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Concept: Brachial plexus


A 46-year old male patient was admitted with a history of an extremely painful right upper arm, associated with unilateral clubbing. Duplex scanning and magnetic resonance imaging were suggestive of a pseudo-aneurysm of the brachial artery. Digital angiography showed an irregular brachial artery, associated with a small pseudo-aneurysm. The brachial artery was partially resected and reconstructed with a venous interposition graft. Pathological examination provided the final diagnosis of fibromuscular dysplasia. Although more encountered in women, this case report describes the occurrence of fibromuscular dysplasia in an unusual location in a male patient with a long-term follow-up.

Concepts: X-ray, Blood pressure, Medical imaging, Nuclear magnetic resonance, Magnetic resonance imaging, Humerus, Radiology, Brachial plexus


Complete brachial plexus avulsion injury is a severe disabling injury due to traction to the brachial plexus. Brachial plexus re-implantation is an emerging surgical technique for the management of complete brachial plexus avulsion injury.

Concepts: Surgery, Injuries, Injury, Amputation, Brachial plexus, Avulsion injury, Avulsion, Brachial plexus injury


Brachial plexus injuries can permanently impair hand function, yet present surgical reconstruction provides only poor results. Here, we present for the first time bionic reconstruction; a combined technique of selective nerve and muscle transfers, elective amputation, and prosthetic rehabilitation to regain hand function.

Concepts: Surgery, Injury, Amputation, Median nerve, Brachial plexus, Axillary artery, Plexus, Brachial plexus injury


The origin of the Papal Benediction Sign has been a source of controversy for many generations of medical students. The question has been whether the Papal Benediction Sign posture is the result of an injury to the median nerve or to the ulnar nerve. The increasingly popular use of online “chat rooms” and the vast quantities of information available on the internet has led to an increasing level of confusion. Looking in major anatomy texts, anatomy and board review books as well as numerous internet sites the answer remains unresolved. Through the analysis of functional anatomy of the hand, cultural and religious practices of the early centuries of the Common Era and church art a clear answer emerges. It will become apparent that this hand posture results from an ulnar neuropathy. Clin. Anat., 2015. © 2015 Wiley Periodicals, Inc.

Concepts: Ulnar nerve, Brachial plexus


Interscalene brachial plexus block (ISBPB) provides excellent analgesia after rotator cuff surgery but is associated with diaphragm dysfunction. In this study, ISBPB with 20 mL of 0.125% or 0.25% bupivacaine were compared to assess the effect on diaphragm function, oxygen saturation, pain control, opioid requirements, and patient satisfaction.

Concepts: Anesthesia, Opioid, Pain, Thoracic diaphragm, Pain management, Rotator cuff, Brachial plexus, Plexus


BACKGROUND: Since the 18th century, the existence of ulnar nerve innervation of the medial head of the triceps brachii muscle has been controversial. The evidence for or against such innervation has been based on macroscopic dissection, an unsuitable method for studying intraneural topography or intramuscular branching. The study of smaller specimens (embryos or fetuses) by means of serial histologic sections may resolve the controversy. QUESTIONS/PURPOSES: Using fetal specimens and histology we determined the contributions of the ulnar and radial nerves to innervation of the triceps brachii muscle. METHODS: We histologically examined 15 embryonic and fetal arms. Radial nerve branches obtained from six adult arms were analyzed immunohistochemically to determine motor fiber content. RESULTS: The medial head of the triceps brachii muscle was always innervated by the radial nerve (ulnar collateral branch). The branches seeming to leave the ulnar nerve at elbow level were the continuation of the radial nerve that had joined the ulnar nerve sheath via a connection in the axillary region. Immunohistochemistry revealed motor and nonmotor fibers in this radial nerve branch. CONCLUSIONS: A connection between the radial and ulnar nerves sometimes may exist, resulting in an apparent ulnar nerve origin of muscular branches to the medial head of the triceps, even though in all our specimens the fibers could be traced back to the radial nerve. CLINICAL RELEVANCE: Before performing or suggesting new muscle and nerve transpositions using this apparent ulnar innervation, the real origin should be confirmed to avoid failure.

