frcs revision - brachial plexus & hands
TRANSCRIPT
Hands II & Brachial PlexusChye Yew Ng
MBChB(Hons) FRCS(Tr&Orth) British Diploma in Hand Surgery European Board of Hand Surgery Diploma
Consultant Hand & Peripheral Nerve SurgeonUpper Limb Fellowship Director
Wrightington Hospital
www.slideshare.net/ChyeYewNg
www.vumedi.com (search for chye yew ng)Clinical examination of brachial plexusExamination of a patient with upper roots BPINerve transfers for C5,C6 BPIExploration of infraclavicular brachial plexus
www.youtube.com (search for CY Ng or brachial plexus exam)
@CY_Hand @Nerve_Clinic
Overview
Peripheral nerve injuriesBrachial plexus injuriesCompression neuropathyCRPSTendon transfersDupuytren’s diseaseExtensor and flexor tendon injuriesSkin coverage
Hierarchical Approach to FRCS Revision
Why?(Indications)
What?(Treatment options)
When?(Timing of surgery)
How?(Technical details)
HOTHigher Order
Thinking
Peripheral Nerve Injuries
Cross Section of a Peripheral Nerve
Axon
Fascicle
Nerve
Endoneurium
Epineurium
Perineurium
EpiPEn = Epi – Peri – Endo
A&E
Extrinsic & Intrinsic vascular supplyLongitudinal – Segmental -
Interconnected
Central Neuronal Death & Neuroprotection
Neuronal death after peripheral nerve injury
Acetyl-L-carnitineArrests sensory neuronal deathSpeeds up regeneration
N-acetyl-cysteineProvides sensory and motor neuronal protection Hart et al. Neurological Research 2008
MechanoreceptorsSlowly Adapting Rapidly
Adapting
Cutaneous
Low frequenc
y vibration
Merkeldiscs
Meissnercorpuscle
s
Subcutaneo
us
High frequenc
y vibration
Ruffiniterminals
Paciniancorpuscle
s
Mechanisms of Nerve Injuries
Crush / compressionStretch / tractionLaceration / transectionMetabolic disturbance
IschaemiaRadiationElectrical injuryThermal injury
Classification of Nerve Injuries
Seddon
BMJ1942
Neurapraxia(Transient Block)
Axonotmesis(Lesion in
Continuity)
Neurotmesis(Division of a
nerve)
Brain1943
• Localised degeneration of the myelin sheaths
• Complete interruption of axons
• Preservation of supporting structures (Schwann tubes, endoneurium, perineurium)
• All essential parts destroyed
• Interruption can occur without apparent loss of continuity
Classification of Nerve Injuries
Neurapraxia Axonotmesis Neurotmesis
Motor - - -Sensory +/- - -Autonom
ic +/- - -NCS
Conduction block at the site
Distal conduction preserved
Loss of conduction both at and distal to the lesion
Loss of conduction both at and distal to the lesion
EMG No fibrillation Fibrillation ++ Fibrillation ++
Recovery
Days to weeks provided the cause is removed
Months provided the cause is removed
No recovery unless repaired
Nerve Conduction StudiesRecording electrode
Neurapraxia
Axonotmesis
Neurotmesis
Wallerian degeneration
Recording electrode
Recording electrode
In clinical practice, how do you distinguish?
