Traumatic Brachial Plexus Injury

Definition

CT myelogram revealing a
small fluid collection indicating
rootlet avulsion from the spinal
cord (above). Fluid collections are
also seen near other spinal
nerves (small arrows, lower image).

The brachial plexus (brachial means arm and plexus mean communication or meeting point) refers to the nerves that exit the cervical spine and pass down to the shoulder and arm. Five major nerves comprise the brachial plexus: C5, C6, C7, C8, and T1 (C refers to cervical [or neck] and T refers to thorax [or chest]). These nerve pass under the skin in the neck and axilla, where they are vulnerable to injury. When the neck and arm are forced away from each other during trauma (e.g., car accidents, motorcycle accidents, falls) the brachial plexus nerves can be stretched or torn apart. If the force is severe, these nerves can even be pulled away from the spinal cord where they originate. Damage to these nerves causes pain, numbness, and weakness in the shoulder, arm, and hand. The pain can be quite severe, and is often described at burning, pins and needles, or crushing. In general, the C5 nerve controls the rotator cuff muscles and shoulder function, C6 controls flexing the arm at the elbow, C7 partially controls the triceps and wrist flexion, and C8/T1 controls hand movements. Several patterns of injury occur, the most common is referred to as an Erb's palsy. This is when C5 and C6 are predominantly affected. These patients are unable to lift their arm or flex at the elbow. Severe atrophy can occur in the shoulder muscles. Another pattern of injury is when C8/T1 is mostly damaged. These patients have hand weakness and pain. Some finger movement may remain, however. The most severe type of injury is when the arm is completely paralyzed due to extensive brachial plexus injury.

Diagnosis

A brachial plexus injury is diagnosed with a thorough history and physical examination. Imaging of the spine with either MRI or CT myelography is important for determining any detachment of the nerves from the spinal cord, which determines prognosis and treatment. Electrical testing also helps guide treatment and predict outcome, however, in general, it should not be performed until 3 weeks after injury. Direct imaging of the brachial plexus is usually not helpful with currently available techniques. It is important to see a physician who specializes in examining, diagnosing, and treating brachial plexus injury within the first few weeks after the accident.

Treatment Options

An example of a severe brachial
plexus injury where C5 and C6
were non-functional, C7 was
avulsed from the spinal cord
(lifted in air), and C8/T1 were
damaged but partially functional
based on intraoperative nerve
action potentials.

In general, patients are observed for spontaneous recovery during the first 3 months after injury. Many patients regain some function during this time. Surgery is not immediately performed because many people may spontaneously recovery without treatment. Furthermore, delicate nerves that may have spontaneously recovered may be injured with early surgery. During this waiting period, pain is aggressively controlled and physical therapy is performed. Imaging of the cervical spine and electrical testing is also performed. No medication is currently available to hasten recovery.

When paralysis remains at 3 months, and electrical testing does not indicate an early recovery, then exploratory surgery is often indicated. Recovering nerves are protected. Injured, non-functional nerves are exposed and examined with both a microscope and intraoperative electrical testing. When possible, injured nerves are repaired or replaced, which allows recovery. Repairing nerves with surgery gives them the opportunity to regenerate themselves. Nerve regeneration progresses about one inch per month. Therefore, even after successful surgery, it can take up to 6 to 12 months before the regenerating nerves reach their target muscle and for movement to occur. Surgery is usually scheduled between 3 and 6 months after injury. If you wait much longer than this then the chances of surgery working decreases with time. The exact timing and type of surgery is often different for each patient. Therefore, it is important for the patient to be evaluated early so that they may consider all of their treatment options.

Despite how well the surgery goes, the chance of recovery is somewhat uncertain. In addition to factors we do not understand, surgical success depends on the type of injury, the nerve injured, the age of the patient, motivation of the patient, and timing of repair. On average, there is a 50% chance surgery for each nerve will allow movement to return. This number may be as high as 90% for certain nerves and injuries. Your surgeon will provide you with an estimate about your chances of recovery. A "success" is defined as strength against both gravity and some resistance. In general, greater the distance a nerve has to regenerate, the less likely there will be a good recovery.

