Brachial plexus injury Flashcards
Perinatal Brachial plexus injury (PBPI)
Paralysis or weakness involving muscles of UE after trauma to spinal roots of nerve roots C5-T1 during birth
Types of PBPI
Erb/upper plexus: C5 + C6
Klumpke/lower plexus: C7-T1
Erb-Klumpke/whole arm: C5-T1
Prognosis of PBPI
Erb: best prognosis for spontaneous recovery
Klumpke: poor prognosis
Erb Klumpke: Worst prognosis
**Most cases of brachial plexus injury have a favorable prognosis
Presentation of Erb’s Palsy
Shoulder adduction + IR
Elbow Ext
Forearm pronation
Wrist flexion
Presentation of Klumpke
Hyperextended MCP
Flexion of IP joints
Presentation of Erb Klumpke
Complete brachial plexus palsy and often results in torticollis
Etiology of PBPI
Brachial plexus injury in infants usually is a result of difficult birth
Risk factors of PBPI at birth
-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
Pathology + MOI of brachial plexus injury
Any force altering the anatomical relationship between neck, shoulder, and arm
Types of nerve injuries (4)
-Neuropraxia
-Neuroma
-Rupture
-Avulsion
Neuropraxia
Stretching w/o tearing nerve
Temporary condition
In infants, nerve sheath is torn and the nerve fibers are compressed by hemorrhage + edema
Neuroma
Scar tissue where an injured nerve has tried to heal putying pressure on the nerve
Rupture
Tearing the nerve peripherally
Avulsion
Tearing the nerve from the spinal cord
Result of passive abduction in PBPI
Passive abduction results in the arm falling limply
Effect on reflexes of PBPI
Moro, biceps, and radial reflexes are absent
Grasp reflex remains intact
Associated lesions with PBPI (5)
-injury to facial nerve
-fractures to clavicle or humerus
-Subluxation of shoulder
-Torticollis
-hemiparalysis of diaphragm by injuring the phrenic nerve at C4
What signifies the best prognosis for PBPI
Elbow flexion within first 4 months
What gives the overall clue to prognosis
Severity of the involvement (degree of neural damage), not the extensiveness
Primary surgery
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
Neurolysis
Primary surgery that clears scar tissue from the nerve
Nerve graft
Primary surgery where nerve is transplanted from infants leg to reconnect damaged nerve
Nerve transfer
Primary surgery where sewing an adjacent functioning nerve or part of nerve into a non functioning nerve
Neuroma dissection
Primary surgery where nerve is dissected and removed
Intercostal or phrenic nerve transfers
Primary surgery for involvement of these nerves
Secondary surgery
When there is less than full recovery, muscle imbalance or contractures
Other procedures can be performed when child is older, 2-10 years
Examples of secondary surgery
Free muscle transfer
Capsule release
Tendon transfer
Correction of the arm (osteotomy)
Joint fusion
Botulinum toxin injection
Into antagonists of paralyzed muscles used to increase ROM, decrease contractures, and improve body scheme
Physical therapy
Conservative treatment option to strengthen partially denervated muscles and other compensating muscles, increase ROM of the UE, and minimize contractures
Analysis of motor function: observation of…
Spontaneous movement + posture
Motor behavior during testing of reflexes + reactions
-Moro reflex
-Placing reflex of the hands
-Galant
-Neck righting reaction
-Parachute reaction
Lack of use of limb will result in…
Disuse weakness of other muscles not involved in original lesion
Waiter’s tip is characteristic of…
Erb’s palsy
Claw hand is associated with…
Klumpke
Analysis of respiratory function
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
Secondary impairments
-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
Goals of PT
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
PT intervention
Rest for 2 weeks to allow hemorrhage + edema to decrease. Partial immobilization is accomplished by positioning the limb gently across abdomen
