Brachial Plexus Injury Flashcards
Injury to brachial plexus usually occurs during
Difficult vaginal delivery (forceful contraction and rotation of head tends to injury c5c6 nerve root)
Birth weight contributing to brachial plexus injury
> 3500g
Infant w/ a birth weight of 4500g had a risk of OBPI 45 times higher than a baby less than 3500 G
Other factors contributing to brachial plexus injury
Difficult delivery of the shoulder Prolonged maternal labor Maternal DM Sedated hypotonic infant during delivery Breech delivery
Pathophys: brachial plexus damage can occur
Anyway along the pathway
Rootlets, roots, trunks, divisions, cords, peripheral nerves
Neurotemesis
Complete rupture of nerve
May develop into neuroma or mass of fibrous tissue
Axonotemesis
Distrution of axon while sheath remains intact
Neurapraxia
Temporary nerve conduction blockage
Axon regrowther proceeds
At 1mm per day
Majority of recovery takes 4-6 mo in Upper arm
7-9 months in lower arm
Continuous recovery can occur up to 2 years in upper arm and 4 in lower
Erbs palsy
Most common
C5 and C6 nerve roots
Childs shoulder held in extension, IR, ADD,
Below ext, forearm pronation, and and fingers flexed
Erbs palsy paralysis
Rhomboids, levator, serratus, subscap Deltoid, infraspinatus, teres minor Biceps brachialis, supinator Brachioradialis Fiber and thumb extensors
Klumpke’s palsy
Rare, usually from breech delivery w arm overhead
Involvement of lower nerve roots of C7-T1
Childs shoulder and elbow not impaired
However resting position of forearm is sup, elbow flex, paralysis of wrist flexors and extensors and intrinsics
Erb-klumpke palsy
Combo of upper and lower nerve roots resulting in total arm paralysis and loss of sensation
Horners syndrome
Can occur w/ avulsion of T1 roots presenting as decisive to sweating, recession of eyeball, decreased pupil size, partial drooping of eyelid, and irises are different color
Substitution during period of neural regeneration -BPI
Medial rotated shoulder w/ forearm pronation and wrist flexion when grasping
May neglect impair contractures arm
Can lead to and abnormal bone growth
Recovery rate BPI
60-80%
Some have spontaneous recovery w/in a few weeks
Recovery in shoulder ER has been shown to accurately predict full recovery
Brachial plexus injury activity limitations
Inability to reach, grasp, bilateral tasks
Developmental delays or asymmetry (ruling and supine to sit may always be done from one side)
Quad position and creeping may not occur due to inability to WB on involved arm
Neglect or self abusive behavior
PT exam followed at
2 weeks, 1, 2, 3, months
If not recovery evident an MRI may be performed to define nerve root integrity
Active movement scale gravity eliminated
0 no contraction 1 contraction, no motion 2 motion less than or equal to half range 3 motion grater than half range 4 full motion
Active movement scale - against gravity
5 motion less than or equal to half range
6 motion grater than half range
7 full motion
Sensory grading for kids with BPI
S0 no reaction to painful or other stim
S1 Rx to pain, not touch
S2 rx to touch, not light touch
S3 apparently normal sensation
Sensation may take ___ to recover
As long as 2 years
Procedural intervention - initial rest period
7-10 days after birth
No ROM
Limb positioned across abs
Avoid lying on limb
Procedural interventions after rest period
PE eval
HEP w/ ROM
Parent ed on risk of dislocation and sensory loss issues
Strengthing activites through play
Active movement
Facitlate normal patterns
Inhibit substitutions during reaching and WB activities
(Watch/ support scapula)
Eliminate gravity for weak muscles
Hand to mouth, transfer objects, weight shift on propped UE
Sidelying on uninvolved arm to free involved to work on reaching
Push up to sit from involved side
Bilateral activities
ROM
Avoid overhead stretching unstable joint
Don’t puck up under axilla
Stretch scapulohumeral muscles
Botox and casting to improve elbow ext
Sensory awareness
Can lead to neglect self mutilation
Games to ID or find objects w/ involved hand
Play w/ various temp and textures
Positioning and splinting
While sleeping arm can be placed in ABER, elbow flex, supination on pillow
Wrist splints to prevent contracture
Constrain uninvolved arms for short periods of time
Neurosx
Only done in 5-10% who do not show spontaneous recovery
Nerve grafting, NeuroM dissection and removal, neurolysis, direct end to tend anastomosis
OBPI GH deformity
Up to 67%
OBPI most common contracture
Shoulder ADIR, elbow flex or ext, supination
OBPI main purpose of sx
Allow enough PROM for self care activities
Scapulohumeral mobility
Develops b/n 3-6 months
Elongation of muscle b/n humerus and scap and humerus and ribs occur during transitions movements of supine to sidelying and supine to prove
Weight o trunk loaded onto upper arm
Reaching in prone stimulates new range
Facilitating scapular thoracic activity
Stability for mid range reaching
Active thoracic ext prevents excessive scapular winging
Initially developed in prone play as early as 2 mo
As child develops enduriance in spinal ext, reach can be added
Increasing shoulder girdle and elbow strength
Fascilitation of movements in which the child uses arms to push from one position to another
Around 5 mo
Sidelying to sitting, sitting to quad and creeping
Developing isolated elbow movements
Hand to body play
-emerges around 3 mo in supine
Manip toys in prone on elbows
Activating and exploring toys
Isolated control of forearm and wrist
Emerges around 5 mo w/ prone on elbow play
Self feeding
Facilitating hand functions
Weight shift on extended arms helps to expand the hand so it will be malleable enough to actively arch during grasp and manipulation
Helping child grasp w. Wrist in neutral will facilitate balance between f/e
Development of release requires child to learn to use long finger flexors for a point of stability
Neurosx age and prevalence
Optimally performed b/n 3-8 months
Outcomes better for those w/ upper root involvement
