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The Brachial Plexus for the Orthopaedic Exams
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The Brachial Plexus for the Orthopaedic Exams
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Language: EN.
Segment:0 .
The knowledge is tested in part one of the FRCS trauma and orthopedic. But that doesn't mean that you are well, you are exempt from being asked about your knowledge. In part two, without knowledge, you can't pass any of the parts.
Then they are asking about how would you approach to answer the question? So don't just start answering the question by the answer. You know, listen to the question. Prepare it in your mind. Some of during my practice, I rehearsed answering the question before just speaking loudly and with time. You are very good at answering the question as quick as possible.
Then they are asking whether or not you are a safe consultant. That's the main point. They are not asking. They are not asking you to be a brachial plexus specialist. They are asking whether or not you are a safe consultant. So that's the ICP, the latest one, which basically for the neurophysiology and the brachial plexus disorders, not the highest level, the level three, but for the examination, it's the level 4.
So be prepared to be asked in the 5a and in the clinicals about the brachial plexus with the new format. There is no patients in it, but you have to know all the movements and all the tests. You have to know how to vocalize the tests now and how to vote and what is the significance of each test. So it's a bit different and easier and difficult in another way.
Reconstructive surgery? Just know about it, ok? You will not be asked in details of how would you reconstruct the reconstructive surgery for the brachial plexus injury? Then what is the basic science behind the brachial plexus? It is a nervous plexus formed of the entire primary remedy of the lower force of nerves and the first thoracic nerve. So the root value of the brachial plexus is C5 to T1 one, and it emerges between the calcaneus anterior and the scoliosis medius.
It is gives afferent and efferent nerves to the upper lip. I struggle to remember. The first part of the triplexes, how is it formed? So the mnemonics of rugby teams drink called beer roots, trunks, divisions, coats, branches that give me the sequence of the names of the nerves that forms the brake and plexus.
Then one of the main questions that can come if in the basic science asked it is how to draw the brachial plexus. So you are being asked and you need to drill this? Wow that's a lot of things to drill and a lot of names to remember. So I made a small video to show people how I drew it.
And how I. In just 30 seconds, 1 minute by most, you can draw the brachial plexus and then start discussing the outcomes. We start with the root values of C five, C six, seven 8 and one with the mnemonics of rugby team drinks cold beer. So it is roots, trunks, divisions, cords and branches.
We drew the three long lines. Like this? And we say that the route will see 5 and 6 from the upper trunk, see 7 from the middle trunk, see AT&T one forms the lower trunk. Then there is connection between the drawings at the division spot. Then for the colts, there is the lateral code steer code in the medial code.
The lateral code. The main branch of it is the musculocutaneous nerve and a branch to form the medial nerve. There is also the lateral pectoral nerve from the medial quarters, the ulnar nerve, which is the main branch of the medial cord. There is also a branch for the medial nerve. That's how the medial nerve is formed and there is the medial pectoral nerve.
Medial cutaneous nerve of the arm and medial cutaneous nerve of the forearm. Close to your coach, you have the radial nerve, axillary nerve. Upper lower subscapularis nerve and through our dorsal nerve from the true value of C5. You have the dorsal scapular nerve and C5 6 and 7 together gives the long thoracic nerve to reach its interior from the upper trunk.
You have the suprascapular nerve. Thank you. To be able to drill the OK, so back to back to me. So basically, there is not a fast route rule of 70s. So before that, ok? That's how we drew the brachial plexus in the basic science and table in.
I drew it, I drew it basically in two minutes. If you if you just view this video just before the Viva by the NIPE. That's it. You don't want to. You don't need to do anything. You can just practice it in five minutes and do it in 1 minute in the exam if needed. So not this rule '70s.
Basically, it's not asked, but it is a good thing if you know it, as this will give the examiners an impression that about this. You know that 70% of the brachial plexus is due to. That's the other one is due to the road traffic accidents, 70% of them is motorcycle and 70% is a trauma patient. So every patient who has a brachial plexus, if you get it in the trauma or get it in anywhere, you will start by saying battles and go through your basic bits about a trauma patient.
70% is a super killer and 70% at least one root of ulcer will go through this a bit more in details as we go. So what is the mechanism of injury? It can be road traffic accidents. It can be obstetric. It can be a shoulder injury like a shoulder dislocation. But this is usually to a peripheral nerve or basically a lower leg, a distal brachial plexus injury, a shotgun or a iatrogenic, usually during cervical lymph node biopsy or basically axillary clearance in breast cancer.
They can endure the brachial plexus. Let us see what, what, what are the different modes of trauma we are talking today about other brachial plexus. But basically, if you have an abduction traction, that's so abduction of the arm with upward traction. That means a lower leg brachial plexus, which means that hand good shoulder.
So your when you are looking at the picture, the clinical fall to. Of you look at two groups of muscles. The shoulder group of muscle and the hand group of muscle. So if the shoulder is wasted, OK, that's the upper plexus injured. If the hand is wasted, that's unclothed, that's the lower brachial plexus injury.
If both, that's a tool for brachial plexus. That's the easy way or the straight away thinking of when you see the picture, what would you say or what would you think? Of course you're not. Say it straight away because you need to show the systematic approach to the patient, but that's how you expect the case to go. So clinical objectives, what are your clinical objectives from that?
First, you need to take history. What happened? Then you want to identify the lesion? Is it superclub in for clavicle and which routes are affected? And then you have to know what is the lesion? Is it the root abortion or a peripheral nerve? And that's the we will go through this. But that's the most important thing, because how will you consent the patient?
How you will consult the patient depends about what type of lesion and where is the lesion? Then you have to know what are the functions lost? What are the functions preserved and how can you help the patient? So so that's the nerve injury, but that's the peripheral nerve injury, and you all know the peripheral nerve injury about the Sydney and the Sunderland, I like more the merchant bony.
But the it is about the degrees and the grades of the nerve injury, starting from just conduction block to degenerative block. That's how Bush and bony classified them and classified that the conduction block can be transient or prolonged, and the degenerative block can be anything from axilo tenodesis to neurogenesis, according to how much of the nerve is affected.
