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Brachial Plexus Blockade in Elbow, Arm or Hand Surgeries  [PDF]
M.T. Mortazavi,M. Niazi-Ghazani,M. Ansari
Pakistan Journal of Biological Sciences , 2009,
Abstract: This study was performed to compare the transarterial (T) and paraarterial (P) approaches for brachial plexus block, in terms of success rate, onset time and duration of analgesia and complications. Hundred patients scheduled for elbow, arm or hand surgery at Tabriz Shohada hospital from October 2005 to December 2006, randomly allocated into two groups (n = 50 per group), based on the approach chosen to block the brachial plexus. For local anesthesia each patient received 22.5 mL of 2% lidocaine with 17.5 mL distilled water (in total volume of 40 mL and total dose of 450 mg) and 1/200000 epinephrine with a standard 23 gauge needle. All patients were sedated with 1 μg kg-1 of fentanyl and 0.02-0.05 mg kg-1 of midazolam. There was no statistical difference between the groups in duration of analgesia but the onset of anesthesia was significantly quicker in paraarterial technique (3.5 vs. 13.4 min, p<0.001). Success rate was 86% in group T and 98% in group P (p = 0.03). Two percent of patients in group P and 6% in group T had total failure of the block and 8% of the group T required supplementary drug. Paraarterial method for axillary block is preferable due to quicker onset of blockade and higher success rate.
Comparison Of Infraclavicular Brachial Plexus Block With Supraclavicular Brachial Plexus Block In Upper Limb Surgeries. (A Study Of 100 Patients)
Sheetal Shah,kamla Mehta,Kirti Patel,Khyati Patel
NHL Journal of Medical Sciences , 2013,
Abstract: Comparative prospective study of two routes of Brachial plexus block – infraclavicular coracoid approach with conventional supraclavicular approach was carried out in 100 patients of ASA RISK I to III, undergoing elective or emergency surgeries on upper limb, at the level of elbow and below elbow. Patients were divided into 2 equal groups, Group I (Infraclavicular) and Group S (Supraclavicular), which were compared for block performance time, onset, quality and duration of block. The applied anatomy, methodology, complications and limitations have been emphasized. The study concludes that infraclavicular brachial plexus block with coracoid approach is a useful block without complications if practiced with precautions.
Finger movement at birth in brachial plexus birth palsy  [cached]
Rahul K Nath,Mohamed Benyahia,Chandra Somasundaram
World Journal of Orthopedics , 2013, DOI: 10.5312/wjo.v4.i1.24
Abstract: AIM: To investigate whether the finger movement at birth is a better predictor of the brachial plexus birth injury. METHODS: We conducted a retrospective study reviewing pre-surgical records of 87 patients with residual obstetric brachial plexus palsy in study 1. Posterior subluxation of the humeral head (PHHA), and glenoid retroversion were measured from computed tomography or Magnetic resonance imaging, and correlated with the finger movement at birth. The study 2 consisted of 141 obstetric brachial plexus injury patients, who underwent primary surgeries and/or secondary surgery at the Texas Nerve and Paralysis Institute. Information regarding finger movement was obtained from the patient’s parent or guardian during the initial evaluation. RESULTS: Among 87 patients, 9 (10.3%) patients who lacked finger movement at birth had a PHHA > 40%, and glenoid retroversion < -12°, whereas only 1 patient (1.1%) with finger movement had a PHHA > 40%, and retroversion < -8° in study 1. The improvement in glenohumeral deformity (PHHA, 31.8% ± 14.3%; and glenoid retroversion 22.0° ± 15.0°) was significantly higher in patients, who have not had any primary surgeries and had finger movement at birth (group 1), when compared to those patients, who had primary surgeries (nerve and muscle surgeries), and lacked finger movement at birth (group 2), (PHHA 10.7% ± 15.8%; Version -8.0° ± 8.4°, P = 0.005 and P = 0.030, respectively) in study 2. No finger movement at birth was observed in 55% of the patients in this study group. CONCLUSION: Posterior subluxation and glenoid retroversion measurements indicated significantly severe shoulder deformities in children with finger movement at birth, in comparison with those lacked finger movement. However, the improvement after triangle tilt surgery was higher in patients who had finger movement at birth.
