Upper Limb - Brachial Plexus

Question 1

Brachial Plexus Examination

Answer 1

1. Observe
   Face - ?Horners
   Upper limbs (anterior/ sides/ posterior)
   - attitude
   - muscle wasting incl shoulders, arms, hands
   - scars/flaps
2. Feel
   Ask “any pain”
   Tinels - supraclavicular
   Dermatomal sensation
3. Move
   Stand behind pt
   - test TRAPEZIUS (“not part of brachial plexus but relevant re. reconstructive options”)
   - test RHOMBOIDS with Gerbers push-off
   Stand to side of pt
   - test SUPRASPINATUS - abduct arm from side / fingers above spine of scapula
   - test INFRASPINATUS - externally rotate arm with elbow flexed to 90 / fingers below spine of scapula
   - test DELTOID - abduct arm from 30 / fingers over ant/middle/post deltoid (but supraspinatus can also abduct beyond 30)
   Also retropulse shoulder at 90 with elbow flexed to 90
   - with arm still abducted test THORACOBRACHIAL PINCH - ask pt to adduct arm
   - feel LD (post axillary fold)
   - feel PEC MAJOR sternal head (ant axillary fold)
   - feel PEC MAJOR clavicular head (below clavicle)
   Move in front of pt and get them to hold my arm
   Elbow bent
   - test SERRATUS ANTERIOR - “push through my arm” / feel tip of scapula
   - test BICEPS - biceps curl mid prone with elbow flexed / feel biceps
   - test BRACHIORADIALIS - biceps curl mid prone with elbow extended / feel BR
   - test TRICEPS - extend elbow / feel triceps
   - test SUPINATOR/PRONATOR
   Elbow straight
   - test WRIST EXTENSION - “cock your wrist back” / feel tendons and observe for radial deviation
   - test FINGER EXTENSION
   - test EPL
   Turn hand over
   - test APB
   - test INTRINSICS - push against IF/LF
   - test FDS/FDP with gross composite flexion - fingers curled round mine
   - (test individually if needed)
   - test FPL
   - test WRIST EXTENSION - “bend your wrist up” / feel FCR, PL, FCR tendons

Question 2

What is Horners syndrome?

Answer 2

Horners syndrome is characterised by classic triad:

Ptosis - drooping of eyelid
Miosis - contracted pupil
Anhydrosis - localised lack of sweating on one side of the face V1 distribution)

Arises as a result of interruption of the sympathetic nerve supply which is responsible for innervatation to iris dilators and Muellers muscle. Fibres also travel with V1 branch of trigeminal which accounts for distribution of anhidrosis.

May also be assoc with apparent enopthalmus - caused by narrowing of palpebral fissure

Typically assoc with lower root pre-ganglionic plexus injury as sympathetic fibres exit spinal cord at T1 to enter the cervical sympathetic chain.