Is it just the axon, just the engineering, just the theory or the epidural? That's so much important, and the picture or the diaphragm diagram shown here is so much important to memorize during the basic science. Then the history, what was the mood of trauma, what event and what was the position of the arm? And we know why now. What was the position of war.
And what is the importance of the position then when did it happen? And we will know from the. In the treatment with the. The there is different strategies to tackle brachial plexus injury, and these strategies actually are dependent on the time, whether or not it's chronic brachial plexus or acute brachial plexus and whether or not you are going to explore it early or late and whether or not there is any recovery or not.
So you need to know when did that happen, then you need to know any associated trauma. So basically, whether or not there is any cervical spine injury, there is any other injury, other fractures, vascular injury, you need to know the associated injuries. What investigations did the patient have so far and what did the treatments that he had so far? And basically, whether or not there was an early exploration or not?
And lastly, the expectation of the patient and the diaphragm and diagram on the right side shows for different injuries to spinal nerve with it is just stretched be it is stretched and usually there is some sort of nerve injury, but we call it nerve injury in continuity. So the whole nerve, the nerve itself wasn't cut.
See, it is a nerve injury, but the nerve injury is basically this is not a root of. And that's so much important to differentiate between a non root abortion injury, which is C And the root of an injury, which is the OK then examination. So now we are talking about the clinical in the air forces exam for the examination.
That's the only bit that you need to in a higher level. That means that you need to know how would you examine the brachial plexus and what is the significance of the examination? The treatment is not as important. We and we mentioned that in the escape part. First, you need to know whether or not there is any ulnar nerve syndrome, and the ulnar nerve syndrome is basically due to the infection of the sympathetic ganglia next to the T1 level.
And this is indicative that. We have a lower brachial plexus injury, and this lower brachial plexus injury is basically proximal, which means it is affecting the roots. So this is a bad sign. If you see a patient with the ulnar nerve syndrome. This is a bad sign. Ulnar nerve syndrome, you know? Oh, sorry for the misspelling, but it is meiosis, ptosis, anhydrous and thongs for then you have to start to see whether or not you have the roots affected or not.
So the roots are affected. The signs for the roots are the wrong voids and serrated interior weakness will go through that, but that means that there is a preganglionic root infection on the chest X-ray. You will find a high defrag that means the phrenic nerve is injured. And again, this is a root injury. The fracture of the transverse processes.
Again, it is an indicative of root infection and scapulothoracic dissociation. That's a common one with brachial plexus RTA. And that is. It that should be investigated, and this is an emergency, and this has a high association with vascular injury as well. So for the examination you stand, if it's a short case, you will stand from the back, assess the spinal accessory first, you're assessing the trapezius.
This is not from the brachial plexus, but this is a very important donor nerve. And how would you examine it? You shrugs the shoulders. Then you have the dorsal scapular nerve as the room boys and you ask the patient to squeeze the shoulder blades together the long thoracic nerve. That's the reason. Basically, every one of how to examine the status anterior by push the wall.
So I could also live like this, Mr. And I like the thing that I hold the patient's elbow. And ask him to mimic as if he's climbing a ladder. So it is basically extension of the shoulder with internal rotation. It is. That's the latest, Mr Sy. Then it is, then the auxiliary nerve, which is the deltoid. And there is three parts of the deltoid anterior for flexion, middle for abduction and posture for extension.
So again, so if we go through the exam, these pictures, so the first one is shrugging the shoulder for the trapezius muscle, a spinal accessory nerve ulnar nerve. The second is squeezing the shoulder blades together for the wrong boys or the dorsal scapular nerve. Then the third, you can see the medial wing of the scapula, the medial wing. Because he has, he has lost.
This reaches anterior function and basically the angle of the scapula is pulled by the trapezius muscle medial. Then the third, that's how you examine the elitism is to say, of course you have to for all of these. You have to do it against resistance, and the other hand, that's so much important. The other hand, should be on the muscle bulk, OK, on the muscle building to see whether or not it's firing.
Then and you will examine the lateral from the medial pectoral nerves. Well, in the books, it says that the lateral picture ulnar nerve supplies the clavicular heads of the pectoral measure, and that's tested by touching the contralateral shoulder. The medial pectoral nerve is the sternal head of the pectoralis major and basically pressing against the waist and beating the anterior axilo reforms.
I find that the pectoralis measure is examined as a whole. Then you have to assess the rotator cuff. The rotator cuff has to be tested. OK, so the subscapularis nerve and this is abduction of the shoulder and the scapula clean with thumbs down. That means the jobs test, the subscapularis sorry, the subscapularis nerve, the spine.
It is muscle, which is external rotation in adduction. The patient has to tuck the elbows towards chest, then the examiner for the tiers minor muscle. That's the whole blower test and the subscapularis with the belly press test again. This is the subscapularis, the lift off test, and this is the interest by neatness, the abduction. That's the external rotation test.
So the external rotation test should be done in adduction, not an abduction, right? To test the infant by nature's power. And then you have the job test, which is the superspy, neatest muscle. It's better to do them simultaneously by lateral to compare between the two. Another thing found that the job test please put your hand above the elbow proximal to the elbow, not distal to the elbow as you are first isolating the supersprint.
A second for the lever arm. OK, for the superspreaders toward the lever arm of the whole arm is very long. Then you have to examine all the terminal branches for the radial nerve. You have to examine the region of proper and the posterior interosseous near the regional proper. You will examine the triceps, you will examine the brake regardless, and you will examine the extensive claw palsy radial aslongas for the posterior atrocious nerve.
You will examine the index and extension and extensive claw palsy. What is the terminal branch of the radial? That means the lost muscle that the posterior atrocious nerve innervates. It is the extensor in these properties, so extension of the index can actually tell you that all the nerves from the roots to the index are intact.