Surgery

Brachial plexus exposed (above)
in an adult with Erb's palsy
(shoulder and arm flexion
weakness). The upper trunk
(C5/C6) was heavily scarred and
nonfunctional (asterisk). Therefore,
it was removed and replaced with
multiple sural nerve grafts (below).

Three general types of brachial plexus surgery are performed:

• Erb's palsy repair (shoulder/elbow weakness)
• Complete brachial plexus reconstruction
• Isolated nerve transfers

Each patient may undergo a combination of procedures.

Erb's palsy surgery requires an incision along the side of the neck and/or the clavicle. The injured C5 and C6 nerves are identified and examined. Depending on the injury, one or more of the following is performed (see technologies and techniques available section): scar tissue is removed, the nerves are re-attached directly or with nerve grafts from the leg, or nerve transfers are performed. This surgery takes about four to six hours.

Severe injuries require a complete exposure of the brachial plexus. Although muscle and bone are preserved, the incision can be long, passing from the neck and over the shoulder. The nerves are examined and reconstructed with multiple nerve grafts and transfers. This surgery can take up to 8-12 hours.

When nerves are found detached from the spinal cord on preoperative imaging, then select nerve transfers away from the site of injury may be recommended. The incisions for these transfers are often placed above the clavicle, behind the shoulder, under the arm, or near the wrist. Your average nerve transfer takes about 90 minutes per nerve transferred. Although certain brachial plexus techniques are associated with postoperative pain (e.g., intercostals nerve transfers), in the majority of patients incisional pain is minimal. Nerve pain before surgery may or may not improve immediately after surgery. More commonly, nerve pain slowly improves as the nerves regenerate.

Complications

A branch to the functioning long
head of the triceps was cut and
attached to the nonfunctioning
axillary nerve to allow this patient
to once again lift their arm. This
is an example of a nerve transfer.

Although complications are uncommon, they can occur. A frank discussion with your surgeon prior to surgery is mandatory. Because of long surgery and large incisions, wound infections may occur in some patients. Damage to important arteries and veins going to the arm may occur, which can lead to loss of limb. Fortunately this is so rare it hardly ever occurs. Additional numbness near the neck or chest may occur, but this usually goes away in a number of months. Additional paralysis is possible, but this is rare considering any functioning nerves are either not exposed, or operated on very gently. Trouble breathing, especially when exercising, may occur after surgery and can be related to new diaphragm weakness, fluid on the lung, or air compressing the lung. The latter two of which may require chest tube drainage. The wound is often mildly swollen for a few weeks after surgery. This is normal and goes away with time. If sural nerve grafts are taken from the legs, then a patch of numbness on the outside of the foot almost always occurs, even though some patients do not notice it. This numbness may diminish over time. Because the sural nerve carries no motor fibers, foot paralysis does not occur after removing the nerve graft.

Day of Surgery

All brachial plexus surgery is performed under general anesthesia with intraoperative electrical testing and microscopic magnification. You should not eat or drink after midnight the day before surgery. Medications may be taken with a sip of water the morning of surgery. You wake in the operating room and may see your family an hour later in the recovery room. Depending on the extent of surgery, you may discharged the same day, or a few days later. Pain is well controlled and you are encouraged to sit in a chair and even walk within the first day after surgery. This movement prevents muscle spasms, which reduces pain.

Recovery

During the first two weeks after surgery you wear a sling to protect the arm and let the wound heal. Pain medication is prescribed as needed. One week after surgery you visit your surgeon who checks your wound and removes any sutures. After about two weeks, physical therapy is prescribed. For the first three months, therapy concentrates on shoulder and elbow range of motion. Immediately after surgery your paralysis should be the same. However, when movement eventually returns, strengthening exercises are performed. Recovery often takes one year or longer.

Kienbocks Disease- A cause of slow wrist pain

What is Kienbock’s Disease?

