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Section 2: Upper Limb
Figure 4
(B). (Courtesy of Rickard Brånemark, MD, PhD, and Stewe Jonsson, CPO, Gothenburg, Sweden.)
the MCP joint is recommended when
the involved digit is at the level of the
proximal phalanx or when the middle
phalanx remains but has inadequate
length. A full-finger prosthesis also can
be used with a more distal level of amputation for activities that will generate
substantial forces because the additional
length increases leverage, providing better resistance to these forces. In either
case, the termination, or transition of a
full-finger prosthesis occurs at the base
of the proximal phalanx or MCP joint. A
ring can be used to enhance the attachment and minimize the transition line.
For distal fingertip amputations in
which part of the nail/nail bed remains
or the amputation is just at the base of
the nail, a half-finger prosthesis is indicated. Because of the space requirements
of the mounting mechanism, using an
acrylic nail is often impossible; a silicone
nail can be used instead. The disadvantages associated with silicone nails are
that they cannot be painted and cannot
be extended beyond the length of the
fingertip.
Thumb Prostheses
Thumb prostheses present unique challenges because of the mobility and stability required of the prosthesis.6 Given
the presence of soft tissue in the web
space between the thumb and index finger and the wide range of motion and
substantial force generated during prehension, a full-length prosthesis is generally indicated to maintain adequate
Photographs of an osseointegrated thumb prosthesis unattached (A) and attached
stability. For maximum stability, a
glove-type partial hand prosthesis may
be preferable. Osseointegration can be
used effectively with a proximal thumb
amputation (Figure 4).
Internal Armatures
In partial or full hand restorations, a
semirigid internal armature can be incorporated into the fingers. The armatures stiffen the fingers and allow them
to flex, pre-positioning them for specific
tasks and providing additional functional capability. The armature adds a skeletal component to the flexible silicone
of the prosthesis. The armature is often
composed of braided stainless steel, but
other materials can be used, provided
they are durable enough to bend and
rebend without breaking. The increased
weight of the finished device with armatures is a consideration.
Partial Hand Prostheses
A partial hand prosthesis is indicated for
acquired or congenital conditions that
involve the total loss of one or more digits, either at the MCP joint or proximal
to the metacarpal region. Depending on
the presence of fingers or a thumb and
their length and range of motion, the
prosthesis is designed to maximize the
active and passive functional potential
of the involved hand and its appearance.
The intended uses considered during
the consultation phase of the process
determine the eventual design. For
passive silicone prostheses, proximal
termination of the silicone usually occurs at an area where a watch or bracelet can be worn to minimize evidence
of the transition to natural skin if it is
necessary or preferred. Design options
include exposing any residual digits that
may be unable to oppose and grasp or
containing them inside the prosthesis.
With the introduction of multiple
mechanically and electromechanically
powered fingers, active control of prosthetic finger position becomes possible
(Figure 5). If desired, silicone skin can
cover the plastic or metal digits to restore a natural appearance (Figure 6).
Full Hand Prostheses
Historically, the standard for aesthetic
restoration of a full hand absence was
a total silicone restoration (Figure 7, A
and B). Over the past decade, roll-on
suction liners with mechanical locking mechanisms have been used with
increasing frequency for passive allsilicone total hand restorations.
In recent years, externally powered
digits and multiarticulating total-hand
TDs have been introduced, and their use
is increasing. These prostheses can be
covered with thin, realistic-appearing
silicone skin and can duplicate more
characteristics of an intact human hand
(Figure 7, C).
Transradial Prostheses
For a patient with a unilateral nondominant arm amputation, a passive, functional aesthetic prosthesis can provide
adequate nongrasping function, acting
as a helper to the intact, dominant hand.
Alternatively, aesthetic restoration is still
possible when a mechanical or electromechanical hand is provided and covered with a custom silicone covering
(Figure 8). The same technological
innovations that changed the options
for individuals with partial and full
hand amputations also have expanded
the options for more proximal amputation levels. Smaller and more anatomically accurate shapes can now be
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
382
Chapter 31: Functional Aesthetic Prostheses: Upper Limb
Figure 5
chanical prosthesis with an aesthetic appearance that is not lifelike. (Courtesy of Touch
Bionics, Manseld, MA.)