OK, that's going through the radial nerve and then the posterior atrociously. Then for the ulnar nerve, which is the flexor-pronator I ulnar nerve and the flexor-pronator founders of the little and the ring fingers, that's flexion of the chipchase of these two things, then the abductor, the a.m.e. and I find if you can see me, I find that asking the patient to push the two little fingers against each other and repeating the abductor the ME is the easiest way to do it.
Then the first dosimeter, osias, is basically to push the two index fingers against each other and complete the first dorsal, ferocious muscle. And then the abductor polishes. Everyone knows how to do the Frohman sign, which is basically a card and held by both hands. The trick is basically the hand has to be flat perpendicular to the card, and he shouldn't recruit the F the flexor polishes longest of the end of the thumb.
Another trick trick movement is that he uses the flexors of the long fingers. Then you have the medial nerve, which is basically the flexor polishers longest and the trick or treaters. Both are done by the anterior ptosis nerve. The flexor digitorum superficialis by the medial nerve proper and the abductor polishes previs by the medial nerve proper after or post carpal tunnel.
Why did I start with the motor? Not the sensory? Because in the brachial plexus, it is advised to start with the motor, not the sensory, because the sensory. For example, if the patient can can't feel his shoulder, it can do either C5 or the auxiliary nerve. But for the motor, it is distinct, distinct nerve supply.
So basically, I would start with the motor and then and then do the sensory. Another thing for the sensation, the sensation can be actually crude because usually the are you testing for the roots of the people, determine the branches or testing? And is there any um, is there any inter territorial?
Fields that are supplied, another question that's why we start with the motor. Don't forget to tell the examiner that you would like to test the vascular or the vascular status of the limb, then you will go for the investigation. So for the investigations, first, you will get a chest X-ray to see whether or not there is any.
If there is any high defrag, as we said and showed before, then you will get a cervical spine, X-ray or a CT scan to see whether or not the transverse processes are fractured. That might mean that there is root convulsions and the chest X-ray. There is another thing, so one of the donors is the first intercoastal nerve. If the first trip?
Is is fractured, so that nerve might be injured, so you have lost a donor then. For the shoulder, if it's a shoulder dislocation or fracture associated with the brachial plexus. You can do an MRI scan. That's the next. But in all times they did CT. My my lomography, just like the one in front of us here. The MRI scan the benefits of that is basically it's non-invasive and you can see a Pseudomonas you seal and an empty sleeve.
And basically, the court shifted away from the middle. So if you can, can you see can you see this? Should you manage your seal here and basically the spinal cord has shifted to the other side? That's a definite route of volume. OK next, you will do neurophysiology. So neurophysiology here is basically to perform to be performed Add 2 to three weeks after the injury earlier can give you a false, reassuring thing.
What type of nerve conduction study would you do? Well, yeah, you can do the basic nerve conduction study, OK and see the motor and the EMG and the sensory. But the sensory nerve action potential is an important one to differentiate whether or not you are dealing with opposed ganglion injury or preganglionic energy. And they will tell you why, if it's a potentially chronic injury, that the sensory nerve action potential is lost because it tests the sensation or the sensory nerve action potential from the receptors in the skin or the terminal receptors all the way, just to the ganglion to the dorsal root ganglion.
So if they are absent, that means it is a potentially unique injury if they are not absent. So that means there is a route of. OK, so basically the root abortion can be diagnosed by just have no sensation, but the sensory nerve action potential is present. Then you can have an emg, which is basically after 4 to six weeks, you will get fibrillation.
That's due to that. The muscle is hypersensitive, but at 8 to 12 weeks. There is no. Mortar action potential. And that is when you. Well, that's done, OK. And that will affect our management after the neurophysiology. You will think now about the algorithm of the surgery, who needs the surgery, when surgery should be done and what type of surgery that means.
What is the aim of yourself? Who needs the surgery first, if there is no hope of spontaneous recovery, OK, just like root of all organs? OK, what will you do for him? There is no hope for recovery, so you have to do a surgery for this, for this patient. If there is no clinical or neurophysiological improvement, so he was improving and then at some point he stopped any improvement clinically and neurophysiology.
What will he do? You have to do for him surgery first. So then you have to ask yourself, when would you do the surgery? If you suspect route evolution, that's when you have a high diaphragm fractured transverse process, your MRI scan shows empty roots sleeves. Now we. You know.
When do diagnose the avulsion, that's when you do an early exploration, because basically he can't he doesn't have any hope of spontaneous recovery or. Usually for the exam, be a safe surgeon, you will say I will send it to the specialized center, but usually they wait for at least three months for recovery before exploration.
Not the early exploration, but that's in the case of there is no signs of fruit available. Then what surgery would you do? What is your aim of the surgery? You can't basically can't bring everything back. OK, we can't turn the clock backwards, but we can, and we hope that we have some elbow flexion. Shoulder abduction and then hand function. So that's in that order.
So you that's your aims, and that's so much important to give to the examiners that you are aiming for these. A surgical goals at the end. How would you do that. So first? Well, if the nerve is in continuity, everything is good and just some scarring around the nerve due to anything like a blast or injury or laceration or anything, you just can do some new releases and that's the nerve was in continuity.
And there is no nerve injury. It's just some compression. That's rarely the case. If you have a cut nerve and it is, it can be repaired end to end. So you will repair it. If the nerve is cut. And there is a crushed part in the middle, you have to excise the crush part, but you will need to take another nerve and graft this and this is usually the donor is the sure ulnar nerve from the leg.
But there is some prerequisite for that. Your stumps, the proximal stump has to be healthy. Because this is the grow to be a tension free repair or neuro neuropathy. It has to have a good tissue bed with no infection and good voice clarity and within a suitable time frame before your muscles are all fibrosis.
Because when the muscles are fibrosis, whatever you do to the nerve will not move a fibrous muscle. That's the main point. So usually it's before a year then. What is new authorization? Well, new sensation is a surgery that's done by a highly specialized and skillful surgeons, basically to transfer a functioning facet or nerve branch.
