Post on 19-Jan-2017
Scottish Adult Brachial Plexus Injury ServiceThe Victoria Infirmary
Langside Road, Glasgow G42 9TY
BPI Service Administrator (direct line) 0141 201 5436
Scottish Adult Brachial Plexus Injury Service
Information for Physiotherapists
Page 2
Page 3
IntroductionThe Scottish Adult Brachial Plexus Service was established in April 2004 to offer specialist treatment for patients with brachial plexus injuries. The team comprises of an orthopaedic surgeon, orthopaedic nurse specialist, occupational therapist and a clinical specialist physiotherapist.
In the UK, traumatic injuries to the brachial plexus are relatively uncommon, about 600 per annum. There are on average 40 such injuries in Scotland a year.
These are complex and disabling injuries and require specialist input. It is essential that they are carefully assessed and managed from the outset.
Lateral cord
Musculocutaneousnerve
Axillarynerve
MediannerveRadialnerveUlnarnerve
Medial cord
Lowertrunk
Middletrunk
T2
Suprascapular nerveUppertrunk
From C4
Posteriorcord
C5
C6
C7
C8
T1
Nerves of the Brachial Plexus
Page 4
Mechanism of injury• Highvelocityinjury-stretchinjury
• Lowimpactinjury-stretchinjury
• Lacerations
If the injury was sustained due to a high velocity accident e.g. a motorcycle RTA, then the likelihood of a more serious pathology is much greater than someone who has sustained an injury from a fall. Patients involved in high velocity accidents are also more likely to sustain other injuries e.g. head injuries, spinal and upper limb fractures and vascular damage.
Patients who have sustained a brachial plexus lesion will present with motor and sensory loss in all or part of the upper limb depending on the extent of the injury.
Clinical factors indicating a relatively mild lesion:
• Lowimpact
• Incompletelesion
• Nopain
• Tinel’ssign
• AbsentHorner’ssign
Clinical factors indicating a more serious lesion:
• Highimpactinjury
• Completelesion
• Burningorshootingpainspresentsincethetimeofinjury
• ?Horner’ssign(ptosisordroopingoftheeyelidwithdilationofthepupil)
Damage to the BP can also occur as the result of tumours or as a result of radiation treatment.
Brachial plexus injuries may occur at the time of birth (Obstetric brachial plexus palsy). There is a separate service for children based at the Royal HospitalforSickChildren,Yorkhill,Glasgow.
Page 5
Grades of injuryThe damage to the brachial plexus nerves can be classified into four different grades:
1. Pre-ganglionictear ................Nerverootavulsion
2. Post-ganglionictear ..............Neurotmesis
3. Severelesionin-continuity ....Axonotmesis
4. Mildlesionin-continuity .......Neurapraxia
The number and combination of nerves injured are very variable. It should be noted that some patients can present with a combination of root avulsions,post-ganglionictearsandlesionsin-continuity.
Adult brachial plexus injuries fall into two categories:
1. Supraclavicular injuries ..........Nervesdamagedabovetheclavicle
2. Infraclavicular injuries ............Nervesdamagedbelowtheclavicle
It is possible for nerves to be injured both above and below the clavicle.
Supraclavicular injuriesSupraclavicular injuries can be caused by a traction injury to the brachial plexus e.g. in a motorcycle accident where the head is side flexed and the shoulder girdle is depressed, or through direct trauma e.g. knife injury or gunshot wound.
Preganglionic tear
Surgicalrepair impossible
Neurotmesis - surgical repair
possible
Postganglionictear
Axonotmesis - recovery possible
Neurapraxia
Page 6
Common patterns of supraclavicular injury occur and can be subdivided into three groups:
1. UpperplexusC5,6(+/-C7and+/-C8)IfC7andC8areinvolvedtheroots are sometimes avulsed. There is less likelihood that the roots of C5andC6willbeavulsed.
2. Totalplexus-thereisdamagetoallnerveroots.C5,C6mayhavepostganglionicruptureswiththerootsofC8andT1avulsed.
3. Lowerplexus-therootsofC8andTIareavulsedbutC5andC6areworking normally.
Avulsion injury/Preganglionic injuryA high velocity accident is more likely to cause avulsion of the nerve roots from the spinal cord. If the nerve roots are avulsed in this way, there is no successful method available for re-implanting the rootlets(experimentalworkisunderwayattheRoyalNationalOrthopaedicHospitalin Stanmore). Patients presenting with avulsion injuries usually complain of an instantaneous onset of pain. This is commonly described as a deep burning pain with frequent shocks of shooting pains throughout the day. The pain is caused by deafferentation of the dorsal horn, which means that with no input from the periphery, pain information passes from the dorsal horn to the brain unmodulated. Interestingly, these patients usually do not have problems with sleep disturbance due to pain.
Apart from the clinical examination, an MRI scan will often help to confirm the diagnosis. From the scan results, the location of the root avulsion can sometimes be seen, as there is the presence of a meningocele (sack filled withCSFleakingfromthespinalcord).