Photograph of an electrome-
incorporated into powered multiarticulating TDs that can be covered with the
same type of custom silicone restoration
to approach a more balanced combination of function and form.
Transhumeral and More
Proximal Prostheses
A passive, transhumeral silicone prosthesis is often an acceptable option for
more proximal amputations. The realistic appearance combined with the
limited weight associated with this type
of device makes it a good alternative for
nondominant unilateral amputees. It is
not possible to cover a wrist, elbow, or
shoulder joint that articulates, whether
passively or otherwise, with silicone
without unnatural distortion of the
silicone occurring at the joint. Often,
the aesthetic skin is discontinuous or
terminated at the joint to minimize or
eliminate this negative attribute.
Bilateral Involvement
Active unilateral or bilateral grasp can
help individuals with bilateral upper
limb involvement achieve a higher level of independence and supersedes the
immediate need for aesthetic function.
For the bilateral amputee, functional
concerns outweigh aesthetic concerns
because of substantial physical impairment, but aesthetic concerns are still
Figure 6
right). (Courtesy of Pohlig, Traunstein, Germany.)
Photographs of a partial hand prosthesis (center) with lifelike coverings (left and
important to these patients and require
consideration.9 Referring these patients
to a rehabilitation team of physicians,
prosthetists, occupational therapists,
and psychotherapists who specialize
in the treatment of bilateral upper limb
amputation will help ensure the best
possible outcomes while addressing
aesthetic concerns.
Childhood limb loss, whether congenital or acquired, is emotionally important, and coping is challenging for both
the child and his or her family.22 A child
fitted with a prosthesis can appear more
like other children, which can start the
process of parental acceptance.
3,4,9,11
Prosthetic fitting at a young age can
also encourage children to use their
prostheses as they reach developmental milestones.
4
Often, the types of prostheses fitted
vary as children develop. Sometimes it
is easier for infants to learn to control
passive functional TDs. As children age,
some may do better with myoelectric
hands, whereas others prefer hooks or
cable hands. Although prosthetic hands
can limit children’s activities after they
begin school, they are often requested when children reach adolescence
(Figure 9).
Lower Limb Prostheses
Considerations
Aesthetic prostheses for lower limb
amputations are routinely provided, although less often than for upper limb
prosthesis users because of several factors, including the ability to more easily conceal lower limb prostheses under
clothing. In addition, materials used for
lifelike prostheses have a limited ability
to withstand the forces incurred during
ambulation, and the costs are relatively
high. When used, these restorations are
usually limited to toe and partial foot
devices.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
383
Section 2: Upper Limb
Figure 7
C, Photograph of an electromechanical full hand prosthesis with a highly customized silicone restoration. (Panels A and B courtesy of Alternative
Prosthetic Services, Bridgeport, CT. Panel C courtesy of Pohlig, Traunstein, Germany.)
Dorsal (A) and palmar (B) photographic views of a passive, functional full hand prosthesis with highly customized silicone restoration.
retain the device (Figure 11). As the
involvement progresses from distal to
more proximal levels of the foot, aesthetic prostheses require internal or supplemental structural components designed
to control unwanted foot movement, to
protect compromised tissue, and to distribute the ground reaction forces generated during walking. Such devices may
be called orthoses or prostheses because
the principles and materials typically
associated with orthotic treatment of intact limbs is applied in the management
of this population.23 The structural designs are covered with an aesthetic skin.
Syme, Transtibial, and
Transfemoral Prostheses
When limb loss involves the entire foot,
Figure 8
ized silicone restoration (B). (Courtesy of Touch Bionics, Manseld, MA.)
Photographs of an electromechanical hand uncovered (A) and with highly custom-
the functional characteristics of the
silicone prosthesis are limited to the
psychosocial benefits associated with
The definition of aesthetic is subjective for lower limb prostheses because
more amputees are comfortable showing
their devices in public. Colorful designs
on sockets, exposed hardware, and
other eye-catching features can make a
prosthesis more pleasing to some individuals (Fig u re 10).