To a innervated muscle. What are the principles of that? First, the ulnar nerve need to be as close as possible to the end plates. It has to be an expandable de ulnar nerve. You don't you can't have a nerve that is basically of an important function and you will sacrifice that.
It has to be a pure motor because the mixed nerves do not do well with neuroses. And you just need the motor out of it. The donor recipient size must match or at least close to each other. The donor function synergy with Recipient function that is to facilitate rehabilitation and for the brain to learn the new movement.
More education improves function, which is basically about the patient. This is one of the patient's prerequisites. There are few examples. You don't need to know all of them, but just for example, you can take one of the ulnar nerve vesicles from the flexor-pronator pioneers to basically to move the biceps. Or you can take the median nerve from the flexor-pronator radial again for the brachialis muscle and again, both of them.
For elbow flexion. That's the first function we need to restore. Then we can restore the shoulder function by basically the spinal accessory nerve and the spinal accessory nerve to the Super suprascapular nerve or the auxiliary nerve. We can also use the intercoastal nerve, and there was a, you know, an interesting case.
So that a patient who has an intercostal nerve to the auxiliary nerve neutralization every time he takes a deep breath, his shoulder abducts. Then we have the radial nerve from the triceps to the axilo ulnar nerve the deltoid because basically the abduction of the shoulder is more important than the extension of the elbow.
Then you have the salvage procedures, usually when you can't do the nerve. Any of the nerve, any of the nerve surgeries, and that's when you are late, usually after a year. Chronic regular plexus injury and the Muslims are basically dead. So what will you do? You can do all three diseases of the shoulder of the rest of the thumb.
You can do tendon transfers like from the trapezius to the deltoid or an elbow. And this elbow surgery is an interesting one actually, in which you mobilize all the flexor-pronator mass from the medial epicondyle and you put it approximately in the humerus. So you are creating a tenodesis effect that will actually aid in the elbow flexion.
Then you can actually take a proceeds. From the. We and restored, but this is muscle graft. Thank you very much. OK thank you. That was great. And, you know, I and I like the fact that you said, you know, go for the motor function when you're doing your brachial plexus examination and exam because you want to find out what's working, what's not working, and then you can talk about tendon transfers for the future, which is where you're scoring your high marks.
Rather than focusing on the sensation, you know, which can be a little bit variable, you know, in these injuries. So that was great. Thank you very much. So I think we have a couple of questions coming to going. Joe, little talk. Really Precice and very well done. But there are a couple of things which I often find are candidates don't realize, and it's worth kind of pointing out.
The reason why patients get owner syndrome is because of a CRT one sympathetic injury. So Kessler trunk motor upper trunk route of option may not present with Horner's syndrome. So just because you don't see a homeowner syndrome, do not presume it is not a patient who hasn't got a plexus or it's not a root abortion. The second reason is people misunderstand why we need to address root ablutions early rather than late.
So the reason why is not so much that there's no potential for healing Joe as the way you phrased it. It's more the option of healing is blocked off because of the formation of the Suderman injured seal, or the dura covers the root abortion and prevents the nerve the nerve weakness in the nerve of peripheral nerve repair system. Yeah, it is basically the root of origin. The dura covering covers small parts of the root itself, so there is a sleeve of dura around the root.
So if the injury is inside this sleeve, that means it is a root of origin. And this is considered as a central nervous system injury which doesn't have a potential for recovery if it's outside this sleeve. That is a peripheral nerve injury, which means that there is a potential for recovery. That's the main point. Yeah, absolutely.
But the reason why it doesn't have this potential is because the juror actually overthrows that the proximal part and prevents any and it's soaked in CSF. It's soaked in water. OK, exactly. Perfect so we're bringing a joke. We're bringing it back to basic science. Yes Yes.
It's basic science. Yeah, everything is basic science. That's why I try to put as much basic science as I can in this story. Brilliant well done. It's a very good talk for them. Yeah, thank you. OK, so another option is sort of mine. So how you can do examination for like a baby or a child with a plexus injury?
So it's very difficult for this child to cooperate with, with you for examinations. have any like any clue for that. Well, the brachial plexus injury in children is totally different story here. This is more or less this talk is about adults, OK in the exam, it is more or less it's an adult brachial plexus injury question in the eye.
Once I have, I've been asked in the Viva that what? If or cold to the maternity unit. And because they are concerned that the arm is not working, the child can't move his arm. OK that's the main point. It is. So it is paralysis of the arm. OK they do not obtain the actually the waiter tip position of the policy straight away.
So basically, you can't actually see that and you can't examine the child motorized. But the most important things if it comes, if it comes in the exam is that you will examine the child for other injuries. You will do an X-ray to exclude fractures of the humerus because it can be just a fracture of the humerus, not brachial plexus injury. And you will follow up this trial if the biceps comes back by around the third month and some, some papers say six months.
OK, that's a good sign. So if the child can actually bend the elbow by 3 to six months, that's a very good sign that this child will progress and this child will improve, ok? And usually surgeries are not done around before one year or two years, at least. OK, thank you. Actually, there's no more questions, I couldn't see, could you see any questions one?
Yeah, there was one in reference to is there any lag period from injury and getting MRI to avoid false positive Suderman initial. Yes well, this is the basic work, you know, the basic work in the exam, you're not being asked about these details in managing and you can't basically refer the patient to the specialist center without an MRI scan.
Sorry OK, but the patient will have a CT scan of the cervical spine, a chest X-ray and the MRI scan to see whether or not there is any suitable injury. OK and there is other clues in the MRI scan other than the Pseudomonas you see, like the transposition of the spinal cord, the empty slip, everything. OK, so it's not just an MRI scan to rely on.
So I'm a bit confused. By the way, the question is phrased as in are we worried that if we see no Suderman Jesse or if we see a Pseudomonas juicio, we're not referring a patient? I would suggest that all those other signs and the presence of a Pseudomonas meningeal and absence, it doesn't matter. I'd be referring to a very complex assertion. Yes, it is.
