Lecture 14: Brachial plexus injury Flashcards
Etiology and Risk Factors:
* Traction Injury during delivery
* Forceful head rotation during delivery - head gets stuck, espeically if they come out posterior/backwards
* Congenital Anomalies - typically clavical / cervical rib
* Prolonged Maternal Labor - stuck for a long time on moms pelvis
* Shoulder Dystocia - their shoulders are just too big
* Breech Delivery - coming out bottom first
* Gestational Diabetes - big babies (macrosomia)
* Birth Weight > 90% - big babies
* Cervical Rib Anomaly
NOTE much less likely to have brachial plexus pathology w/ C-section becaue they’re not going through birth canal (small)
Patholophysiology:
Damage to nerve structure
* Level of nerve attached to spinal cord
* Rootlets
* Spinal nerve
* peripheral n
* Complete or partial rupture
Traction injures may resolve spontaneously
Avulsion injures - may require surgery
What is Erbs Palsy?
Injury to C5-C6
This is a waiters tip - so its because these muscles are working, their antagonists are fucked
* Shoulder: Extension, IR, Adduction
* Elbow: Extension
* Forearm: Pronated
* Wrist and Fingers: Flexed
Loss of scapulo-humeral rhythm
Sensory deficit
Paralysis or paresis of involved muscles
What 3 nerves are impacted w/ Erbs Palsy?
* What muscles w/ these nerves?
* What about sensory
Axillary n
* Teres minor
* Deltoid
msculocutaneous n
* Motor: Coracobrachialis, biceps brachii, brachialis
* Sensory: Forearm
Suprascapular n
* Motor: Supraspinatus and infraspinatus
* Sensory: AC joint and glenohumeral joint
Whats impacted in Global palsy?
C5-T1
* makes sense, its gloabl, thats the entire brachial plexus
Paralysis or decreased activation of all muscles of the affected arm
Decreased or loss of sensation
Significant functional deficits
typically more sevre injury = typically paralysis instead of paresis (partial paralysis)
Klumpke’s Palsy:
* Injury to what n roots
* are the shoulder/elbow impacted?
* How does the forearm rest?
* What happens to wrist flexors and extensors?
* What happens to the intrinsic finger muscles?
C8-T1
Shoulder = not impaired
Elbow = Not impaired
Forearm: typically rests in supination
Wrist: Paralysis of wrist flexors and extensors
Fingers: Paralysis of intrinsic muscles
claw hand
Risks associated w/ Brachial Plexus injuries:
* Injuries due to neglect-self absuve behaviors, burns, insect bites, abrasions - really anything that could happen to your arm because you can’t feel it - not actual self abuse, they just mess w/ it because they can’t feel it
* Torticollis - tilting head because arm doesnt work right
* Plagiocephaly
* Asymmetry of trunk muscles
* Flattening of the humeral head - wolfs law
* Short clavicle
* Humeral Head hypoplasia - underdevelopment - don’t have that wt bearing through ball and socket = might not develop as well
* Posterior Subluxation of the humeral head - muscles are messed up / glenoidfossa isnt formed correctly due to lack of wt bearing
* Irregular glenoid fossa -
* Ligamentous pathology - don’t have the m pull the corerct way
* Muscle tightness
* Poor shoulder biomechanics
Examination:
* Active and PROM - depends on severity if you’re doing all this. If established diagnosis this should be fine - litteraly can just do it w/ a goni
* Strength - make it functional - remember, function is different for kids than adults | can also use reflexes
* Posture - look at symmetry. Remember kids don’t get cervical extension till prone on elbows (5-7 months) - look and see if scap is winging
* Pain
* Sensory Status - rub on them and see if they attended to it
* Vision/Visual Attention to UE - do they notice that arm? if you move it around are they neglecting it?
* Neglect - can teach them to take their arm w/ them
* Developmental Status
* Function -
* Reflexes - looking for symmetry
Might have lots of different imaging or might have no imaging (because you typically need to knock baby out so its still)
know the active movement scale exists
* its a way to measure strength in babies
* Do not need to know different grades / motiosn
Modified Mallet Classification
* do not need to memorize all
* know that this is for kids w/ brachial plexus injuries
* Can look at lots of their different movements and give them a grade
Be able to diliniate this apart form other scales knowing its used for the brachial plexus
Treatment:
* Partial immobilization 1-2 weeks to avoid further injury - onsie with safety pins pinning arm across the body - protect it so the shoulder doesnt get tractioned again
* Gentle ROM after immobilization to avoid contractures
* Elicit muscle activity with age-appropriate functional movements of UE and scapula
* Gentle constraint of unaffect UE - however, for babies this takes away the opportunity for them to do brain mapping of that good side - SO WE CANT DO IT TO EARLY, OR TO MUCH WHEN THEY’RE SUPER YOUNG
* Positioning for protection and function - make sure arm isnt trapped behind them all the time
* Functional E-stim - if they cant communicate probs dont use it
* Protection of joints
* Splinting and bracing
* Strengthening as age-Play and weight bearing
* Serial casting following botox
* Aquatics - can get lots of ROM - good to decrease pain
* joint mobilizations
* Promotion of symmetry
* Progression of gross and fine motor skills
* Sensory awareness - sometimes they have some hypersensitivity when sensation comes back
Recovery:
* Majority of infants recover-triceps, biceps, deltoid, and wrist extensor function by 6 months of age - if you see a tiny bit of motion that means you can strengthen it
* No signficiant improvement by 6 months = long term disability likely
* Variety of recovery
When putting on a shirt:
* Which extremeity goes in first?
* Which extremity comes out first?
Affected in first so unaffected can help pull the shirt on
Unaffected out first so that it can help get the rest of the shirt off
