Brachial Plexus Injury

Question 1

What is brachial plexus injury?

Answer 1

an injury to one or more of the spinal nerves in the UE

Question 2

OBPI

Answer 2

obstetrical brachial plexus injury

Question 3

Erb’s Palsy

Answer 3

○ Most common BPI
○ Involves damage to the spinal nerve C5 to C6 and possibly C7

Question 4

Erb’s palsy results in

Answer 4

Paralysis or weakness in the shoulder muscles, the elbow flexors, and the forearm
supinators (waiter’s tip)

Question 5

Klumpke’s Palsy

Answer 5

Avulsion of the lower spinal roots, C8-T1, pure lower root injuries are rare

Question 6

Klumpke’s palsy results in:

Answer 6

■ Weakness of triceps, forearm pronators, and wrist flexors
■ “Claw-like” paralysis of the hand
■ Horner’s syndrome may be present

Question 7

Erb-Klumpke

Answer 7

○ second most common OBPI ○ injury to the complete plexus – C5-T1

Question 8

Erb-Klumpke Results in:

Answer 8

■ Total sensory and motor deficits of the entire upper extremity
■ Flail, paralyzed, areflexic arm with no sensation

Question 9

Prevalence

Answer 9

• vertex presentation with shoulder dystocia accounts for most OBPI cases
• R > L

Question 10

Etiology

Answer 10

● Shoulder dystocia
● Large birth weight
● Breech delivery
● Diabetes in pregnancy
● Maternal small stature/small pelvis
● Prolonged second stage of labor
● Multiple fetuses
● Use of forceps/vacuum to deliver

Question 11

Types of BPI - Avulsion

Answer 11

Complete tear at proximal root

Question 12

Types of BPI - Rupture

Answer 12

more distal on the nerve

Question 13

Types of BPI - neuroma

Answer 13

scar tissue

Question 14

types of BPI - Neuropraxia or stretch

Answer 14

just stretched
good recovery

Question 15

Pathophysiology

Answer 15

● OBPI results from excessive lateral traction on the head away from the shoulder during
delivery
● Spontaneous recovery occurs with remyelination and reinnervation of sensory
receptors and/or muscle endplates
● Neonate more susceptible to nerve injury than older child

Question 16

Narakas Classification - Group 1

Answer 16

C5,6: paralysis of shoulder, absent elbow flexion – spontaneous recovery in >80%.

Question 17

Narakas Classification - Group 2

Answer 17

C5,6,7: As above with wrist drop – good hand, good shoulder and elbow in 60%

Question 18

Narakas Classification - Group 3

Answer 18

All: complete paralysis – good hand in most, good shoulder and elbow in 30–50%

Question 19

Narakas Classification - Group 4

Answer 19

All: complete paralysis, Horner sign, limb atonic – full recovery very unlikely

Question 20

Diagnosis

Answer 20

● Typically first noticed by nurse or neonatologist
● Neonate should be examined in supine: movements, primitive reflexes, sensory, function, face and scalp presentation, respiratory status
● Confirmed through diagnostic tests

Question 21

Diagnostic Tests

Answer 21

● X-rays – clavicle and humerus
● Ultrasound
● EMG/NCS – 4 weeks of age
● CT scan with contrast-older child
● MRI – older child

Question 22

PT Examination

Answer 22

• AROM/PROM
• Strength and motor function
• sensation: sensory grading system
• Development: symmetry of reflexes

Question 23

Strength and motor function testing

Answer 23

• toronto active movement scale
• Mallet’s Classification of function
• Raimondi score for hand function

Question 24

Sensory grading system for children with BPI

Answer 24

S0 – no reaction to painful or other stimuli
S1 – reaction to painful stimuli, none to touch
S2 – reaction to touch, not to light touch
S3 – apparently normal sensation

Question 25

Recovery

Answer 25

● Recovery may be noted within a few days.
● In most cases, some degree of spontaneous recovery occurs within 1 month.
● Evidence of full recovery may not appear for up to 3 months

Question 26

Immediate treatment

Answer 26

• protect joints and surrounding ligaments
• maintenance of PROM of affected joints (after 1 wk and before 3 wks)
• Positioning
• comfort management for pain due to nerve sheath edema and hemorrhage

Question 27

Protecting the joints

Answer 27

hold arm across abdomen to prevent from dangling, do not pick up under axilla

Question 28

Positioning

Answer 28

use blanket rolls to support affected arm in a swing or car seat, reposition regularly to prevent asymmetry. AVOID SWADDLING

Question 29

Affect on development

Answer 29

● Symmetry
● Bilateral UE use
● Posture
● Movement/mobility= participation and fxn

Question 30

Interventions - Acute phase

Answer 30

• SENSORY STIMULATION
• no stretching!
  -support extremity
• gentle range of motion
• positioning

Question 31

Long term PT treatment

Answer 31

● Exercise
● NMES
● Kinesiotape
● Splinting: hand splints, theratogs, etc.
● Biofeedback
● Surgery

Question 32

Prognosis

Answer 32

● Majority resolve over the first 3-4 months
● May continue to recover hand function 3-4 years
● 5%-25% have life long disability