Althoughre-implantationofnerverootletsisnotwidelyused,othermethodsof restoring nerve supply can be undertaken, e.g. nerve transfers. This will vary from patient to patient and will depend on the extent of the damage andthereforethefeasibilityofusingunaffectednerves.Commonlyusednerves for nerve transfers are the intercostals, accessory nerve and the medial pectoral nerve.
This group of patients will always have some form of motor deficit. Secondary operationsmaybeconsidered-forexampleanunstableshouldermaybenefit from a shoulder arthrodesis.
Page7
Infraclavicular injuriesThis type of injury can affect any one or all of the peripheral nerves. The most common presentations are:
• Acompletelesion
• Damagetoaxillarynerve
• Damagetomusculocutaneousnerve
These injuries are usually caused by excessive tractioning of the brachial plexus e.g. following shoulder dislocation or in conjunction with a fractured humerus.
As with all BPI, assessment including muscle testing, sensation testing and neurophysiology tests help to complete the clinical picture. It is especially important to check with those patients presenting following shoulder dislocation that the disruption of shoulder movement is not caused by a tear in the rotator cuff.
Where there has been a severe infraclavicular injury affecting several peripheral nerves, the surgeon may choose to reconstruct only some of the peripheral nerves. This could be because the gap between the damaged nerve ends is too wide to successfully bridge. Sometimes if a nerve is irreparable it is used to reconstruct another peripheral nerve.
Surgical patientBefore deciding to operate the surgeon will take into consideration the age of the patient. Older patients are known to not recover as well from reconstruction surgery as younger patients.
There are two categories of surgical patient:
1. Primary
2. Secondary
Primary repairsThese are normally carried out as soon as possible and usually within 3 months of injury.
1.Nervegrafting/reconstruction
2.Nervetransfer
Page8
Nerve graft/Nerve transfer
Post-operativelypatientswhoundergonervegraftingandnervetransfersare managed in a similar way.
Patients are normally admitted to the Orthopaedic ward, one day prior to surgery. They will usually have been assessed (see appendix 1) at the Brachial PlexusInjuriesClinicpre-operatively.Inadditionotherinvestigationssuchas neurophysiology tests and MRI will already have been done.
OtherassessmenttoolsusedattheclinicaretheDASHquestionnaire,HADScore (HospitalAnxietyandDepressionScore)and theNarakasScore.These are recorded at regular intervals.
When a patient is admitted to the ward the physiotherapy inpatient staff liaisewiththeClinicalLead,SpecialistNurseandOccupationalTherapist.A unified approach is important to avoid conflicting information being given to the patient.
Page 9
Rehabilitation1-4 weeks post-op Patients are usually discharged from the ward on Day 2 or 3 post- operatively.
Outpatientfollow-upisarrangedwhenthedischargedateisknown.Thisisorganisedbythephysiotherapyin-patientstaff.Oncethereisconfirmationof the arrangements, the information is passed to the BPI physiotherapist. Operation notes are available and a copy can be requested from the BPI administrator.
After nerve grafting and nerve transfers, the patients are immobilised in a polysling for 4 to 6 weeks. During this time they are not allowed to move their shoulder, however they should be encouraged to maintain the movements of their wrist and fingers.
It is possible that patients will have sustained multiple injuries, which will also require rehabilitation. If the patient has been treated at another hospital for other injuries sustained at the time of their BPI then it is usual for that hospitaltocontinuewiththereview/managementoftheseinjuries.TheBPIserviceisspecificallyfundedtotreatBPI’sonly.
4-6 weeks post-opThepatient isnormally reviewedat theBPIclinicoroneofMr.Hems’Orthopaedicclinicsbeforethepolyslingisremoved.However,ifthetimingdoes not coincide with the next clinic appointment and the operation notes clearly specify when the sling is to be removed you can go ahead and remove the sling. If in doubt contact a member of the BPI team.
When the sling is initially removed the patient will be apprehensive. Sometimes there is increased pain due to the change in position, so it is important to advise the patient to take their pain medication before treatment.
As one would expect once the sling is removed the patients have restricted passive movements of the upper limb. It is therefore important to start on a passive movement programme (see Appendix 4). If they have any active movements then this should also be started. There are usually no restrictions as to what they are allowed to do.
Page 10
Characteristic limitations of movementShoulder joints: ........................Elevation, abduction, lateral rotation
Elbow joints: ..............................Extension and supination
Wrist joints: ................................Flexion and extension
MCPjoints: ................................Flexion
PIP joints: ...................................Extension
Soft tissue changes• Reducedwebspace
• Shorteningofthelongflexors
• Fibrosisoftheintrinsicmuscles
(Victoria Frampton 1999 Journal of Hand Therapy)
If the movements of the shoulder are very restricted it is useful to show a relative how to help with the exercises, particularly lateral rotation and abduction. Once a reasonable passive range has been achieved, the patientcanstart tocombinemovements (i.e.elevation/abductionandlateral rotation) and continue their exercise independently. This is an importantaspectofthepatient’supperlimbmanagement.
