Brachial plexus injury

Question 1

Perinatal Brachial plexus injury (PBPI)

Answer 1

Paralysis or weakness involving muscles of UE after trauma to spinal roots of nerve roots C5-T1 during birth

Question 2

Types of PBPI

Answer 2

Erb/upper plexus: C5 + C6
Klumpke/lower plexus: C7-T1
Erb-Klumpke/whole arm: C5-T1

Question 3

Prognosis of PBPI

Answer 3

Erb: best prognosis for spontaneous recovery
Klumpke: poor prognosis
Erb Klumpke: Worst prognosis

**Most cases of brachial plexus injury have a favorable prognosis

Question 4

Presentation of Erb’s Palsy

Answer 4

Shoulder adduction + IR
Elbow Ext
Forearm pronation
Wrist flexion

Question 5

Presentation of Klumpke

Answer 5

Hyperextended MCP
Flexion of IP joints

Question 6

Presentation of Erb Klumpke

Answer 6

Complete brachial plexus palsy and often results in torticollis

Question 7

Etiology of PBPI

Answer 7

Brachial plexus injury in infants usually is a result of difficult birth

Question 8

Risk factors of PBPI at birth

Answer 8

-High birth weight
-Prolonged maternal labor
-Heavily sedated mother or infant
-Traction in breech position
-Rotation of head in cephalic presentation
-Difficult C section
-Multiples
-Shoulder distocia with lateral traction of head and neck
-Traction of the shoulder with arms over head during delivery

Question 9

Pathology + MOI of brachial plexus injury

Answer 9

Any force altering the anatomical relationship between neck, shoulder, and arm

Question 10

Types of nerve injuries (4)

Answer 10

-Neuropraxia
-Neuroma
-Rupture
-Avulsion

Question 11

Neuropraxia

Answer 11

Stretching w/o tearing nerve
Temporary condition

In infants, nerve sheath is torn and the nerve fibers are compressed by hemorrhage + edema

Question 12

Neuroma

Answer 12

Scar tissue where an injured nerve has tried to heal putying pressure on the nerve

Question 13

Rupture

Answer 13

Tearing the nerve peripherally

Question 14

Avulsion

Answer 14

Tearing the nerve from the spinal cord

Question 15

Result of passive abduction in PBPI

Answer 15

Passive abduction results in the arm falling limply

Question 16

Effect on reflexes of PBPI

Answer 16

Moro, biceps, and radial reflexes are absent

Grasp reflex remains intact

Question 17

Associated lesions with PBPI (5)

Answer 17

-injury to facial nerve
-fractures to clavicle or humerus
-Subluxation of shoulder
-Torticollis
-hemiparalysis of diaphragm by injuring the phrenic nerve at C4

Question 18

What signifies the best prognosis for PBPI

Answer 18

Elbow flexion within first 4 months

Question 19

What gives the overall clue to prognosis

Answer 19

Severity of the involvement (degree of neural damage), not the extensiveness

Question 20

Primary surgery

Answer 20

Infants who do not heal by 3-4 months of age or those with avulsions or ruptures need surgery to improve or correct nerve function. Surgery at 3-9 mo of age

Question 21

Neurolysis

Answer 21

Primary surgery that clears scar tissue from the nerve

Question 22

Nerve graft

Answer 22

Primary surgery where nerve is transplanted from infants leg to reconnect damaged nerve

Question 23

Nerve transfer

Answer 23

Primary surgery where sewing an adjacent functioning nerve or part of nerve into a non functioning nerve

Question 24

Neuroma dissection

Answer 24

Primary surgery where nerve is dissected and removed

Question 25

Intercostal or phrenic nerve transfers

Answer 25

Primary surgery for involvement of these nerves

Question 26

Secondary surgery

Answer 26

When there is less than full recovery, muscle imbalance or contractures

Other procedures can be performed when child is older, 2-10 years

Question 27

Examples of secondary surgery

Answer 27

Free muscle transfer
Capsule release
Tendon transfer
Correction of the arm (osteotomy)
Joint fusion

Question 28

Botulinum toxin injection

Answer 28

Into antagonists of paralyzed muscles used to increase ROM, decrease contractures, and improve body scheme

Question 29

Physical therapy

Answer 29

Conservative treatment option to strengthen partially denervated muscles and other compensating muscles, increase ROM of the UE, and minimize contractures

Question 30

Analysis of motor function: observation of…

Answer 30

Spontaneous movement + posture
Motor behavior during testing of reflexes + reactions
-Moro reflex
-Placing reflex of the hands
-Galant
-Neck righting reaction
-Parachute reaction

Question 31

Lack of use of limb will result in…

Answer 31

Disuse weakness of other muscles not involved in original lesion

Question 32

Waiter’s tip is characteristic of…

Answer 32

Erb’s palsy

Question 33

Claw hand is associated with…

Answer 33

Klumpke

Question 34

Analysis of respiratory function

Answer 34

Phrenic nerve involvement will result in decreased movement of IPs thorax with respiratory distress, cyanosis, UL diaphragmatic elevation and persistent atelectasis

PT assessment involves observation of thoracic + abdominal movement to detect asymmetry

Question 35

Secondary impairments

Answer 35

-Persistent + abnormal substitutions
-Abnormal posturing of arm
-Soft tissue contracture
-GH sublux or dislocation
-posterior displacement of humeral epiphysis and posterior radial dislocation
-Skeletal deformity and poor bone growth
-uneven muscle growth

Question 36

Goals of PT

Answer 36

Prevent loss of ROM, disorganized movement of the arm, and neglect of the arm

Stimulate + facilitate muscle function, active movement as nerve regenerates, gross motor skill development and age appropriate reach + grasp patterns

Education of family

Question 37

PT intervention

Answer 37

Rest for 2 weeks to allow hemorrhage + edema to decrease. Partial immobilization is accomplished by positioning the limb gently across abdomen