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Chapter 12A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Special Considerations: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management

John W. Michael, M.Ed., C.P.O. 
James A. Nunley M.D. 

BASIC CONCEPTS

Brachial plexus lesions can result from a variety of causes including birth injuries, gunshot wounds, irradiation, and motor vehicle trauma. These injuries may be divided into open penetrating trauma and closed injuries. Closed injuries produce the majority of cases and may be the result of traction, compression, or traction and compression combined. Traction on the brachial plexus occurs when the head and neck are moved in a lateral direction away from the shoulder. Because the brachial plexus is tethered by the clavicle and scalene muscles, forceful neck motion to the side frequently produces a traction injury to the upper brachial plexus (C5-6). Traction to the brachial plexus may also occur because of arm movement; as the arm is brought up and over the head, traction will occur within the lower brachial plexus (C8-T1). Compression injuries to the brachial plexus occur between the clavicle above and the first rib below.

Narakus' "law of seven seventies," based on experience with more than 1,000 patients over an 18-year span, estimates the current demographics:

• 70% of traumatic brachial plexus injuries (BPIs) are due to motor vehicle accidents.
• 70% of the vehicle accidents involve motorcycles or bicycles.
• 70% of the cycle riders have associated multiple injuries.
• 70% have a supraclavicular lesion.
• 70% of those with supraclavicular lesions have at least one root avulsed.
• 70% of patients with root avulsions have the lower roots (C7, C8, Tl or C8, Tl) avulsed.
• 70% of patients with lower-root avulsions experience persistent pain.

It has been suggested that the increasing cost of gasoline results in a larger number of motorcycle riders while the proliferation of helmet laws increases the percentage who survive serious accidents with residual BPI.Most patients with BPI are males between 15 and 25 years of age.

Based on a thorough physical examination, BPI can be divided into preganglionic and postganglionic injuries. This division of injuries has both prognostic and therapeutic implications. Preganglionic injury indicates that avulsion of the nerve root has occurred proximal to the spinal ganglion; there is complete motor and sensory loss in the involved root, and there also will be denervation of the deep paraspinal muscles of the neck. There will be no Tinel sign present, and frequently the patient will have a Horner's syndrome or a fracture of the transverse process of the adjacent cervical vertebra. Postganglionic injuries occur distal to the spinal ganglia and have a more favorable prognosis than do preganglionic injuries both for spontaneous recovery as well as for surgical reconstruction. Postganglionic injuries may be further subdivided into trunk and cord injuries.

Treatment recommendations for complete lesions have varied widely over the past 50 years; no one approach has enjoyed widespread success. Following World War II, the standard approach was surgical reconstruction by shoulder fusion, elbow bone block, and finger tenodesis. In the 1960s, transhumeral (above-elbow) amputation combined with shoulder fusion in slight abduction and flexion was advocated. The classic paper of Yeoman and Seddon noted the tendency to become "one-handed" within 2 years of injury, which led to a dramatic reduction in successful outcomes regardless of the treatment approach. Their retrospective study revealed no "good" results from the primitive surgical reconstruction of that era but predominantly "good" and "fair" outcomes when amputation plus shoulder fusion were performed within 24 months of injury.

Yeoman and Seddon also noted that the loss of gleno-humeral motion caused by BPI limited the effectiveness of body-powered devices and that manual laborers seemed to accept hook prostheses much more readily than did office workers with similar injuries. These observations remain valid today.

CURRENT CONCEPTS

Surgery is indicated in nearly every BPI if spontaneous recovery is not expected within a reasonable time interval. Surgical reconstruction of preganglionic lesions will be discussed separately from postganglionic lesions.

