2018 HTRC St. Louis Brachial Plexus Kahn - asht.org · Hand Therapy Review Course Washington University St. Louis, MO April 27‐29, 2018 The Brachial Plexus: Innervation of the Upper

Hand Therapy Review CourseWashington UniversitySt. Louis, MOApril 27‐29, 2018

The Brachial Plexus:

Innervation of the Upper Extremity

Lorna C. Kahn, PT, CHT

Spinal accessory nerve injuryMedian nerve injury

Upper trunk injuryUlnar neuropathy

Outline

• Anatomy of the nervous system

• Nerve injuries

• Nerve repair options

• Brachial plexus

• Spinal nerves: pathways, classic lesions, and compression sites


• Nerve injuries


• Brachial plexus

• Spinal nerves: pathways, classic lesions, and compression sites

Neuroanatomy

• Central Nervous System: inside brain and spinal cord

• Peripheral Nervous System: outside brain and spinal cord

• Connective Tissue: between the nerves-provides nutrition; prevents compression; allows lengthening; speeds conduction

• Unit structure of nervous system is the nerve cell or neuron

• Dendrites conduct impulses toward the cell body

• Axons conduct impulses away from the cell body

• Efferent (motor) fibers conduct away from CNS

• Afferent (sensory) fibers conduct toward the CNS

Peripheral Nerve Anatomy All peripheral nerve fibers have a sheath cell called a Schwann cell or neurolemma

Larger nerve fibers have a fatty (myelin) sheath in addition to the Schwann cell

Presence of myelin speeds conduction

Nodes of Ranvier: constrictions separating successive segments of myelin

Nerve impulses “leap” from node to node

Farther apart = faster conduction

Peripheral Nerve Anatomy: Connective Tissue

• Epineurium-binds fascicles into named nerve

• Perineurium-surrounds fascicles

• Endoneurium-surrounds the axon

• Connective tissue – Protection vs. compression,

traction

– Allows lengthening

Mixed Spinal Nerve


• Nerve injuries


• Brachial plexus

• Spinal nerves: pathways, classic

lesions, and compressions sites

Nerve Injury

• Agents of nerve injury are mechanical, thermal, chemical, or ischemic

• Motor loss results in venous/lymphatic stasis; muscle atrophy; muscle/joint fibrosis

• Sensory loss results in decreased functional use and increased risk for burn/pressure injury

• Sympathetic loss results in vasomotor, sudomotor, pilomotor, and trophic changes

sympathetic nerve changes with nerve injury

• Vasomotor: changes in skin temperature, color, edema, and cold intolerance

• Sudomotor: changes in sweat patterns (hypo-hidrosis in denervated areas; hyper-hidrosis with partial nerve injury)

• Pilomotor: absence of “goose flesh”

• Trophic: changes in skin texture; atrophy of finger pulps; nail changes; hair growth changes (hyper/hypotrichosis); slowed skin healing

VASOMOTOR CHANGES POST NERVE INJURY

SUDOMOTOR CHANGES POST NERVE INJURYPILOMOTOR CHANGES POST NERVE INJURY

TROPHIC CHANGES POST NERVE INJURY

• SOURCE: Callahan, Anne D. : SensibilityTesting: Clinical Methods Rehab of the Hand ,

ed2, 1984 The CV Mosby Co.

TROPHIC CHANGES POST NERVE INJURY

Connective Tissue

• In vulnerable areas of the body such as anatomic tunnels there are usually more fascicles in the nerves

• Fascicle arrangement more complex proximally

• Jabaley: protection from compression, tensile forces

• More fascicles means more epineurium to protect axons from friction or pressure Sunderland: 21-81% CT, greater % closer to joint

Connective Tissue

Greater number of fasculi: greater connective tissue protection: less deformation with mechanical stress

Connective Tissue

• Undulations of the nerves allow for more nerve gliding without tension “Spiral bands of Fontana” Dellon & Mackinnon: absent in area of compression

