Case 1: Brachial Plexus Flashcards
What is obstetric brachial plexus palsy (OBPP)?
a birth injury that occurs when the nerves of the brachial plexus are damaged during delivery, often d/t excessive stretching of the neck or shoulder dystocia, leading to weakness or paralysis in the baby’s arm.
What is shoulder dystocia?
complication during birth when a baby’s shoulder gets stuck behind the mother’s pubic bone
Developmental reflex; as the baby’s head is turned toward one side, the UE on that side extends and the UE on the opposite side flexes.
Asymmetrical tonic neck reflex
Involuntary responses that are also called primitive reflexes; in typically developing infants, these disappear or are inhibited during development.
developmental reflexes
Developmental reflex that is observed in response to a sudden loss of support at the head; the typically developing infant symmetrically abducts both upper extremities and then symmetrically adducts both upper extremities.
Moro reflex
Developmental reflex observed in typically developing infants when an object is placed in the infant’s palm, the infant grasps the object.
palmar grasp reflex
unilateral shortening of the sternocleidomastoid muscle that causes the infant’s head to be turned to one side and laterally flexed to the opposite side; may be congenital or may develop as a result of habitual positioning
CMT
congenital muscular torticollis
PT POC/goals for infants with OBPP
- maintain or improve passive and active ROM
- encourage functional use of involved extremity
-improve sensory awareness - avoid further injury
PT interventions for infants with OBPP
- passive, active assisted, & active ROM
- strengthening exercises
- function UE activities such as bimanual tasks
- parent/child education regarding joint alignment and extremity protection
- neuromuscular estim
- biofeedback
- splinting
Precautions during PT for infants with OBPP
- surgeon/physician specific protocols for activity restriction
- avoid overstretching
- awareness of potential decreased sensation
- maintenance of appropriate biomechanical alignment of UE during weightbearing
Complications interferring with PT in infants with OBPP
- development of torticollis
- decreased sensation
- unstable joints
- contractures
- flaccidity
- neglect of involved UE
Brachial plexus injuries are divided into 3 groups: upper, lower, and total. What is the difference?
- Upper = Erb’s Palsy - involves C5-C6 and possible C7 (most common)
- Lower = Klumpke’s Palsy - involves C7-T1 (least common)
- Total = Erb-Klumpke Palsy - C5-T1
neuropraxia vs complete avulsion
- Neuropraxia: temporary nerve conduction block d/t stretching of nerves
- complete avulsion: nerve root is forcefully torn away from spinal cord
Risk factors for OBPP
- increased birth weight
- shoulder dystocia
- maternal diabetes
- prolonger or difficult labor
- breech delivery
- vacuum or forceps assisted delivery
Erb’s Palsy (upper OBPP) causes a position called waiter’s tip - describe the position of the involved arm.
- shoulder adduction
- shoulder IR
- elbow extension
- forearm pronation
- wrist and finger flexion
Describe musculataure/arm position of a child with Klumpke’s Palsy (Lower OBPP).
- intact shoulder and elbow musculature
- paralysis of wrist flexor and extensors, and intrinsic hand muscles
- involved forearm held is supination
- poor grasp
Describe deficits of Erb-Klumpke Palsy (total OBPP).
- total arm paralysis and loss of sensation
- deficits can diminish over time
Some children with OBPP exhibit Horner Syndrome d/t loss of sympathetic nerve inputs from T1. What are symptoms of Horner syndrome?
- decreased sweating
- abnormal pupillary contraction
- ptosis (droopy eyelid)
What are some secondary impairments that may develop in children with OBPP?
- contracture
- abnormal bone growth
What are some neurosurgical options?
What are the primary determinant for neurosurgical intervention?
- nerve grafting
- removal of scar tissue
- direct end-to-end anastamosis of nerve endings
- long ago: lack of bicep function
- now: lack of shoulder ER and forearm supinators
Contraindications and precautions for children with OBPP.
- any movement (including PT assessment) of involved UE during rest period (7-10 days after birth)
- aggressive movements that force joints or overstretch involved UE
- Treatment and HEP: use precaution related to joint dislocation and subluxation
3 tools used to assess children with OBPP and what ages they are used for
- Assisting Hand Assessment (AHA) - 18 mos to 12 years
- Pediatric Evaluation of Disability Inventory (PEDI) - 6 mos to 7.5 yrs
- Pediatric Outcomes Data Collection Instrument (PODCI) - 19 years and younger