NERVE SURGERY

Preganglionic

Depending on the number of roots that have been avulsed, preganglionic BPI generally falls into one of three categories:

1. A completely flail arm with avulsion of all roots (C5-T1)
2. A lower avulsion of the C8-T1 roots
3. An upper lesion in which only the C5 and C6 roots have been avulsed

Typically, patients with upper lesions and C5 and C6 root avulsion will have no shoulder function or elbow flexion. There will be finger and wrist extension and hand function. In these patients, the goal of surgical reconstruction would be first to re-establish elbow flexion and then to address shoulder stability. Preganglionic nerve root avulsions are not amenable to direct nerve repair. Tendon transfer procedures are ineffective; the classic pectoralis major transfer and the latissimus dorsi transfer are not possible with a C5-6 avulsion since these muscles are paralyzed. Transfer of the triceps muscle to achieve elbow flexion, while possible, is frequently ineffective since the triceps is usually weak. Transposition of the medial epicondyle from the elbow with the common head of the flexor pronator muscle group to the humeral shaft is certainly a possibility; however, this tendon transfer works best when the patient has some small amount of active elbow flexion present prior to the transfer. A Steindler (flexor-pronator) transfer alone in the case of a completely paralyzed shoulder and paralyzed biceps and brachialis is generally unsatisfactory.

Our preference for reconstruction of the important function of elbow flexion is through neurotization with intercostal motor nerves. Through a lateral fourth-rib thoracotomy the motor portion of the third, fourth, and fifth intercostal nerves may be transferred subcutane-ously into the axilla to be anastomosed to the musculocutaneous nerve (Fig 12A-1.). This yields an excellent reconstruction of elbow flexion if performed within 12 months of injury (Fig 12A-2.). Our best results have been where the neurotization is performed within 6 months of injury.

If the interval from BPI to reconstruction is delayed beyond 12 months, the results of surgical reconstruction with the intercostal nerves alone have been poor. These poor results have usually been attributed to fibrosis of the motor end plates of the biceps muscle. Under these circumstances, a free innervated gracilis muscle has been used quite successfully to replace the biceps (Fig 12A-3.). The gracilis is harvested on its neurovascular pedicle with the obturator nerve, artery, and vein. The fibrotic and denervated biceps muscle is excised and the gracilis muscle inserted in its place. Attachment is made proximally with the gracilis origin to the coracoid process and distally to the biceps tendon. After successful vascular anastomosis of the artery and vein, through an ipsilateral thoracotomy, intercostal motor nerves to the third, fourth, and fifth ribs are used to successfully reinnervate the gracilis. Results of this procedure have been particularly gratifying in young patients (Fig 12A-4.).

Postganglionic

Postganglionic lesions frequently involve nerve injuries that are directly reconstructible. It has been our practice to follow patients conservatively for up to 3 months to watch for spontaneous motor recovery. In upper-plexus injuries, if the biceps muscle has not recovered within 3 months, then surgical exploration of the brachial plexus is indicated. If spontaneous recovery occurs, then the patient is monitored until the recovery plateaus, at which point a decision is made as to whether exploration or other reconstruction is indicated. Exploration of postganglionic lesions will frequently show combined injuries in which a neuroma in continuity can be identified along with a complete nerve rupture. By using the operating microscope, it is possible to surgically separate intact fascicles from damaged fascicles at a very proximal level.

If complete transection of the brachial plexus has occurred, the results of nerve grafting for upper-trunk lesions have been reasonable. Following nerve grafting for lower-trunk injury, useful motor function is obtained in a lesser percentage of patients primarily because of the long distance required for muscle reinner-vation to occur. If exploration reveals a lesion of the lower brachial plexus (C8 to Tl) that can be re-established with nerve grafting, nerve grafting should certainly be performed; however, a later tendon transfer may still be required.

RECONSTRUCTIVE PROCEDURES

Shoulder

To be able to use the hand successfully, the patient's shoulder must be stable to allow positioning of the hand and forearm in space. In the majority of BPIs, insufficient muscles remain for successful tendon transfer about the shoulder. In the upper BPI in which rotator cuff, deltoid, and biceps function have been lost, tendon transfer of the trapezius and the levator scapulaehas been tried. Although the shoulder will no longer interiorly subluxate, active function in forward flexion and abduction is not generally possible. Thus, the majority of these patients should benefit from shoulder fusion.