Axonotmesis versus NeurotmesisNature of injury
Serial observations
Exploration
Seddon BMJ 1942
(Imaging)
Classification of Nerve Injuries
Sunderland
1951I II III IV V
Focalconduction
block
NO Wallerian
degeneration
AxonalDisruption
Axon+
Endoneurium
Disruption
Axon +
Endoneurium+
Perineurium
Disruption
Axon +
Endoneurium+
Perineurium+
EpineuriumDisruption
Cross-innervation
Sunderland ‘VI’
Grabb & Smith’s Plastic Surgery 6th edition. Chapter 9
HOT
Physiological Conduction Block
Type AIntraneural circulatory arrestMetabolic block with no nerve fibre pathologyImmediately reversible
Type BIntraneural oedemaIncreased endoneurial fluid pressureReversible within days or weeks
Classification of Nerve Injuries
Lundborg
1988
Physiological
conduction block
Myelindamage
Axonal damage
Axon +
Endodamage
Axon +
Endo +
Peridamage
Axon +
Endoneurium+
Perineurium+
Epineurium
damage
Type A
Type B
Sunder
land1951
I II III IV V
Seddon
1942Neurapraxia
(Transient Block)
Axonotmesis
(Lesion in Continuity
)
Neurotmesis(Division of a nerve)
Classification of Nerve Injuries
Lundborg
1988
Physiological
conduction block
Myelindamage
Axonal disruptio
n
Axon +
Endo
Axon +
Endo +
Peri
Axon +
Endoneurium+
Perineurium+
Epineurium
Type A
Type B
Sunder
land1951
I II III IV V
Seddon
1942Neurapraxia
(Transient Block)
Axonotmesis
(Lesion in Continuity
)
Neurotmesis(Division of a nerve)
Non-degenerative
Degenerative
Nerve in Danger!Pain, Pain, Pain• Burning• Severe
Autonomic dysfunction• Absence of sweating• Smoothness & dryness of skin
Tinel sign• Distal to Proximal• Regenerating touch fibres
HOT
Nerve Surgery
Neurolysis
Nerve repair
Nerve grafting
Nerve transfer
Prerequisites for Nerve Repair
Skeletal stability
Healthy tissue bed
Healthy nerve ends
No undue tension
Adequate soft tissue coverage
Epineurial versus Group Fascicular Repairs
EpineurialLess exactSimple
Group FascicularBetter alignmentMore dissection (scarring)
The functional results of group fascicular repair has not been shown to be more superior than that of epineurial repair.
Lee & Wolfe. Peripheral nerve injury & repair. JAAOS 2000
Prognostic Factors of Outcomes
• Age• DM, alcohol
Patient factors
• Level of injury (distal vs proximal)
• Type of nerve (pure vs mixed)• Condition of nerve ends
Injury factors
• Delay to repair• Length of gap
Surgical factors
Which of the following is false regarding fibrin glue?
a) Fibrin glue is nontoxic and does not block axon regeneration
b) It may be used in combination with suture repair
c) The outcome of fibrin glue repair is inferior to that of suture repair
d) The common components of fibrin sealants include fibrinogen, thrombin and calcium chloride e) It has low tensile strength
Tse & Ko. Nerve glue for upper extremity reconstruction. Hand Clinics 2012
Nerve Grafts/ConduitsAutologous SourceNerve autograftVein (+/- muscle)
Off-the-shelfType I collagenCaprolactonePolyglycolic acid (PGA)Submucosal ECM Processed nerve allograft
Lin et al. Nerve Allografts & Conduits in Peripheral Nerve Repair. Hand Clinics 2013Kaushik & Hammert. Options for Digital Nerve Gap. JHSAm 2015
A 35 year-old male presented with numbness along the radial border of his right index finger 9 months after he sustained a cut in his first web. After surgical exploration and debridement, there is a 3.5cm nerve defect in the radial digital nerve.
What is the most appropriate surgical reconstructive option?
a) Flexion of digit to achieve primary repair before gradual distraction
b) Type I collagen nerve conduit
c) Autologous vein graft
d) Posterior interosseous nerve graft
e) Polyglycolic acid (PGA) conduit
Principles of Motor Nerve Transfers
Donor nerve near target motor end platesExpendable donor nervePure motor donor nerveDonor-recipient size matchDonor function synergy with recipient functionMotor re-education improves function
Mackinnon SE, Novak CB. Hand Clin 1999
Brachial Plexus Injuries
Brachial Plexus Injuries
• Time• Breadth
• Length
• Depth
Severity
(Seddon, Sunderland)
Level(Supra vs
Infraclavicular)
Acutevs
Chronic
Number of
roots(C5-T1)
HOT
Leffert Classification
I OpenII Closed
IIA Supraclavicular Pre-ganglionic Post-ganglionic
IIB InfraclavicularIII Radiation inducedIV Obstetric
IVA Erb’s (upper root)IVB Klumpke’s (lower root)IVC Mixed
Objectives of Examination
Where is the lesion?