Foot Prostheses
The functional requirements for toe,
partial foot, and foot amputations can
be largely cosmetic.23 A silicone aesthetic
prosthesis can help an individual with a
toe amputation while restoring normal
appearance, provided that the residual
toe has adequate length and shape to
normal appearance. In these cases, conventional prosthetic componentry is fitted and aligned. Silicone, vinyl, or other
coverings are manufactured and fitted
over the prosthesis. For transtibial prostheses, the covering terminates at the
proximal edges of the prosthetic socket.
For transfemoral prostheses, continuous
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
384
Chapter 31: Functional Aesthetic Prostheses: Upper Limb
Figure 9
(right) and the contralateral hand (left).
Photographs de pict palmar (A) and dorsa l (B) views of a congenital hand de ciency. C, Photograph of a customized sil icone restoration
covers distort during knee flexion and
inhibit knee function and safety. Therefore, these coverings are best applied
with termination at the knee joint or
made in a discontinuous manner. Mod
ifications to foot shape or footshell are
matched to the shape of the sound foot.
If a natural appearance is preferred, the
colors of the foot, leg, hair, and nails on
the sound side can be incorporated into
the prosthetic cover.
Enhancements
Nails
Fingernails and toenails that mimic
human nails can be made from either
a hard acrylic or softer, more flexible
silicone material. The most realistic appearance is achieved using hard acrylic,
which can be formed to match any nail
in shape, length, and color, and also can
be painted with nail polish. Silicone or
vinyl nails are soft and flexible, cannot be extended beyond the tip of the
finger, and should not be painted with
nail polish. Acrylic nails are most often
used in finger prostheses for which the
length of the residual finger is not an
issue and in most partial and full hand
passive functional restorations. For
electric or mechanical devices, it may
be more appropriate to exclude acryl-
-
ic nails, which can become dislodged
during strong grasping and/or impede
fine motor grasping.
Hair and Surface Embellishments
In an individual with moderate or dense
body hair, the appearance of the device
may not be acceptable without an attempt to reproduce the hair, even in instances in which the color, shape, and
texture of the prosthetic skin are a good
match. Hair matching is accomplished
by painting the illusion of hair into the
silicone or by applying synthetic or human hair in/onto the skin in a pattern
similar to that of the patient’s skin (Fig-
ure 12, A). Tattoos, freckles, age spots,
or prominent veining also can be added
(Figure 12, B).
Skin Color
Human skin constantly changes colors, sometimes subtly or dramatically,
and can be the result of external causes
Figure 10
ic leg cover with specic fashion and design.
(Courtesy of ALLELES Design Studio, Medicine
Hat, Canada, D. Monzon, 2011.)
Photograph shows a prosthet-
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
385
Section 2: Upper Limb
Figure 11
prosthesis with a highly customized silicone
restoration. (Courtesy of Ottobock, Austin, TX.)
Figure 13
of pigment stain to temporarily darken a prosthesis. (Courtesy of Touch Bionics, Manseld,
MA.)
Photograph of a partial foot
Photograph shows application
(such as sun tanning) or internal causes
(such as capillary dilation). Unlike human skin, silicone and vinyl are static.
When pigmented, these surfaces are
carefully matched to the colors of the
amputee’s skin at the time of painting;
once applied, they cannot easily be
changed. If an amputee’s skin darkens
substantially, the prosthesis may need
to be changed to maintain an acceptable
match. To address this, some providers make two devices that match the
lighter and darker shades typical of the
amputee’s color changes. Alternatively, a surface pigment to temporarily
Figure 12
B, Photograph of an upper limb prosthesis with tattoo application. (Courtesy of Alternative Prosthetic Services, Bridgeport, CT.)
darken the prosthetic skin can be applied (Figure 13).
Summary
No single prosthesis addresses the multiple deficits associated with upper limb
loss. Given this, the role of aesthetics
in prosthetic restoration should not be
underestimated, especially in individuals with upper limb loss. Educators,
case managers, and healthcare workers
treating this patient population increasingly understand that a false distinction
has been made between cosmetic and
functional prostheses. The concept that
a prosthesis that mimics a normal appearance is nonfunctional is obsolete.
When circumstances establish a sound
basis for the prescription and use of aesthetic prostheses, they should be provided either as primary prostheses or as
one of a combination of prostheses that
together address the cluster of functional
deficits experienced by the amputee.