Shoulder fusion works best when scapular control has been preserved through the function of the serratus anterior and the trapezius muscles. Occupation is also a factor; employment as a manual laborer suggests consideration of shoulder fusion. However, it should be emphasized that many patients are best served by leaving the shoulder in its flail condition if (1) they do not have pain from chronic traction and (2) their occupation makes a mobile flail shoulder more cosmetically acceptable than a fused shoulder.

Elbow

Restoration of elbow flexion is of primary importance for all patients with BPI. Even if the patient has a flail and completely anesthetic arm, restoration of active elbow flexion will allow the patient to have a transradial (below elbow) amputation. The transradial prosthesis, combined with voluntary elbow flexion, is certainly easier to use and better tolerated than a transhumeral prosthesis.

Elbow flexion can be restored by intercostal neurotization or tendon transfer. When the pectoralis major and latissimus dorsi are available for transfer, superior results can be anticipated. The Steindler (flexor-pronator) transfer is only utilized when the patient has weak, but present elbow flexors.

CLINICAL PATTERNS

It is possible to summarize the functional deficits associated with particular lesions to simplify our understanding in this area. However, normal anatomic variations frequently result in clinical findings that differ from these theoretical types. The clinical picture is further complicated since many lesions are incomplete or have been surgically repaired. Due to these limitations, careful assessment of residual function provides the best rationale for orthotic/prosthetic intervention.

C5-6 type results in complete loss of voluntary shoulder and elbow control, although many can still extend the wrist by using finger extensors and the extensor carpi ulnaris. Thumb and index finger sensation will be impaired. Several cases of successful orthotic design have been reported when a figure-of-8 harness and Bowden cable are used to provide body-powered elbow flexion, sometimes with an elbow hinge that can be locked in several positions. Shoulder subluxation is reportedly reduced by such an orthosis as well (Fig 12A-5.).

C5-7 type adds radial palsy to the above picture. Not only does the sensory loss in the hand increase, but all active extension at the wrist, hand, and fingers is lost as well. It is possible to add either static or spring-assisted wrist, hand, and finger extension to the previous orthosis (Fig 12A-6.).

C7-S, Tl type has good shoulder and elbow function but loses finger flexors, extensors, and intrinsics. Surgical reconstruction is often of particular value to this group. Those who sustain a concomitant traumatic transradial amputation should be able to operate a body-powered or switch-controlled terminal device. Loss of forearm innervation eliminates myoelectric control sites below the elbow.

C8, Tl type enjoys the greatest percentage of orthotic success since motor rather than sensory loss is significant. Although finger flexors and intrinsics are paralyzed, sensory loss is limited to the ring and small digits, which are not involved in pinch prehension.

The complete plexus type has the greatest loss. Not only is the arm totally flail and anesthetic, but chronic pain is frequently present as well. Virtually all authors agree that this group has the lowest long-term success rate regardless of treatment. When direct surgical reconstruction is not feasible, transhumeral amputation plus shoulder fusion is the most common recommendation in the literature.

PROSTHETIC OPTIONS

Transhumeral amputation plus shoulder fusion is still a viable approach to complete and untreatable plexus lesions, although many authors have noted that a significant percentage discard their prostheses over time. Leffert's excellent text notes that arthrodesis of the flail or weak shoulder is widely accepted because it is both predictable and uncomplicated. However, fusion increases the leverage on the scapula from the weight of the arm plus prosthesis/orthosis. Leffert suggests that trapezius and serratus anterior strength must be good (or preferably normal) in order to provide sufficient control; motion will be smoother if the levator scapulae and rhomboids are also functioning.