• Normal muscle tone helps prevent excessive traction to the nerve

Nerve Traction

• Axon

• Endoneurium

• Perineurium

• Epineurium

Undulation Stretched

Progressive Disruption

Double Crush SyndromeMacKinnon & Novak

• Axoplasmic flow is decreased in chronic compressive injuries – Distal to the compressive force, the nerve becomes

more sensitive to sub-clinical levels of entrapment• Double Crush

– 2 or more levels of compression occur along the same nerve

• Water hose analogy– Less compression required to create symptoms with an

existing compromise in nerve circulation

Observed in approximately 50% of TOS cases

Classification of Nerve Injury

Seddon Sunderland

Seddon’s Neuropraxia = Sunderland 1

A conduction block involving local demyelination

Prognosis is good to excellent

Axon remains intact; NO Wallerian degeneration

Nerve conduction preserved proximal and distal to

the lesion

Complete recovery within 4-12 weeks

“Saturday night palsy”

Seddon’s Axontomesis = Sunderland 2

Axons are damaged

endo/peri neurium are intact

+ Wallerian Degeneration distal to injury

no distal stimulation once WD occurs

typically complete recovery but timing is based on distance to end organ (inch per month)

+ advancing tinel


Axons are damaged

Axons must regenerate but may “get lost”

endoneurium is NOT intact; scarred

perineurium is intact


no distal stimulation once WD occurs

incomplete recovery and timing is based on distance to end organ (inch per month)

+ advancing tinel


Axons are damaged

No regeneration can occur through scar

Endo and perineurium are NOT intact


no distal stimulation once WD occurs; poor recovery

NO advancing tinel


No advancing Tinel’s

Surgery required: resection of neuroma and graft or other procedure

Sequential EMG at 3 mo will confirm failure to improve

Seddon’s Neurotomesis = Sunderland 5

Complete transection of nerve

No advancing Tinel’s

More straight forward diagnostically; early surgical repair may lead to better outcome

summary of outcomes

Grade I: Recovers within 3 months

Grade II: Complete recovery at 1mm/day

Grade III: Incomplete recovery at 1mm/day

Grade IV: No recovery and requires surgery

Grade V: Requires surgery

“Sixth Degree"

Classification added by MacKinnon and Dellon

Combination of I-V degree fascicular injuries within same nerve

Variable recovery and prognosis

Treatment based on pattern and degree of injury

a challenge for the surgeon

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Anatomy of the nervous system

Nerve injuries

Nerve repair options

Brachial plexus

Spinal nerves: pathways, classic lesions and compressions sites


1. direct repair

2. nerve graft:1. autograft= self donor

2. allograft=cadaveric tissue (acellularized matrix); ie Axogen

3. conduit= “bioartificial”

3. nerve transfer

4. (decompression occasionally used with grades 2+3)

Nerve Repair

Microscopic repair- typically epineurial

Grouped fascicular and fascicular: better alignment for fascicular match but extremely

time consuming and technically challenging• nervesurgery.wustl.edu

Nerve Repair/autografts

Potential donors and available lengths

○ Medial antebrachial cutaneous nerve(MABC): < 8cm

○ Sural nerve: up to 30cm

○ Posterior interosseous nerve: distal digital nerve < 2cm

Pros – non-immunogenic, bridge nerve gap

Cons - sensory loss, scarring, neuroma formation, second incision, limited supply, inferior to tension free primary repair

Nerve Repair/allografts

Cadaveric graft (ie: “Axogen”)

Frequently used in sensory repairs

Pros - readily accessible, unlimited supply, bridge nerve gap, avoids donor site morbidity,

Cons – potential side effects of host immunosuppression

Nerve Repair/conduits

biologic or synthetic “tube”

best for sensory repairs and gaps <3cm

Pros - Readily available, avoids donor site morbidity, bridges a nerve gap, barrier to scar tissue infiltration, may allow for accumulation of local neurotrophic factors

Cons - Variable outcomes, lack of scaffold and Schwann cells, limits its use to short nerve gaps

Nerve Repair/nerve transfer

recover motor or sensory function

“rob Peter to pay Paul”

nerve transfers allow a closer proximity of donor to recipient thereby decreasing distance and time for reinnervation and improving functional motor outcomes. (Fu SY, J Neuroscience 1995)

