Brachial Plexus Injury

　　There are many causes of shoulder nerve injury, mainly the following several kinds:

　　1. Traction injury: such as injury caused by the upper limb being wrapped by a belt;

　　2. Collision injury: such as being hit by a fast car or being hit by flying stones on the shoulder;

　　3. Shoulder injury and shoulder nerve injury caused by incision or gunshot wounds.

　　4. Compression injury: such as clavicle fracture or compression of the shoulder clavicular region.

　　5. Birth injury: Shoulder nerve injury caused by abnormal fetal position during delivery or traction during labor.

　　Complications easily caused by shoulder nerve injury

　　1. Injury to the lateral bundle: Paralysis of the musculocutaneous, median nerve lateral root, and lateral胸前 nerves. The elbow joint cannot be flexed, or although it can be flexed (compensated by the brachioradialis), the biceps brachii is paralyzed; the forearm can be pronated but the pronator teres is paralyzed, the wrist joint can be flexed but the radial flexor carpi is paralyzed, and the other joints of the upper limb are still normal. There is sensory loss on the radial border of the forearm. The biceps brachii, the radial flexor carpi, the pronator teres, and the sternal part of the pectoralis major are paralyzed, and the movement of the shoulder and hand joints is still normal.

　　2. Injury to the medial bundle: Paralysis of the ulnar and median nerves' medial roots and the medial胸前 nerves. All the intrinsic muscles of the hand and the flexor muscle group of the forearm are paralyzed, the fingers cannot be flexed or extended, the thumb cannot be abducted掌侧, cannot be opposed or fingered, and the hand is functionless. The sensory loss of the ulnar side of the upper limb and the hand is absent. The hand presents with a flat hand and a claw hand deformity. The function of the shoulder and elbow joints is normal. The symptoms of injury to the medial bundle and the C8-T1 nerve root are similar, but the latter often has Horner's sign, and there is partial paralysis of the triceps brachii and the extensor muscle group of the forearm.

　　3. Damage to the posterior bundle: Paralysis of the axillary, radial, thoracodorsal, and subscapular nerves, as well as the deltoid, teres minor, extensor muscles, latissimus dorsi, subscapularis, and teres major muscles. The shoulder joint cannot be abduced, the upper arm cannot be internally rotated, the elbow and wrist joints cannot be extended, the metacarpophalangeal joints cannot be extended, the thumb cannot be extended and abducted radially, and there is sensory disturbance or loss in the lateral aspect of the shoulder, the dorsal aspect of the forearm, and the radial aspect of the hand.

　　Typical symptoms of brachial plexus injury include

　　1. Atrophy of the deltoid muscle, limitation of abduction of the shoulder joint. In cases of pure axillary nerve injury, the injury level is below the branch; in cases of combined radial nerve injury, the injury level is at the posterior bundle; in cases of combined musculocutaneous nerve injury, the injury level is at the upper trunk; in cases of combined median nerve injury, the injury level is at the C5 root.

　　2. Atrophy of the biceps brachii, flexion of the elbow joint is limited. In cases of pure musculocutaneous nerve injury, the injury level is below the branch; in cases of combined axillary nerve injury, the injury level is at the upper trunk; in cases of combined median nerve injury, the injury level is at the lateral bundle; in cases of combined radial nerve injury, the injury level is at the C6 nerve root.

　　3. Atrophy of the triceps brachii, brachioradialis, and wrist extensors, and extension of the thumb and fingers are atrophied and functionally limited. In cases of pure radial nerve injury, the injury level is below the branch; in cases of combined axillary nerve injury, the injury level is at the posterior bundle; in cases of combined musculocutaneous nerve injury, the injury level is at the C6 nerve root; in cases of combined median nerve injury, the injury level is at the C8 nerve root.

　　4. Atrophy of the flexor carpi ulnaris and flexor digitorum, atrophy of the thenar eminence, flexion and extension of the thumb and fingers are limited, and the function of opposition is limited, sensory disturbance occurs in the first to third fingers. In cases of pure median nerve injury, the injury level is below the branch; in cases of combined musculocutaneous nerve injury, the injury level is at the lateral bundle; in cases of combined radial nerve injury, the injury level is at the C8 nerve root; in cases of combined ulnar nerve injury, the injury level is at the lower trunk or lateral bundle.