Rowe has noted that shoulder fusion attitudes originally intended for pediatric poliomyelitis survivors are not optimal for BPI. Fig 12A-7. illustrates Rowe's recommendations. Fusion in this attitude permits scapular motion, when combined with elbow motion, to allow the patient to reach all four major functional areas: face, midline, perineum, and rear trouser pocket.

Numerous harnessing variants have been developed to maximize the limited excursion remaining after BPI (See Chapter 6B). Although complicated harnessing may make donning or doffing the prosthesis independently more difficult, some patients find the body-powered components a good choice. Unlocking the elbow mechanism is often inconsistent due to limited shoulder movement, so a friction elbow or nudge control may be utilized (Fig 12A-8.).

With the widespread availability of externally powered components, limited body excursion is now less problematic. Microswitch control requires only a few millimeters of motion and can be utilized to operate an electric hand, an electric elbow, or both (Fig 12A-9.). Myoelectric control may also be feasible since even very weak muscles may generate sufficient signal to operate an externally powered device. It can be argued that myoelectric control for the terminal device is preferable for precise grasp (Fig 12A-10.). It may also be possible to utilize myoelectric control for both elbow and hand function (and perhaps for wrist rotation as well), but control sites will likely be on the chest or back (Fig 12A-11.). Advances in available prosthetic componentry have multiplied the options available for amputees with BPI and have increased the percentage who can actuate an active prosthesis. Whether this will result in increased long-term utilization remains to be documented.

In the presence of lesions that spare some elbow function, transradial amputation is sometimes performed. This may also be necessary due to the original trauma or because of vascular complications. Prosthetic fitting is often complicated by residual weakness at the shoulder or elbow. Dralle reported a case with good shoulder control and elbow flexors but no triceps function. When the amputee attempted to operate a body-powered hook, the force generated along the control cable forced the elbow into full flexion. It was necessary to utilize an outside locking joint normally intended for elbow disarticulation to stabilize the arm; difficulty in operating the lock was noted due to the triceps absence (Fig 12A-12.). Van Laere et al. reported a case complicated by complete absence of elbow and shoulder function. Following surgical arthrodesis of the shoulder, a switch-operated electric hand and passive friction elbow joints were incorporated into a prosthesis that the patient reportedly used for many daily activities (Fig 12A-13.).

Leffert has reported good success with transradial fittings provided that the amputee could sense elbow position:

It is all-important to attempt to preserve the elbow if there is proprioceptive feedback from the joint, since the usefulness and degree of acceptance of the prosthesis will be much enhanced by it. Even if the elbow is flail and the skin over the proposed stump is insensate, proprioception may be intact and a useful prosthetic fitting may be obtained without stump breakdown (Fig 12A-14.).

FLAIL ARM ORTHOSES

In view of the substantial percentage of BPI amputees who reject prosthetic devices, it has been argued that orthotic restoration is an equally plausible alternative. Wynn Parry has reported his experience with a series of over 200 cases and states that 70% continue to use a full-arm orthosis for work or hobby activities after 1 year.

Originally developed in London during the early 1960s, this device has recently become available in the United States. It consists of a series of modules that can be interconnected to provide any degree of control desired (Fig 12A-15.). For the completely flail arm, a body-powered prosthetic hook mounted adjacent to the patient's hand is used to provide grasp (Fig 12A-16.). In essence, the patient has a prosthesis over his flail arm. Incomplete lesions may require only the elbow or shoulder control modules.

REHABILITATION

Modern surgical advances have resulted in a much less predictable range of impairment following BPI, and the prosthetist-orthotist is now faced with a confusing array of residual functions. Muscle transfers sometimes result in powerful EMG signals suitable for myoelectric control in abberant anatomic locations. Nerve transfers further complicate the issue since anomalous neuroanatomy may preclude precise myoelectric control despite a grossly powerful signal. Finally, muscle fatigue is frequently overlooked and virtually impossible to predict. It is frustrating for all involved when the BPI survivor can operate a sophisticated device flawlessly in therapy or the clinic but does not use it at home long-term because the small mass of functioning remnant muscle becomes totally fatigued after 1 or 2 hours of work.

