Brachial Plexus Injury Flashcards
What are two different MOI for brachial plexus can be injured at birth?
- traction
2. Compression
How does traction cause BPI?
uneven decent of one shoulder vs other shoulder becomes stuck @ mother’s pubic symphysis anterior, sacrum posteriorly
How does compression cause BPI?
combination of abnormally shaped uterus and position of fetus
Where can a BP lesion be in SC?
- at level of nerve rootlet
- at anterior and posterior rootlets
- at distal to where the rootlets form mixed nerve roots
What is etiology of BPI?
difficult vaginal delivery, congenital abnormalities
What are risk factors for BPI in regards to the infant?
- high birth weight over 3500 g
2. sedated infant during delivery from meds given to mom leads to low tone
What are risk factors for BPI in regards to the mother?
maternal diabetes, prolonged maternal labor, breech or shoulder dystocia
What are three types of BPI lesions?
- neurotmesis
- Axonotmesis
- neurapraxia
What is neurotmesis?
rupture or avulsion of BPI, axon, myelin and connective tissue avulsed, no regeneration possible, can be partial or complete
What can result as sequelae from neurotmesis?
fibrous mass formation, hemorrhage into subarachnoid space (diagnostic indicator for avulsion)
What is axonotmesis?
disruption of axons with intact neural sheeth, regeneration is possible
What is neurapraxia?
temporary nerve conduction block, intact axons good prognosis
What are signs and symptoms of a BPI?
spinal cord level c5-T1, motor and sensory innervation, decreased spontaneous movement, absent moro reflex, absent grasp, Horner’s syndrome
What is Horner’s syndrome?
if sympathetic chain is involved- mitosis (contracted pupils), ptosis and anhidrosis (lack of face sweating)
What is a big indicator of a positive outcome in recovery for BPI?
are the neural sheaths still intact if they are than neurons can still reconnect
What is regeneration rate of axons?
1 mm/day, upper arm 4-6 mo., lower arm 7-9 mo., continues 2-4 years
How are BPI injuries classified?
based on spinal root level, severity of injury
Narakas usually used
What are examples of Narakas classification?
Upper Erb’s c5-6- 80% recovery rate
Total palsy with Horner’s syndrome c5-t1- worst outcome
What is Erb’s palsy?
most common type of BPI affecting upper plexus roots c5-c6 resulting in paralysis of shoulder. scap muscles, elbow forearms, wrist and fingers
What muscles of shoulder are affected by Erb’s palsy?
deltoid, RC, SA, rhomboids, LS
What muscles of elbow are affected by Erb’s palsy?
biceps, brachioradialias, brachialis, supinators
What muscles of hand are affected by Erb’s palsy?
wrist extensors and finger extensors
What are other possible impairments of Erb’s palsy?
sensation loss- lateral aspect of upper arm, can also have elbow extension if C7, “waiter’s tip resting position”
What is most serious type of BPI?
Erb- Klumpke- also second most common ,global plexus palsy C5-T1, ms weakness
What are other SE of Erb Klumpke?
initially clawed hand, insensate arm, may be incomplete, can have horners syndrome if avulsion at T1 root (rare)
What is Klumke’s palsy?
lower plexus C7-T1
What will pt have if they have pure Klumke’s palsy?
shoulder/elbow motions intact, weak grasp, forearm rests in supination
ms involved: wrist flexors and extensors, hand intrinsics (claw hand), weak elbow extension
What are two types of medical management of OBPI?
- conservative- always preferable (3-4 months before surgery considered)
- surgical intervention- neurosurgery, ortho surgery
What are the indications for neurosurgery?
no longer making progress, significant impairments/activity limitations
-lack of ER and supination
What are different types of neurosurgery for BPI?
nerve grafting, neurolysis
outcomes mixed- level of evidence low
What are goals for orthopedic surgery?
AROM and PROM for hand to head/mouth function, prevent deformities
What is important information to ask during a history of BPI pts?
birth weight, older child- history of intervention, impact on functions
What is important of MS systems review for BPI?
shoulder girdle integrity (winging, subluxation)
What is important of NM systems review for BPI?
red flag- spasticity bc its and UMN sign
What is important of CP systems review for BPI?
breathing patterns and norms, phrenic nerve damage- hemi elevated diaphragm
What is important of integ systems review for BPI?
signs of self injury such as biting arm
What type of movement grading systems is used for infants?
Active movement scale 0-7 0- no contraction 1- contraction with movement 2- 1/2 ROM mvmt 3- more than 1/1 ROM mvmt 4- full mvmt
AG:
5- less than 1/2 ROM mvmt
6- more than 1/2 ROM movement
7- full movement
What type of movement grading system is used for older children?
MMT, Mallet classification of UE function
What is Mallet Classification of UE function?
1- nothing 2- 1/3 of movement 3- 2/3 movement 4- almost full range 5- full range
What are two different types of movement tests used for BPI pts?
- towel test for biceps function- infants 0-3 months, towel over eyes restrict uninvolved limb and see how baby removes it
- Cookie test- 6-9 months, see if they can bring cookie to mouth via elbow flexion vs head and mouth
What is Narakas sensory grading system?
S0- no reaction to painful stim.
S1- reaction to painful stim.
S2- reaction to touch
S3- normal
used for infants, older children use more formal tests
What activity test is used for infants with BPI?
Tests of Infant Motor performance (TIMP)
- 0- 5months
older children use PDMS 2
What is ultimate goal for POC for BPI pts?
age appropriate function, support spontaneous recovery
What must be done for a newborn consultation with BPI?
rest and immobilization first 7-10 days, no ROM, position arm across abdomen, don’t lie on limb
What can be done in PT after 10 days?
baseline exam, HEP, use of therapeutic play
CIMT can be used, try to avoid learned non use and promote B UE use
