Partial Brachial Plexus Injury

Understanding Partial Brachial Plexus Injuries

Partial Brachial Plexus Injuries involve the injury of C5, C6 nerve roots with or without C7 nerve root in the neck, leading to weakness, numbness, or loss of movement in the affected shoulder and elbow. Hand function remains good in cases of partial Brachial Plexus injuries. Deficits include shoulder stability, abduction (outward movement), external and internal rotation, elbow flexion (inner bending of the elbow), and forearm supination (rotating the forearm outward). If C7 is involved, there may also be variable weakness in the extension of the elbow, wrist, and fingers (straightening of elbow, wrist, and finger joints). This type of injury is often seen more frequently in men aged between 15-25 years.

Challenges in Seeking Timely Treatment for Brachial Plexus Injuries

Similar to Complete BPI, one of the major challenges in treating Brachial Plexus Injuries is delayed presentation due to limited awareness about these injuries. Patients often seek medical attention late after the injury has occurred. This highlights the importance of consulting plastic surgeons specialized in Brachial Plexus surgery for the management of such cases. Dr. Amit Agarwal specializes in this field with over 14 years of expertise, making him well-equipped to handle all aspects of treatment.

Timing of Nerve Repair Surgery in Partial BPI

In Brachial Plexus injuries, the principle of “sooner the treatment, better the outcome” holds true. Surgery involves exploring, repairing, and transferring nerves. If no recovery is observed within 3 months of the accident, nerve transfer surgery is performed as early as possible. While surgery can still be considered for injuries occurring within 9 months to 1 year of the accident, the chances of recovery diminish compared to surgeries performed within the first 3 months.

Nerve Surgery Beyond 1 Year of the Accident in Partial BPI

Attempting nerve transfer surgery after 1 year of the accident is associated with significantly reduced chances of success. There is insufficient time left for nerve regeneration. Consequently, specific targeted muscle and tendon transfers become the preferred option instead of nerve transfer surgery beyond 1 year of the accident.

Treatment Approach for Late Cases with Partial BPI at Kayakriti

If the patient presents to us after one year of the accident, and no surgery has been performed during that time, or no recovery is seen after the initial nerve repair, targeted muscle and tendon transfers are carried out. These procedures aim to achieve acceptable movements in the shoulder and elbow joints.

Investigations for Late Cases of BPI

After one year of the accident, specific investigations like MR Neurography and NCV studies are not typically performed. However, a thorough examination of the brachial plexus, muscle movements, sensory return, history of previous surgeries, fracture assessments, and evaluations of the patient’s vocational abilities are essential before proceeding with reconstruction.

Expected Results in Patients with Partial Brachial Plexus Injuries

In partial Brachial Plexus injuries, there is usually good recovery after nerve surgery (70-80%), but the results can be unpredictable in some patients.

Surgical Procedures for Partial Brachial Plexus Injuries After One Year of Accident

For late presentations of Partial Brachial Plexus Injuries, targeted muscle and tendon transfers are the primary surgical approach. These procedures are also recommended when initial nerve repair surgeries fail to yield any response even after one and a half years.

LD Muscle to Biceps (For Elbow Flexion)

The LD muscle, located in the back, is typically preserved in upper partial Brachial Plexus injuries. It is innervated by the thoracodorsal nerve, which is mostly preserved in patients with C5-6 injury. In cases of C5-6-7 complete injury, the LD muscle may not be available for transfer. Therefore, careful pre-operative evaluation of muscle function is crucial for the success of surgery. This muscle is harvested from the back and transferred to the arm to replicate the action of the biceps muscle, restoring elbow flexion.

How Is the Surgery (LD to Biceps) Done for Partial BPI?

• Admission of the patient one day prior to the surgery.
• Routine pre-operative investigations and pre-anesthetic checkups.
• An incision is made on the side of the chest, and the LD muscle is dissected free from its attachments.
• The LD muscle is then transferred to the arm region while retaining its vascular and nerve supply arising from the axilla.

Recovery After Surgery

• The patient is kept under observation for about 7-8 days after surgery, followed by splinting.
• Dressings are changed once or twice in between, and the patient is called for follow-up after 3 weeks for suture removal.
• After about 6 weeks of surgery, physiotherapy is advised.
• Follow-up appointments are scheduled every month initially for recovery, later every 3-6 months.
• Elbow flexion may begin to reappear between 3 to 6 months post-surgery, with complete recovery taking about one year.