Kienbock’s disease, or avascular necrosis of the lunate, is a condition in which the lunate bone, one of eight small carpal bones in the wrist, loses its blood supply, leading to death of the bone.  The lunate is a central bone in the wrist, important for proper movement and support of the joint. The lunate, along with the adjacent bones on either side of it, the scaphoid and triquetrum, make up the proximal carpal row. This row of bones articulates with the 2 forearm bones (the radius and ulna), to form the portion of the wrist that provides the most motion.  Damage to the lunate can lead to pain, stiffness, and in late stages, arthritis of the wrist. Kienbock’s disease is most common in men between the ages of 20 and 40 and rarely affects both wrists.

What causes it?

There is probably no single cause of Kienbock’s disease. Its origin may involve multiple factors, such as the blood supply (arteries), the blood drainage (veins), and skeletal variations. Skeletal variations associated with Kienbock’s disease include a shorter length of the ulna, one of the forearm bones, and also the shape of the lunate bone itself. Trauma, either single or repeated episodes, may possibly be a factor in some cases.  Kienbock’s disease can be found more commonly in people who have medical conditions that affect blood supply, and it is also associated with diseases like lupus, sickle cell anemia, and cerebral palsy.

How is it diagnosed?

Most patients with Kienbock’s disease initially present with wrist pain. There is usually tenderness directly over the lunate bone, decreased motion or stiffness of the wrist, and there can be swelling. The diagnosis of Kienbock’s disease can often be made by history, physical examination, and plain x-rays. In early stages the x-rays may be normal and special studies are needed to confirm the diagnosis. Probably the most reliable special study to assess the blood supply of the lunate is Magnetic Resonance Imaging, or MRI . CT scanning, specialized CT scanning, and bone scan may also be used. Patients often have the condition for months or even years before they seek treatment, and especially in its earlier stage it can be difficult to diagnose.

             

          

What is its course?

The progression of Kienbock’s disease varies but is usually slow over many years. There are 4 stages used to classify Kienbock’s disease. In stage 1, x-rays appear normal, but the lunate has lost its blood supply and is painful and may fracture. In stage 2 the bone hardens due to lack of blood supply and appears abnormally dense on X-ray. In stage 3 the bone collapses and fragments. In the final stage, stage 4, the lunate is collapsed and the bones around the lunate have developed degenerative changes and become arthritic. In the early stages there may be only pain and swelling, but as the disease progresses the mechanics of the wrist become altered, which puts abnormal stresses and wear on the joints within the wrist itself. One should be aware that not every case of Kienbock’s disease progresses through all stages to the severely deteriorated arthritic end-stage.

What are the treatment options?

Treatment options depend upon the severity and stage of the disease. In very early stages, the treatment can be as simple as observation or immobilization. For more advanced stages, surgery is usually considered to try to reduce the forces on the lunate bone by lengthening, shortening, or fusing various bones in the forearm or wrist. Surgery can also be aimed at trying to restore blood supply to the lunate (revascularization), using a bone graft with a blood vessel attached to it. This is not an option in more advanced stages if the relationship of the bones has markedly deteriorated; complete wrist fusion may then be the preferred treatment. Hand therapy does not change the course of the disease; however, hand therapy can help to minimize the disability from the problem. Treatment is designed to relieve pain and restore function. Your hand surgeon will advise you of the best treatment options and explain the risks, benefits, and side-effects of various treatments for Kienbock’s disease

 What can I expect?

The results of Kienbock’s disease and its treatment vary considerably, depending on the severity of the involvement, and whether or not the disease progresses. The disease process and response to treatment can take several months. On occasion, several forms of treatment, and even multiple operations, might be necessary.

Scaphoid bone fracture in the Wrist- A common misdiagnosed cause of wrist pain

The scaphoid bone is one of the carpal bones in your hand around the area of your wrist towards the thumb side. It is the most common carpal bone to break (fracture). This bone broken usually  by a fall on to an outstretched hand. Symptoms can include pain and swelling around the wrist. 

Diagnosis of a scaphoid fracture can sometimes be difficult, as not all show up on X-rays. for a  period of one to two weeks, and an MRI/CT Scan may be needed to ascertain the treatment. 

