1. Brachial plexus injury (BPI)
These nerves originate in the fifth, sixth, seventh and eighth cervical (C5–C8), and first thoracic (T1) spinal nerves, and innervate the muscles and skin of the chest, shoulder, arm and hand.

2. Injury classified Obstetric
Mechanical injury involving shoulder dystocia during difficult childbirth
Falls from a height on to the side of the head and shoulder, the nerves of the plexus are violently stretched
Direct violence or gunshot wounds, by violent traction on the arm, or by efforts at reducing a dislocation of the shoulder joint

3. Signs and symptoms :
A limp or paralyzed arm, lack of muscle control in the arm, hand, or wrist, and lack of feeling or sensation in the arm or hand.
Nerve compression or stretch. Infants, in particular during delivery and these present with typical patterns of weakness
depending on which portion of the brachial plexus
The most severe form of injury is nerve root avulsion
complete weakness in corresponding muscles.

4. Location of the nerve damage
* Musculocutaneous nerve damage weakens elbow flexors,
* Median nerve damage causes proximal forearm pain
* Ulnar nerve causes weak grip and finger numbness
* Total and irreversible paralysis
* The cardinal signs of brachial plexus injury then, are
weakness in the arm, diminished reflexes, and
corresponding sensory deficits.

5. Classification : * Neurapraxia * Axonotmesis * Neurotmesis
The severity of brachial plexus injury is determined by the type of nerve damage.
Seddon's classification, based on three main types of nerve fiber injury :
* Neurapraxia
* Axonotmesis
* Neurotmesis

6. Injury type : Erb's palsy ( upper trunk BPI , C5-6) Mixd palsy
Klumpke's paralysis ( lower trunk BPI C8-T1)

7. DiagnosIs : Clinical exams Axon reflex testing
Electrophysiological testing
Myelographic study
MRI

8. * Some injuries may heal without treatment
* Many infants improve or recover within 6 months
* The ability to bend the elbow (biceps function) by the
third month of life is considered an indicator of probable
recovery
* Additional upward movement of the wrist,
as well as straightening of thumb and fingers an
stronger indicator of excellent spontaneous improvement

9. Treatment : Orthosis/splinting Occupational or physical therapy
Surgery

10. Surgery :
Hand
Wrist
Forearm
Elbow
Upper arm
Shoulder

11. Opponoplasty of hand
Pinch function

12. Wrist arthrodesis

13. Steindler-Mayer elbow flexorplasty

14. Steindler-Mayer elbow flexorplasty

15. Shoulder Tendon Transfer &
Elbow Flexorplasty

16. Steindler-Mayer elbow flexorplasty

17. Shoulder Tendon Transfer &
Elbow Flexorplasty

18. Elbow Flexorplasty &
Shoulder Arhtrodesis

19. Shoulder Tendon Transfer &
Elbow Flexorplasty

20. Prognosis :
Avulsion and rupture injuries require timely surgical intervention for any chance of recovery.
The potential for improvement varies, but there is a fair prognosis for spontaneous recovery with a return of function.
Reconstruction of paralytic arm is remedy procedure.

21. 21

22. Further References :
Brachial Plexus Injuries: National Institute of Neurological Disorders and Stroke. Last updated September 29, see bottom of webpage. Retrieved
"Brachial Plexus Injury”: Description & illustrations". Cincinnati
Children's Hospital, health information website Retrieved

23. Q & A
Dr. 熊永萬
Dr. Bear