If the patient is happy to keep the sling off then this should be encouraged. If not, gradually reduce the amount of time that the sling is worn for. Some patients like the comfort of the sling when they go out, or when they are playing football.
Aims of treatment• ·Increase/maintainrangeofmovement
• ·Mobilisetightscartissue
• ·Maintaingoodjointposition,splintifnecessary
• ·Discuss/helpwithpaincontrol
• ·Improvepostureandbalance
• ·Encouragereturntoworkorsport
In terms of rehabilitation, the main aim is to maintain joint range of movement, improving muscle power in any group of muscles that have surviving motor units and regain a maximum level of function.
Page 11
PainSome patients who have severe pain may find pain relief modalities helpful (i.e.TENSoracupuncture).Themosteffectivemethodofeasingpatient’sawarenessofpainisbyactionanddistraction.TheClinicalNurseSpecialistoffers relaxation therapy and counselling whilst Occupational Therapists can also utilise relaxation and visualisation techniques as a part of a pain management programme and discuss various coping skills that can be utilised with chronic pain.
Since causalgia is related to tension and stress, relaxation techniques are beneficial in pain management. Some patients may be referred to their localpaincontrolteam.However,theirpainmedicationisdiscussedatthe clinic and recommended changes in their drugs are conveyed to the patient’sGP.
For patients complaining of mechanical pain related to shoulder sub- luxation, it may be worthwhile trying a shoulder support. A variety of these are on the market.
“Return to work is vital in the rehabilitation of these patients, not only to get back to normal life, but, if they are suffering pain, this is probably the only consistent means of providing distraction from pain”.
(WynnParry,1984)
One year +Patients should be starting to show signs of recovery in the nerves that havebeenreconstructed.EarlysignswouldbeaprogressiveTinel’ssignwhich would become apparent before other signs of recovery. Once a flicker can be detected in a muscle it is important to intensify treatment again.Itmaybethatpatientsareshownanti-gravitypositionstoexercisein, or use muscle stimulators over motor points (see Appendix 1) or ice brushing. Sometimes it is hard to convince the patient that the muscle is working as no movement is being produced. Once recovery starts it normally continues to progress. Recovery may continue for 4 to 5 years.
Aim of surgery and expected outcome The aim of a primary repair is principally to improve motor function. However,primary surgical repair can aim to improve sensory functionparticularly protective sensation in the hand.
The expectation from primary repair is to achieve elbow flexion. Results in terms of effective shoulder control have so far been mixed with some patients requiring a secondary operation for shoulder arthrodesis.
Page 12
Handandwrist functioncanbe improvedwithprimary surgerybut ifnecessary can benefit from secondary operations e.g. tendon transfers and bony fusions.
Secondary operationsSecondary operations fall into two categories:
·1. Bonyfusions
·2. Tendontransfers
Bony fusions will only be considered when there is no chance of further useful recovery. The joints most commonly fused are the wrist and the shoulder.
Shoulder arthrodesisThis is one of the most common secondary operations undertaken. It is performed because the patient has poor shoulder control but has gained other functional return in the hand and elbow. Due to the lack of control at theshouldertherestoftheupperlimb’sfunctioncannotbemaximised.Inorder for the patient to be suitable for this procedure they must have good thoracoscapular muscle power e.g.upper trapezius, serratus anterior.
Rehabilitation
Following shoulder arthrodesis patients are immobilised in an abduction brace for at least 6 weeks. They are advised about the position, function and appearance of the brace. Once the brace is removed they can start passive and active movements. The range of movement usually progresses quite quickly, with the expectation that they will be able to achieve between 60 to 90 degrees of elevation and abduction.
The patient is warned that they will have loss of medial rotation, hand behind back and that the arm will hang in a slightly abducted position.
Tendon transfersTendon transfers are considered at a later stage, usually at about two years post injury. Sometimes tendon transfers will be considered before this to aid function while recovery in the nerves takes place.
Tendontransfersaremostcommonlyperformedinthehand.However,occasionally free muscle transfers may be used to improve elbow flexion e.g. gracilis.
Patientswhopresentwithavulsionoftherootsoflowertrunk(C8-T1)only may eventually be appropriate for tendon transfer. In order for this
Page 13
to be successful it is important to teach the patient how to maintain joint range of movement and to maximise the strength in the muscle groups which are still functional. Tendons used for transfer must be a Grade 4 or better. Tendon transfers in the hand must be planned so that pinch and grip will be improved.
Rehabilitation involves the re-education of function, occasionally withtrickmovementsorwiththeco-ordinationofothermovementse.g.wristextension with finger flexion. Operation notes will be available with some indicationoftheexercises/functionalmovementsthatthepatienthastoperform.