Treatment is usually with a cast worn on your arm up to your elbow for 8 to 12 weeks. Sometimes surgery is advised. Correct diagnosis and prompt treatment of a scaphoid fracture can help to reduce complications.

Anatomy around your wrist

In the hand, there are eight small bones known as the carpal bones. They are arranged in two rows, one on top of the other.

The proximal row is the row that is closest to the elbow. In the proximal row are the scaphoid, lunate, triquetrum and pisiform bones. The distal row is the row below this. In the distal row are the hamate, capitate, trapezoid and trapezium bones.

The scaphoid bone(marked with arrow) is one of the largest of the carpal bones and is on the thumb side of the wrist. It looks a bit like a cashew nut and is roughly the same size. It links the two rows of carpal bones together and actually helps to stabilise them. The scaphoid bone and the lunate bone connect with the radius at the wrist joint.

What is a scaphoid fracture and what is the usual cause?

A scaphoid fracture occurs when you break your scaphoid bone. It most commonly happens after a fall on to your outstretched hand. That is, when your palm is flat and stretched out and your wrist is bent backwards as you fall to the ground. Instinctively, you will usually put your hands out in this position for protection if you fall forwards.

Sometimes a direct blow to the palm of your hand can cause a scaphoid fracture. Occasionally, repeated 'stress' on the scaphoid bone can lead to a fracture. This can occur, for example, in gymnasts and shot putters.

Commonly you will just fracture your scaphoid bone but sometimes other bones around the wrist area may be broken at the same time.

Scaphoid fractures may be non-displaced (the fragments of the broken bone haven't moved out of position) or displaced (there is some movement of the bone fragments).

How common is a scaphoid fracture?

The scaphoid bone is the most commonly fractured carpal bone. This is because of its size and position in the two rows of carpal bones in the hand.

What are the symptoms of a scaphoid fracture?

Usually, most people who break (fracture) a scaphoid bone will remember a specific injury or fall. There will be pain around the wrist area after the injury. There may also be some bruising or swelling around the wrist on the affected side.

In some people, symptoms may be milder. Quite commonly, people with a scaphoid fracture just assume that they have sprained their wrist and they don't seek medical attention for some time afterwards. The fracture may only be diagnosed when they see a doctor some weeks later because of pain that is not settling or reduced movement around their wrist.

How is a scaphoid fracture diagnosed?

A doctor will usually suspect a scaphoid break (fracture) by the mechanism of the injury that has happened - for example, a fall on to an outstretched hand. Also, when they examine your wrist and hand, there is a specific point where you are likely to be tender if you have a scaphoid fracture. This is known as the anatomical snuffbox. It is a depression in your skin on the back of your hand near to the base of your thumb. Movement of your wrist in certain directions may also be painful if you have fractured your scaphoid.

It can sometimes be quite difficult to diagnose a scaphoid fracture. However, it is important to recognise and treat a scaphoid fracture as soon as possible because the complication of non-union and wrist arthritis  is more likely if treatment is delayed.

Standard X-rays may not pick up all scaphoid fractures. This is because the scaphoid bone can 'hide' behind the other carpal bones on an X-ray. Special scaphoid view X-rays taken with your hand and wrist in a certain position may help to show up a scaphoid fracture. However, between 1 and 2 in every 10 scaphoid fractures may not be seen on X-ray.

In some cases, a scaphoid fracture will not show up on an X-ray until around 10 to 14 days after the initial injury. At this time, the healing process will have started in the bone, which will help the fracture site to show up. So, if a scaphoid fracture is suspected but not confirmed on an initial X-ray, you will usually be treated as if you have a scaphoid fracture and a repeat X-ray may be suggested after 10 to 14 days.

Sometimes, at this time, it is still not clear whether you have had a scaphoid fracture. If this is the case, a CT scan or MRI scan may be suggested to look for the fracture. A radionuclide bone scan is occasionally used as an alternative but this is used less often these days, as MRI and CT scans are more widely available.

What is the treatment of a scaphoid fracture?