A, Photograph of an upper limb prosthesis with hair, veining, and acrylic nails.
References
1. Kistenberg RS: Prosthetic choices
for people with leg and arm amputations. Phys Med Rehabil Clin N Am
2014;25(1):93-115. Medline DOI
2. Fraser CM: An evaluation of the
use made of cosmetic and functional prostheses by unilateral upper
limb amputees. Prosthet Orthot Int
1998;22(3):216-223. Medline
3. Hubbard S, Bush G, Naumann
S: Myoelectric prostheses for
the limb-decient child. PM R
1991;2:847-866.
4. Hubbard SA, Kurtz I, Heim W, et al:
Powered prosthetic intervention in
upper extremity deciency, in Herring JA, Birch JG, eds: e Child With
a Limb Deciency. Rosemont, IL,
American Academy of Orthopaedic
Surgeons, 1998, pp 417-431.
5. Kyberd PJ, Davey JJ, Dougall Morrison J: A survey of upper-limb prosthesis users in Oxfordshire. J Prosthet
Orthot 1998;10:85-91. DOI
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6. Michael JW, Buckner H: Options for
nger prostheses. J Prosthet Orthot
1994; 6(1):10-19.
7. Millstein SG, Heger H, Hunter GA:
Prosthetic use in adult upper limb
amputees: A comparison of the body
powered and electrically powered
prostheses. Prosthet Orthot Int
1986;10(1):27-34. Medline
8. O’Farrell DA, Montella BJ, Bahor JL,
Levin LS: Long-term follow-up of
50 Duke silicone prosthetic ngers.
J Hand Surg Br 1996;21(5):696-700.
Medline DOI
9. Pillet J, Mackin EJ: Aesthetic restoration, in Bowker JH, Michael JW,
eds: Atlas of Limb Prosthetics, ed 2. St
Louis, MO, Mosby Year Book, 1992,
pp 227-235.
10. Pilley MJ, Quinton DN: Digital prostheses for single nger amputations.
J Hand Surg Br 1999;24(5):539-541.
Medline DOI
11. Uellendahl JE, Riggo-Heelan J: Prosthetic management of the upper limb
decient child. Phys Med Rehabil Clin
N Am 2000;11:221-235.
12. van Lunteren A, van LunterenGerritsen GH, Stassen HG, Zuitho
MJ: A eld evaluation of arm
prostheses for unilateral amputees.
Prosthet Orthot Int 1983;7(3):141-151.
Medline
13. Passero T: Devising the prosthetic
prescription and typical examples. Phys Med Rehabil Clin N Am
2014;25(1):117-132 . Medline DOI
14. Burkhart A, Weitz J: Oncological
applications for silicone gel sheets
in so tissue contractures. Am
J Occup er 1990;45(5):460-462.
Medline DOI
15. Life-Like Laboratory: History. Available at: http://www.lifelikelab.com/
history.html. Accessed June 2, 2015.
16. Ohmori S: Eectiveness of silastic
sheet coverage in the treatment of
scar keloid (hypertrophic scar).
Aesthetic Plast Surg 1988;12:95-99.
Medline DOI
17. Quinn KJ: Silicone gel in scar
treatment. Burns Incl erm Inj
1987;13(suppl):S33-S40. DOI
18. Alison A, Mackinnon SE: Evaluation
of digital prostheses. J Hand Surg Am
1992;17(5):923-926. Medline DOI
19. Beasley RW, de Beze GM: Prosthetic
replacements for the thumb. Hand
Clin 1992;8(1):63-69. Medline
20. Manurangsee P, Isariyawut C,
Chatuthong V, Mekraksawanit S:
Osseointegrated nger prosthesis:
An alternative method for nger
reconstruction. J Hand Surg Am
2000;25(1):86-92. Medline DOI
21. Herring HW, Romerdale EH:
Prosthetic nger retention: A
new approach. Orthot Prostet
1983;37(2):28-30.
22. Kahle AL: Psychological issues in
pediatric limb deciency, in Bowker
JH, Michael JW, eds: Atlas of Limb
Prosthetics, ed 2. St Louis, MO, Mosby Year Book, 2004, pp 801-811.