　　5. Atrophy of the ulnar flexor muscle of the forearm, hypothenar muscle, intrinsic muscles of the hand including interosseous muscles and lumbricals, and adductor pollicis atrophy, fingers are adducted, abduction is limited, interphalangeal joints are extended, fine hand function is limited, and there is sensory disturbance in the fourth to fifth fingers. In cases of pure ulnar nerve injury, the injury level is below the branch; in cases of combined median nerve injury, the injury level is at the lower trunk or lateral bundle; in cases of combined radial nerve injury, the injury level is at the C1 nerve root.

　　Prevention of neonatal brachial plexus injury:

　　1. Proper estimation of fetal weightWhen the fetal head circumference is large, the shoulder circumference should be measured, and one should be vigilant about the occurrence of shoulder dystocia. Pregnant women with diabetes, tall stature, post-term pregnancy, or those who have delivered a macrosomic fetus should be vigilant. For non-diabetic pregnant women, if the estimated fetal weight is ≥4500g, and for diabetic pregnant women, if the estimated fetal weight is ≥4000g, cesarean section should be performed. Therefore, it is recommended to accurately estimate the fetal weight before delivery and carefully choose the mode of delivery when considering macrosomia.

　　2. Close observation of labor progressDuring pregnancy, diabetic fetal heads are small and shoulders are wide, which are prone to shoulder dystocia. In cases of non-macrosomic fetus with malpresentation and flattened inlet of the pelvis, the first and second stages of labor may be prolonged, especially when the second stage is prolonged or the presenting part is descending with obstruction, the incidence of shoulder dystocia increases. For prolonged second stage of labor, descending obstruction or slow descent of the presenting part, especially when the estimated fetal weight before delivery is >4000g, one should be vigilant about the occurrence of shoulder dystocia and relax the indications for cesarean section.

　　3. Proper handling of shoulder dystociaOnce shoulder dystocia occurs, it should be handled immediately to prevent severe asphyxia and death in newborns. Routine episiotomy and increasing the space for fetal delivery are recommended.

　　(1) Bend the thighs: The mother's legs are extremely bent close to the abdomen, holding the knees with both hands, reducing the obliquity of the pelvis, straightening the anterior凹 of the lumbar sacral area, and fully utilizing the posterior triangle.

　　(2) Press the anterior shoulder: Apply pressure downwards from the upper part of the pubic symphysis to the posterior direction, while the midwife pulls the fetal head;

　　(3) Rotate the shoulder: Insert the index and middle fingers into the vagina and press tightly against the posterior shoulder and back of the fetus, rotate the posterior shoulder upwards and laterally, rotate the fetal head in the same direction, and deliver the posterior shoulder when it rotates to the position of the anterior shoulder;

　　(4) Deliver the posterior shoulder after the arm: When it is difficult to deliver the anterior shoulder, choose to deliver the posterior shoulder first, which is very effective;

　　(5) Master the skills of臀位助产: After the fetus's trunk is delivered, assist in the inward retraction of the shoulders immediately, pull out the arms after the arms are delivered, pull the fetal head with moderate force, do not pull forcibly, appropriately relax the indications for cesarean section, and improve the quality of newborns with breech presentation.

　　Laboratory tests needed for shoulder nerve injury

　　1. Electrophysiological examination of the muscle electromyogram (EMG) and nerve conduction velocity (NCV) is of great reference value for determining whether there is nerve injury and the degree of injury. Generally, it is recommended to check sensory nerve action potential (SNAP) and somatosensory evoked potential (SEP) 3 weeks after the injury to help distinguish between pre-ganglionic and post-ganglionic injuries. In pre-ganglionic injury, SNAP is normal (the reason is that the sensory neuron cell bodies of the posterior root are located outside the spinal cord, and the injury occurs exactly near it, so there is no Wallerian degeneration in the pre-ganglionic sensory nerve, which can induce SNAP), and SEP disappears; in post-ganglionic injury, both SNAP and SEP disappear.

