2006 big sky athletic training sports medicine conference l.
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2006 Big Sky Athletic Training Sports Medicine Conference Traumatic Brachial Plexus Injury In A Collegiate Football Player: A Case Study Report Background 20 year old, African-American, Male Junior Position: Strong Safety Height: 6’ 2” Weight: 210 lb.

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background
Background
  • 20 year old, African-American, Male
  • Junior
  • Position: Strong Safety
  • Height: 6’ 2”
  • Weight: 210 lb.
  • No history of Brachial Plexus injury
mechanism
Mechanism
  • Direct contact in football game
  • Mechanism of injury involved direct contact to the athletes right shoulder/neck by opponents helmet
sideline evaluation
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.
immediate care
Immediate Care
  • Transported to hospital
  • X-rays - Cervical spine
  • CT Scan - Upper cervical spine
  • Pain management
  • Sling
immediate care8
Immediate Care
  • Return to Minneapolis
  • Hospitalized

(3 days)

  • Repeat x-rays
  • MRI – Brachial plexus
  • Referred to neurologist
  • Referred to neurosurgeon
immediate care9
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
immediate care10
Immediate Care
  • Plan
    • Manage Pain
    • Maintain ROM
      • Shoulder
      • Elbow
      • Wrist
      • Hand
    • Observation
day 3 10
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
day 3 10 physical therapy
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
day 10
Day 10
  • Increasing pain in low back
  • Pain with leg extension
  • Pain with Straight Leg Test
  • Radiating pain down into buttocks
day 1014
Day 10
  • Diagnostic Testing
    • Lumbar Spine MRI
      • Blood in distal thecal sac
  • Additional Testing
    • Brain MRI
    • Brain MRA
    • Cervical Spine MRI
    • Thoracic Spine MRI
day 1015
Day 10
  • Re-Hospitalized

3 days

    • Pain management
    • Medrol dose pack
day 1016
Day 10
  • Conclusions
    • Brachial Plexopathy
    • Possible nerve root avulsion at C6
4 weeks referral
4 Weeks - Referral
  • Mayo Clinic
    • EMG
    • Neurologist
    • Meet with brachial plexus team
      • Neurosurgeon
      • Orthopedists
4 weeks referral20
4 Weeks - Referral
  • Conclusions
    • Diffuse Brachial Plexopathy
  • Plan
    • Observation
    • Physical Therapy
    • Schedule additional testing at 3 months from DOI
4 weeks rehabilitation
4 Weeks - Rehabilitation
  • Continue motion and strength exercises
  • Wrist extension splint
  • Shoulder support brace
  • Sling
12 weeks
12 Weeks
  • Mayo Clinic
    • Repeat EMG
    • CT Myelogram
    • Seen by brachial plexus team
12 weeks23
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
surgery
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.
surgery25
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
surgery goals
Surgery - Goals
  • Highest Priority of Restoration
    • Elbow flexion
    • Shoulder Abduction/Stability
    • Hand Sensitivity
    • Wrist Extension
    • Finger Extension
surgical expectations
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
13 weeks surgery
13 weeks - Surgery
  • Electrodiagnostic exploration showed nerve root avulsions at C6, C7, and C8
  • Surgical Plan formulated
13 weeks surgery29
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
13 weeks surgery30
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
13 weeks surgery31
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.
13 weeks surgery32
13 Weeks - Surgery
  • Nerve Transfer
  • Spinal accessory nerve transfer to triceps branch
  • Restores active elbow extension
13 weeks surgery33
13 Weeks - Surgery
  • Surgical procedure – 8 hours
  • Released after 4 days in hospital
expected recovery
Expected Recovery
  • 2- 3 years before full benefit of surgery
  • Nerve growth 1mm/day or 1” /month
24 weeks surgery
24 weeks - Surgery
  • Tendon transfer
  • Restore limited wrist extension
  • Restore limited finger extension
conclusions
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