23. Condie DN, Stills M: Prosthetic and
orthotic management, in Bowker
JH, Michael JW, eds: Atlas of Limb
Prosthetics: Surgical, Prosthetic, and
Rehabilitation Principles, ed 2. St
Louis, MO, Mosby-Year Book, 1992,
pp 403-412.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
387
Chapter 32
Brachial Plexus Injuries
Peter Charles Rhee, DO, MS Alexander Yong Shik Shin, MD
Abstract
Brachial plexus injuries can vary in the degree of neural damage and the potential for
nerve regeneration. orough serial physical examinations are necessary to monitor for
reinnervation. Imaging and electrodiagnostic studies can aid in the detection and characterization of brachial plexus injuries. If reinnervation is not possible because of the type of
brachial plexus injury (root avulsions), or functional recovery is not expected to occur prior
to irreversible motor end plate deterioration, or nerve regeneration is not exhibited aer
a period of observation of approximately 6 months, then brachial plexus exploration and
reconstruction is indicated. Secondary brachial plexus reconstruction is sometimes necessary to provide additional improvements in function aer index reconstructive attempts.
In select patients, amputation may be a viable surgical option to allow early prosthetic
tting. e decision to perform reconstruction versus amputation is complex and requires
a multidisciplinary and patient-centered approach.
Keywords: brachial plexus injuries; brachial plexus reconstruction;
free-functioning muscle transfer; nerve grafting; nerve transfers
Introduction
Brachial plexus injuries (BPIs) are devastating injuries that can result in longterm functional disability, psychologic
anguish, aesthetic issues, and chronic
pain. The annual incidence of traumatic
BPIs increases with greater participation
in extreme athletic activities, improved
patient survival after high-speed motor
vehicle crashes, and ballistic trauma.
Epidemiology
BPIs usually occur in males age 15
to 25 years.
traumatic BPIs occur in a motor vehicle crash, 70% of which are associated
with motorcycle or bicycle injuries.9 Of
those injured while operating a cycling
vehicle, 70% sustained polytraumatic
Dr. Shin has received royalties from Trimed; serves as a paid consultant to or is an employee of
LMT Orthopedics; has received research or institutional support from Bacterin; and serves as a
board member, owner, ocer, or committee member of the American Society for Surgery of the
Hand. Neither Dr. Rhee nor any immediate family member has received anything of value from or
has stock or stock options held in a commercial company or institution related directly or indirectly
to the subject of this chapter.
6-8
Approximately 70% of
injuries. Overall, 70% of patients sustained a supraclavicular BPI (root and
trunk level); of these, 70% had at least
one root avulsion. In the presence of a
root avulsion, 70% of patients had avulsions involving the lower roots (C7, C8,
T1); 70% of these patients had persistent
pain.9 Narakas9 termed these findings
the rule of “seven seventies,” based on
1-6
his observations of 1,068 patients with
BPIs over an 18-year period.
Traumatic BPIs can result from a
closed (traction, compression, or both)
or open (penetrating) mechanism of
injury. Closed BPIs are often the result
of traction on the plexus caused by a
forcible separation of the shoulder girdle from the head and neck, downward
traction on the arm, or abduction of the
9,10
arm away from the torso (Figure 1).
Other etiologies of closed injuries include tumors, irradiation, and compression.11 Open BPIs are usually the result
of penetrating injuries (gunshot or stab
wounds).
Pathoanatomy
Five cervical nerve roots coalesce to
form the brachial plexus, typically C5,
C6, C7, C8, and T1. Contributions from
C4 and T2 also have been described.12
In the presence of a C4 or T2 contribution, the brachial plexus is termed prefixed or postfixed, with an incidence of
28% to 62% and 16% to 73% in cadaver
specimens, respectively. The brachial
plexus has five sections: roots, trunks,
divisions, cords, and terminal branches
(Figure 2).
The dorsal and ventral nerve rootlets converge to form the spinal root as
it passes through the spinal foramen.
The cell bodies for motor nerves that
course within the ventral rootlets originate from the anterior horn cells of the
spinal cord. Conversely, the cell bodies
for the sensory nerves that travel within
the dorsal rootlets reside in the dorsal
root ganglion (DRG), which is protected within the spinal canal and foramen
(Figure 3, A).