If a non-displaced scaphoid break (fracture) is confirmed on X-ray or is suspected, it is usually treated by putting your arm in a cast (commonly referred to as a plaster cast but actually made of fibreglass or another similar synthetic material) up to your elbow. The cast is usually worn for 8 to 12 weeks until the scaphoid bone heals. In some cases, it may be needed for longer.

If a scaphoid fracture is displaced, surgery may be advised. A small screw or a special pin is inserted into the scaphoid bone to hold the bone fragments together in the correct position. This can often be done via a small cut in your skin.

Sometimes surgery may be an option for some groups of people even if a scaphoid fracture is non-displaced. The idea is that it avoids you having to wear a cast for a long period of time. In some cases it may remove the need for wearing a cast altogether. Some also argue that it allows normal movement of your wrist to return more quickly than if you had just been treated with a cast. This means that you can return to your usual activities more quickly. For example, if you are an athlete, a musician, or if there is another reason why you have significant pressure to return to high-level activity quickly, this treatment option may be a consideration. However, this does mean going through a surgical procedure that does carry some small risks.

Are there any complications?

A scaphoid break (fracture) will usually heal well if it is recognised and treated early. However, occasionally, complications can occur after a scaphoid fracture. These can include the following.

Delayed union or non-union

Delayed union occurs when the scaphoid bone has not healed completely after four months of being treated in a  cast. Non-union occurs when the scaphoid fracture has not healed at all. In non-union, the bony fragments are still completely separated. Delayed and non-union may be more likely if treatment of a scaphoid fracture is delayed for some reason. So, this is the main reason why a scaphoid fracture needs to be recognised and treated promptly. However, the exact position of the fracture in the scaphoid bone, whether the fracture is displaced of not, and whether or not there is avascular necrosis  can also affect the healing of a scaphoid fracture.

If delayed or non-union occurs, various treatments may be suggested, including wearing a cast for a longer period or surgery to help join the bone fragments together. Surgery may involve a bone graft to help with fracture healing. This is a procedure where bone tissue is taken from another area of bone in the wrist and inserted into the fracture site.

Malunion

This is where the fragments of the scaphoid bone heal in an incorrect position - for example, at a slight angle. If this occurs, it may affect the movement of the wrist and lead to pain and problems gripping and holding objects. Malunion may be seen on an X-ray or scans of the scaphoid bone. Surgery is usually needed to correct this complication. The scaphoid bone is re-broken, aligned correctly and a bone graft is used to correct the deformity and encourage healing.

Avascular necrosis

Most commonly, a fracture occurs at the narrowest part of the scaphoid (known as the waist). This is where the blood supply to the scaphoid bone enters. So, there is a risk that if you have a fracture in this area, it can sometimes interrupt the blood supply to part of the scaphoid bone, leaving part of the bone without a blood supply. This means that the scaphoid will not be able to heal properly and part of the scaphoid bone 'dies', collapses and breaks up. ('Avascular' refers to having no blood supply and 'necrosis' means death.) If it occurs, avascular necrosis can be seen on an X-ray of the scaphoid bone some months after the initial injury. However, avascular necrosis does not occur with all fractures around the waist of the scaphoid.

Arthritis

Osteoarthritis can develop some time after a scaphoid fracture in some people. It is more likely if there have been complications of non-union, malunion or avascular necrosis.

Post Traumatic Elbow Stiffness- A problem with meager options

Elbow - the middle joint of our upper limb, is that joint of our body which lies between shoulder and wrist joints. Its main role is in the spacial orientation of the hand, both towards and away from the objects .

The commonest fracture of paediatric age group occurs around elbow, and mismanagement of this injury is a major cause of deformity and stiffness due to massage leading to formation of bone in the muscles, a condition known as heterotrophic ossification. It has been observed that in adults the chances of developing heterotrophic ossification in simple elbow dislocation is around 3%, but increase to 20% if dislocation also involves a fracture of the joint, moreover its important to note that if any person has head injury along with injured elbow his chances of developing heterotrophic ossification are increased to 75 to 90%

Although it is not the commonest joint to get injured in the adults, but its a joint where post traumatic stiffness is very common. Not only this, the management of this stiffness is even more time consuming and difficult and in some cases the stiffness may persist for life.