As a result of all these factors, a diagnostic prosthesis (see Chapter 8B) is strongly recommended (Fig 12A-17.) and an interdisciplinary team approach encouraged. A thorough physical examination including manual and EMG muscle testing is required to assess rehabilitation potential. Since BPI often has a lengthy recovery period, the majority will have become accustomed to functioning unilaterally, which can significantly reduce enthusiasm to master an adaptive device. It is therefore imperative that the patient be actively involved in all prescription decisions from the outset; without a motivated and cooperative individual, even heroic prosthetic/orthotic interventions are doomed to failure.

Wynn Parry recommends utilization of a full-arm orthosis during the recovery period, beginning as soon as the patient has come to terms with the serious and potentially permanent nature of his injuries. He also notes that fitting more than a year after injury is much less successful. Robinson has suggested 6 to 8 weeks postinjury as the optimal time for orthotic intervention, i.e., "when the patient is beginning to accept the implications of his injury and yet has not become too one-handed."

Once surgical reconstruction and spontaneous recovery are complete, amputation and trial with a prosthesis can be considered. The decision to choose amputation is always difficult; the opportunity to meet another BPI amputee who has successfully mastered a prosthesis may be helpful. Psychological and social work consultation may be useful to help the patient discuss the altered body image and employment possibilities that will follow amputation.

The presence of chronic pain complicates prosthetic-orthotic intervention. In those cases where humeral traction worsens the pain, special care must be taken to prevent the weight of the device from displacing the arm downward at the shoulder. This is often a difficult task since conventional prosthetic harnessing supports axial loads via pressure on the ipsilateral trapezius or by encumbering the contralateral shoulder; neither approach is ideal in the presence of BPI. One alternative is to unweight the arm with a strut along the axillary midline attached to a waist belt or to a well-molded pelvic hemigirdle. Cool from the Netherlands recently reported a clever approach using the weight of the paralyzed forearm acting across a fulcrum at the radial head level to literally lever the humerus back into the glenoid fossa (Fig 12A-18.). Although over 1,600 patients have been fitted in Europe, this approach is just now reaching North America.

In general, any device should be as lightweight as possible to minimize inferior shoulder subluxation. Since external power is often required, a trial with an appropriately weighted socket can help determine tolerance for the added weight of powered components.

LIMB FUNCTION PREREQUISITES

David Simpson has summarized the prerequisites for upper-limb function as follows:

• Proximal stability
• Placement in space
• Functional grasp

It is useful for both physician and prosthetist-orthotist to keep these principles in mind when evaluating the patient with BPI.

Proximal stability is absolutely essential for successful fitting. The shoulder girdle and elbow flexors must be strong enough to support the arm or arm remnant plus the orthotic/prosthetic device. If body-powered control is anticipated, they must also be able to resist the forces generated during cable actuation. This force typically varies between 2 kg (4.4 lb) and 10 kg (22 lb), depending on the grip strength desired at the terminal device (Fig 12A-19.).

When shoulder stability is marginal, a trial with exercises to improve muscular control may be warranted. Functional electric stimulation can also be helpful in strengthening residual musculature. In the absence of intrinsic stability, the prosthetic or orthotic device must stabilize the arm by extending well onto the torso. Many patients find this awkward or uncomfortable, although some will tolerate it (Fig 12A-20.).

Although Rorabeck has suggested transhumeral amputation without shoulder arthrodesis, an unstable shoulder will always compromise prosthetic function. Surgical stabilization is often the most practical approach despite requiring several weeks' immobilization for the bony fusion to occur. Malone et al. have suggested that postsurgical fitting with a prosthesis immediately following arthrodesis may be useful (Fig 12A-21.).

Elbow stability can be provided by a variety of locking mechanisms. Unfortunately, many orthoses require use of the uninvolved hand for unlocking. Wrist stability is readily achieved since orthoses that fix the hand in slight wrist extension are well known and well tolerated. Thumb and finger stabilization is determined individually by following accepted orthotic principles.

