2006 Big Sky Athletic Training Sports Medicine Conference

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2006 Big Sky Athletic Training Sports
Medicine Conference
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Traumatic Brachial Plexus Injury In A
Collegiate Football PlayerA Case Study Report
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Background

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

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Mechanism

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

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Video
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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.

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Immediate Care

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

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Immediate Care

• Return to Minneapolis
• Hospitalized
• (3 days)
• Repeat x-rays
• MRI Brachial plexus
• Referred to neurologist
• Referred to neurosurgeon

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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

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Immediate Care

• Plan
• Manage Pain
• Maintain ROM
• Shoulder
• Elbow
• Wrist
• Hand
• Observation

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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

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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

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Day 10

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

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Day 10

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

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Day 10

• Re-Hospitalized
• 3 days
• Pain management
• Medrol dose pack

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Day 10

• Conclusions
• Brachial Plexopathy
• Possible nerve root avulsion at C6

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Brachial Plexus Picture
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Brachial Plexus Picture
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4 Weeks - Referral

• Mayo Clinic
• EMG
• Neurologist
• Meet with brachial plexus team
• Neurosurgeon
• Orthopedists

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4 Weeks - Referral

• Conclusions
• Diffuse Brachial Plexopathy
• Plan
• Observation
• Physical Therapy
• Schedule additional testing at 3 months from DOI

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4 Weeks - Rehabilitation

• Continue motion and strength exercises
• Wrist extension splint
• Shoulder support brace
• Sling

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12 Weeks

• Mayo Clinic
• Repeat EMG
• CT Myelogram
• Seen by brachial plexus team

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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

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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.

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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

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Surgery - Goals

• Highest Priority of Restoration
• Elbow flexion
• Shoulder Abduction/Stability
• Hand Sensitivity
• Wrist Extension
• Finger Extension

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Surgical Expectations

• No return to football activity
• Limited shoulder function
• Shoulder Abduction lt 60 degree
• Elbow flexion Strength lt 2 lbs.
• Triceps
• No wrist extension
• No finger extension

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13 weeks - Surgery

• Electrodiagnostic exploration showed nerve root
  avulsions at C6, C7, and C8
• Surgical Plan formulated

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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

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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

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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.

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13 Weeks - Surgery

• Nerve Transfer
• Spinal accessory nerve transfer to triceps branch
• Restores active elbow extension

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13 Weeks - Surgery

• Surgical procedure 8 hours
• Released after 4 days in hospital

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Expected Recovery

• 2- 3 years before full benefit of surgery
• Nerve growth 1mm/day or 1 /month

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24 weeks - Surgery

• Tendon transfer
• Restore limited wrist extension
• Restore limited finger extension

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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

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Thank You