Free Functioning Muscle Transfer (For Elbow Flexion)

This surgery is usually done when the LD muscle is weak or not working, or the patient has not consented to the harvest of muscle from their back. The restoration of elbow flexion is achieved using the reinnervated free-muscle transfer technique.

How Is the FFMT Surgery Done for Elbow Flexion in Patients with Partial BPI?

• The patient is admitted a day prior to the surgery, and routine pre-operative investigations and pre-anesthetic checkup are done.
• The surgery is performed under General Anesthesia with informed written consent.
• During the surgery, the area of the arm and the forearm is explored for donor nerves and vessels, and a tunnel is created for the insertion of the muscle.
• The gracilis muscle is harvested from the thigh along with its vessels and nerves.
• This muscle/flap is then transferred to the paralyzed arm and sutured, with vessels and nerves anastomosed under a microscope using microsurgical techniques.

Recovery After FFMT Surgery

• Continuous monitoring of the free flap after surgery.
• The patient is observed for about 10-12 days after surgery before discharge.
• Dressings are changed regularly, and the patient is called for follow-up at weekly intervals.
• After approximately 1-1.5 months post-surgery, once the flap has settled, physiotherapy and TENS therapy are recommended.
• Follow-up continues every month initially for stability and later every 3-6 months.
• Elbow flexion typically begins to reappear between 6 to 9 months after FFMT surgery, with complete recovery taking around one to one and a half years.

Tendon Transfer for Wrist/Finger Extension

In cases where there is combined C7 palsy with C5-6 palsy, wrist and finger extensors can be paralyzed, leaving the wrist unstable. While some hand function remains in flexion, tendon transfer surgery stabilizes the wrist joint to enhance finger function and grip strength. This procedure also places the wrist in a stable functional position and can improve movement and power in the elbow.

How Is the Tendon Transfer for Wrist/Finger Extension Done for Partial BPI?

• The patient is admitted for the procedure, with routine pre-operative investigations and pre-anesthetic checkup.
• The surgery involves incisions on the back and front of the forearm to expose the tendons, which are then transferred to extend the wrist and fingers.

Trapezius Transfer (For Shoulder)

In partial Brachial Plexus injuries, there is complete loss of movement of the shoulder. Partial restoration of shoulder joint abduction can be achieved through either shoulder joint fusion or trapezius muscle transfer.

What Is Trapezius Transfer?

In this surgery, the trapezius muscle, situated at the back, is transferred to the side of the arm to mimic the action of the deltoid muscle, partially restoring the outward movement (abduction) of the shoulder joint.

When Is Trapezius Transfer Surgery Done in Patients with Partial BPI?

For patients seen after a year of the accident, the first surgery is typically performed to restore elbow flexion. Surgery to restore shoulder joint movement can be considered as a second-stage procedure.

Why Is Trapezius Muscle Chosen for Transfer?

The trapezius muscle is a large muscle of the upper back. It is usually spared due to its innervation by the spinal accessory nerve, in addition to contributions from C3 and C4 neck nerves. Moreover, it often increases in bulk after deltoid muscle paralysis, making trapezius transfer the most commonly performed tendon transfer for shoulder abduction movement in adult brachial palsy.

How Is Trapezius Transfer Surgery Done?

• The patient was admitted one day before the surgery.
• Routine pre-operative investigations, pre-anesthetic checkups, and muscle strength assessments are conducted.
• A horizontal incision is made over the shoulder region.
• The trapezius muscle is dissected, mobilized, brought forward, and fixed to the bone in the arm.

Recovery After Surgery

• The patient is kept under observation for about 3-4 days after surgery, with splinting provided.
• Dressings are changed once or twice during recovery, and the patient is scheduled for follow-up after 2 weeks for suture removal.
• After approximately one month of surgery, once the scars have matured, physiotherapy is recommended.
• Follow-up appointments are initially scheduled monthly for recovery, later extending to every 3-6 months.

Treatment Options If Less Than 1 Year Has Elapsed Since the Accident

If less than one year has passed since the accident, nerve repair or transfers are advised in Partial Brachial Plexus Injuries (C5678T1) .