The non-surgical group of patientsPatients who fit into this category are those who have suffered temporary damage to the conduction of the nerve for example a neurapraxia or an axonotmesis or those who have had a virus causing a brachial neuritis. These injuries/pathologiescantakefromseveralmonthstooverayearto recover and it is therefore essential that the patient understands this and knows the importance of maintaining joint range of movement while waiting for recovery.
Rehabilitation of the non-surgical patientPhysiotherapy input is important and it needs to be tailored to suit the individual patient. Reassurance is one of the key issues and it is important to fulfil this role. It may be that the patient only needs to have treatment once every 4 to 6 weeks if they are managing their exercises and have good range of movement.
It may be necessary to provide some form of splinting to aid function or to maintain hand position. If you feel that this would be beneficial and are unable to provide this type of splinting please contact the BPI service.
When planning return visits you should take into consideration the stage of recovery and estimated time for signs of recovery starting. Sometimes early signs of recovery are difficult to detect and this highlights the importance of accurate record keeping. Once a flicker of muscle contraction can be detected the patient should then be started on exercises to maximise this improvement e.g. ice brushing, muscle stimulation (see Appendix1AandBformotorpointchart),gravity-assistedexercises.
Even the smallest sign of recovery gives the patient tremendous encouragement.
The Brachial Plexus Service also has a number of muscle stimulators which areavailableonloan.ContacttheBPIServicePhysiotherapist.
Page 14
Simplified diagram of the brachial plexus
Adduction -Pectoral nerves(C5, 6, 7, 8)
SHOULDERExternal Rotation -Suprascapular nerve (C5)
Abduction -Axillary nerve (C5)
Ulnar nerve
Extension -Radial nerve (C6, 7, 8)
FINGERS
Adduction -Ulnar nerve (T1)
Flexion -Median (and Ulnar) nerve(s) (C7, 8)
THUMBAbduction -Median nerve (C8, T1)
WRISTExtension -Radial nerve
ELBOWFlexion -Musculocutaneous nerve (C5, 6)
Median nerve
Radial nerve
C5C6C7C8T1
Musculocutaneous nerve
Extract from 'Guidelines on management and transfer of Brachial Plexus Injury', Scottish Brachial Plexus Injury
Service.
Page 15
Brachial plexus peripheral nerve distributionSuprascapular nerve C5,6
Shoulder Girdle:
Supraspinatus
Infraspinatus
Long thoracic nerve C5,6,7
Shoulder Girdle:
Serratus anterior
Axillary nerve C5,6
Shoulder Girdle:
Teres minor
Deltoid
Musculocutaneous nerve C5,6
Arm:
Biceps
Coracobrachialis
Brachialis
Median nerve C6-T1
ForearmandHand:
Pronator teres; Pronator quadratus; APB; Opponens; FCR; Palmaris longus; FDS; FDP to index and middle fingers; FPB (lateral head); Lumbricals
Radial nerve C6-T1
Arm:
Triceps - long, lateral and medial head
Brachioradialis
ForearmandHand:
ECRL
ECRB
Supinator; EDC; EDM; ECU; APL; EPB; EI
Ulnar nerve (C7) C8-T1
Forearm and hand:
FCU
FDP (ring and little fingers)
FDMB; ADM; ODM; Interossei; Lumbricals; Adductor pollicis; FPB (medial head)
Page 16
Brachial plexus peripheral nerve distribution and functional limitationsNerves Muscles Functional limitations
SuprascapularnerveC5,6
(Shoulder girdle)
Supraspinatus
Infraspinatus
Weakened lateral rotation of humerus.
LongthoracicnerveC5-7
(Shoulder girdle)
Serratus interior 'Winged scapula'.
Difficulty flexing outstreched a r m a b o v e l e v e l o f shoulder.
D i f f i cu l ty p rot rac t ing shoulder.
AxillarynerveC5,6 Teres minor
Deltoid
Loss of arm abduction.
Weakened lateral rotation of humerus.
Musculocutaneous nerve C5-7
(Arm)
Biceps
Coracobrachialis
Brachialis
Loss of forearm flexion and supination.
MediannerveC5-T1 Pronator terres
Pronator quadratus
APB;Opponens;FCR,Palmarlongus; FDS; FDP (to index and middle); FPB (lateral head)
Lumbricals
'Monkey hand' deformity.
Weakened grip.
Thenar atrophy.
Unopposed thumb, loss of pinch grip.
RadialnerveC5-T1
(Arm)
Triceps (long, lateral and medial head)
Brachioradialis
Absent/weaksupination.
'Wrist drop'
Extensor paralysis of fingers and thumb.
RadialnerveC5-T1
(Forearm and hand)
ECRL;ECRB
Supinator
EDC; EDM;ECU;APL; EPB;EI
Loss of wrist, thumb and finger extension.