What functions are lost?
What functions are present?
How can you improve functions of the limb?
Draw the brachial plexus
C5
C6
C7
C8
T1
C5
C6
C7
C8
T1
MC
MEDIAN
ULNAR
R
Ax
C5
C6
C7
C8
T1
MC
MEDIAN
ULNAR
R
Ax
LTN
C5
C6
C7
C8
T1
MC
MEDIAN
ULNAR
R
Ax
LTN
LPSSDS
C5
C6
C7
C8
T1
MC
MEDIAN
ULNAR
R
Ax
LTN
LPSSDS
USs TD LSs
C5
C6
C7
C8
T1
MC
MEDIAN
ULNAR
R
Ax
LTN
LPSSDS
USs TD LSs
MP MBC MABC
C5
C6
C7
C8
T1
MC
MEDIAN
ULNAR
R
Ax
LTN
LPSSDS
USs TD LSs
MP MBC MABC
Sc
C5
C6
C7
C8
T1
MC
MEDIAN
ULNAR
R
Ax
LTN
LPSSDS
USs TD LSs
MP MBC MABC
Sc
Roots Trunks Divisions Cords Terminal branches
C5
C6
C7
C8
T1
MC
MEDIAN
ULNAR
R
Ax
LTN
LPSSDS
USs TD LSs
MP MBC MABC
Sc
Roots Trunks Divisions Cords Terminal branches
Upper
Lower
Middle
Lateral
Medial
Posterior
Post
erior
PosteriorPosterior
Anterior
Anterior
Ante
rior
Dermatomes
Myotomes
Common Clinical Patterns
Closed traction BPI
Supraclavicular
Upper roots
Total palsy
Infraclavicular
Cord(s)
Terminal branch(es)
Motorcycle accident
Shoulder trauma
Common Clinical Patterns25yo RTA polytraumaNo shoulder motion
No elbow flexionGOOD HAND
25yo RTA polytraumaFLAIL UPPER LIMB
65yo anterior dislocation of shoulder
NO DELTOID
C5, C6
C5 – T1
Axillary nerve
Common Clinical Patterns
25yo RTA polytraumaNo shoulder motion
No elbow flexionGOOD HAND
C5, C6XR neck chest
shoulderMRI cervical spine, BPNCS/EMG at 3 weeks
25yo RTA polytraumaFLAIL UPPER LIMB C5 – T1
XRMRI
NCS/EMG at 3 weeks
65yo anterior dislocation of shoulder
NO DELTOIDAxillary nerve
NCS/EMG at 6 weeks
if no recovery
Pre- versus Post-ganglionic?