The first and foremost requirement to prevent this stiffness is the appropriate management of any type bony or soft tissue injury around the joint. Any insult to the joint can cause stiffness if adequate measures are not taken to prevent it. But what if the stiffness is already set in?

As soon as you recognize that your elbow movements are restricted, you should consult an expert, the treatment of elbow stiffness  is dependent on the type, severity, duration and age of the patient.

On the basis of how much movement you have the stiffness is categorised as mild moderate and severe, In mild to moderate types with duration of insult of less than 6 weeks physiotherapy is tried with splinting, but with more duration and in severe cases surgery is only alternative left to gain if not full movement, at least functional range which in studies have been found to be between 30 degree to extension to 130 degree of flexion ( the normal range being 0 degree to 150 degree).

The surgery of stiff elbow is not without complications, and poor results can come if adequate follow up and physiotherapy post surgery is neglected. So the decision to operate on stiff elbow is taken with a judicious consultation between the patient, the therapist and the doctor.

Carpal Tunnel Syndrome- Early identification and treatment is key to full recovery.

Carpal tunnel Syndrome is a condition when you start feeling numbness in your fingers, mostly this occurs in the early morning after sleep. It is when your nerve(structure used by body to carry sensations form your skin to brain, and instructions to muscles from the Brain) named Median Nerve develops some conduction block due to compression at the site of passing under a tunnel at the wrist called Carpal tunnel

This occurs more commonly in females, although males are also affected. The symptoms are commonly seen in pregnant females, premenstrual period, hypothyroidism and other hormonal disorders, but this could also occur without any identifiable reason (known as Idiopathic). These days more men are also seen affected due to over use of computer keyboard, where while typing they keep there wrist flexed.

You need to consult a Hand Surgeon if you are facing with such problems, Your doctor would do some tests on you and examine you for conduction block in your nerve. He/She may also order for some electrophysiological investigations known as NCV(Nerve Conduction Velocity)

Once the diagnosis is established, it would be necessary to intervene and depending on your symptoms and duration of symptoms, your doctor may advice a splint or local injection or  surgical release to decompress your tunnel and let the nerve breath.

After you have a surgery, regular check ups and exercises are advised which should be regularly done to prevent any adhesions of the nerve to the scar.

The early you recognize your symptoms, the better it is for the nerve and the prognosis is also good. In late stages even surgical decompression may not be of much help in recovery of the wasted muscles, although it may give good symptomatic relief.

Door Entrapment Injuries of the fingers in Young Children- Be Causious

Being a hand Surgeon I have come across many finger tip or finger pulp or nail injuries, resulting due to entrapment of fingers in the door while closing it. In one case the child himself closed the door, while majority of the times its one child closing the door and others hand gets entrapped. 

The severity of injury depends on the fact of amount of pressure from the door, and the volume of finger entrapped. It can range from total amputation to just pulp avulsion. 

The first and foremost thing for us to know is that, these are common preventable injuries if door latches are kept locked, moreover vigilance of the child that he or she does not play close to the door or with the door. But beyond all if this occurs what to do?

We must be aware of the fact that despite these looking minor injuries the consequences of ill treatment age quite grave, in my opinion if any such injury occurs to the child, it’s important to consult and Hand Surgeon, as he is the right person trained to manage such injuries.

To exemplify my point I would show you a recent case that came to me, His thumb got entrapped, and became necrotic, and thus looking like it will need amputation.   

We derided the necrotic part, and found that partial nail bed was intact, although the nail got avulsed, all the viable elements of the pulp skin were preserved, and reconstruction of the nail bed and the pulp of the thumb were done.

Finally the nail was re posited after cleaning, this reposition, and gives way to the new nail, which will come naturally over time.

The end result was that the length and the cosmesis of the thumb in this one and half year old were preserved.

Message- Watch for door latches, and your child playing with doors