UlnarnerveC8-T1
(Forearm and hand)
FCU
FDP (ring and little)
FDMB; ADM; ODM
Interossei
Lumbricals
AP; FPB (medial head)
'Clawhanddeformity'.
Interosseus atrophy.
Loss of thumb abduction.
Modified from Pedretti, L in Pendleton & Krohn (2006)
Page17
Further reading
Birch,R.,Bonney,G.W.L.,&Parry,W.C.B.(1998)
Surgical Disorders of the Peripheral Nerves
Churchill Livingstone
Lundborg, G. (2004)
Nerve Injury and Repair. Regeneration, Reconstruction and Cortical Remodelling (2nd Ed.)
Elsevier Churchill Livingstone
Pendleton,H.M.&Krohn,W.S.(2006)
Pedretti’s Occupational Therapy (6th Ed.)
Elsevier Mosby
Salter.M,&Cheshire,L.(2000)
Hand Therapy, Principles and Practice
Butterworth Heinmann
Spinner, R., Shin, A., Bishop, A. (2004)
Update on brachial plexus surgery in adults
Current Opinion in Orthopaedics, 15. pp 203-214
WynnParry,C.,B.(1984)
Clinics in Plastic Surgery
Page18
Brachial Plexus Injury Service Team - contact names and telephone numbers
Lead Clinician: TimHems
(Contactbelow*)
Clinical Specialist Physiotherapist: Jane Green
0141 201 5541
Clinical Nurse Specialist: Beverley Wellington
0141 201 5394
Occupational Therapist: DebbieClyde
0141 201 1500
BPI Service Administrator: *DavidMcKay
0141 201 5436
Brachial Plexus Injury Service Websitewww.brachialplexus.scot.nhs.uk
Brachial plexus injury management guidelines (see Appendix 2) and referral forms can be viewed and downloaded.
Page 19
Appendix 1A - Motor points (anterior aspect of right arm)
Del
toid
(m
iddl
e fib
res)
Bice
ps B
rach
ii
Brac
hial
is
Brac
hior
adia
lis
Flex
or C
arpi
Rad
ialis
Flex
or D
igito
rum
Sup
erfic
ialis
(su
perf
icia
l fib
res)
Flex
or P
ollic
is L
ongu
s
Flex
or D
igito
rum
Pro
fund
us (
late
ral f
ibre
s)
Abd
ucto
r Po
llici
s Br
evis
Opp
onen
s Po
llici
sFl
exor
Pol
licis
Bre
vis
Del
toid
(an
terio
r fib
res)
Pect
oral
is M
ajor
Cor
acob
rach
ialis
Pron
ator
Ter
es
Flex
or C
arpi
Uln
aris
Palm
aris
Lon
gus
Flex
or D
igito
rum
Pro
fund
us (
med
ial f
ibre
s)
Lum
bric
als
Flex
or D
igito
rum
Sup
erfic
ialis
(de
ep fi
bres
)
Abd
ucto
r D
igiti
Min
imi
Flex
or a
nd O
ppon
ens
Dig
iti M
inim
i
Page 20
Appendix 1B - Motor points (posterior aspect of right arm)
Del
toid
(po
ster
ior
fibre
s)
Tric
eps
(long
hea
d)
Tice
ps (
med
ial h
ead)
Supi
nato
r
Exte
nsor
Car
pi U
lnar
is
Exte
nsor
Dig
iti M
inim
i
Inte
ross
ei
Del
toid
(m
iddl
e fib
res)
Tric
eps
(late
ral h
ead)
Exte
nsor
Car
pi R
adia
lisLo
ngus
and
Bre
vis
Add
ucto
r Po
llici
s
Exte
nsor
Pol
licis
Lon
gus
Exte
nsor
Pol
licus
Lon
gus
and
Exte
nsor
Pol
licis
Bre
vis
Page 21
Gui
del
ines
on
man
agem
ent
and
tra
nsf
er o
f B
rach
ial P
lexu
s In
jury
Vict
oria
Infir
mar
y, A
cute
Ser
vice
s D
ivis
ion,
NH
S G
reat
er G
lasg
ow a
nd C
lyde
C3
C4
T2
T3
T4
T5T2
T3
C5
C6
C5
T1
C7
C6
C8
Mo
tor
asse
ssm
ent
Sen
sory
are
as
ASS
ESS
We
wel
com
e re
ferr
al o
f a
ny
acut
e tr
aum
a p
atie
nt
wit
h a
bra
chia
l ple
xus
inju
ry.
We
can
als
o a
dvi
se o
n a
ny
per
iph
eral
ner
ve in
jury
an
d a
dm
it a
s n
eces
sary
.A
ll p
atie
nts
mus
t b
e as
sess
ed b
y lo
cal t
raum
a te
am.