ClinicalHorner’s syndromeRhomboid, serratus anterior, paraspinal muscles paralysisAbsent Tinel signHistamine test (historical)
RadiologyPhrenic nerve palsy (raised hemidiaphragm)Cervical transverse process /1st rib♯PseudomeningocelesRootlets abnormalities
NeurophysiologyPreserved SNAP (but insensate)
Intraoperative Assessment - Is there a graftable nerve
stump?• Direct inspection• PalpationSurgical
• Somatosensory Evoked Potentials (SSEP)
• Motor Evoked Potentials (MEP)Neurophysiolo
gy
• Frozen section (fascicles / scar)• Choline acetyltransferase (CAT)
activity – identify motor fasciclesLaboratory
Timing of Surgery
Emergent- Open injury- Arterial injury- Deteriorating neurology
Early (<3months)- Closed injury- Complete/partial palsy- Neurolysis/grafts/ transfers
Late (>12months)- Muscle transfers- Bony procedures
Surgical Priorities1 – Restore elbow flexion2 – Restore shoulder abduction & ER (stability)3 – Restore hand function
Common Nerve TransfersPalsy Donor Recipient
C5, 6Spinal accessory Radial (long head of triceps) Ulnar fascicle Median fascicle
SuprascapularAxillary (anterior)Biceps branchBrachialis branch
C5, C6, C7Spinal accessory Intercostals Ulnar fascicle Median fascicle
SuprascapularAxillary (anterior)Biceps branchBrachialis branch
C8, T1Brachioradialis or brachialis branchSupinator branch
AINPIN
Common Clinical Patterns ?Prognosis
25yo RTA polytraumaNo shoulder motion
No elbow flexionGOOD HAND
C5, C6Regain good elbow flexion, moderate shoulder movementReturn to work
25yo RTA polytraumaFLAIL UPPER LIMB C5 – T1 Poor-to-fair function
Long-term disability
65yo anterior dislocation of shoulder
NO DELTOIDAxillary nerve
Fair-to-good recovery
Compression Neuropathy
What do (I think) you need to learn?
Carpal tunnel syndromeCubital tunnel syndromeGuyon canal syndromeRadial tunnel syndrome / PIN palsyPronator syndrome / AIN palsy
Carpal Tunnel SyndromeA collection of symptoms and signs due to increased pressure within the carpal tunnel leading to compression of the median nerve
• Pins & needles or Tingling• Numbness• Pain• Weakness or clumsiness• Wasting of thenar muscles
What are the contents of the carpal tunnel?
Median nerveFDS x4FDP x4FPL
Anatomical variations of the recurrent motor branch of median
nerve
Who is affected? Risk Factors
Age: 45- 65Females > malesFamily historyPregnancyMedical conditions: Diabetes mellitus, Rheumatoid arthritis, HypothyroidismObesityVibrationAnatomical abnormalities of the wrist
What is the Gold Standard?
CTS
Signs Symptoms
Neurophysiology
Treatment Options Comments
Nocturnal neutral wrist splint • Those with night symptoms
Steroid injection • Consider in pregnancy-related CTS• 1 in 4-5 symptom-free at 1 year
Carpal tunnel release
• Complete division of transverse carpal ligament
• Open and endoscopic CTR both equally effective. Endoscopic CTR may offer earlier return to work but this may not be justifiable by its increased risks of nerve injury and costs (in the NHS).
Cubital tunnel syndromeWhat is your preferred surgical treatment for primary cubital tunnel syndrome?
Cubital tunnel syndromeWhat is your preferred surgical treatment for primary cubital tunnel syndrome?
I would perform in-situ decompression because meta-analyses have shown comparable clinical outcomes but lesser complications/morbidity when compared to anterior transposition.
Cubital tunnel syndromeWhat are the indications of anterior transposition?
Cubital tunnel syndromeWhat are the indications of anterior transposition?
• Revision• Subluxation/Instability of ulnar nerve• Poor tissue bed for the nerve• (Elbow trauma surgery)
Sensory branch (after PB)
Ulnar artery aneurysm or thrombosis
Guyon’s canalWhat you need to know?