Nerve Repair/recovery

Nerve recovery after surgical repair in an uncomplicated case is

1-3 mm/day or an inch/month

faster proximally

Nerve Repair/post op care

protection after nerve repair 10 days of protection with orthosis following repair with NO tension 3+ weeks following repair under tension

Eur J Hand Surg 2012. A Comparison Between Complete Immobilisation and Protected Active Mobilisation in Sensory Nerve Recovery Following Isolated Nerve Injury Isolated digital nerve repair, n=46 Follow-up 18 mo No difference: RTW, cold intolerance, 2pd, temperature differentiation

prognostics for good result: distal injury age time of repair non smoker

Microsurgery. 2011 Jan;31(1):59-65. doi: 10.1002/micr.20820. Epub 2010 Dec 28. The effect of cigarette smoking on functional recovery followingperipheral nerve ischemia/reperfusion injury.Rinker B1, Fink BF, Barry NG, Fife JA, Milan ME, Stoker AR, Nelson PT

Order of Nerve Recovery; sensory

SENSORY RETURN

pain/temp----------------------

vibration 30 cps--------------

moving touch------------------

constant touch----------------

vibration 256 cps------------

touch localization------------

2 pt. discrimination----------

stereognosis------------------

TEST

sharp/dull, temp

tuning fork 30 cps

moving light touch

Semmes Weinstein

tuning fork 250 cps

touch localization

2 pt. discrimination

stereognosis

Evaluation of nerve recovery/ Motor r FunctionMMT EMG

Anatomy of the nervous system

Nerve injuries


Brachial plexus

Spinal nerves: pathways, classic lesions, and compression sites

Brachial plexus

Roots

Trunks

Divisions

Cords

Nerves

Brachial plexus/ key surrounding structures

Brachial Plexus: Roots

Location: behind anterior scalene

muscle

Direct Branches Dorsal scapular nerve C5

○ Rhomboid muscles○ Levator scapulae muscle

Long thoracic nerve C5,6,7○ Serratus anterior muscle

Long thoracic nerve

Dorsal scapular nerve

C5

C6

C7

C8

T1

Brachial Plexus: Roots

Dermatome specific skin areas supplied by a specific spinal nerve,

regardless of the cutaneous nerve that supplies that area (relates to sensation)

Typically crosses 2 or more joints

Myotome:represents motor function (weakness) C5- muscles above elbow except triceps C6- elbow region C7- muscles in mid forearm C8, T1- muscles of hand

Brachial Plexus: Roots /test myotomes

C4 resist shoulder shrug

C5 resist shoulder abduction

C6 resist elbow flexion

C7 resist wrist flexion

C8 resist thumb extension

T1 finger abduction & adduction

Dermatomes vs. Cutaneous InnervationSegmental Testing C5

Motor: DeltoidReflex: Biceps

Sensation: Lateral Arm

Segmental Testing C6Motor: biceps, wrist extensorsReflex: brachioradialis

Sensation: thumb (index finger)

Segmental Testing C7Motor: triceps, Wrist Flexors, Finger Ext Reflex: tricepsSensation: index/middle finger

Segmental Testing C8Motor: finger flexorsReflex: noneSensation: ring and small fingers

Segmental Testing T1Motor: InterosseiReflex: None

Sensation: Medial proximal forearm

Brachial Plexus: Trunks

SUPRACLAVICULAR: between lateral border of anterior scalene and clavicle

Upper Trunk C5,6

Middle Trunk C7

Lower Trunk C8,T1

Direct branches:

Subclavian nerve C5,6○ Subclavius m.

Suprascapular nerve C5,6○ Supraspinatus muscle○ Infraspinatus muscle

3 TRUNKS

C5

C6

C7

C8

T1

Brachial Plexus: Trunks/ trunk lesion

symptoms-segmental upper trunk lesion: proximal pain paresthesias

in C5,6 dermatome Lower trunk lesion: distal pain, paresthesias

medial arm, hand


Upper Trunk

Erb’s Palsy: “waiter’s tip posture”—IR, elbow extension, wrist/finger flexion

Lower Trunk

Klumpke’s Palsy: may imitate ulnar nerve lesion

Cervical Rib Syndrome

Thoracic Outlet Syndrome


Hint: wasting of Supraspinatus, Infraspinatus

Which nerve innervates SS, IS?