Tel:
0141
201
543
6 (O
ffic
e h
our
s) O
R: 0
141
201
6000
Ble
ep 5
440
Fax:
014
1 20
1 50
82Em
ail:
bra
chia
l.ple
xus@
gvi
c.sc
ot.
nh
s.uk
Web
site
: ww
w.b
rach
ialp
lexu
s.sc
ot.
nh
s.uk
Co
mp
lete
a r
efer
ral f
orm
Plea
se p
rovi
de t
he fo
llow
ing
info
rmat
ion
for
all p
atie
nts.
VI MEDICAL ILLUSRATION• ORTHO • 6802/22.12.06
Co
mp
lex
upp
er li
mb
tra
uma
ASS
ESS
- Ve
ssel
s; N
erve
s; B
ones O
pen
or
clos
ed in
jury
Co
nta
ct B
rach
ial P
lexu
s Se
rvic
e
Vasc
ular
rep
air
Art
erio
grap
hy
Thin
k: V
esse
l…N
erve
…B
on
e
Brac
hial
ple
xus
expl
orat
ion
Vasc
ular
inju
ryN
o va
scul
ar
inju
ry
Life
th
reat
enin
g ha
emor
rhag
e
Not
life
thre
aten
ing
Emer
genc
y op
erat
ion
to
repa
ir ve
ssel
s
An
expe
rt o
pini
on s
houl
d be
sou
ght
imm
edia
tely
in
cas
es o
f vas
cula
r in
jury
or
open
inju
ry, a
nd w
ithin
48
hou
rs in
all
othe
r ca
ses.
Ass
ess
Acu
te -
res
usci
tate
and
sta
bilis
e p
atie
nt.
Air
way
, Br
eath
ing,
Circ
ulat
ion.
Ris
k fa
cto
rs a
nd
ass
oci
atio
ns
for
Bra
chia
l Pl
exus
In
jury
• H
igh
vel
ocity
RTA
, es
peci
ally
mot
orbi
ke.
• Fr
actu
re o
r di
sloc
atio
n of
sho
ulde
r, s
capu
lar,
or e
lbow
. •
Ope
n/pe
netr
atin
g in
jury
to
neck
, upp
er q
uadr
ant
of
trun
k, o
r ar
m.
• A
rter
ial
inju
ry in
upp
er li
mb.
• Tr
actio
n in
jury
to
the
upp
er l
imb.
Sig
ns
of
inju
ry•
Swel
ling
abov
e an
d/or
bel
ow t
he c
lavi
cle.
• H
orne
r’s s
ign.
• Se
vere
pai
n in
the
upp
er li
mb.
• Pa
raly
sis.
• Se
nsor
y lo
ss.
Inve
stig
atio
ns
Man
dat
ory
: Ra
diog
raph
s -
Che
st; C
-spi
ne.
Op
tio
nal
: M
RI o
f th
e C
-spi
ne o
r C
T-m
yelo
grap
hy.
Bot
h
ar
e us
eful
in
dia
gnos
ing
roo
t a
vuls
ions
alth
ough
neith
er i
s 1
00%
acc
urat
e. M
RI i
s e
asie
r t
o
pe
rfor
m e
arly
aft
er i
njur
y.N
euro
phys
iolo
gy -
Is n
ot u
sual
ly h
elpf
ul i
n th
e a
cute
situ
atio
n.
Ref
erra
l Cen
tre
- G
lasg
ow
Mr
T. H
ems
____
____
___T
el. 0
141
201
5436
Mr
C. D
regh
orn
(Dep
t. o
f Ort
hopa
edic
Sur
gery
, Vic
toria
Infir
mar
y, G
lasg
ow G
42)
Loca
l co
ordi
nato
rsH
ighl
and
____
____
____
_Mr.
D.F
inla
yson
(Te
l. (0
141)
704
00)
Abe
rdee
n __
____
____
___M
r. A
. Joh
nson
(Te
l. 01
224
5567
5)
Loth
ian
____
____
____
___M
r. C
. Oliv
er T
el. (
0131
242
340
2)
Tays
ide
____
____
____
___M
r. J.
Den
t (T
el. 0
1382
660
111)
Ayr
shire
and
Arr
an _
____
Mr
C. M
acle
od (
Tel.
(015
63)
5778
96)
Arg
yll a
nd C
lyde
___
____
Mr
S.Ba
rnes
(Te
l. 01
475
6337
77)
Ob
stet
ric
Bra
chia
l Ple
xus
Pals
yRe
ferr
als
are
wel
com
ed t
o D
epar
tmen
t of
Ort
hopa
edic
Sur
gery
, Roy
al
Hos
pita
l for
Sic
k C
hild
ren,
Yor
khill
, G
lasg
ow (
Mr
Dav
id S
herlo
ck a
nd
Mr
Tim
Hem
s).
Inju
ries
to
th
e Lu
mb
rosa
cral
Ple
xus
Indi
catio
ns fo
r re
ferr
al-
Ope
n in
jurie
s.-
Clo
sed
inju
ries:
Aft
er 3
mon
ths
- C
ompl
ete
abse
nce
of fu
nctio
n in
th
e fe
mor
al n
erve
or
the
tibia
l div
isio
n of
the
sci
atic
ner
ve.