MixedLEFT HAND
Superficial branch (sensory only after Palmaris brevis)
Ulnar artery aneurysm or thrombosis
Deep motor branch
Ganglion or hook of hamate fracture (zones 1 & 2)
MixedLEFT HAND
Posterior Interosseous Nerve
Radial tunnel syndrome
Pain syndromeEMG normal
PIN palsyMotor deficitEMG abnormal
Common Sites of Compression:Fibrous band btw brachialis & BRRecurrent leash of HenryExtensor carpi radialis brevis edgeArcade of FröhseSupinator muscle edge
Proximal Median NervePronator syndromePain (forearm) syndromeParaesthesiaEMG/NCS inconclusive
AIN palsyMotor deficit onlyEMG/NCS abnormal
Sites of Compression:Supracondylar processLigament of StruthersLacertus fibrosusBtw two heads of pronator teresFDS arch
Sites of Compression:Tendinous edge of deep head of PTLacertus fibrosusFDS archAccessory head of FPL (Gantzer’s muscle)Accessory muscle from FDS to FDPAberrant muscles (FCRB, palmaris profundus)Thrombosis of ulnar collateral vesselsAberrant radial arteryBicipital bursa
Complex Regional Pain Syndrome
Disproportionate PainSensory changesAbnormal skin color Temperature change Abnormal sudomotor activity OedemaJoint stiffness
EXCLUSION OF OTHER CAUSES!
International Association for Study of Pain
CRPS Type I
Reflex sympathetic dystrophy (RSD)
No definable nerve injury
CRPS Type II
Causalgia
Definable nerve injury
Symptoms NOT restricted to dermatome
CRPS – Budapest Criteria
Management of Suspect CPRS
Prevention (Vitamin C – distal radius fractures)
Treat any treatable cause
Physiotherapy (Desensitisation, mirror therapy)
Pain specialistMultimodal analgesicsRegional blockadeBisphosphonate infusion
Psychology
Tendon Transfers
IndicationsRestore function
Muscle paralysis/nerve injuriesIrreparable injuries to the musculotendinous units
Restore balanceStroke, cerebral palsy, tetraplegia
Why?
Decision makingWhat is missing
What needs reconstructing (think of FUNCTION)
What is available
What is appropriate
What?
HOT
PrinciplesTissue equilibrium is achieved
Bony stability
Good soft tissue envelope/gliding plane
Full passive range of motion
Expendable donorMinimum 1 wrist extensor, 1 wrist flexor1 extrinsic flexor & extensor to each digit
When?
Force proportional to cross-sectional area of muscle
Average fibre length proportional to potential excursion
Amplitude/Excursion (The 3-5-7 rule)Wrist flexors/extensors: 33mmFinger extensors, FPL, EPL: 50mmFinger flexors: 70mmTenodesis effect +20mm
Expect decrease of one MRC grade after transfer
PrinciplesHow?
Single line
Single joint
Single function
Synergy
Sensibility
PrinciplesHow?
Ideal principles but not obeyed all the times
Median Nerve Palsy
LowDonor Tendon
Camitz Palmaris longus
Burkhalter Extensor indicis proprius
Bunnell FDS IV
Huber Abductor digiti minimi
HighLost Function Donor Tendon
Opposition EIP APB
Thumb IPJ flexion
Brachioradialis FPL
Index finger flexion
FDP I Sutured to neighbour FDPs
Radial Nerve Palsy
PIN HighLost Function Donor Tendon
Wrist extension PT ECRB
Fingers extension
FCR EDC
Thumb extension
PL EPL
Lost Function Donor Tendon
Fingers extension
FCR EDC
Thumb extension
PL EPL
Ulnar Nerve Palsy
LowLost Function Donor TendonClawing (Grasp) FDS III slips
lateral bandsThumb adduction
ECRB + PL graft Adductor pollicis
Index finger abduction
Accessory APL 1st dorsal interosseous
Little finger adduction(Wartenberg sign)
EDM radial lateral band
HighLost Function Donor TendonIn addition to lowFDP IV/V DIPJ flexion
Side-to-side tenorrhaphy FDP III
Anti-clawing ProceduresStatic
Zancolli capsulodesisFasciodermadesisTenodeses
DynamicMCPJ flexionMCPJ flexion + IPJ extension
Bouvier manoeuvre?
