Thread by @PlasticsFella

#BrachialPlexus #Webinar

Great content in this next webinar at 7pm EST (just over an hour)

Speakers include @PeterMurrayMD
Link: handsurgery.org/education/webi…

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Live tweets will follow in a thread for those who can't watch the webinar or those who want notes.

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https://twitter.com/HandSurgeryAssn/status/1258476232225591297

@HandTherapyASHT @HandSociety @ASPSMembers
@AAOS1 @ChrisDyMD @NickPulosMD @AmyMMooreMD

1/ Degrees of Nerve Injury:
Neuropraxia
Axonotomesis
Neurtomesis
Avulsion

2/

Mnemonic: Randy Travis Drinks Cold Beer

Roots, Trunks, Divisions, Cords Branches

3/

Common Exam Question: What are branches of the brachial plexus off the roots and trunks?

Dorsal Scapula Nerve to Rhomboids
Long thoracic Nerve
Suprascapular Nerve

4/

Common Exam Question: What Nerve arises from the posterior cord between the upper and lower subscapular nerves?

thoracodorsal to latissimus dorsi

5/ Great simplicity

c5/6 - Upper trunk: Shoulder, elbow flexion, supination

c7 - middle trunk: elbow + finger extension, pronation

c8/t1 - lower trunk: hand function

6/ Facts

95% are supraclavicular
75% with a head injury
20% with vascular trauma

7/ Workup of Injury

Key Findings:
Atrophy of shoulder
Horners Sign
Tilted head sign (away from the side of complete plexus)

Investigations:
Ct/myelogram scan is gold standard

8/

The priority of Surgical Management

1. Elbow Function
2. Shoulder
3. Hand Function

9/ Indications for Surgery

Evidence of pan plexus nerveroot avulsion
Acute pentrating truama
Repairaible lesion
Physical stability
Psychological Stability

10/ Exposure in Surgery

Different techniques available
Supraclavicular: Access to all roots
Infraclavicular: access to medial cord or branches

11/ Prerequisites for Grafting

Intact proximal nerve
Limited zone of injury
Healthy soft tissue bed

12/ NB!

Nerve graft is the gold standard for brachial plexus reconstruction

13/ Nerve Transfers for BP Injuries

1st Gen: Extra-plexal transfers
Spinal Accessory Nerve to the Suprascapular Nerve
Elevates the shoulder and external rotation

14/ Intercostal Nerve transfer

Workhouse extra-plexal nerve
Common recipients are MCN, axillary, long thoracic
Often used in total plexus cases

15/ 2nd Gen transfer

- Ulnar nerve fascicle to biceps transfer (Oberlin - 1994)
- Double-fascicular transfer to regain elbow flexion (ulnar and median nerve)

16/

Common Exam Point:
Double Fascicular transfer = Oberlin II transfer key in C5-6 brachial plexus injury

17/

Another 2nd gen (intra-BP)

triceps branch to axillary nerve transfer
For shoulder function
Popularised by Somsak

18/

3rd Gen: Distal Transfer

Distal AIN to ulnar nerve transfer
Restores pinch grip and anti-claw
Popularised by McKinnnon

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