Ref
erra
l fo
rms
can
be
ob
tain
ed b
y te
lep
ho
nin
g:
0141
201
543
6
or
can
be
do
wn
load
ed a
s a
file
fro
m:
ww
w.b
rach
ialp
lexu
s.sc
ot.
nh
s.ukTh
e V
icto
ria
Infi
rmar
yD
epar
tmen
t o
f O
rth
op
aed
ic S
urg
ery
Lan
gsi
de
Ro
adG
lasg
ow
G42
9TY
The
Vic
tori
a In
firm
ary,
Gla
sgo
w
Bra
chia
l Ple
xus
Inju
ry R
efer
ral
Plea
se p
rovi
de t
he fo
llow
ing
info
rmat
ion
for
all p
atie
nts
Nam
e:D
oB:
Mo
tor
asse
ssm
ent
Add
ress
:A
ctiv
e m
ove
men
ts
MRC
gra
de (
0-5)
Shou
lder
ext
erna
l rot
atio
n (in
fras
pin
atus
)
GP:
Shou
lder
abd
uctio
n (d
elto
id)
Shou
lder
abd
uctio
n (p
ecto
ralis
maj
or)
Sex:
CH
I no:
Elbo
w fl
exio
n (b
icep
s)
Dom
inan
t ha
nd:
Elbo
w e
xten
sion
(tr
icep
s)
Occ
upat
ion:
Wris
t ex
tens
ion
Inju
ry d
ate
and
time:
Fing
er fl
exio
n
Det
ails
of
inci
den
t (l
ow
or
hig
h e
ner
gy;
p
enet
rati
ng
etc
.)Th
umb
abdu
ctio
n (t
hena
r m
uscl
es)
Fing
er a
bduc
tion
(intr
insi
c m
uscl
es)
Sen
sory
ass
essm
ent
Der
mat
ome
char
t:C
5C
6C
7C
8T1
Sens
atio
n: N
orm
al
A
ltere
d
A
bsen
t
Inve
stig
atio
n r
esul
tsC
hest
x-r
ay:
Alc
ohol
or
drug
s?
Hos
pita
l and
war
d:C
-sp
ine:
Tele
pho
ne:
Con
sulta
nt:
C-s
pin
e M
RI /
CT-
mye
logr
aphy
:
Tele
pho
ne:
Refe
rrin
g do
ctor
: Pa
ge n
o:(R
adio
grap
hs a
nd s
cans
film
s m
ust
acco
mp
any
the
pat
ient
whe
n tr
ansf
erre
d)
Clin
ical
co
nd
itio
nTr
eatm
ents
so
far
Air
way
:
Brea
thin
g:
Circ
ulat
ion:
Pu
lse:
BP
:
Oth
er in
juri
esPa
st m
edic
al h
isto
ryH
ead
Che
st:
Abd
omen
:
Lim
bs:
Med
icat
ion
sB
rach
ial p
lexu
s d
etai
lsSi
de a
ffect
ed:
Op
en o
r cl
osed
inju
ry:
Puls
es a
ffect
ed in
lim
b:C
2H5O
H w
ithdr
awal
(se
dativ
e an
d th
iam
ine)
If ab
sent
, is
ther
e cr
itica
l lim
b is
chae
mia
?Te
tanu
s
Hor
ner’s
sig
n:M
RSA
sta
tus:
Swab
s ta
ken:
Site
of b
ruis
ing:
Furt
her
cop
ies
of t
his
form
are
ava
ilabl
e fr
om: 0
141
201
5436
or w
ww
.bra
chia
lple
xus.
scot
.nhs
.uk
Frac
ture
s/di
sloc
atio
ns:
VI M
EDIC
AL
ILLU
STRA
TIO
N
• O
RTH
O •
680
2/21
.12.
