Torticollis and Brachial Plexus Injuries Flashcards
What is the associated muscle problem involved with CMT?
Unilateral shortening of the sternocleidomastoid
What is the presentation for a child with CMT?
- limited cervical ROM
- laterally flexed toward the shortened muscle and rotated away
(ex: shortened R SCM, laterally flexed to R, rotated to L)
What is the proposed etiology for CMT?
Delivery complications or how the baby is positioned in utero
What babies are most at risk for developing CMT?
Breech babies, first born babies, babies that require instruments during delivery, heavier babies, babies born during complicated labor and delivery
What changes can be seen in the SCM for those with CMT?
A palpable mass or fibrotic tumor. Fibrosis of SCM is present in all children with CMT, mass may or may not be present.
What is the hypothesized reason that the SCM is damaged during labor?
Occlusion to the blood vessels with resultant anoxic injury to SCM muscle
What are the 3 types of CMT?
- SCM Tumor
- Muscular Torticollis (MT)
- Positional Torticollis (POST)
Describe a SCM Tumor
A definitive mass or tumor is palpable within the SCM muscle
Describe MT
Contracture of the SCM is present but no palpable mass is present
Describe POST
Contracture of the SCM muscle and a palpable mass are ABSENT
What are some conservative methods of treating MT?
- prolonged passive stretching of the SCM muscle
- positioning and handling
- active cervical ROM with strengthening exercises
- symmetric development activities to correct head position
What orthotic device can be useful in treating MT?
A TOT collar
What does the TOT do?
Elongates targeted muscles and limits motion in the opposite direction
When is a TOT recommended?
For infants at least 4 months old with a consistent head tilt of 5 degrees or more for more than 80% of the day, who perform all movements with a head tilt
When is surgery recommended for CMT?
For infants that don’t respond after 6 months of conservative treatment.
Have a residual head tilt and exhibit deficits of passive rotation and lateral flexion of the neck >15 degrees
What is the term for infants with cranial-facial asymmetry?
Plagiocephaly
What does DOC stand for? Is it approved by the FDA?
Dynamic Orthotic Cranioplasty, it is approved
How does the DOC work?
It’s a cranial band that applies pressure to the anterior and posterior prominences of the cranium but allows growth in the flattened areas
Who are DOC bands recommended for?
Between 3 and 4 and below 12 months of age
How long should a DOC band be worn?
23-24 hours a day initially
What are 2 other additional treatments that can be used for infants with plagiocephaly?
PT and Botox injections
Where do brachial plexus injuries occur?
- rootlet attached to spinal cord
- anterior or posterior rootlets
- distal to rootlet attachment leaving vertebral canal
________ is a complete rupture of the nerve and nerve sheath.
Neurotmesis
neuro + tmesis=cut
_______ is a disruption of the axons with the neural sheath intact.
Axonotmesis
axono + tmesis=cut
_____ is a temporary nerve conduction block with intact axons.
Neurapraxia
neuro + praxia=from apraxia, uncoordinated
What is the prognosis for a brachial plexus injury? What is the regrowth rate for axons?
Depends on severity.
Regrowth = 1mm/day
UE = 4-6 months
LUE = 7-9 months
What are the risk factors for brachial plexus birth palsies?
- shoulder dystocia
- maternal diabetes
- difficult deliveries
What occurs during shoulder dystocia?
The baby’s shoulder is caught on the mother’s pubic bone and is dislocated
How can maternal diabetes lead to a brachial plexus injuries?
Mother has high glucose levels, brings extra glucose the baby, causes baby to put on extra weight
What are some labor difficulties that can cause brachial plexus injuries?
- breech birth (head is caught in birth canal)
- impacted shoulder (vacuum may be needed for extraction, can stretch nerves of brachial plexus)
What are some of the negative effects that occur with traction during delivery?
- injure cervical roots
- fracture clavicle or humerus
- sublux the shoulder
Traction and rotation of the head tends to injure ______ roots.
C5 and C6
What occurs with an injury to C4?
Less common- will cause ipsilateral hemiparesis of the diaphragm
Infants with a birth weight over ____ lbs had a risk of BPI ___x greater of that of infants born less than ____ lbs.
9.9 lbs (4500 g)
45x
7.7 lbs (3500 g)
What is the most important risk factor for developing a BPI?
Birth weight
What is the most common presentation of BPI? What nerves are affected?
Upper roots of C5-C6
Erb’s Palsy
What changes occur with Erb’s Palsy?