Where does it come off BP?

Also wasting of Deltoid (and TM)

Which nerve innervates deltoid & teres minor?

Where does this nerve come off the BP?

Where is this lesion occurring?

Brachial Plexus/ trunks/supraclavicularThoracic Outlet Syndrome

NEUROGENIC SYMPTOMS (95%):

Motor: weakness

Sensory: paresthesiasand numbness

Autonomic: hyperhidrosis, discoloration, burning pain

VASCULAR SYMPTOMS (5%):

Venous: distal edema, dull pain with a nonspecific distribution, sensation of heaviness, cyanosis

Arterial: fatigue; ischemia; coldness of distal extremity; Raynaud’s


Potential compression sites:1. Interscalene triangle: between

anterior and middle scalenes

2. Costoclavicular space: between 1st rib and clavicle

3. Subcoracoid space:

retro pectoralis minor


Differential diagnoses Cervical Radiculopathy Cubital Tunnel Syndrome, Carpal

Tunnel Syndrome Shoulder disorders i.e. Impingement or

rotator cuff tear Pancoast Tumor Brachial Neuritis Complex regional pain syndrome

Brachial Plexus: Divisions

Location: behind clavicleCause of lesion: clavicle fx

Anterior division:innervates volar structures

Posterior division:innervates dorsal structures

Direct branches: Lateral anterior thoracic nerve

C5,6,7 Pectoralis

DIVISIONS

Brachial Plexus/ Cords

Location Below clavicle, behind

pectoralis minor Named relative to axillary artery Lesions at cord level do not

cause segmental symptoms Motor and sensory deficits

follow the distribution of the affected peripheral nerve

LATERAL POSTERIOR MEDIAL

CORDS

Anatomy of the nervous systemNerve injuriesNerve repair optionsBrachial plexusSpinal nerves: pathways, classic lesions, and compression sites

lateral cord: c5,6,7 upper/mid trunks, anterior division

Musculocutaneous nerve C5,6,7

Biceps

Brachialis (along with radial nerve)

Corocobrachialis

Lateral root of Median nerve C5,6,7

Motor to all median nerve muscles except the intrinsics

The Lateral Cord gives rise to 2 nerves

Lateral portion of Median Nerve:� PT, FCR, PL, FDS(weak)

MusculocutaneousNerve:� Coracobrachialis

� Biceps

� Brachialis

lateral cord: musculocutaneous nerve C5,6

LABC innervation

Arises from lateral cord

Innervates biceps, brachialis(with radial) and corocobrachialis

Sensory branches to lateral forearm

Functional deficitBiceps atrophyWeak elbow flex in supDecreased sensation along

radial and volar aspects of forearm

Dermatomes vs. Cutaneous Innervation

Posterior Cord: all trunks, posterior division Posterior Cord

Posterior Cord

Upper subscapular nerve C5,6 Subscapularis muscle

Lower subscapular nerve C5,6 Teres major muscle

Axillary nerve C5,6○ Deltoid muscle, teres minor

Thoracodorsal nerve C6,7,8 Latissimus dorsi muscle

Radial nerve C5,6,7,8,T1 Triceps, BR, Anconeus, ECRL/B, Supinator, ECU, EDC,

EDM, APL, EPL, EPB, EIP

Posterior Cord: 5 nerves

Radial Nerve:Triceps, BR, Anconeus, ECRL/B,Supinator, ECU, EDC, EDM, APL, EPL, EPB, EIPAxillary Nerve:

Deltoid Teres minor

Thoracodorsal Nerve: Lattisimus Dorsi

Upper/Lower Subscapular Nerve: SubscapularisTeres Major

Posterior Cord: Axillary nerve Posterior Cord: Axillary nerve C5,6

Originates in ventral aspect of subscapularis

Passes laterally toward inferior shoulder joint just inferior to humeral head

Through quadrangular space Medial: humerus Lateral: long head of triceps Superior: teres minor Inferior: teres major

