Brachial Plexus Injury Flashcards
Brachial Plexus Injury
Occurs d/t trauma to the shoulder and spine
Obstetric m/c—> OBPI
Involvement is usually unilateral
Etiology and Incidence
Occurs due to difficult vaginal delivery by traction on the baby’s shoulder during delivery of the head in a breech delivery can damage the nerve roots, fracture clavicle or humerus, or sublux shoulder
Vertex presentation (head first) = injury to C5-C6
Associated damage to C4 is less common but will cause ipsilateral hemiparesis of diaphragm
Congenital abnormalities can also place increased pressure on lower plexus
Pathophysiology
Types of lesions
Recovery
Damage can occur at : level of nerve root attached to SC, A or P rootlets, or where nerves exit vertebral canal
Roots, trunks, divisions, cords, and peripheral nerves can all suffer the following types of lesions
neurotmesis: complete rupture
- —limited recovery
axonotmesis: disruption of axons while neural sheath remains intact—better prognosis
- —takes 4-6 months to recover in upper arm, 7-9 months in lower arm. Continued recovery can occur for up to 2 y in upper arm and 4 in lower arm
neurapraxia: temporary nerve conduction block with intact axons
- — early recovery as edema resolves, quick and complete recovery, days or weeks
**combination of types of lesions is common can mean variable return of motor fxn
Partial or complete rupture can lead to neuroma and mass of fibrous tissue
Hemorrhage into subarachnoid space leads to presence of blood in CSF = more serious injury
Axons grow 1mm/day
Changes in body structure/fxn (impairments) Palsy's Substitution and neglect Contractures Orthopedic Abnormalities Torticollis
Injury can occur at any level of brachial plexus.
M/C at upper roots C5-6 = Erb’s palsy
Lower roots C7-T1 = Klumpke
T1 avulsion = horner’s
During neural regeneration after injury children use abnormal mm substitutions
May neglect involved UE due to sensory loss
Neglect and substitutions result in repetitive patterns and can result in contractures or abnormal bone growth
Contracture: scapular protraction, shoulder ext/IR/add, elbow flex/ext, forearm pronation, and wrist/finger flexion
Ortho: flattening of humeral head, short clavicle, hypoplasia (under-development) of humeral head, abnormal glenoid fossa
Positional torticollis can develop due to injury
Prognosis
Good 66-73% recovery rate
Adults report varying degrees of disability following OBPI
Activity limitations
Vary greatly
Primary activity limitations: inability to reach, grasp, bilateral manual activities (catching ball with 2 hands), ADLs that require bilateral ue’s (dressing)
Typical developmental activities may be impaired: asymmetrical movement from prone to supine or sitting—usually only perform to one side, creeping on all 4’s may not occur due to inability to WB–may result in scooting or progress directly to walking
Neglect
Shoulder pain and neuritis in adults
PT Exam
Establish baseline AROM PROM Sensation Screen developmental status EMG can be used to determine extent of involvement
ROM
ROM measurements of involved arm and c-spine
Compare with contralateral side
Use caution as child’s joints may be unstable and limbs may have sensory loss
Baseline needs to be established to identify secondary contractures
Newborn infants may have more limited mobility
MM strength and motor fxn
observe limb/head mvmt or palpate mm cxn by testing reactions and reflexes: visual tracking, head righting, moro, galant, hand placing reaction
Document if mvmt is against gravity or gravity eliminated
Examine thoracic and abdominal mvmt as may indicate phrenic involvement
Active mvmt scale- infants less than 1 y/o
Older children can use standard MMT- mm and grasp strength
look for compensatory strategies and posturing of arm as result of mm imbalance and sensory loss
Mallet’s classification of ue fxn
Spasticity is not included in OBPI Impairments
TIMP may be used to document motor function in infants younger than 5m
Sensation
Exam of sensation in infants/newborns is not sensitive or reliable
identify areas believed to have compromised sensation
Sensory loss does not necessarily correspond to motor involvement
Sensory Grading system S0-S3
Due to regeneration sensory loss may change to hyperasthesia before normal sensation is achieved. May result in pain or discomfort in response to simple touch or sensory stimulation—> document this as may be a sign of progression of regeneration
Map areas of sensory loss in older children
Sensation can take up to 2 yrs to recover
PT Goals
Ideal outcome = complete recovery of motor control and sensation with no activity/participation restrictions
PT during 1st few months = support spontaneous recovery, prevent secondary impairments (mm contracture or joint injury)
Majority of spontaneous recover occurs by 9m but can continue for up to 2y
Depending on injury full ROM and normal strength may be goals for 1st 2 years of life
Revise goals based on presence of neural regeneration
Goals at 2y: develop age appropriate self care, participation in age appropriate activities
Need continual monitoring of strength and ROM
Active Mvmt Scale
Developed esp for OBPI
good interrater reliability and validity
used for infants younger than 1 y/o
Mallet’s classification of ue fxn
used for older children
reliable for children with OBPI
Sensory Grading System
S0 = no rxn to pnful or other stimuli S1 = rxn to pnful stimuli but not touch S2 = rxn to touch, not to light touch S3 = apparently normal sensation
Neurosurgery
5-10% of cases who do not have spontaneous recovery
Techniques include: nerve grafting, neuroma dissection or removal, neurolysis, direct end to end nerve anastamosis
Indications: lack of biceps function and elbow flexion, shoulder—lack of active ER and forearm supination and scores on active mvmt scale
Surgery done between 3-8 months, can delay surgery to 12m of age if only upper nerve root involvement
Outcomes: most have improvement following surgery, better outcomes for surgical intervention on C5-6 injury