Concepts: Muscle, Biceps brachii muscle, Triceps brachii muscle, Nerve, Ulnar nerve, Brachial plexus, Radial nerve, Radial sulcus


Restoration of stability and movements at the shoulder joint are the 2 most important goals in the management of brachial plexus injuries. The 2 nerves that are preferentially targeted for this purpose are the suprascapular (SSN) and the axillary (AXN) nerves. These nerve transfers have conventionally been performed by the anterior approach, but recently transfers performed by posterior incisions have been gaining popularity, by virtue of being selective and located close to the target muscles. Herein, we describe the technical details of spinal accessory nerve (SAN) to SSN and triceps branch to AXN for upper plexus injuries, both performed by the posterior approach.

Concepts: Cranial nerves, Brachial plexus, Suprascapular nerve, Trapezius muscle, Axillary nerve, Radial nerve, Accessory nerve


The authors described a modified pathological classification (PC) of brachial plexus injury (BPI) and its magnetic resonance (MR) imaging characteristics. The reliability and diagnostic accuracy of MR imaging for detecting nerve injury was discussed. Between 2006 and 2010, 86 patients with BPI were managed surgically in our department. Their preoperative MR images and surgical findings were analyzed retrospectively. The PC of BPI was classified into five types: (I) nerve root injury in continuity (including Sunderland grade I-IV injury); (II) postganglionic spinal nerve rupture with or without proximal stump; (III) preganglionic root injury (visible); (IV) preganglionic nerve root injury and postganglionic spinal nerves injury; (V) preganglionic root injury (invisible). The main MR imaging characteristics of BPI included traumatic meningocele, displacement of spinal cord, the absence of nerve root, “Black line” sign, nerve root/trunk injury in continuity, and thickening and edema of nerve root. The accuracy of MR imaging for detecting C5, C6, C7, C8, and T1 nerve roots injury were 93.3, 95.2, 92.3, 84, and 74.4%, respectively. The modified PC provides a detailed description of nerve root injury in BPI, and MR imaging technique is a reliable method for detecting nerve root injury.

Concepts: Nervous system, Spinal cord, Surgery, Magnetic resonance imaging, Reliability, Nerve, Spinal nerve, Brachial plexus


Scapular winging secondary to serratus anterior muscle palsy is a rare pathology. It is usually due to a lesion in the thoracic part of the long thoracic nerve following violent upper-limb stretching with compression on the nerve by the anterior branch of thoracodorsal artery at the “crow’s foot landmark” where the artery crosses in front of the nerve. Scapular winging causes upper-limb pain, fatigability or impotence. Diagnosis is clinical and management initially conservative. When functional treatment by physiotherapy fails to bring recovery within 6months and electromyography (EMG) shows increased distal latencies, neurolysis may be suggested. Muscle transfer and scapula-thoracic arthrodesis are considered as palliative treatments. We report a single-surgeon experience of nine open neurolyses of the thoracic part of the long thoracic nerve in eight patients. At 6months' follow-up, no patients showed continuing signs of winged scapula. Control EMG showed significant reduction in distal latency; Constant scores showed improvement, and VAS-assessed pain was considerably reduced. Neurolysis would thus seem to be the first-line surgical attitude of choice in case of compression confirmed on EMG. The present results would need to be confirmed in larger studies with longer follow-up, but this is made difficult by the rarity of this pathology. LEVEL OF EVIDENCE: III.

Concepts: Heart, Muscle, Electromyography, Brachial plexus, Scapula, Serratus anterior muscle, Winged scapula, Long thoracic nerve


: Children with obstetrical brachial plexus injury often develop an internal rotation and adduction contracture about the shoulder as a secondary deformity, resulting in an inability to externally rotate and abduct the shoulder. The Hoffer procedure is evaluated for its potential benefit in improving shoulder abduction and external rotation and its impact on activities of daily living.

Concepts: Shoulder, Deltoid muscle, Brachial plexus, Abduction, Adduction