Bilateral Obstetric Palsy of Brachial Plexus  [cached]
?zlem Alt?nda?,Sava? Gürsoy,Ahmet Mete
Türkiye Fiziksel Tip ve Rehabilitasyon Dergisi , 2009,
Abstract: Obstetric Brachial Plexus Palsy (OBPP) is one of the devastating complications of difficult or assisted deliveries. Brachial plexus palsy with upper root involvement most commonly affects the external rotators and abductors. Twenty percent of obstetrical brachial plexus palsies are bilateral and they represent a more severe condition. An eight-year-old girl patient with bilateral brachial plexus palsy was described and discussed in this report. Turk J Phys Med Rehab 2009;55:126-7.
Surgical correction of unsuccessful derotational humeral osteotomy in obstetric brachial plexus palsy: Evidence of the significance of scapular deformity in the pathophysiology of the medial rotation contracture
Rahul K Nath, Sonya E Melcher, Melia Paizi
Journal of Brachial Plexus and Peripheral Nerve Injury , 2006, DOI: 10.1186/1749-7221-1-9
Abstract: Four patients with Scapular Hypoplasia, Elevation And Rotation (SHEAR) deformity who had undergone unsuccessful humeral osteotomies to treat internal rotation underwent acromion and clavicular osteotomy, ostectomy of the superomedial border of the scapula and posterior capsulorrhaphy in order to relieve the torsion developed in the acromio-clavicular triangle by persistent asymmetric muscle action and medial rotation contracture.Clinical examination shows significant improvement in the functional movement possible for these four children as assessed by the modified Mallet scoring, definitely improving on what was achieved by humeral osteotomy.These results reveal the importance of recognizing the presence of scapular hypoplasia, elevation and rotation deformity before deciding on a treatment plan. The Triangle Tilt procedure aims to relieve the forces acting on the shoulder joint and improve the situation of the humeral head in the glenoid. Improvement in glenohumeral positioning should allow for better functional movements of the shoulder, which was seen in all four patients. These dramatic improvements were only possible once the glenohumeral deformity was directly addressed surgically.Obstetric brachial plexus injury (OBPI) has been described as a discrete entity since 1754 [1]. The pathophysiology of the secondary deformities encountered in this population was described succinctly in 1905 by Whitman who wrote that the large majority of internal rotation and subluxation deformities of the shoulder in children with obstetric brachial plexus injuries were caused by fibrosis and contractures developed as a consequence of the neurological injury [2]. The medial rotation contracture (MRC) is the most significant secondary shoulder deformity in children with severe OBPI, requiring surgery in more than one third of patients whose injury did not resolve spontaneously [3].The current surgical approach to treating persistent MRC in OBPI patients is derotational humeral ost
A randomized controlled double-blinded prospective study of the efficacy of clonidine added to bupivacaine as compared with bupivacaine alone used in supraclavicular brachial plexus block for upper limb surgeries  [cached]
Singh Shivinder,Aggarwal Amitabh
Indian Journal of Anaesthesia , 2010,
Abstract: We compared the effects of clonidine added to bupivacaine with bupivacaine alone on supraclavicular brachial plexus block and observed the side-effects of both the groups. In this prospective, randomized,double-blinded, controlled trial, two groups of 25 patients each were investigated using (i) 40 ml of bupivacaine 0.25% plus 0.150 mg of clonidine and (ii) 40 ml of bupivacaine 0.25% plus 1 ml of NaCl 0.9, respectively. The onset of motor and sensory block and duration of sensory block were recorded along with monitoring of heart rate, non-invasive blood pressure, oxygen saturation and sedation. It was observed that addition of clonidine to bupivacaine resulted in faster onset of sensory block, longer duration of analgesia (as assessed by visual analogue score), prolongation of the motor block (as assessed by modified Lovett Rating Scale), prolongation of the duration of recovery of sensation and no association with any haemodynamic changes (heart rate and blood pressure), sedation or any other adverse effects. These findings suggest that clonidine added to bupivacaine is an attractive option for improving the quality and duration of supraclavicular brachial plexus block in upper limb surgeries.
