Brachial Plexus injury (BPI)

Question 1

Birth related brachial plexus injuries are referred to as

Answer 1

• Neonatal brachial plexus palsy (NBPP)
• obstetric brachial plexus injury (OBPI)
• perinatal brachial plexus injury (PBPI)
• brachial plexus birth palsy (BPBP)
• birth brachial plexus injury (BBPI)
• erb’s palsy
• klumpke’s palsy

Question 2

What is obstetric/perinatal brachial plexus palsy/injury

Answer 2

• almost always involves traction of the C5 and C6 nerve root
• resulting in weakness of shoulder function and elbow flexion
• traumatic birth, bigger babies can be a factor with this

Question 3

Incidence of BPP

Answer 3

• around 1 to 3 per 1000 live birth in US
• decreasing incidence
• majority of cases are erb’s palsy
• Involvement of C5 and C6 +/- C7 resulting in proximal muscle weakness

Question 4

Pathogenesis: perinatal brachial plexus injury

Answer 4

• stretching or avulsion of the brachial plexus by extreme lateral traction
• relationship between gross pathology and outcome
• can occur during difficult delivery, when the brachial plexus is stretched or torn

Question 5

Etiology of BPP/contributing factors durig pregnancy

Answer 5

• genetics: 2-3% recurrence risk for siblings (may be more to do with genetics of mothers hips
• teratogens: increased risk with maternal alcoholism (increased sugar levels)
• nutritional deficiency: lack of folic acid

Question 6

Degrees of injury with BPP

Answer 6

• most severe third degree: peripheral or central avulsion, rupture: neurotmesis
• Moderate or second-degree: injury characterized by damage of the axons and myelin sheath: axonotmesis
• Overstretch, distraction, or pull of the nerve(s) of the brachial plexus called: neuropraxia (stretched but not torn - child should recover full)

Question 7

Types of injury

Neuropraxia/stretch

Answer 7

• varies in degrees of intensity
• nerves in plexus compressed not torn due to swelling or bruising from birth trauma of shoulder
• stretch injuries will spontaneously recover in 1-2 years of age with 90-100% return of function

Question 8

Types of injury

Rupture

(not at the root)

Answer 8

• nerves are torn at either one or several places in the plexus requiring surgery for the nerves to recover
• some children dont get surgery - 75% return of function

Question 9

injury types

Avulsion at the root

Answer 9

• most severe injury
• nerves are pulled from the spinal cord as evidence by a totally flaccid extremity
• requires surgery and testing to make sure they did not stroke

Question 10

injury types

neuroma

Answer 10

• from a torn nerve that begins to heal
• scar tissue develops and puts pressure on the injured nerve and prevents signals from being transmitted between nerves and muscles
• neuroma injuries require treatment to heal

Question 11

insult prior to delivery?

Answer 11

• 50% of all BPI attributed to unavoidable intrapartum or antepartum events and not to actual management of the shoulder dystocia
• before acutal recognition of shoulder dystocia a significant degree of stretch pressure may have been applied to the FETAL brachial plexus

Question 12

examples of non-obstetric causes

Answer 12

• contact sports, especially wrestling and football
• high speed impact accidents: motorcycle, bicycle, car
• falls
• industrial accidents
• tumors of the neck
• viral disease

Question 13

Draw the brachial plexus

Answer 13

compare to online

Question 14

Risk factors for BPP

Answer 14

• birth weight >4500 g (7.8 lbs)
• prolonged labor and difficult delivery (take history from parents
• maternal diabetes Larger than average weight newborn
• breech
• hypotonia, sedation - mother is sedated = baby is sedated
• difficulty delivering the baby’s shoulder after the head has already come out
• flat contracted or platypelloid pelvis (doesnt round out)
• overdue baby
• prior birth of child greater than 8.5 lbs or child with BPI
• use of tolls or external assistance during delivery
• postdate destation
• disparity between fetal size and maternal pelvis size (small pelvis)
• short/small maternal size
• epidural

Question 15

platypelloid pelvis

Answer 15

• uncommon in both sexes
• pelvic inlet appears slightly flattened (kidney shaped)
• transverse diameter is greater than AP diameter
• sacral promontory pushed forwards

Question 16

what are the classifications of BPI

Answer 16

• upper erbs palsy C5, C6
• extended Erb’s C5, C6, C7
• total palsy with no horner syndrome C5, C6, C7, C8, T1
• Total palsy with horner syndrome C5, C6, C7, C8, T1

Question 17

Upper erb’s C5-C6

Answer 17

• shoulder abduction/ER, elbow flexion affected
• good spontaneous recovery expected in over 80% of cases

Question 18

Extended Erbs C5-C7

Answer 18

• shoulder abduction/ER and definite wrist drop
• good spontaneous recovery in about 60% of cases
• C7

Question 19

Total palsy with horner syndrome

C5-T1

Answer 19

• complete flaccid paralysis with horner syndrome
• the worst outcome
• without surgery, severe defects throughout the limb functon
• visual system involved
• need muscle transplant

