The treatment of brachial plexus injuries is one of the difficult problems in peripheral neurosurgery. The injuries are not life-threatening, but can cause severe functional loss. Brachial plexus injury is the most serious disability of the upper extremity, mostly seen in falls, car accidents, strains during sports, followed by crush injuries, cuts, gunshot wounds, birth injuries, and also drug, surgical, and radiation injuries.
The pathology of brachial plexus injury, like other peripheral nerve injuries, is determined by the extent and location of the injury. Due to the increasing understanding of peripheral nerve anatomy, physiology and metabolism, nerve repair methods are improving and the nerve repair results are more desirable. However, at present, the early stage of brachial plexus nerve injury at home and abroad is still mainly applied to nerve displacement, and the late stage can also be treated by muscle displacement and other methods.
Therefore, early diagnosis, active and effective treatment plan, together with appropriate rehabilitation measures, can maximize the restoration of the function of patients with brachial plexus nerve injury. Brachial plexus injuries are generally classified as upper brachial plexus injuries, lower brachial plexus injuries and total brachial plexus injuries.
According to the mechanism of brachial plexus injury and injury site to make the following classification.
1, open brachial plexus injury.
2, closed (pulling) brachial plexus injury.
(1) supraclavicular brachial plexus injury
① Brachial plexus injury above the ganglion (preganglionic injury);
② brachial plexus injury below the ganglion (postganglionic injury).
(2) subclavian brachial plexus injury.
3.Radiation brachial plexus injury.
(4) birth palsy.
Brachial plexus injury mainly manifests as sensory and motor disorders in the shoulder, elbow, wrist and hand joints. Clinical manifestations vary greatly depending on the location and severity of the damaged nerve. Judgment of the presence or absence of brachial plexus injury needs to be made by a professional hand surgeon, and the presence of brachial plexus injury should be considered in one of the following conditions.
(1) Combined injury (cut injury not in the same plane) to any two of the five major nerves of the upper extremity (axillary, musculocutaneous, median, radial, and ulnar nerves).
(2)Any one of the three major nerves of the hand (median, radial and ulnar nerves) combined with shoulder or elbow joint dysfunction (normal passive movement).
(3) Any of the three major nerves in the hand (median, radial, and ulnar nerves) combined with medial forearm cutaneous nerve injury (non-cutting injury).
Clinical manifestations of the five major nerve injuries.
1, axillary nerve injury: atrophy of the deltoid muscle, shoulder joint abduction is limited. Single axillary nerve injury its injury plane below the branch; combined radial nerve injury, its injury plane in the posterior bundle; combined myocutaneous nerve injury its injury plane in the upper stem; combined median nerve injury its injury plane in the root of C5.
2, musculocutaneous nerve injury: biceps atrophy, elbow flexion is limited. Single myocutaneous nerve injury, the plane of injury below the branch; combined axillary nerve injury, the plane of injury in the upper trunk; combined median nerve injury the plane of injury in the lateral bundle; combined radial nerve injury, the plane of injury in the C6 nerve root.
3, radial nerve injury: triceps brachii, brachioradialis and wrist extension, thumb extension, finger extension muscle atrophy and functional limitation. Radial nerve injury alone, the plane of injury is below the branch; combined with axillary nerve injury, the plane of injury in the posterior bundle; combined with myocutaneous nerve injury, the plane of injury in the C6 nerve root; combined with median nerve injury, the plane of injury in the C8 nerve root.
4, median nerve injury: flexor wrist and flexor finger muscles, atrophy and atrophy of the greater interphalangeal muscle, thumb and finger flexion and thumb to palm function is limited, the first to third finger sensory impairment. Injury to the median nerve alone, the plane of injury is below the branch; combined with myocutaneous nerve injury, the plane of injury is in the lateral bundle; combined with radial nerve injury, the plane of injury is in the C8 nerve root; combined with ulnar nerve injury, the plane of injury is in the lower trunk or medial bundle.