Wraps horizontally around post surgical neck of humerus

Enters deltoid

Posterior Cord: Axillary nerve C5,6

Innervates: deltoid and teres min

Sensation: lateral aspect of the upper arm/deltoid tuberosity area

Functional loss-shoulder Abd/ER/elevation, numbness of lateral upper arm

Possible causes of lesions: Shoulder dislocation Humeral neck fracture Serum/vaccine induced Brachial neuritis

Posterior Cord: Axillary nerve C5,6/injury

deltoid atrophy

Posterior Cord:Radial Nerve

Posterior Cord: Radial Nerve

Emerges between long and medial heads of triceps

Crosses under lateral head of triceps, pierces lateral intermuscularseptum, enters anterior compartment of arm

Diverges anterior to radial head in forearm

Posterior Cord: Radial Nerve

Cutaneous branches:

Posterior cutaneous of arm

Lower lateral cutaneous of arm

Posterior cutaneous of forearm

Motor innervation in upper arm:

Triceps

Anconeus

BR

ECRL

Brachialis (musculocutaneous)

Posterior Cord: Radial Nerve Bifurcates at anterior radial head

Superficial branch:Superficial Radial Sensory N. Descends forearm just medial to BR Cutaneous supply to dorsoradial hand

Deep branch: Posterior InterosseousNerve Supinator ECRB EDC EDM ECU EPL, EPB, APL EIP

Dermatomes vs. Cutaneous InnervationSuperficial RADIAL NERVE Sensory Innervation

Posterior cord/RADIAL NERVEPotential Sites of Compression

Radial Groove of Humerus

Lateral Intermuscular Septum

Fibrous Band betweenBR and Brachialis/ECRB

Leash of Henry

Arcade of Frohse

Supinator

Distal BR

Medial Cord: lower trunk, anterior division

Medial Cord

Medial anterior thoracic nerve C8,T1 Pectoralis minor muscle Pectoralis major muscle

Medial cutaneous nerve of arm C8,T1

Medial cutaneous nerve of forearm C8,T1

Ulnar nerve C8,T1

Medial root of median nerve C8,T1 Median intrinsics and cutaneous in the hand

Medial Cord

The Medial Cord gives rise to

three motor nerves

Medial Ant. Thoracic N.: Pectoralis Major/ Minor

Ulnar Nerve:FCU, FDP ¾, AddP, FPB,Lumbrical ¾Interossei, ADM,ODM,FDM

Medial Portion of the Median N.: FDS, FDP 1,2, FPL, PQ, APB, FPB, OP, Lumbricals 1,2

Medial and Lateral Cords c5,6,7,8/median nerve

Lateral root of median nerve from lateral cord

Medial root of median nerve from medial cord

Medial and Lateral Cords c5,6,7,8/median n

Arises from medial andlateral cords

Descends arm in medial neurovascular bundle withulnar nerve and brachial artery

Moves laterally to enter cubitalfossa and passes deep tobicipital aponeurosis

Exits cubital fossa between 2 heads of PT and fibrous FDSarch in forearm

Median nerve in the forearm Medial and Lateral Cords c5,6,7,8/median n

AIN (anterior interosseous n) branches off median nerve at approximately level of PT or FDS arch

Median nerve continues in deep position down forearm between FDS and FDP

MPC (median palmar cutaneous) branches from median at distal 1/3 of FA.

