BPI and juvenile idiopathic arthritis Flashcards
The incidence rate of BPI (decreases/increases) with a c-section
decrease
What are the etiologies of BPI?
- traction and ROT of the head (injury to C5 -C6)
- congenital anomaly (cervical rib or abnormal thoracic vertebrae)
- traction of the shoulder
What are risk factors for BPI?
- maternal diabetes
- high birth weight (greater than 90th percentile)
- prolonged labor
- sedation
- shoulder dystocia
- Breech delivery
- complex c-section
Neurotmesis is a ____ rupture of a portion of the brachial plexus.
complete rupture
Has limited recovery; complete functional loss of affected nerve
What is axonotmesis?
Disruption of the inner elements of the brachial plexus
Has improved recovery compared to neurotmesis; gradual recovery
What is the mildest form of traumatic peripheral nerve injury?
Neurapraxia
Commonly has a full recovery; recovers as edema resolves
Brachial plexus injuries can hemmorhage into the ____ space.
subarachnoid space
Axons regrow by _ mm/day
1 mm
Recovery to the axons in the Upper arm normally takes how long?
4-6 months
can continue for up to 2 years
Recovery to the axons in the lower arm normally takes how long?
7-9 months
may continue for up to 4 years
What percentage of brachial plexus injuries do not fully recover?
approx. 35%
What is the most common brachial plexus injury? What nerve roots does it involve?
Erb’s Palsy (C5-C6)
What is observed within the UE when Erb’s palsy is present?
Shoulder: ADD, IR, EXT
Elbow: EXT
Forearm: PRON
Wrist/finger FLX
- Waiter’s tip position
- sensory loss
(true/false) Grasp is not intact if Erb’s Palsy is present
FALSE (it is present)
(true/false) Klumpke’s Palsy is common.
False
Rare condition that is only 2% of cases
What Nerve roots does nerve palsy include?
C7-T1
What is the presentation of Klumpke’s palsy?
- SUP
- Paralysis of wrist mm and intrinsic muscle of the hand
What is Erb-Klumpke Palsy?
Complete brachial plexus injury (C5-T1)
What is the presentation of Erb-Klumpke’s palsy?
- lack of sensation
- absent DTRs
- Asymmetric MORO response
Erb-Klumpke’s Palsy is typically (unilateral/bilateral) paralysis of an extremity
Unilateral paralysis
What is Horner’s syndrome?
Avulsion of T1 nerve
What can Horner’s syndrome result in?
- deficient sweating
- recession of eyeball(s)
- abnormal pupillary response
- myosis
- ptosis
- different color iris
myosis: reflex contraction of the sphincter muscle of the iris in response to a bright light (or certain drugs) causing the pupil to become smaller
What does damage to the phrenic nerve at C4 cause?
ipsilateral hemiparesis of the diaphragm
What is the presentation of a BPI affecting the phrenic nerve?
Presents as respiratory distress with an elevated chest on one side
What are secondary diagnoses/considerations for BPI?
- compensation with other muscles
- neglect the extremity
- contractures
- abnormal bone development
- torticollis
- Horner’s syndrome
- damage to the phrenic nerve
Contractures:
Scapular protraction
shoulder ABD, EXT, and IR
PRON
Wrist and finger FLX
What are the primary activity limitations with BPI?
- reaching
- grasping
- bilateral manipulation
What developmental screening tools would you use for children with BPI?
TIMP
AIMS (< 4 months)
What are rehab goals for children with BPI?
- support spontaneous recovery
- minimize pain
- prevent secondary impairments
- promote typical movement patterns and development
- increase PROM, strength, sensory awareness, and self-care
What is the prognosis of BPI?
3-25% chance of FULL recovery
How is prognosis determined in BPI cases?
Indicators within the first few weeks
Complete recovery is unlikely if no improvement is seen within the first 2 weeks
(true/false) Neurosurgery is useful for restoring full function in BPI cases
FALSE
Just some function
When does neurosurgery for BPI have the best outcome?
If done between 3-8 months
Surgeries to treat complete paralysis (Erb-Klumpke’s Palsy) should be done by 3 months
–> has better outcomes than adults
–> improved outcome in infants with total palsy
What are indications for neurosurgery in BPI patients?
- limited recovery
- lack of shoulder ER and forearm SUP
What is neurosurgery for BPI typically followed-up with?
Immobilization for 3 weeks and then PROM and AROM
JIA is a term that encompasses all forms of arthritis that begin before the age of ____ years, persist for longer than 6 weeks, and are of unknown cause
16 y/o
(true/false) There are definitive tests for diagnosis of JIA
FALSE
only clinical Dx and exclusion of other possible Dx
What must you rule out for a Dx of JIA?
- joint infection
- rheumatic diseases
- trauma
- malignancies
- systemic illnesses
- toxic synovitis
Once all other possible Dx are ruled out, JIA symptoms must persist for _ weeks before Dx
6 weeks
What must the patient present with for JIA dx?
arthritis
AND 2+ of the following:
- heat
- ROM limitations
- TTP with motion
What are the categories of JIA? Which one is more common?
- oligoarthritis*
- Rheumatoid-factor- positive polyarthritis
- Rheumatoid-factor-negative polyarthritis
- Systemic disease
RF(-) polyarthritis is more common than RF(+) polyarthritis
Oligoarthritis is common in what population?
Girls 2-4 y/o
How many joints are inflammed with oligoarthritis?
< 4
Common invovement: elbow, knee, ankle
What form of JIA develops iridocyclitis?
oligoarthritis
Iridocyclitis: inflammation of the iris
30% of cases and may be asymptomatic
(true/false) Those with oligoarthritis typically have systemic signs
FALSE
When does RF(+) polyarthritis present itself?
Peaks at 2-4 y/o and then again at 6-12 y/o
When does RF(-) polyarthritis present itself?
Late childhood or adolescence
How many joints does polyarthritis affect?
5+
Common joint involvement: TMJ, Cx spine, Elbows, Wrists, Knees, ankles
Polyarthritis presents with (mild/severe) systemic signs
mild
When does joint involvement occur with Systemic JIA?
After systemic onset
What are signs of possible systemic JIA?
- hepatosplenomegaly
- lymphadenopathy
- pleuritis
- pericarditis
Hepatosplenomegaly: enlargement of liver and spleen
Lymphadenopathy: swelling of the lymph nodes
pleuritis: inflammation of lung lining
pericarditis: inflammation of sac around the heart
What is required for systemic JIA?
- fever spikes 2x/day with return of normal for 2 weeks
- Rash
- joint involvement after systemic onset
What is the etiology of JIA?
unknown
considerations/theories: autoimmune, infection, trauma, genetics
What medications are used for medical management of JIA?
- NSAIDS
- DMARD
- glucocorticoids
methotrexate (DMARD) is the most common disease modifying agent – must monitor liver enzymes for possible toxicity
Glucocorticoids are potent and effective anti-inflamatories – side effects consist of cushing’s syndrome and growth retardation
What JIA factors cause poor articular and functional outcomes?
- hip involvement
- Polyarthritis w/in first year of disease
What form of JIA has the best prognosis for joint preservation and function?
Oligoarthritis
What are those with oligoarthritis at risk of forming?
- contractures
- degenerative arthritis
(True/false) RF(+) polyarthritis has good functional outcome
FALSE (persistent diesase)
Hip disease occurs in -% of those with JIA
30-50%
Signs:
- LLD
- pain in the groin, buttocks, medial thigh, knee
- gluteus medius limp (trendelenburg)
Hip disease of JIA is commonly caused by what?
Compensation for hip FLX contractures and increased lumbar lordosis