MRI of the Brachial Plexus
Seyed Hassan Mostafavi
Iranian Journal of Radiology , 2010,
Abstract: Evaluation of the brachial plexus is a clinical chal-lenge. Physical examination has traditionally been a mainstay in evaluating and localizing pathology involving the brachial plexus. Physical examination is especially difficult in patients with scarring and fibrosis secondary to surgery or irradiation. Electrophysiologic studies may be used to detect abnormalities in nerve conduction, but are poor for localizing a lesion. "nMRI has become increasingly important in the evaluation of brachial plexus pathology, as the technology and resolution has improved. Correlation of imaging results with electrophysiologic findings increases the overall specificity and sensitivity. CT has increased sensitivity for depicting extrinsic masses that com-press the nerves; however, it offers poor soft tissue contrast to directly evaluate the nerves."nWith the advent of MRI, nerves that compose the brachial plexus can now be directly evaluated. Intrinsic and extrinsic pathology may be evaluated. Exact anatomic components of the brachial plexus, such as the roots, trunks, divisions, and cords may be identified. MRI has the additional benefit of multiplanar imaging and increased soft tissue contrast. The tissue resolution of MRI is constantly improving with new pulse sequences and coil designs."nWith radiography and CT, changes in the shape or position of the brachial plexus were used to assess the pathology. With MRI, the nerve can be directly visualized and evaluated for pathology. MRI sequences such as fat-saturated T2-weighted spin-echo, short-tau inversion recovery (STIR), and gadolinium-enhanced T1-weighted spin-echo sequences help in depicting subtle changes in the signal intensity of the nerves or enhancement and aid in refining the differential diagnosis. In addition, maximum intensity projections can make localization and visualization of the pathology most understandable for referring clinicians and surgeons.
Desmoid Tumour of the Brachial Plexus  [PDF]
Orege Juliette,Koech Florentius,Ndiangui Francis,Benson Ndegwa Macharia,Mbaruku Neema
Case Reports in Surgery , 2013, DOI: 10.1155/2013/575982
Abstract: Desmoid tumours of the brachial plexus are rare and may occur in extra-abdominal sites. The tumours are of fibroblastic origin and, although benign, are locally aggressive. Their relationship to critical neurovascular structures in their anatomic locations presents a challenge to the operating surgeons trying to adhere to the principles of surgery. Surprisingly little neurosurgical literature exists which was devoted to this topic despite the challenge these lesions present in surgery both at surgery and in choosing adjuvant therapies. We report a case of a large brachial plexus tumour in a patient which was diagnosed radiologically and histopathologically and the patient underwent surgical excision with good outcome. Desmoid tumours histologically are benign and are usually composed of proliferating, benign fibroblasts in an abundant matrix of collagen. They do not transform into malignant tumours or metastasize. Surgery is the mainstay of treatment; however, adjuvant radiation and chemotherapy remain controversial. 1. Introduction Many terms have been used to refer to desmoids tumours over the years, including fibromatosis, desmoid tumors, and aggressive fibromatosis. However, “Desmoid-type fibromatosis” has emerged as the designation of choice by the World Health Organization [1]. A review of the literature identified three case series reporting the treatment of desmoids tumours involving the brachial plexus. The first series, reported by Binder et al. [2] in June 2004, served to ascertain the rarity of these tumours. Twenty-four patients were treated at the University of California, San Francisco, CA, USA, who had primary brachial plexus tumours and only one (4%) had a desmoid tumour. The second case series reported by Seinfeld et al. [3] in 2006 included four cases of desmoid-type fibromatosis involving the brachial plexus. This series additionally assessed these lesions for mutations in the c-KIT oncogene in hopes of establishing a basis for predicting which of these lesions would respond to the chemotherapy agent imatinib mesylate. In the third case series, Dafford et al. [4] in June 2007 undertook a retrospective study of 15 desmoid tumors in 11 women and four men (ranging in age from 32 to 67 years; median 48 years) treated at their institution. In this study, the results were that there were 13 patients (86%) with brachial plexus lesions. In this review, we document the clinical presentation, neuroimaging, surgical, and pathological findings in a patient with a desmoid tumour arising from the brachial plexus. 1.1. Age and Gender Incidences of