Median curves laterally at proximal wrist to be volar to FDS to cross into hand under TCL

Medial and Lateral Cords c5,6,7,8,T1 median n Median motor innervation:

PT FCR PL FDS FPB (superficial head) APB OP Lumbricals 1 + 2

AIN motor innervation: FPL PQ FDP to IF (MF)

Medial and Lateral Cords c5,6,7,8, T1 median n

Medial Cord/ MEDIAN NERVE Sensory Innervation

AREA OF SENSORY CHANGE DUE TO COMPRESSION AT THE CARPAL TUNNEL

AREA OF SENSORY CHANGE DUE TO COMPRESSION PROXIMAL TO THE CARPAL TUNNEL

Median Palmar Cutaneous (superficial palmar nerve)supplies skin of lateral hand and base of thenar eminence

Cutaneous branch supplies skin of lateral thumb, 2 1/2 digits volarlyand distal to the DIP joints dorsally

Dermatomes vs. Cutaneous Innervation

Medial and Lateral Cords c5,6,7,8, T1 median n

Causes of injury:

Lacerations of the arm, forearm, wrist, or hand

Prolonged compression

Ulnar dislocation

Fracture of elbow joint or distal radius

Toxic or infectious neuritis

MEDIAN NERVE/ Potential Sites of Compression

Ligament of Struthers (1% of population)

Lacertus Fibrosis/BicipitalAponeurosis

Pronator Teres

Flexor DigitorumSuperficialis

Transverse Carpal Ligament

Medial Cord/ Ulnar Nerve Medial Cord/ Ulnar Nerve Medial Cord/ Ulnar Nerve

Descends arm in medial neurovascular bundle with median nerve, brachial artery

At distal 1/3 of arm, passes through medial intermuscular septum into posterior compartment

Descends supracondylar area in fascial groove, crosses elbow posteriorly in condylar groove

Enters FA passing between medial epicondyle and olecranon then deep to FCU

Medial Cord/ Ulnar Nerve

Passes through entire FA deep to FCU

DCU,UPC branch off ulnar nerve about distal third of FA

At FCU attachment to pisiform, ulnar nerve passes lateral to pisiform and medial to hook of hamate

Ulnar nerve branches superficial (cutaneous) and deep (motor)within this canal (Guyon’s)

Medial Cord c8, T1 Ulnar Nerve

Motor innervation in FA: FCU FDP to RF/SF

Motor innervation in hand: ADM FDM ODM Palmar and Dorsal Interossei

(8) Lumbricals 3 & 4 Deep head of FPB ADd Pollicis

Medial Cord c8, T1 Ulnar Nerve

Cutaneous branch supplies skin of ulnar 1 1/2 digits volarly and distal to the PIP joints dorsally

Palmar Cutaneous Ulnar supplies skin of ulnar volar palm

Dorsal Cutaneous Ulnar supplies the skin of the dorso-medial hand

Medial Cord c8, T1/ Ulnar Nerve

AREA OF SENSORY CHANGE FROM LESION OF THE ULNAR NERVE DISTAL TO THE DORSAL CUTANEOUS BRANCH

AREA OF SENSORY CHANGE FROM LESION OF THE ULNAR NERVE DISTAL TO PALMAR CUTANEOUS BRANCH

Dermatomes vs. Cutaneous Innervation Ulnar Nerve/ Potential Sites of Compression

Arcade of Struthers

Medial Intermuscular Septum

Subluxing Medial Head Triceps

Cubital Tunnel

Osbourne’s band

Flexor Carpi Ulnaris

Guyon’s Canal

109

Ulnar Neuropathy SIGNS Ulnar nerve/Duchenne Sign

• RF/SF MCP hyperextension due to unchecked pull of extrinsic extensors and absence/weakness of intrinsic extension (lumbricals and interossei)

• IP joints flexion due to unopposed extrinsic flexors• FDP weakness with high ulnar nerve palsy diminishes

this posture

Claw deformity of thering and small finger

Low ulnar nerve palsy

Ulnar nerve/Andre Thomas Sign

Exaggeration of the claw deformity The unconscious attempt straighten fingers by flexing the wrist which results in the tenodesis effect on the extensors and thereby the increases claw deformity.