The anatomic location of nerve injury
in relation to the DRG has prognostic
value. When the spinal rootlets are injured proximal to the DRG, a preganglionic injury has occurred (Figure 3,
B). Preganglionic BPIs can be further
differentiated into central avulsions in
which the rootlets are avulsed directly
off the spinal cord and intradural ruptures in which the rootlets rupture
proximal to the DRG. Injuries to the
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
389
Section 2: Upper Limb
Figure 1
sult in a closed, traumatic brachial plexus injury. The arrow represents the direction of the force
causing the ner ve avulsions and ruptures. (Cour tesy of the Mayo Foundation for M edical Education
and Research, Rochester, MN.)
Illustration depicts one common mechanism (a fall from a motorcycle) that can re-
brachial plexus distal to the DRG result
in postganglionic injury
10
(Figure 3, C
and D). Although the dorsal and ventral rootlets are both avulsed in most
cases, either rootlet can be avulsed in
isolation in as many as 10% of cases.
13-1 5
Distinguishing a preganglionic from a
postganglionic injury is imperative
because spontaneous recovery cannot
occur with a preganglionic BPI. In addition, the technique for brachial plexus
reconstruction is markedly different for
the two types of injuries.
The roots merge to form the upper
trunk (C5 and C6), middle trunk (C7),
and lower trunk (C8 and T1). The site
at which C5 and C6 unite (the point
of Erb) marks the location where the
suprascapular nerve emerges.10 The
Figure 2
cutaneous, TD = thoracodorsal, USS = upper subscapular. (Courtesy of the Mayo Foundation for Medical Education and Research, Rochester, MN.)
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
390
Illustration of the brachial plexus nerves. LSS = lower subscapular, MABC = medial antebrachial cutaneous, MBC = medial brachial
trunks divide into anterior and posterior divisions as the brachial plexus
passes beneath the clavicle (Figure 4).
The posterior divisions coalesce to form
the posterior cord; the anterior divisions
of the upper and middle trunk form the
lateral cord. The anterior division from
the lower trunk continues as the medial cord. The cords are named based
on their location relative to the axillary
artery (Figure 4).
Many terminal branches of the brachial plexus originate from the cords
(Figure 2). The lateral cord splits into
the musculocutaneous nerve and the
lateral cord contribution to the median
nerve. The medial cord parts to form
the ulnar nerve and the medial cord
contribution to the median nerve. The
posterior cord divides into the axillary
and radial nerves.
Terminal branches can arise in various sites within the brachial plexus. The
phrenic, dorsal scapular, and a contribution to the long thoracic nerve branches
off the C5 nerve root. The suprascapular
nerve and the nerve to the subclavius
muscle originate from the upper trunk.
The lateral pectoral nerve originates
from the lateral cord; the medial pectoral, medial brachial cutaneous, and
medial antebrachial cutaneous nerves
form from the medial cord. The thoracodorsal and upper and lower subscapular
nerves emerge from the posterior cord.
In addition to root avulsions causing BPIs, traumatic BPIs can occur
when the neural elements are stretched
or ruptured (Figure 3, C and D). Lesions that remain in continuity (stretch)
have the potential for spontaneous recovery based on the degree of neural
injury (neurapraxia or axonotmesis).11
A rupture (neurotmesis) of the neural
elements can occur at any site distal to
the DRG to the terminal branches. Ruptures most commonly occur at the root
or peripheral nerve levels.
BPIs can be described by the nerve
root level involved, by the location of
the injury, or in relation to the DRG.
Chapter 32: Brachial Plexus Injuries
Figure 3
Illustrations d epict avulsion (B), stretch (C), and rup ture (D) brachial plexus injuries . (Courtesy o f the
Mayo Foundation for Medical Education and Research, Rochester, MN.)
Figure 4
(Courtesy of the Mayo Foundation for Medical Education and Research, Rochester, MN.)
Common patterns of injury based on the
neural level involved include the upper
trunk, upper and middle trunk, lower
A, Illustration of spinal rootlets and the dorsal root ganglion within the spinal canal.
Illustration of the brachial plexus in relation to the clavicle and the axillary artery.
trunk, and panplexus (complete) BPIs. A
panplexus BPI affects all neural elements
of the brachial plexus with similar or
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
391
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