Brachial Plexus Injury Flashcards
What is the brachial plexus?
Complex network of nerves arising from the cervical spine and across the shoulder to the upper limb
What is an example of a brachial plexus injury in newborns?
Traction injury to shoulder during delivery of the head
What are the characteristics of a brachial plexus injury?
- Stretching of the nerve of brachial plexus
- Weak or paralysed UL
- Passive > active ROM
How are brachial plexus injuries categorised?
Gilbert & Tassin/Narakas:
- I: C5, 6 (deltoid, biceps)
- II: C5, 6, 7 (deltoid, biceps, triceps, wrist extensors)
- III: C5, 6, 7, 8, T1 (flail arm)
- IV: C5, 6, 7, 8, T1 (flail arm, with Horner’s syndrome)
What is the waiter’s tip position?
Shoulder adduction/IR with wrist flexion & finger extension
What is Klumpke’s palsy?
- Flaccid hand in otherwise active arm
- Lower plexus palsy
- Extremely rare
What is “Pan” plexopathy?
- Total plexus palsy
- Groups III & IV with total loss of function of the arm (flail arm)
What is neuropraxia?
- Transient nerve injury
- Brief ischaemic episode
- Compression, demyelination, axonal constriction or stretch
What is axonotmesis?
- Transient or permanent nerve injury
- Disruption of axonal nerve fibres with majority of supporting structures of the nerve ok
What are the characteristics of a likely permanent nerve injury?
Axon lesion with some or all supporting structures also damaged
What are the characteristics of a permanent nerve injury?
- Neurotmesis (complete rupture)
- Location important too in relation to motor body
What is the likely clinical picture of brachial plexus injuries?
- Shoulder extension, IR, adduction
- Elbow extension
- Forearm pronation
- Wrist, finger flexion
- Grasp may be ok
- Sensory loss present (neglect possible)
- Paralysis
When are babies with brachial plexus lesions seen by physio?
- Usually on post-natal ward then as OP
- Clinical exam at 2-4 weeks key for mapping probably sit of injury
- Birth hx & any activity since then noted
What is assessed by physio at 2-4 weeks in babies with brachial plexus injuries?
- Position at rest
- Active movement
- Movement with stimulation
- Passive range
- Head position & neck ROM
- Clavicle & humerus integrity
- Reflexes
- Eyes (miosis, ptosis, Horner’s syndrome)
What movements are observed in supine, sidling & prone in babies with brachial plexus injuries?
- Spontaneous movements
- PROM (limited = suspect other impairments)
- AROM (stimulation i.e. stroking, tapping, vibrating muscle belly)
- Against/across gravity
- Scapula winging
- Chest expansion
- Reflexes
- Sensory responses
What are the standardised assessments used for brachial plexus injuries?
- Active movement scale for newborns
- Mallet scale for children
- PEDI (ADL focus)
What are the medical/surgical assessments used for brachial plexus injuries?
- Electrodiagnostic examination
- Nerve conduction studies
- EMG
- CT
- MRI
What is the treatment for brachial plexus injuries?
- Protect arm
- Pain relief if required
- Review 2 weeks
- Gentle ROM/stimulation exercises from 2 weeks
- Stretching to prevent loss of ROM
- Developmentally appropriate stimulation (tummy time, sidelying)
What are some of the AROM exercises for babies with brachial plexus injuries?
- Stroking, tapping or vibration in gravity eliminated position, then anti-gravity, then weight-bearing position
- Hand to face with bicep stroking
- Elbow extension to overhead toy
- Wrist extension to reach toy
- Weight bearing through UL over a ball
- Arm into visual field to minimise neglect
What are some of the prognostic signs in babies with brachial plexus injuries?
- Shoulder ER & forearm supination
- Biceps function
- Elbow extension/flexion at 1 month with EMG motor unit potential
What are some of the longer-term treatment options for babies with brachial plexus injuries?
- Neurosurgery (nerve graft/transfer)
- Secondary MS surgery
- Serial casting
- Constraint induced therapy