06
REF
ER A
ND
TR
AN
SFER
Add
uctio
n-
Pect
oral
nerv
es(C
5,6,
7,8)
SHO
ULD
EREx
tern
alRo
tatio
n-
Supr
asca
pula
rne
rve
(C5)
Abd
uctio
n-
Axi
llary
nerv
e(C
5)
Uln
arne
rve
Exte
nsio
n-
Radi
alne
rve
(C6,
7,8)
FIN
GER
S
Add
uctio
n-
Uln
arne
rve
(T1)
Flex
ion
-M
edia
n(a
ndU
lnar
)ne
rve(
s)(C
7,8)
THU
MB
Abd
uctio
n-
Med
ian
nerv
e(C
8,T1
)
WRI
STEx
tens
ion
-Ra
dial
nerv
e
ELBO
WFl
exio
n-
Mus
culo
cuta
neou
sne
rve
(C5,
6)
Med
ian
nerv
e
Radi
alne
rve
C5
C6
C7
C8
T1
Mus
culo
cuta
neou
sne
rve
Appendix 2 - Guidelines on management and transfer of Brachial Plexus InjuryAlso available at www.brachialplexus.scot.nhs.uk
Page 22
Appendix 3 - BPI Injury Patient Assessment Form
The Victoria Infirmary, Glasgow
National Brachial Plexus Injury ServicePatient Assessment
Patient details
Name; DoB; Address; Telephone
Use addressograph label if available
Dominant hand:
Occupation:
Date of injury:
Social support: Yes No Family Partner Alone
List other injuries:
Previous treatments:
Brachial Plexus details
Side affected:
Open or closed injury:
Arterial Injury: Yes No
Pulses affected in limb:
If absent, is there critical limb ischaemia?:
Horner’s Sign: Yes No
Tinel’s Sign: Yes No Site:
Site of bruising:
Referring hospital:
Consultant:
Chest x-ray:
C-spine:
C-spine MRI:
Relevant past medical history:
List of medications:
Excessive alcohol use: Yes No Units/week:
Drugs (IVDA): Yes No
MRSA status + / - OR swabs taken:
Date / /
Details of incident (low or high energy. penetrating etc.)
Chart continues overleaf
Page 23
Motor Assessment(Grade 1-5) Comments
Trapezius
Serratus Anterior
Supra / Infraspinatus
Deltoid
Pectoralis Major
Lat. Dorsi / Teres Major
Biceps
Triceps
Wrist Extensors
Extensor Digitorum
EPL
FCR
Palmaris Longus
FCU
FDPs
FDSs
FPL
Thenar Muscles
Interossei
Sensory Assessment(Normal, Altered, Absent)
C5
C6
C7
C8
T1
Median nerve
Ulnar nerve
Radial nerve
Passive movement
Shoulder
Elbow
Hand
Functional Scores
DASH Score
Narakas Score
VAS Score
HAD Score
Employment status
Employment status key:Return to previous employment 1Return to different employment 2Training 3Not working 4
VI MEDICAL ILLUSTRATION • ORTHO • 10849
Page 24
Appendix 4 - Exercise Programme
The text and illustrations below are an extract from the patient information bookletforbrachialplexusinjurypatients'ScottishNationalBrachialPlexusInjuryService-InformationforPatients'.
Physiotherapy Exercise ProgrammeThe following programme of exercises is designed to help you be as independent as possible while doing the exercises.
You will be told when you are ready to start these exercises. A physiotherapist will show you exactly what you have to do.
The shoulder and elbow exercises are usually started at 4 to 6 weeks, once the Polysling has been removed. The wrist and hand exercises can be done while the Polysling is on. You should repeat each exercise 10 times, twice or three times each day.
Shoulder exercises1. Lying on your back, clasp
your affected arm by the wrist or hand and lift your arm above your head. This should gradully improve until you are able to take your arm all the way above your head as shown.
2. You will need help with this exercise. The person helping you puts one hand across the top of your shoulder to stop it moving. With their other hand they grasp around your elbow and then fix your forearm between their body and side. Your arm is then moved out to the side as far as possible
1. Shoulder
2. Shoulder
Page 25
3. Shoulder
3. You will need help with this exercise. The helper holds around your elbow to keep your arm close to your side. Their other hand holds around the wrist and in this position turns your arm out towards them.
4. Once your movement improves enough for you to reach above your head, you can stop exercises 2 and 3 and use this combined exercise instead.
Lift your affected arm up as far as you can and put your hands behind your head. In this position, stretch your elbow back towards the pillow.
Elbow exercises5. While standing, hold your
affected arm around the wrist and help bend your elbow up as far as you can.
4. Shoulder
5. Elbow
Page 26
6. Straighten your elbow out as far as you can. To help you get more straightening, place your other hand behind the point of elbow.
If you find this difficult, try adding a light weight as shown below.
Wrist exercises7. While seated, help your
affected hand by putting palm to palm and push the wrist back.
8. While seated, place yourunaffected hand over the back of your affected hand and bend the wrist forward.
6. Elbow. Try adding a light weight to help straighten your elbow.
7.Wrist
8.Wrist
Page27
9. Holdyouraffectedhand inthe mid part of the palm and turn your hand up.
10. Holdyouraffectedhand inthe mid part of the palm and turn your palm down.
Hand exercises11. Use your unaffected hand to
help bend your fingers into your palm. Make sure you bend your fingers from the knuckles so you are curling your fingers as much as possible.
9. Wrist
10. Wrist
11.Hand
Page28
12. Spread your fingers by placing the fingers of your unaffected hand in between the fingers of your affected hand and strech them apart.
Thumb exercises13. Stretch your thumbs across
your palm as far as you can.
12.Hand
13. Thumb
14. Thumb
14. While seated, fix your hand between your knees and stretch your thumb away from the fingers.
Page 29
VIMEDICALILLUSTRATION • ORTHO • 10679