Placement in space is closely related to stability and is imperative to provide a useful work envelope and thereby allow the individual to reach above, below, in front of, and behind the body. In cases where residual shoulder musculature can steady the arm but not support its weight when reaching out, the utility of the prosthetic/orthotic device is severely compromised. Orthotic control of the shoulder is cumbersome and requires extensions onto the torso, as noted previously. Again, surgical stabilization via fusion may be preferable.

Elbow placement is more readily provided, usually by Bowden cable harnessing adapted from transhum-eral prosthetic principles (see Chapter 6B). Because the weight of the arm/orthosis/prosthesis provides a reliable extension moment, a locking mechanism is not always required. A flexion moment generated by bicapular shoulder abduction, for example, can be readily controlled by the patient to precisely counterbalance the extension forces due to gravity. This is particularly effective when weak elbow flexors are present but shoulder stability is good. Springs or elastics can also be used to help counterbalance the weight of the forearm (Fig 12A-22.).

Functional grasp is readily restored in a variety of ways. Body-powered hooks of the voluntary-opening type are the traditional approach and are often effective. In addition to being lightweight and durable, they provide a constant, limited pinch force without continued exertion by the patient. Electric hands or hooks are increasingly common and offer powerful grip forces with minimal exertion. Switch control is utilized when necessary, but myoelectric control is often more precise, provided that suitable muscle sites can be found.

Sophisticated orthoses can also restore grasp to the paralyzed hand by using mechanical or external power. Most are variations of the "wrist-driven" styles originally developed for quadriplegics (Fig 12A-23.). Other approaches include mounting a prosthetic hook near the palm of the paralyzed hand and the use of adaptive utensil cuffs for various specific activities.

Mastery of any prosthetic/orthotic device is contingent upon its effectiveness in augmenting functional activities. Actively including the BPI individual in the decision-making process, particularly in the choice of specific componentry and design options, increases the success rate. One key to long-term utilization is to identify specific tasks important to the individual that will be facilitated by using the device.

A major limitation of all current prosthetic/orthotic grasp modalities is the absence of sensation, which requires close attention to visual cues by the user. As Simpson has noted, when control of the arm becomes the main task, the rate of rejection increases significantly. The difficulties involved in using the insensate "blind" hand are well documented. The alternative of teaching the individual with BPI one-handed independence should always be carefully considered.

SUMMARY

Despite recent surgical advances, BPI presents one of the greatest challenges to the rehabilitation team. Providing grasp is only the first step and is often the easiest to accomplish. Practical restoration of the ability to place the arm in space can be difficult, while provision of external shoulder stability is cumbersome at best. Surgical stabilization by shoulder fusion should always be carefully considered if functional use of the limb is desired.

Residual neuromuscular deficits make fitting the BPI amputee a complicated undertaking. The use of a diagnostic prosthesis prior to determination of the final prescription is highly recommended due to the complexity of interrelated factors.

The longer the time lapse between injury and functional use of the arm, the greater the likelihood of a poor result. Early provision of a flail arm orthosis may be useful to encourage two-handed activities during the recovery phase. Timely surgical intervention should enhance residual function.

Leffert has emphasized the importance of educating BPI survivors considering prosthetic fitting about what is realistically possible.

Patients often come with totally unrealistic ideas of "bionic arms" such as are seen on television. Unless they are disabused of such fantasies, they are unlikely to be satisfied with their results. . . . Whenever possible, patients with brachial plexus injuries contemplating amputation should have the opportunity to see and talk with other patients who have already undergone the procedure.

The ideal environment to manage BPI is a multidisci-plinary clinic specializing in this most challenging problem. Despite recent advances in both surgical and pros-thetic-orthotic technique, many individuals with BPI will find that the functional capabilities of the affected limb remain significantly limited.

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Chapter 12A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

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