Brachial Plexus Hand Surgery Workup

Author: Alan Bienstock, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS more...

Updated: Feb 9, 2011

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Imaging Studies
Other Tests
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Tables

References

Imaging Studies

Initial management

After brachial plexus injury is initially diagnosed, an immediate neurologic evaluation is performed.
Digital imaging and video may be beneficial to document function in children.
Radiographic studies in the neonatal period are used to evaluate any concomitant injuries. These studies include chest radiographs to depict an elevated hemidiaphragm secondary to phrenic nerve injury and shoulder and arm radiographs to identify fractures and dislocations.

Additional study

CT myelography is the best method to visualize the nerve roots and detect avulsions and ruptures. CT has a sensitivity of 95% and specificity of 98%.
MRI may be used to diagnose large pseudomeningoceles, and recent studies have shown its promise in diagnosing nerve root avulsion.
MRI is reportedly superior to CT because of its multiplanar capability, which allows clinicians to view the components of the brachial plexus in their own optimal planes (axial plane for roots, oblique coronal for trunks, sagittal plane for cords). However, controversy surrounds the superiority of MRI versus CT myelography. Some suggest that MRI is not as sensitive as CT and that it reduces visualization of rootlets, whereas MRI proponents claim that it has great promise in diagnosing nerve root avulsion.

Other Tests

Terzis et al have suggested that electromyelography (EMG) is one of the most valid techniques for assessing a brachial plexus lesion.^[3]

When experts perform the study and analyzed the results, EMG can help in determining the location and extent of the injury and the likelihood of recovery. This ability is exemplified in supraganglionic lesions, in which sensory perception is lost but sensory potentials remain intact.
In practice, EMG has several limitations related to difficulties in administering this test in infants, in localizing the lesion along the length of the nerve, and in interpreting the results and correlating them with clinical findings. For these reasons, EMG has largely been abandoned as a first-line study for diagnosis, but remains useful during and after surgery.

Proceed to Treatment & Management

Contributor Information and Disclosures

Author

Alan Bienstock, MD Consulting Staff, Division of Plastic and Reconstructive Surgery, Department of Surgery, Lennox Hill Hospital, St Luke's/Roosevelt Hospital

Alan Bienstock, MD is a member of the following medical societies: American Medical Association and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

John YS Kim, MD Assistant Professor, Department of Surgery, Division of Plastic Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Northwestern Plastic Surgery

John YS Kim, MD is a member of the following medical societies: American College of Surgeons and American Society of Plastic Surgeons

Disclosure: Mentor Worldwide LLC Consulting fee Consulting; Mentor Worldwide LLC Grant/research funds Principal Investigator; Musculoskeletal Transplant Foundation Grant/research funds Principal Investigator; Musculoskeletal Transplant Foundation Consulting fee Consulting

Specialty Editor Board

Milton B Armstrong, MD, FACS Associate Professor of Clinical Surgery, Associate Professor of Clinical Orthopedics, Department of Surgery, University of Miami Miller School of Medicine

Milton B Armstrong, MD, FACS is a member of the following medical societies: American Association for Hand Surgery, American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, and National Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David W Chang, MD, FACS Associate Professor, Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas Medical School at Houston

Disclosure: Nothing to disclose.

Nicolas (Nick) G Slenkovich, MD Director, Colorado Plastic Surgery Center

Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Joseph A Molnar, MD, PhD, FACS Director, Wound Care Center, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Peripheral Nerve Society, Undersea and Hyperbaric Medical Society, and Wound Healing Society

Disclosure: KCI, Inc. Honoraria Speaking and teaching; Integra Life Sciences Honoraria Speaking and teaching; Clincal Cell Culture Grant/research funds Co-investigator; KCI, Inc Wake Forest University receives royalties Other

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Saleh M Shenaq, MD†, to the development and writing of this article.

References

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Table. Surgical Treatments and Secondary Procedures

Table. Surgical Treatments and Secondary Procedures

Condition or Deficit	Surgical Treatment and Secondary Procedures
Internal rotation, shoulder adduction	Muscle releases: subscapularis, pectoralis major and minor Muscle transfers to the teres minor: latissimus dorsi, teres major Neurolysis and decompression of the axillary nerve
Poor elbow extension	Nerve exploration and neuroplasty of the radial nerve with or without tendon transfers
Poor extension of the wrist and digits	Muscle transfers Pronator teres to the extensor carpi radialis brevis Flexor carpi radialis to the extensor digitorum communis Palmaris longus to the extensor pollicis longus
Poor extension of the wrist and fingers if flexors are weak	Musculocutaneous nerve transfer Placation or tenodesis of the extensor digitorum communis Wrist fusion and tendon transfers Free muscle transfer
Poor elbow flexion, poor supination	Exploration and neuroplasty of the radial and musculocutaneous nerves with or without nerve transfers Oberlin technique Double nerve transfer Fascicular transfers Ulnar nerve to the biceps Median nerve to the brachialis
Elbow flexion contracture	Lengthening of the biceps if serial casting is unsuccessful
Poor flexion of the wrist and fingers	Nerve exploration and neuroplasty of the median and order nerves Once muscle transfer
Forearm supination contracture	Rerouting of the biceps Rerouting of the supinator
Forearm pronation contracture	Rerouting of the pronator teres

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