforts are made to strengthen the muscles by repeated self-resistive exercises, PNF techniques, etc.
        
        Re-education of the muscles
        
        This is done by
        
        encouraging movements of the shoulder,
        
        percutaneous electrical stimulation,
        
        stimulating techniques like icing, brushing, etc.
        
        Modifying The splints and dynamizing it helps.
        
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- - - - Reconstructive surgeries are
        planned after 2 years when the recovery can no longer take place. Surgeries are planned according to the residual paralysis.
        
        For shoulder function:
        
        Trapezius transfer to the neck of the humerus to improve abduction is advised.
        
        Arthrodesis of the shoulder is done in
        functional position.
        
        For elbow function:
        
        Steindler’s flexorplasty (transfer of latissimus dorsi or pectoralis major to biceps)
        
        For wrist and
        finger extension:
        
        After the surgery,
        the patient is put on a detailed regime for
        re-educating the transplanted muscle