Brachial Plexus

Question 1

The brachial plexus is made up of spinal nerve roots…

Answer 1

C5, C6, C7, C8, T1

Question 2

Obstetric Brachial Plexus Injury (OBPI) usually occurs during…

Answer 2

A difficult vaginal delivery.

Question 3

Traction on the newborns shoulder during delivery can injure the…

Answer 3

Cervical roots, fracture the clavicle or humerus, or sublux the shoulder

Question 4

Forceful traction and rotation of the head during a vertex presentation to deliver the shoulder tends to injure the…

Answer 4

C5 and C6 nerve roots

Question 5

Associated damage to the phrenic nerve at C4 is less common yet will cause…

Answer 5

Ipsilateral Hemiparesis of the diaphragm

Question 6

Congenital anomalies such as cervical rib, abnormal thoracic vertebrae, or shortened scalenus anticus muscle can also cause pressure on…

Answer 6

The lower plexus

Question 7

BPI in Older Children

Answer 7

Result of a sports injury or other trauma

Question 8

Factors that increase Neonates risk of Obstetric Brachial Plexus injury

Answer 8

-Gestational weight over 8 pounds
-Breech presentation (transverse orientation rather than head down in pelvis) during delivery
-Use of forceps or evacuation pump to deliver the baby
(the dysfunction seen in the infant depends upon which nerves are stretched)

Question 9

Damage can occur at the level of the…

Answer 9

-Nerve rootlet attached to the spinal cord, the anterior or posterior rootlets, or distal to where the rootlets coalesce to form the mixed innerve root that exits the vertebral canal.

Question 10

Neurotmesis (BPI)

Answer 10

Complete rupture

Question 11

Axonotmesis (BPI)

Answer 11

Disruption of axons while neural sheath remain intact

Question 12

Neuropraxia (BPI)

Answer 12

Temporary nerve conduction block with intact axons

Question 13

Partial or complete rupture may evolve into a…

Answer 13

Neuroma and a mass of fibrous tissue is disorganized neurons on the proximal end attempt to reach their distal end.

Question 14

Hemorrhage into the subarachnoid space leads to…

Answer 14

Presence of blood in the cerebrospinal fluid, which can be diagnostic of this more serious injury.

Question 15

Recovery After Nerve Rupture

Answer 15

-Very limited

Question 16

Prognosis after Axonotmesis

Answer 16

• Better as the neurons reconnect more successfully through the intact neural sheath
• As axon regrowth proceeds at approx. 1 mm per day, the majority of recovery usually takes 4 to 6 months in the upper arm and 7 to 9 months in the lower arm.
• Continued recovery can occur for up to 2 years in the upper arm and 4 years in the lower arm.

Question 17

The two most common types of BPI are…

Answer 17

• Erbs Palsy (C5 and C6)

- Klumpkes Palsy (C7-T1)

Question 18

Appearance of Erbs Palsy

Answer 18

• “Waiters tip”

- Shoulder is in internal rotation and adduction, wrist is flexed, and the fingers are extended

Question 19

Appearance of Klumpke’s Palsy

Answer 19

Affects the muscles of the hand and the sensation of the medial arm
-The hand is held in a claw position of extension of the metacarpal phalangeal joints and flexion of distal, intra, and proximal phalangeal, thumb is in abduction

Question 20

Erb-Klumpke Palsy

Answer 20

Combination of the injury to the upper and lower roots (C5-T1) resulting in total arm paralysis and loss of sensation

• Involvement is usually unilateral but has been reported to be bilateral in 4% of cases
• The extent of the initial paralysis frequently recedes, with a total paralysis becoming limited to muscles innervated by the upper roots

Question 21

Horners Syndrome

Answer 21

• Usually a result of avulsion of T1 roots
• Can cause deficient sweating, recession of the eyeball, abnormal pupillary contraction, myosis, ptosis, and irises of different colors.
• Considered rare, eng and colleagues reported 8 of 15 infants w/ BPI had Horner’s syndrome.

Question 22

Prognosis for Complete Brachial Plexus Injury (C1-C6 and C7-T1)

Answer 22

-Poor prognosis with traditional therapy and should be referred to a neurosurgeon for possible reconstruction

Question 23

Prognosis for Erb’s Palsy

Answer 23

• Very good prognosis, if therapy is initated at birth
• The majority of infants have recovered tricep, bicep, deltoid, and wrist extensor by 6 months of age
• If significant improvement is not seen by 6 months of age, long-term disability is likely

Question 24

Treatment for Brachial Plexus Injury

Answer 24

• Successful outcome is dependent on treatment beginning at birth
• Family will ned info on arm positioning (arm not left hanging)
• Perception of pain is not present in involved arm (injury can occur without crying)
• Incorporating frequent ROM can help prevent contractures due to static positioning caused by muscle imbalances
• In initial period, activities that minimize the effects of gravity on the movement will be helpful.