　　2. During imaging examination, CTM (Myelography combined with Computed Tomography) can show contrast medium extravasation into the interstitial spaces of surrounding tissues, tears in the dura mater sac, protrusion of the dura mater, and displacement of the spinal cord. Generally speaking, most of the protrusion of the dura mater indicates a tear of the nerve root, or although there is partial continuity of the nerve root, the internal injury is very serious and has extended to a very close plane, often suggesting that there is sufficient force to cause a tear of the arachnoid membrane. Similarly, MRI (Magnetic Resonance Imaging) can not only show the tear of the nerve root but also simultaneously show the associated dura mater protrusion, leakage of cerebrospinal fluid, spinal cord hemorrhage, edema, and so on. Hematomas are hyperintense in T1WI and T2WI, and edema appears as hyperintense in T2WI and hypointense in T1WI. MRI water imaging technology is more clear in showing the subarachnoid space and leakage of cerebrospinal fluid, at this time, water (cerebrospinal fluid) is hyperintense while other tissue structures are hypointense.

　　Dietary taboos for patients with shoulder nerve injury

　　One, light and nutritious food, such as Longan and Jujube Soup, lean meat, eggs, fish, and so on, because such patients often have insufficient Yin and blood; for those who are overweight, it is advisable to have light meals, eat more fresh vegetables and fruits, such as celery, sprouts, cucumbers, bananas, oranges, and so on.

　　Two, eat more oatmeal: Regular consumption of oatmeal can improve the overall condition of the nerves. After chopping the oat straw and soaking it in warm water for 2 minutes and filtering it, it becomes a health supplement. It is recommended to drink 1-4 grams a day. To alleviate skin itching, wrap oatmeal pieces in fine cotton cloth and hang them under the showerhead, then bathe with the water passed through the oatmeal. This article is from Healthy Central Plains.

　　III. It is necessary to eat foods rich in choline and vitamin B12, such as soy products, eggs, peanuts, walnuts, fish, meat, oatmeal, millet, seaweed, red soy sauce, stinky bean curd, Chinese cabbage, and radish, etc. Because acetylcholine has the effect of enhancing memory, and acetylcholine is all synthesized from choline. Therefore, it is necessary to eat more foods rich in choline.

　　IV. Drink more water, eat more fruits and vegetables: Patients should take in more water and avoid stimulants such as coffee, soda, and cigarettes. Eat more fruits, vegetables, nuts, seeds, grains, and other beneficial foods.

　　Conventional methods of Western medicine for the treatment of shoulder nerve injury

　　1. Protection of sensory loss: For the root injury of C5-7, although the function of the hand is basically present, there is a sensory impairment in the thumb and index finger, which also has a certain impact on the fine function of the hand. For the root injury of C8 and T1, although the sensory function of the thumb and index finger is basically present, the function of the hand is basically lost, and the sensation of 4-5 fingers also disappears, which is prone to further injury such as injury or scalding. It is difficult to repair the skin injury after the denervation of the skin, so it is necessary to protect the denervated skin, wear protective gloves, train the habit of touching the temperature of objects with the healthy hand, and frequently apply emollient skin care cream.

　　2. Treatment of pain: Although shoulder injury patients rarely have severe pain, once pain occurs, treatment is also difficult. This kind of pain is generally呈灼性痛, more common in patients with gunshot wounds and partial root avulsion injuries. The main method to relieve this kind of pain is to cut off part of the damaged nerve and nerve tumor and reconnect the nerve after removing the bullet from the nerve. Shoulder nerve block, cervical sympathetic ganglion block, surgical resection, and the application of acupuncture and various analgesic drugs can only temporarily relieve pain.

　　3. Prevention and treatment of swelling: After the shoulder injury patients lose the function of limb muscles, they also lose the function of squeezing and returning blood flow in the limb veins. Especially when the limbs are in a下垂 position and the joints are in an extremely屈曲 position, and there is scar contracture in the armpit, which aggravates the venous return obstruction of the limbs. Therefore, using a triangular bandage to suspend the limb, frequently performing passive muscle activities, and changing the joint position to relieve the scar contracture in the armpit (rehabilitation or surgical method) is the main method for preventing and treating limb swelling.