I think the question is that whether or not we are worried about the root of an earlier root of culture and whether or not an early MRI scan giving.
Segment:0 .
The knowledge is tested in part one of the FRCS trauma and orthopedic. But that doesn't mean that you are well, you are exempt from being asked about your knowledge. In part two, without knowledge, you can't pass any of the parts.
Then they are asking about how would you approach to answer the question? So don't just start answering the question by the answer. You know, listen to the question. Prepare it in your mind. Some of during my practice, I rehearsed answering the question before just speaking loudly and with time. You are very good at answering the question as quick as possible.
Then they are asking whether or not you are a safe consultant. That's the main point. They are not asking. They are not asking you to be a brachial plexus specialist. They are asking whether or not you are a safe consultant. So that's the ICP, the latest one, which basically for the neurophysiology and the brachial plexus disorders, not the highest level, the level three, but for the examination, it's the level 4.
So be prepared to be asked in the 5a and in the clinicals about the brachial plexus with the new format. There is no patients in it, but you have to know all the movements and all the tests. You have to know how to vocalize the tests now and how to vote and what is the significance of each test. So it's a bit different and easier and difficult in another way.
Reconstructive surgery? Just know about it, ok? You will not be asked in details of how would you reconstruct the reconstructive surgery for the brachial plexus injury? Then what is the basic science behind the brachial plexus? It is a nervous plexus formed of the entire primary remedy of the lower force of nerves and the first thoracic nerve. So the root value of the brachial plexus is C5 to T1 one, and it emerges between the calcaneus anterior and the scoliosis medius.
It is gives afferent and efferent nerves to the upper lip. I struggle to remember. The first part of the triplexes, how is it formed? So the mnemonics of rugby teams drink called beer roots, trunks, divisions, coats, branches that give me the sequence of the names of the nerves that forms the brake and plexus.
Then one of the main questions that can come if in the basic science asked it is how to draw the brachial plexus. So you are being asked and you need to drill this? Wow that's a lot of things to drill and a lot of names to remember. So I made a small video to show people how I drew it.
And how I. In just 30 seconds, 1 minute by most, you can draw the brachial plexus and then start discussing the outcomes. We start with the root values of C five, C six, seven 8 and one with the mnemonics of rugby team drinks cold beer. So it is roots, trunks, divisions, cords and branches.
We drew the three long lines. Like this? And we say that the route will see 5 and 6 from the upper trunk, see 7 from the middle trunk, see AT&T one forms the lower trunk. Then there is connection between the drawings at the division spot. Then for the colts, there is the lateral code steer code in the medial code.
The lateral code. The main branch of it is the musculocutaneous nerve and a branch to form the medial nerve. There is also the lateral pectoral nerve from the medial quarters, the ulnar nerve, which is the main branch of the medial cord. There is also a branch for the medial nerve. That's how the medial nerve is formed and there is the medial pectoral nerve.
Medial cutaneous nerve of the arm and medial cutaneous nerve of the forearm. Close to your coach, you have the radial nerve, axillary nerve. Upper lower subscapularis nerve and through our dorsal nerve from the true value of C5. You have the dorsal scapular nerve and C5 6 and 7 together gives the long thoracic nerve to reach its interior from the upper trunk.
You have the suprascapular nerve. Thank you. To be able to drill the OK, so back to back to me. So basically, there is not a fast route rule of 70s. So before that, ok? That's how we drew the brachial plexus in the basic science and table in.
I drew it, I drew it basically in two minutes. If you if you just view this video just before the Viva by the NIPE. That's it. You don't want to. You don't need to do anything. You can just practice it in five minutes and do it in 1 minute in the exam if needed. So not this rule '70s.
Basically, it's not asked, but it is a good thing if you know it, as this will give the examiners an impression that about this. You know that 70% of the brachial plexus is due to. That's the other one is due to the road traffic accidents, 70% of them is motorcycle and 70% is a trauma patient. So every patient who has a brachial plexus, if you get it in the trauma or get it in anywhere, you will start by saying battles and go through your basic bits about a trauma patient.
70% is a super killer and 70% at least one root of ulcer will go through this a bit more in details as we go. So what is the mechanism of injury? It can be road traffic accidents. It can be obstetric. It can be a shoulder injury like a shoulder dislocation. But this is usually to a peripheral nerve or basically a lower leg, a distal brachial plexus injury, a shotgun or a iatrogenic, usually during cervical lymph node biopsy or basically axillary clearance in breast cancer.
They can endure the brachial plexus. Let us see what, what, what are the different modes of trauma we are talking today about other brachial plexus. But basically, if you have an abduction traction, that's so abduction of the arm with upward traction. That means a lower leg brachial plexus, which means that hand good shoulder.
So your when you are looking at the picture, the clinical fall to. Of you look at two groups of muscles. The shoulder group of muscle and the hand group of muscle. So if the shoulder is wasted, OK, that's the upper plexus injured. If the hand is wasted, that's unclothed, that's the lower brachial plexus injury.
If both, that's a tool for brachial plexus. That's the easy way or the straight away thinking of when you see the picture, what would you say or what would you think? Of course you're not. Say it straight away because you need to show the systematic approach to the patient, but that's how you expect the case to go. So clinical objectives, what are your clinical objectives from that?
First, you need to take history. What happened? Then you want to identify the lesion? Is it superclub in for clavicle and which routes are affected? And then you have to know what is the lesion? Is it the root abortion or a peripheral nerve? And that's the we will go through this. But that's the most important thing, because how will you consent the patient?
How you will consult the patient depends about what type of lesion and where is the lesion? Then you have to know what are the functions lost? What are the functions preserved and how can you help the patient? So so that's the nerve injury, but that's the peripheral nerve injury, and you all know the peripheral nerve injury about the Sydney and the Sunderland, I like more the merchant bony.
But the it is about the degrees and the grades of the nerve injury, starting from just conduction block to degenerative block. That's how Bush and bony classified them and classified that the conduction block can be transient or prolonged, and the degenerative block can be anything from axilo tenodesis to neurogenesis, according to how much of the nerve is affected.