Donor options to correct clawing
Dupuytren’s Disease
Dupuytren’s DiseaseA benign proliferative disease that occurs in the fascia of the palm and digits resulting in nodules, cords and contractures.
EpidemiologyCaucasian of northern European ancestry 5th-7th decades M>F until 70 then M=FAutosomal dominant pattern with variable penetrance
Ectopic manifestationsLedderhose disease (plantar fascia)Peyronie's disease (dartos fascia of penis)Garrod’s pads (knuckle pads)
Components of Spiral Cord?
4 – Grayson ligament
3 – Lateral digital sheet
2 – Spiral band
1 – Pretendinous band
Luck Stages of Dupuytren
Proliferative (Myofibroblasts predominate)
Involutional (Type III > I collagen)
Residual (Fibrocytes predominate)
Risk factors / associations
Hueston diathesisCaucasiansPositive family historyBilateral diseaseEctopic lesionMaleAge of onset < 50
Other conditionsDiabetes mellitusAlcoholismHIVAnti-epilepticsTrauma(Vibration)
Indications for Intervention
Tabletop testMCPJ 30°contracturePIPJ any contracture
Functional limitation
Traditional teaching
Treatment Options
5-year recurrence
rates
Needle fasciotomy 85%
Collagenase 50%
Fasciectomy 20%
Dermofasciectomy 10%
Increasing downtime and
complexity
Collagenase clostridium histolyticum (CCH)
AUX-I AUX-II
Class I Class II
Cleaves terminal ends of collagen
Cleaves internal sections of collagen
Extensor & Flexor Tendon Injuries
Extensor Tendon Compartments
Compartment Tendons Conditions
1 APLEPB de Quervain’s tenovaginitis
2 ECRLECRB Intersection syndrome
3 EPL Attrition rupture post-distal radial fracture
4 EIPEDC Tenosynovitis
5 EDM Vaughan-Jackson syndrome
6 ECU Subluxation / Snapping
Zones Treatment
I (II)• Mallet injury• Open: repair and pin• Closed: splint 8/52• If chronic, risk of Swan-neck
III (IV)• Open: repair and splint• Closed: immobilise PIPJ for 3/52
& leave DIPJ free• If chronic, risk of Boutonniere
V VI• Watch out for fight bites!• Rehab: Static vs Dynamic vs
EAM
VII • Repair retinaculum• Splint wrist in extension for 4/52
VIII • Core suture-type tendon repair
IX • Muscle belly injury• Beware of PIN injury
Leddy-Packer Classification
Flexor Tendon Repair
ChallengesRupture, adhesion, joint stiffness, infection
Surgical AimTo restore continuity to the tendon with a repair that is robust for EAM
Philosophy/ConceptManaging a number of compromises according to a hierarchy of priorities
How do you manage a zone II flexor tendon injury?
Anaesthesia GA, regional, Wide-awake technique (LA + adrenaline)
Core suture At least 4 strands (Kessler, Cruciate, Adelaide)4-0 monofilament (Prolene)
Epitendinous suture
Continuous configuration6-0 monofilament (Prolene)
Rehabilitation Dorsal splint for 6 weeksEarly active mobilisation
Skin Coverage
Reconstructive LadderFree
Tissue
Transfer
Distant flap
Local & Regional flap
Skin graft
Primary closure
Healing by secondary intention
Elev
ator
Summary• Most injuries are mixed• Pain, Autonomic dysfunction & Tinel
signPeripheral nerve
injuries
• 4 dimensionsBrachial plexus injuries
• Carpal & cubital tunnel syndromesCompression neuropathy
• Budapest criteriaCRPS
Summary• What is missing• What function needs reconstructing• What is available• What is appropriate
Tendon transfers
• Luck stages• Spiral cord • Collagenase (AUX-I & II)
Dupuytren disease
• Zone of injuriesExtensor and flexor tendon
injuries
• Reconstructive ladder & elevatorSkin coverage
Thank you and good luck!@CY_Hand