Shoulder is held in EXT, IR, ADD Elbow is extended Forearm is pronated Wrist and fingers are flexed Grasp is intact, sensory loss may be present
What occurs if C7 is invovled?
Elbow and finger extension are compromised
What is Erb-Klumpke Palsy?
Combination of the injury to the upper and lower roots (C5-T1)
What is the presentation of Erb-Klumpke Palsy?
Total arm paralysis and loss of sensation.
Unilateral involvement, pattern doesn’t always fit classic definitions indicating incomplete or mixed upper/lower types
What syndrome is associated with Erb-Klumpke Palsy?
Horner’s Syndrome- deficient sweating, recession of eyeball (ptosis), abnormal pupillary contraction
What is Klumpke’s Palsy?
Involves only lower roots of C7-T1
What is affected in Klumpke’s Palsy?
- shoulder and elbow movement are not impaired, resting position of forearm is in supination
- paralysis of wrist flexors/extensors, and intrinsics of the wrist/hand
What are the key observation/examination findings for Erb-Klumpke Palsy?
- UE neglect
- Soft tissue contractures
- Abnormal bone growth
What orthopedic abnormalities are noted with Erb-Klumpke Palsy?
- Flattening of the humeral head
- Shortened clavicle
- Hypoplasia (hypo=under, plasia=formation) of the humeral head
- Abnormal glenoid fossa
What type of torticollis is associated with Erb-Klumpke Palsy? Why?
Positional Torticollis
Can develop if the head is habitually positioned away form the involved arm or may be present from same trauma
What are the 3 main activities will a child with EKP be impaired with/unable to complete?
1) Reach
2) Grasp
3) Tasks involving bilateral manual abilities
What changes can be present in a child with EKP in the following areas:
1) prone/supine to sit
2) creeping
3) mobility
1) may be done to one side, thereby asymmetrically strengthening one side of the trunk or delaying balance reactions
2) creeping on all 4’s may not occur
3) child may scoot in sitting or progress directly to walking
What problems can result from sensory impairments associated with EKP?
Burns, insect bites and abrasions may go unnoticed
What are the goals of management for a patient with EKP?
1) provide opportunity for adequate growth/development with a multidisciplinary approach
2) continued assessment of motor function return
3) possible activity limitations
What types of neurosurgical interventions are available for patients with EKP?
- nerve grafting
- neuroma dissection and removal
- neurolysis
- direct end-to-end nerve anastomosis of the nerve ends
Describe the active movement scale chart for BPI
0= no contraction 1= contraction w/o movement 2= 1/2 ROM 4=full ROM (gravity eliminated) 5=1/2 ROM 7=full ROM
Why may orthopedic surgery be an option for patients with BPI?
Contractures and deformities.
Shoulder ADD/IR, elbow flex/ext, forearm pronation
What types of orthopedic surgical intervention are available for BPI?
- Soft tissue releases
- reduction of GH joint dislocations
- transfers of muscles
- osteotomies
What is the prognosis for BPI?
Early studies report 80-90%
More recent report 66-73%
What is the common presentation for a patient with a BPI?
Decreased ER IR contractures Weak/limited should ABD Scapular winging Stronger IR
What special test is specific to BPI? What other test is it best used with?
Brachial Plexus Outcome Measure
Active Movement Scale
What does the Brachial Plexus Outcome Measure consist of?
Evaluates the UE movement with 11 movements. Graded on 5 point ORDINAL scale. Demonstrates good internal consistency and CONSTRUCT validity.
What are the PT goals for a patient with a BPI?
Ideal Outcome: return of motor control and sensation without limitations
- increase shldr ABD to >90 degrees
- correct IR of arm
- increase flex/ext against resistance in elbow, wrist, fingers
- improve sensation in arm/hand
- prevent deformities in arm/hand
- achieve developmental milestones
How long/why should a rest period be enforced before beginning any interventions after a BPI?
7-10 days to wait for swelling to go down
Why are ROM and sensory interventions necessary in BPI?
ROM to prevent adhesions
Sensory awareness to reduce neglect
How can splinting be beneficial is patients with a BPI?
- can place UE in optimal position, promote soft tissue mobility
- intermittent splinting can preserve tendons and reduce contractures
- restraining splints can promote activity of involved limb
What position should the arm with the BPI be placed in while splinting?
shoulder ABD and ER, elbow flexion and forearm supination