Is it just the axon, just the engineering, just the theory or the epidural? That's so much important, and the picture or the diaphragm diagram shown here is so much important to memorize during the basic science. Then the history, what was the mood of trauma, what event and what was the position of the arm? And we know why now. What was the position of war.
And what is the importance of the position then when did it happen? And we will know from the. In the treatment with the. The there is different strategies to tackle brachial plexus injury, and these strategies actually are dependent on the time, whether or not it's chronic brachial plexus or acute brachial plexus and whether or not you are going to explore it early or late and whether or not there is any recovery or not.
So you need to know when did that happen, then you need to know any associated trauma. So basically, whether or not there is any cervical spine injury, there is any other injury, other fractures, vascular injury, you need to know the associated injuries. What investigations did the patient have so far and what did the treatments that he had so far? And basically, whether or not there was an early exploration or not?
And lastly, the expectation of the patient and the diaphragm and diagram on the right side shows for different injuries to spinal nerve with it is just stretched be it is stretched and usually there is some sort of nerve injury, but we call it nerve injury in continuity. So the whole nerve, the nerve itself wasn't cut.
See, it is a nerve injury, but the nerve injury is basically this is not a root of. And that's so much important to differentiate between a non root abortion injury, which is C And the root of an injury, which is the OK then examination. So now we are talking about the clinical in the air forces exam for the examination.
That's the only bit that you need to in a higher level. That means that you need to know how would you examine the brachial plexus and what is the significance of the examination? The treatment is not as important. We and we mentioned that in the escape part. First, you need to know whether or not there is any ulnar nerve syndrome, and the ulnar nerve syndrome is basically due to the infection of the sympathetic ganglia next to the T1 level.
And this is indicative that. We have a lower brachial plexus injury, and this lower brachial plexus injury is basically proximal, which means it is affecting the roots. So this is a bad sign. If you see a patient with the ulnar nerve syndrome. This is a bad sign. Ulnar nerve syndrome, you know? Oh, sorry for the misspelling, but it is meiosis, ptosis, anhydrous and thongs for then you have to start to see whether or not you have the roots affected or not.
So the roots are affected. The signs for the roots are the wrong voids and serrated interior weakness will go through that, but that means that there is a preganglionic root infection on the chest X-ray. You will find a high defrag that means the phrenic nerve is injured. And again, this is a root injury. The fracture of the transverse processes.
Again, it is an indicative of root infection and scapulothoracic dissociation. That's a common one with brachial plexus RTA. And that is. It that should be investigated, and this is an emergency, and this has a high association with vascular injury as well. So for the examination you stand, if it's a short case, you will stand from the back, assess the spinal accessory first, you're assessing the trapezius.
This is not from the brachial plexus, but this is a very important donor nerve. And how would you examine it? You shrugs the shoulders. Then you have the dorsal scapular nerve as the room boys and you ask the patient to squeeze the shoulder blades together the long thoracic nerve. That's the reason. Basically, every one of how to examine the status anterior by push the wall.
So I could also live like this, Mr. And I like the thing that I hold the patient's elbow. And ask him to mimic as if he's climbing a ladder. So it is basically extension of the shoulder with internal rotation. It is. That's the latest, Mr Sy. Then it is, then the auxiliary nerve, which is the deltoid. And there is three parts of the deltoid anterior for flexion, middle for abduction and posture for extension.
So again, so if we go through the exam, these pictures, so the first one is shrugging the shoulder for the trapezius muscle, a spinal accessory nerve ulnar nerve. The second is squeezing the shoulder blades together for the wrong boys or the dorsal scapular nerve. Then the third, you can see the medial wing of the scapula, the medial wing. Because he has, he has lost.
This reaches anterior function and basically the angle of the scapula is pulled by the trapezius muscle medial. Then the third, that's how you examine the elitism is to say, of course you have to for all of these. You have to do it against resistance, and the other hand, that's so much important. The other hand, should be on the muscle bulk, OK, on the muscle building to see whether or not it's firing.
Then and you will examine the lateral from the medial pectoral nerves. Well, in the books, it says that the lateral picture ulnar nerve supplies the clavicular heads of the pectoral measure, and that's tested by touching the contralateral shoulder. The medial pectoral nerve is the sternal head of the pectoralis major and basically pressing against the waist and beating the anterior axilo reforms.
I find that the pectoralis measure is examined as a whole. Then you have to assess the rotator cuff. The rotator cuff has to be tested. OK, so the subscapularis nerve and this is abduction of the shoulder and the scapula clean with thumbs down. That means the jobs test, the subscapularis sorry, the subscapularis nerve, the spine.
It is muscle, which is external rotation in adduction. The patient has to tuck the elbows towards chest, then the examiner for the tiers minor muscle. That's the whole blower test and the subscapularis with the belly press test again. This is the subscapularis, the lift off test, and this is the interest by neatness, the abduction. That's the external rotation test.
So the external rotation test should be done in adduction, not an abduction, right? To test the infant by nature's power. And then you have the job test, which is the superspy, neatest muscle. It's better to do them simultaneously by lateral to compare between the two. Another thing found that the job test please put your hand above the elbow proximal to the elbow, not distal to the elbow as you are first isolating the supersprint.
A second for the lever arm. OK, for the superspreaders toward the lever arm of the whole arm is very long. Then you have to examine all the terminal branches for the radial nerve. You have to examine the region of proper and the posterior interosseous near the regional proper. You will examine the triceps, you will examine the brake regardless, and you will examine the extensive claw palsy radial aslongas for the posterior atrocious nerve.
You will examine the index and extension and extensive claw palsy. What is the terminal branch of the radial? That means the lost muscle that the posterior atrocious nerve innervates. It is the extensor in these properties, so extension of the index can actually tell you that all the nerves from the roots to the index are intact.