Ulnar nerve/Crossed Finger Sign

Weakness of the interossei limiting ability of the middle finger to fully cross the index finger

Compare with uninvolved side

Ulnar nerve/Egawa Sign

MF unable to ab/adduct when flexed at IP joints (hook fist position)

IP joint flexion limits ability of extrinsic extensors to aid ab/adduction

Ulnar nerve/Froment Sign

Pt asked to pull/resist piece of paper held between thumb and radial index finger

*With loss/weakness of Adductor Pollicis, Flexor DigitorumProfundus overcompensates with thumb IP joint flexion

Ulnar nerve/Jeanne’s Sign

Thumb MCP hyperextension in addition to IP joint

flexion

Observed during evaluation of Adductor Pollicis (paper

pull/resist test or resisted lateral pinch)

Ulnar nerve/Wartenberg Sign

Small finger posturing in abduction

Inability/weakness limiting SF adduction to RF

Ulnar nerve/Masse Sign

Intrinsic muscle wasting causing flattening of the hypothenar eminence and metacarpal arch

case

17 yr old cello player with right thumb pain

7 year hx of pain

R hand holds the bow

Pain increases with length of play

ReferencesBell Krotoski JA. Sensibility Testing: History, Instrumentation, and Clinical

Procedures in Rehabilitation of the Hand and Upper Extremity, 6th Edition. Skirven, Osterman, Fedorczyk, Amadio. Elsevier/Mosby: Philadelphia, PA 2011.

Boyd KU, Nimigan AS & MacKinnon SE. Nerve Reconstruction in the Hand and Upper Extremity. Clin Plast Surg. 2011 Oct; 38(4):643-60.

Callahan A. Sensibility Assessment For Nerve Lesions-In-Continuity and Nerve Lacerations in Rehabilitation of the Hand and Upper Extremity, 5th Edition. Hunter, Mackin, Callahan. Mosby: St. Louis, MO 2002.

Fox IK & MacKinnon SE. Adult Peripheral Nerve Disorders- Nerve Entrapment, Repair, Transfer and Brachial Plexus Disorders. Plast Reconstr Surg 2011 May; 127(5).

Giuffre JL, Kakar S, Bishop AT, Spinner RJ & Shin AY. Current Concepts of the Treatment of Adult Brachial Plexus Injuries. JHS 2010; 35A:678-688.

Henry FP, Farkhad RI, O’Shaughnessy M & O’Sullivan ST. A Comparison Between Complete Immobilisation an Protected Active Mobilization in Sensory Nerve Recovery Following Isolated Digital Nerve Injury. J Hand Surg Eur 2012 Jun; 37(5):422-6.

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References (cont) Hooper TL, Denton J, McGalliard MK, Brismee JM & Sizer PS. Thoracic Outlet Syndrome: a

controversial clinical condition. Part I: anatomy, and clinical examination/diagnosis. J Manual & Manipulative Therapy 2010 Jun; 18(2):74-83.

Kattan AE & Borschel GH. Anatomy of the Brachial Plexus. J Ped Rehab Med: An Interdisciplinary Approach 2011; 4:107-111.

Limthongthang R, Bachoura A, Songcharoen P & Osterman AL. Adult Brachial Plexus Injury Evaluation and Management. Orthop Clin N Am 2013; 44:591-603.

Novak CB & Mackinnon SE. Outcomes Following Conservative Management of Thoracic Outlet Syndrome. JHS 1995; 20(4):542-548.

Osterman AL & Lincoski C. Thoracic Outlet Syndrome in Rehabilitation of the Hand and Upper Extremity, 6th Edition. Skirven, Osterman, Fedorczyk, Amadio. Elsevier/Mosby: Philadelphia, PA 2011.

Pratt N. Anatomy of Nerve Entrapment Sites in the Upper Quarter. J Hand Ther 2005; 18:216-229.

Ray WZ, Mackinnon SE. Management of nerve gaps: Autografts, allografts, nerve transfers, and end-to-side neurorrhaphy. Experimental neurology. 2010;223(1):77-85. doi:10.1016/j.expneurol.2009.03.031.

Sheth RN & Campbell JN. Surgical Treatment of Thoracic Outlet Syndrome: A Randomized Trial Comparing Two Operations. J Neurosurg Spine 2005; 3(5):355-363.

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Documents

2018 HTRC St. Louis Brachial Plexus Kahn - asht.org · Hand Therapy Review Course Washington University St. Louis, MO April 27‐29, 2018 The Brachial Plexus: Innervation of the Upper