2006 Big Sky Athletic Training Sports Medicine Conference

1. 2006 Big Sky Athletic Training Sports Medicine Conference

2. Traumatic Brachial Plexus Injury In A Collegiate Football Player:A Case Study Report

3. Background • 20 year old, African-American, Male • Junior • Position: Strong Safety • Height: 6’ 2” • Weight: 210 lb. • No history of Brachial Plexus injury

4. Mechanism • Direct contact in football game • Mechanism of injury involved direct contact to the athletes right shoulder/neck by opponents helmet

5. Video

6. Sideline Evaluation • Signs and Symptoms • No loss of consciousness • No cervical spine pain • Athlete able to walk off field • Numbness/tingling/pain into R upper extremity • No motor control in R upper extremity • No sensation in R upper extremity • Normal neurological exam in lower extremities/ left upper extremity.

7. Immediate Care • Transported to hospital • X-rays - Cervical spine • CT Scan - Upper cervical spine • Pain management • Sling

8. Immediate Care • Return to Minneapolis • Hospitalized (3 days) • Repeat x-rays • MRI – Brachial plexus • Referred to neurologist • Referred to neurosurgeon

9. Immediate Care • Conclusions • Brachial plexus neuropathy • Some return of C5, C7, C8,T1 sensation • Finger flexion • Wrist flexion • Shoulder shrugs • Shoulder Protraction/Retraction • No indication of nerve root avulsion • RX medication • Medrol dose pack • Pain medication • Sling/wrist extension brace

10. Immediate Care • Plan • Manage Pain • Maintain ROM • Shoulder • Elbow • Wrist • Hand • Observation

11. Day 3 - 10 • Released from hospital • Gradual decrease in neck/shoulder pain • Increased sensation • C5, C7, C8, T1 • Athlete able to actively flex fingers/thumb, flex wrist, some intrinsic motions, shoulder shrugs, shoulder protraction/retraction • Physical Therapy – Weekly appointments

12. Day 3-10 – Physical Therapy • ROM • Finger/ thumb extension • Wrist extension • Pronation/ supination • Ulnar/radial deviation • Elbow extension • Shoulder internal/external rotation • Shoulder flexion • Strength • Finger/thumb flexion • Pronation • Wrist Flexion • Shoulder Elevation • Shoulder Protraction/Retraction

13. Day 10 • Increasing pain in low back • Pain with leg extension • Pain with Straight Leg Test • Radiating pain down into buttocks

14. Day 10 • Diagnostic Testing • Lumbar Spine MRI • Blood in distal thecal sac • Additional Testing • Brain MRI • Brain MRA • Cervical Spine MRI • Thoracic Spine MRI

15. Day 10 • Re-Hospitalized 3 days • Pain management • Medrol dose pack

16. Day 10 • Conclusions • Brachial Plexopathy • Possible nerve root avulsion at C6

17. Brachial Plexus Picture

18. Brachial Plexus Picture

19. 4 Weeks - Referral • Mayo Clinic • EMG • Neurologist • Meet with brachial plexus team • Neurosurgeon • Orthopedists

20. 4 Weeks - Referral • Conclusions • Diffuse Brachial Plexopathy • Plan • Observation • Physical Therapy • Schedule additional testing at 3 months from DOI

21. 4 Weeks - Rehabilitation • Continue motion and strength exercises • Wrist extension splint • Shoulder support brace • Sling

22. 12 Weeks • Mayo Clinic • Repeat EMG • CT Myelogram • Seen by brachial plexus team

23. 12 Weeks • Conclusions • EMG showed no evidence of significant reinnervation • CT myelogram showed evidence of avulsions at C7 and C8 on right side • No significant increase in motor function

24. Surgery • Surgery should be performed only in the absence of clinical or electrical evidence of recovery or when spontaneous recovery is impossible • Surgery should be performed 3 to 6 months post injury. • The time for the nerve to regenerate to the target muscles is greater than the survival time of the motor end plate after deenervation.

25. Surgery • Surgical exploration Electrodiagnostic techniques – allow the surgeon to test a nerve directly across a lesion to detect reinnervation • Combination of nerve grafting/nerve transfers • Possible tendon transfer in 6 months

26. Surgery - Goals • Highest Priority of Restoration • Elbow flexion • Shoulder Abduction/Stability • Hand Sensitivity • Wrist Extension • Finger Extension

27. Surgical Expectations • No return to football activity • Limited shoulder function • Shoulder Abduction < 60 degree • Elbow flexion – Strength < 2 lbs. • Triceps • No wrist extension • No finger extension

28. 13 weeks - Surgery • Electrodiagnostic exploration showed nerve root avulsions at C6, C7, and C8 • Surgical Plan formulated

29. 13 Weeks - Surgery • Nerve grafting from C5 root to suprascapular nerve • Nerve grafting from C5 root to axillary nerve • Restores shoulder stability • Restores limited active shoulder abduction

30. 13 Weeks - Surgery • Intercostal motor nerve transfer of the 4th, 5th, and 6th intercostal nerve to the motor branch of the musculataneous nerve, including the brachialis and biceps branch • Restores limited active elbow flexion

31. 13 Weeks - Surgery • Sensory intercostal neurotization • Intercostal sensory nerve transfer of the 4th, 5th, and 6th intercostal nerve to the median nerve • Restore sensation to palmar aspect of hand/fingers.

32. 13 Weeks - Surgery • Nerve Transfer • Spinal accessory nerve transfer to triceps branch • Restores active elbow extension

33. 13 Weeks - Surgery • Surgical procedure – 8 hours • Released after 4 days in hospital

34. Expected Recovery • 2- 3 years before full benefit of surgery • Nerve growth 1mm/day or 1” /month

35. 24 weeks - Surgery • Tendon transfer • Restore limited wrist extension • Restore limited finger extension

36. Conclusions • Severe brachial plexus injuries in athletics can be catastrophic in nature and result in permanent disability • Evaluation, diagnostic studies, and referral are essential in determining the severity of these injuries • Surgical intervention may be needed to restore limited function • Patient selection, timing, and prioritizing restoration of function are critical when considering surgical intervention

37. Thank You