Axillary Brachial Plexus Block  [PDF]
Ashish R. Satapathy,David M. Coventry
Anesthesiology Research and Practice , 2011, DOI: 10.1155/2011/173796
Abstract: The axillary approach to brachial plexus blockade provides satisfactory anaesthesia for elbow, forearm, and hand surgery and also provides reliable cutaneous anaesthesia of the inner upper arm including the medial cutaneous nerve of arm and intercostobrachial nerve, areas often missed with other approaches. In addition, the axillary approach remains the safest of the four main options, as it does not risk blockade of the phrenic nerve, nor does it have the potential to cause pneumothorax, making it an ideal option for day case surgery. Historically, single-injection techniques have not provided reliable blockade in the musculocutaneous and radial nerve territories, but success rates have greatly improved with multiple-injection techniques whether using nerve stimulation or ultrasound guidance. Complete, reliable, rapid, and safe blockade of the arm is now achievable, and the paper summarizes the current position with particular reference to ultrasound guidance. 1. Introduction The axillary approach to brachial plexus was first demonstrated in 1884 by William Halsted when he injected cocaine under direct vision [1]. In 1911, G. Hirschel performed the first percutaneous axillary block [2]. It was only after Burnham’s publication in 1959 [3] that this block gained popularity among anaesthetists. Since then, it has become the most used peripheral nerve block for forearm and hand surgery, especially due the low incidence of complications compared to the more proximal approaches to the brachial plexus. 2. The Brachial Plexus in the Axilla [4] The brachial plexus supplies the nerve supply to the upper limb and is formed by the ventral rami of the lower four cervical nerves and the first thoracic nerve. It consists of roots, trunks, divisions, and cords. The roots are arranged between the scalenus anterior and medius muscles, and they combine in the posterior triangle to form three trunks: upper, middle, and lower. On approaching the clavicle, each of the three trunks divides into an anterior and posterior division to supply the flexor and extensor compartments of the arm, respectively. Anterior divisions of the upper and middle trunk unite to form the lateral cord, anterior division of the lower trunk continues as the medial cord, and posterior divisions of all the three trunks assemble to from the posterior cord. The three cords enter the axilla at the apex and are arranged, according to the names, around the second and third parts of the axillary artery. In relation to the first part of the artery, however, the lateral and posterior cords are lateral, and
Angiosomes of medial cord of brachial plexus  [cached]
D. Suseelamma,S. Deepthi,K. Krishna Chaitanya,H. R. Sharada
International Journal of Research in Medical Sciences , 2013, DOI: 10.5455/2320-6012.ijrms20130508
Abstract: This anatomical study analyzed the neurovascular relationship of the brachial plexus. Ten formalized specimens of brachial plexuses were examined after injection of lead oxide in to the subclavian artery. The vascular, anatomical features of the brachial plexus were documented .The specimens were analyzed by dissection method, subjected for microscopic study. The vascular supply was markedly rich, often with true anastomotic channels found within the nerves. There was much variation in supply, depending on the branching pattern of subclavian artery. [Int J Res Med Sci 2013; 1(2.000): 79-82]
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