OK, that's going through the radial nerve and then the posterior atrociously. Then for the ulnar nerve, which is the flexor-pronator I ulnar nerve and the flexor-pronator founders of the little and the ring fingers, that's flexion of the chipchase of these two things, then the abductor, the a.m.e. and I find if you can see me, I find that asking the patient to push the two little fingers against each other and repeating the abductor the ME is the easiest way to do it.
Then the first dosimeter, osias, is basically to push the two index fingers against each other and complete the first dorsal, ferocious muscle. And then the abductor polishes. Everyone knows how to do the Frohman sign, which is basically a card and held by both hands. The trick is basically the hand has to be flat perpendicular to the card, and he shouldn't recruit the F the flexor polishes longest of the end of the thumb.
Another trick trick movement is that he uses the flexors of the long fingers. Then you have the medial nerve, which is basically the flexor polishers longest and the trick or treaters. Both are done by the anterior ptosis nerve. The flexor digitorum superficialis by the medial nerve proper and the abductor polishes previs by the medial nerve proper after or post carpal tunnel.
Why did I start with the motor? Not the sensory? Because in the brachial plexus, it is advised to start with the motor, not the sensory, because the sensory. For example, if the patient can can't feel his shoulder, it can do either C5 or the auxiliary nerve. But for the motor, it is distinct, distinct nerve supply.
So basically, I would start with the motor and then and then do the sensory. Another thing for the sensation, the sensation can be actually crude because usually the are you testing for the roots of the people, determine the branches or testing? And is there any um, is there any inter territorial?
Fields that are supplied, another question that's why we start with the motor. Don't forget to tell the examiner that you would like to test the vascular or the vascular status of the limb, then you will go for the investigation. So for the investigations, first, you will get a chest X-ray to see whether or not there is any.
If there is any high defrag, as we said and showed before, then you will get a cervical spine, X-ray or a CT scan to see whether or not the transverse processes are fractured. That might mean that there is root convulsions and the chest X-ray. There is another thing, so one of the donors is the first intercoastal nerve. If the first trip?
Is is fractured, so that nerve might be injured, so you have lost a donor then. For the shoulder, if it's a shoulder dislocation or fracture associated with the brachial plexus. You can do an MRI scan. That's the next. But in all times they did CT. My my lomography, just like the one in front of us here. The MRI scan the benefits of that is basically it's non-invasive and you can see a Pseudomonas you seal and an empty sleeve.
And basically, the court shifted away from the middle. So if you can, can you see can you see this? Should you manage your seal here and basically the spinal cord has shifted to the other side? That's a definite route of volume. OK next, you will do neurophysiology. So neurophysiology here is basically to perform to be performed Add 2 to three weeks after the injury earlier can give you a false, reassuring thing.
What type of nerve conduction study would you do? Well, yeah, you can do the basic nerve conduction study, OK and see the motor and the EMG and the sensory. But the sensory nerve action potential is an important one to differentiate whether or not you are dealing with opposed ganglion injury or preganglionic energy. And they will tell you why, if it's a potentially chronic injury, that the sensory nerve action potential is lost because it tests the sensation or the sensory nerve action potential from the receptors in the skin or the terminal receptors all the way, just to the ganglion to the dorsal root ganglion.
So if they are absent, that means it is a potentially unique injury if they are not absent. So that means there is a route of. OK, so basically the root abortion can be diagnosed by just have no sensation, but the sensory nerve action potential is present. Then you can have an emg, which is basically after 4 to six weeks, you will get fibrillation.
That's due to that. The muscle is hypersensitive, but at 8 to 12 weeks. There is no. Mortar action potential. And that is when you. Well, that's done, OK. And that will affect our management after the neurophysiology. You will think now about the algorithm of the surgery, who needs the surgery, when surgery should be done and what type of surgery that means.
What is the aim of yourself? Who needs the surgery first, if there is no hope of spontaneous recovery, OK, just like root of all organs? OK, what will you do for him? There is no hope for recovery, so you have to do a surgery for this, for this patient. If there is no clinical or neurophysiological improvement, so he was improving and then at some point he stopped any improvement clinically and neurophysiology.
What will he do? You have to do for him surgery first. So then you have to ask yourself, when would you do the surgery? If you suspect route evolution, that's when you have a high diaphragm fractured transverse process, your MRI scan shows empty roots sleeves. Now we. You know.
When do diagnose the avulsion, that's when you do an early exploration, because basically he can't he doesn't have any hope of spontaneous recovery or. Usually for the exam, be a safe surgeon, you will say I will send it to the specialized center, but usually they wait for at least three months for recovery before exploration.
Not the early exploration, but that's in the case of there is no signs of fruit available. Then what surgery would you do? What is your aim of the surgery? You can't basically can't bring everything back. OK, we can't turn the clock backwards, but we can, and we hope that we have some elbow flexion. Shoulder abduction and then hand function. So that's in that order.
So you that's your aims, and that's so much important to give to the examiners that you are aiming for these. A surgical goals at the end. How would you do that. So first? Well, if the nerve is in continuity, everything is good and just some scarring around the nerve due to anything like a blast or injury or laceration or anything, you just can do some new releases and that's the nerve was in continuity.
And there is no nerve injury. It's just some compression. That's rarely the case. If you have a cut nerve and it is, it can be repaired end to end. So you will repair it. If the nerve is cut. And there is a crushed part in the middle, you have to excise the crush part, but you will need to take another nerve and graft this and this is usually the donor is the sure ulnar nerve from the leg.
But there is some prerequisite for that. Your stumps, the proximal stump has to be healthy. Because this is the grow to be a tension free repair or neuro neuropathy. It has to have a good tissue bed with no infection and good voice clarity and within a suitable time frame before your muscles are all fibrosis.
Because when the muscles are fibrosis, whatever you do to the nerve will not move a fibrous muscle. That's the main point. So usually it's before a year then. What is new authorization? Well, new sensation is a surgery that's done by a highly specialized and skillful surgeons, basically to transfer a functioning facet or nerve branch.