Question 20

Horner syndrome 4 classic signs

Answer 20

• constricted pupil (miosis)
• dropping of the upper eyelid (ptosis)
• absence of sweating of the face (anhidrosis)
• sinking of the eyeball into the bony cavity that protects the eye (enophtalmos)

• relatively rare disorder

Question 21

Horners syndrome

what happens

Answer 21

• interruption of the sympathetic nerve supply to the eye due to a lesion or growth
• lesions develops along the path of the eye to the region of the brain that controls the sympathetic nervous system (hypothalamus)

Question 22

Erbs paralysis

Answer 22

• affects the upper and lower arm
• usual have hand function C5, C6 maybe C7
• scapular involvement possible
• posturing: waiter’s tip position

Question 23

Klumpke paralysis

Answer 23

• affects the intrinsics of hand
• the infant may also have an eyelid droop on the opposite side
• C8-T1
• rarely in newborns

(may also have erbs)

Question 24

Total palsy

Answer 24

• C5-C8 and occasionally T1 involved
• flaccid arm

Question 25

Shoulder dystocia

Answer 25

• a delivery that requires additional obstetric maneuvers following failure of gental downward traction on the fetal head to effect delivery of the shoulders

Question 26

Brachial plexus injury without dystocia

Answer 26

• is a distinct entity
• BPI posterior shoulder is affected
• antecedent shoulder dystocia or c-section highly suggestive of an in utero mechanism
• neonates are smaller birth weight
• usually have a second stage of labor

shoulder dystocia is birth complication where shoulder gets stuck behind pubic boene

Question 27

Leiden three item test

Answer 27

• active elbow extension at one month
• active elbow flexion at one month
• needle EMG of the biceps muscle. absent bicep motor unit potential at one month

Question 28

Referrals after leiden three item test and decision rule

Answer 28

• prediction at one month of age > at 1 week and 3 months
• children without active elbow extension at one month should be referred
• children with active elbow extension as well flexion should not
• when there is elbow extension, but no active elbow flexion an EMG is neded; absence of MUPs in bicep muscle is reason for referral

Question 29

active movement scale

describe what it is

Answer 29

• created by the hospital for sick children in toronto to assess motor function in infants with brachial plexus injuries
• an infant is scored on 15 separate movements based on observational analysis
• a muscle grade score of 0 (no contraction) to 7 (full motion) is assigned based on motion elicited
• fifteen movements are evaluated from the affected shoulder to the handgood interrater reliability

Question 30

Gilbert shoulder classification

Answer 30

• grade 0 = complete flail shoulder
• grade 1 (poor) is abducted equal to 45º, with no active external rotation
• grade 2 (fair) = abduction of less 90º with no external rotation
• Grade 3 (satisfactory) = abduction equal to 90º, with weak external rotation
• grade 4 (good) = abduction less than 120º with incomplete ER
• grade 5 (excellent) = abduction of greater than 120º with active ER

Question 31

Pediatric outcomes data collection instrument

Answer 31

• established tool that measures upper extremity function, transfers and basic mobility, sports and physical function, comfort and pain, and happiness with physical condition
• may have further application as a tool to measure baseline function and postoperative functional gains for children with BPP

Question 32

Interventions for BPP

Answer 32

• transitional movements
• protective reactions
• bimanual tasks
• strengthening with toys

Question 33

Bone mineral density (BMD)

Answer 33

• BMD is significantly reduced in BPP children
• the retardation of bone accrual increases as the child height and weight decreases and the degree of paralysis increases
• weight bearing exercises significantly promoted BMD improvement when compared to traditional exercises in those children

Question 34

Physical therapy interventions

BPP

Answer 34

• ROM
• strengthening
• constrained induced movement therapy (CIMP)
• neuromuscular electrical stim
• joint mobilization (keep them as mobile as possible)
• aquatic therapy
• Kinesio taping
• serial casting: time, good results ith contractures
• orthosis may be used to encourage recover

Question 35

Tasks to encourage movement

Answer 35

• infant only wrist flexion
• toddler has shoulder flexion to 65º, limited movement of fingers generalized strength is 3+
• school age 7-9

Question 36

indications for use of botox with BPP

Answer 36

• internal rotation or adducted contracture: inject pectoralis and occasionally the Lat (subscapularis, teres minor, and teres major)
• limited active elbow flexion (inject triceps)
• limited active elbow extension: inject biceps, sometimes brachialis and brachioradialis
• pronation contraction: inject pronator teres

Question 37

treatment for BPP

Answer 37

general treatment strategy is neurosurgical repair if antigravity deltoid and bicep movement is not available by 2 months of age

mostly wait until they grow more muscle (mature muscle)

Question 38

BPI

Secondary surgery

Answer 38

• secondary surgeries are usually performed on children who are at least 18 months to 2 years
• this allows the children to mature and the injury to fully show itself, yet the child is still young enough to benefit from the reconstruction

Question 39

surgeries for BPP

Answer 39

• mod quad
• tendon transfers
• tendon shortening or lengthening
• joint capsule tightening
• free nerve and muscle flaps
• and bony work

Question 40

surgeries for resultant bony deformities

Answer 40

• triangle tilt surgery
• humeral osteotomy
• shoulder arthrodesis/fusion