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Pediatric PT > Brachial Plexus injury (BPI) > Flashcards

Brachial Plexus injury (BPI) Flashcards

1
Q

Birth related brachial plexus injuries are referred to as

A
  • 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
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2
Q

What is obstetric/perinatal brachial plexus palsy/injury

A
  • almost always involves traction of the C5 and C6 nerve root
  • resulting in weakness of should function and elbow flexion
  • traumatic birth, bigger babies can be a factor with this
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3
Q

Incidence of BPP

A
  • 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
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4
Q

Pathogenesis: perinatal brachial plexus injury

A
  • 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
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5
Q

Etiology of BPP/contributing factors

A
  • 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
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6
Q

Degrees of injury with BPP

A
  • 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)
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7
Q

Types of injury

Neuropraxia/stretch

A
  • 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
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8
Q

Types of injury

Rupture

(not at the root)

A
  • 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
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9
Q

injury types

Avulsion at the root

A
  • 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
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10
Q

injury types

neuroma

A
  • 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
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11
Q

insult prior to delivery?

A
  • 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
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12
Q

examples of non-obstetric causes

A
  • contact sports, especially wrestling and football
  • high speed impact accidents: motorcycle, bicycle, car
  • falls
  • industrial accidents
  • tumors of the neck
  • viral disease
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13
Q

Draw the brachial plexus

A

compare to online

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14
Q

Risk factors for BPP

A
  • 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
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15
Q

platypelloid pelvis

A
  • uncommon in both sexes
  • pelvic inlet appears slightly flattened (kidney shaped)
  • transverse diameter is greater than AP diameter
  • sacral promontory pushed forwards
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16
Q

what are the classifications of BPI

A
  • upper erbs palsy C5, C6
  • extended Erb’s C5, C6, C7
  • total plasy with no horner syndrome C5, C6, C7, C8, T1
  • Total palsy with horner syndrome C5, C6, C7, C8, T1
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17
Q

Upper erb’s C5-C6

A
  • shoulder abduction/ER, elbow flexion affected
  • good spontaneous recovery expected in over 80% of cases
18
Q

Extended Erbs C5-C7

A
  • as above with wrist drop
  • good spontaneous recovery in about 60% of cases
  • C7
19
Q

Total palsy with no horner syndrome

C5-T1

A
  • complete flaccid paralysis with horner syndrome
  • the worst outcome
  • without surgery, severe defects throughout the limb functon
  • visual system involved
  • need muscle transplant
20
Q

Horner syndrome 4 classic signs

A
  • relatively rare disorder
  • 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)
21
Q

Horners syndrome

what happens

A
  • interruption of the sympathetic nerve supply to the eye due to a lesion or groth
  • lesions develops along the path of the eye to the region of the brain that controls the sympathetic nervous system (hypothalamus)
22
Q

Erbs paralysis

A
  • affects the upper and lower arm
  • usual have hand function C5, C6 maybe C7
  • scapular involvement possible
  • posturing: waiter’s tip position
23
Q

Klumpke paralysis

A
  • 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)

24
Q

Total palsy

A
  • C5-C8 and occasionally T1 involved
  • flaccid arm
25
Q

Shoulder dystocia

A
  • a delivery that requires additional obstetric maneuvers following failure of gental downwrad traction on the fetal head to effect delivery of the shoulders
26
Q

Brachial plexus injury without dystocia

A
  • 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
27
Q

Leiden three item test

A
  • 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
28
Q

Referrals after leiden three item test and decision rule

A
  • prediction at one month of age > at 1 week and 3 months
  • children withouth 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
29
Q

active movement scale

A
  • 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 movemetns 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
30
Q

Gilbert shoulder classification

A
  • grade 0 = complete flail shoulder
  • grade 1 (poor) is abducted equal to 45º, with n oactive 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
31
Q

Pediatric outcomes data collection instrument

A
  • 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
32
Q

Interventions for BPP

A
  • transitional movements
  • protective reactions
  • bimanual tasks
  • strengthening with toys
33
Q

Bone mineral density (BMD)

A
  • BMD is significantly reduced in PBPP 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
34
Q

Physical therapy interventions

A
  • 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
35
Q

Tasks to encourage movement

A
  • infant only wrist flexion
  • toddler has shoulder flexion to 65º, limited movement of fingers generalized strength is 3+
  • school age 7-9
36
Q

indications for use of botox with BPP

A
  • 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
37
Q

treatment for BPP

A

generall 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)

38
Q

Secondary surgery

A
  • 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
39
Q

surgeries for BPP

A
  • mod quad
  • tendon transfers
  • tendon shortening or lengthening
  • joint capsule tightening
  • free nerve and muscle flaps
  • and bony work
40
Q

surgeries for resultant bony deformities

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

Pediatric PT (4 decks)

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