To a innervated muscle. What are the principles of that? First, the ulnar nerve need to be as close as possible to the end plates. It has to be an expandable de ulnar nerve. You don't you can't have a nerve that is basically of an important function and you will sacrifice that.
It has to be a pure motor because the mixed nerves do not do well with neuroses. And you just need the motor out of it. The donor recipient size must match or at least close to each other. The donor function synergy with Recipient function that is to facilitate rehabilitation and for the brain to learn the new movement.
More education improves function, which is basically about the patient. This is one of the patient's prerequisites. There are few examples. You don't need to know all of them, but just for example, you can take one of the ulnar nerve vesicles from the flexor-pronator pioneers to basically to move the biceps. Or you can take the median nerve from the flexor-pronator radial again for the brachialis muscle and again, both of them.
For elbow flexion. That's the first function we need to restore. Then we can restore the shoulder function by basically the spinal accessory nerve and the spinal accessory nerve to the Super suprascapular nerve or the auxiliary nerve. We can also use the intercoastal nerve, and there was a, you know, an interesting case.
So that a patient who has an intercostal nerve to the auxiliary nerve neutralization every time he takes a deep breath, his shoulder abducts. Then we have the radial nerve from the triceps to the axilo ulnar nerve the deltoid because basically the abduction of the shoulder is more important than the extension of the elbow.
Then you have the salvage procedures, usually when you can't do the nerve. Any of the nerve, any of the nerve surgeries, and that's when you are late, usually after a year. Chronic regular plexus injury and the Muslims are basically dead. So what will you do? You can do all three diseases of the shoulder of the rest of the thumb.
You can do tendon transfers like from the trapezius to the deltoid or an elbow. And this elbow surgery is an interesting one actually, in which you mobilize all the flexor-pronator mass from the medial epicondyle and you put it approximately in the humerus. So you are creating a tenodesis effect that will actually aid in the elbow flexion.
Then you can actually take a proceeds. From the. We and restored, but this is muscle graft. Thank you very much. OK thank you. That was great. And, you know, I and I like the fact that you said, you know, go for the motor function when you're doing your brachial plexus examination and exam because you want to find out what's working, what's not working, and then you can talk about tendon transfers for the future, which is where you're scoring your high marks.
Rather than focusing on the sensation, you know, which can be a little bit variable, you know, in these injuries. So that was great. Thank you very much. So I think we have a couple of questions coming to going. Joe, little talk. Really Precice and very well done. But there are a couple of things which I often find are candidates don't realize, and it's worth kind of pointing out.
The reason why patients get owner syndrome is because of a CRT one sympathetic injury. So Kessler trunk motor upper trunk route of option may not present with Horner's syndrome. So just because you don't see a homeowner syndrome, do not presume it is not a patient who hasn't got a plexus or it's not a root abortion. The second reason is people misunderstand why we need to address root ablutions early rather than late.
So the reason why is not so much that there's no potential for healing Joe as the way you phrased it. It's more the option of healing is blocked off because of the formation of the Suderman injured seal, or the dura covers the root abortion and prevents the nerve the nerve weakness in the nerve of peripheral nerve repair system. Yeah, it is basically the root of origin. The dura covering covers small parts of the root itself, so there is a sleeve of dura around the root.
So if the injury is inside this sleeve, that means it is a root of origin. And this is considered as a central nervous system injury which doesn't have a potential for recovery if it's outside this sleeve. That is a peripheral nerve injury, which means that there is a potential for recovery. That's the main point. Yeah, absolutely.
But the reason why it doesn't have this potential is because the juror actually overthrows that the proximal part and prevents any and it's soaked in CSF. It's soaked in water. OK, exactly. Perfect so we're bringing a joke. We're bringing it back to basic science. Yes Yes.
It's basic science. Yeah, everything is basic science. That's why I try to put as much basic science as I can in this story. Brilliant well done. It's a very good talk for them. Yeah, thank you. OK, so another option is sort of mine. So how you can do examination for like a baby or a child with a plexus injury?
So it's very difficult for this child to cooperate with, with you for examinations. have any like any clue for that. Well, the brachial plexus injury in children is totally different story here. This is more or less this talk is about adults, OK in the exam, it is more or less it's an adult brachial plexus injury question in the eye.
Once I have, I've been asked in the Viva that what? If or cold to the maternity unit. And because they are concerned that the arm is not working, the child can't move his arm. OK that's the main point. It is. So it is paralysis of the arm. OK they do not obtain the actually the waiter tip position of the policy straight away.
So basically, you can't actually see that and you can't examine the child motorized. But the most important things if it comes, if it comes in the exam is that you will examine the child for other injuries. You will do an X-ray to exclude fractures of the humerus because it can be just a fracture of the humerus, not brachial plexus injury. And you will follow up this trial if the biceps comes back by around the third month and some, some papers say six months.
OK, that's a good sign. So if the child can actually bend the elbow by 3 to six months, that's a very good sign that this child will progress and this child will improve, ok? And usually surgeries are not done around before one year or two years, at least. OK, thank you. Actually, there's no more questions, I couldn't see, could you see any questions one?
Yeah, there was one in reference to is there any lag period from injury and getting MRI to avoid false positive Suderman initial. Yes well, this is the basic work, you know, the basic work in the exam, you're not being asked about these details in managing and you can't basically refer the patient to the specialist center without an MRI scan.
Sorry OK, but the patient will have a CT scan of the cervical spine, a chest X-ray and the MRI scan to see whether or not there is any suitable injury. OK and there is other clues in the MRI scan other than the Pseudomonas you see, like the transposition of the spinal cord, the empty slip, everything. OK, so it's not just an MRI scan to rely on.
So I'm a bit confused. By the way, the question is phrased as in are we worried that if we see no Suderman Jesse or if we see a Pseudomonas juicio, we're not referring a patient? I would suggest that all those other signs and the presence of a Pseudomonas meningeal and absence, it doesn't matter. I'd be referring to a very complex assertion. Yes, it is.
I think the question is that whether or not we are worried about the root of an earlier root of culture and whether or not an early MRI scan giving.
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