5, ulnar nerve injury: atrophy of the ulnar carpal flexor muscle, small interosseous muscle, internal hand muscle including interosseous muscle and earthworm muscle, and thumb adductor muscle atrophy, finger adduction, abduction limitation, interphalangeal joint extension limitation, hand fine function limitation, 4th to 5th finger sensory impairment. For ulnar nerve injury alone, the plane of injury is below the branch; for combined median nerve injury, the plane of injury is in the lower trunk or medial bundle; for combined radial nerve injury, the plane of injury is in the thoracic 1 nerve root.
Diagnosis of brachial plexus injury includes clinical examination, electrophysiology such as electromyography and imaging diagnosis including X-ray, CT, brachial plexus MRI, and for brachial plexus injuries that require surgical exploration, intraoperative diagnosis is also made.
Based on the symptoms and signs specific to different nerve branch injuries, combined with the history of trauma, anatomical relationships and special examinations, the injured nerve, its plane of injury and the degree of injury can be identified. To determine the site of brachial plexus injury clinically, the pectoralis major clavicularis represents neck 5 and 6, the latissimus dorsi represents neck 7, and the pectoralis major sternocostalis represents neck 8 chest 1.
The presence of the above muscle function indicates that the injury is below the clavicle, that is, the bundle branch injury. This is an important basis for identifying injuries above and below the clavicle.
Brachial plexus nerve injury treatment, general treatment of common pulling brachial plexus injury, early to conservative treatment, that is, the application of neurotrophic drugs (vitamin B1, vitamin B6, vitamin B12, etc.), physical therapy for the injury, such as electrical stimulation therapy, infrared, magnetic therapy, etc., the affected limb for functional exercise, prevention and control of joint capsule contracture, and can be combined with acupuncture, massage, massage, conducive to the elimination of nerve shock In addition, acupuncture, massage and massage can be used to help eliminate nerve shock, loosen nerve adhesions and relax joints. The observation period is usually about 3 months.
Surgical treatment of brachial plexus nerve injury.
1, surgical indications.
① open injury of the brachial plexus nerve, cutting injury, gunshot injury, surgical injury and drug injury, should be explored early and surgically repaired.
② Brachial plexus nerve collision injury, strain injury, pressure smash injury, such as an absent preganglionic injury should be operated early, for closed postganglionic injury, can be first by conservative treatment for 3 months. In the following cases, surgical exploration can be considered: those who have not recovered significantly after conservative treatment; those who have jumped to recover function, such as those who have not recovered the function of shoulder joint, but recovered the function of elbow joint first; those who have interrupted the process of functional recovery for 3 months without any progress.
③Patients with birth injury: Those who have no obvious functional recovery or only partial functional recovery six months after birth can undergo surgical exploration. Surgical methods: brachial plexus exploration: supraclavicular brachial plexus exploration; infraclavicular brachial plexus exploration; brachial plexus exploration at the clavicle
2, according to the principles of treatment found in surgery as follows: nerve release; nerve grafting; nerve transposition.
Delivering brachial plexus nerve injury is also known as birth palsy, and the prevention of birth palsy requires attention to.
1, the correct estimate of fetal weight when the fetal head diameter is large need to measure the shoulder diameter and chest circumference, should be alert to the occurrence of shoulder obstructed labor. If you have diabetes, a tall pregnant woman, a premature birth, or have delivered a huge baby, you should be alert. The estimated fetal weight of non-diabetic pregnant women ≥ 4500g and diabetic pregnant women ≥ 4000g should undergo cesarean section. Therefore, estimate the fetal weight as accurately as possible before delivery, and choose the delivery method carefully when considering a huge baby.
If the fetus with gestational diabetes has a small head and wide shoulders, it is easy to have a difficult shoulder delivery. For prolonged second stage of labor, obstructed or slow descent of the first dewlap, especially if the prenatal estimated fetal weight is >4000g, the occurrence of obstructed shoulder delivery should be alerted and the indication for cesarean delivery should be relaxed.
3.Proper handling of obstructed shoulder delivery Once obstructed shoulder delivery occurs, it should be handled immediately to prevent severe asphyxia and death of the newborn. Routine lateral incision should be made to increase the space for delivery of the fetus.