Obstetric brachial plexus injury (OBPI)


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My seminar While Pursuing Master of Physiotherapy (MPT) at Manipal University

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Obstetric brachial plexus injury (OBPI)

  1. 1. D.A.ASIR JOHN SAMUEL., ( Paed.Neuro) Final Yr MPT Under, Mr. M.MANIKANDAN., MPT (Neuro) Associate Professor
  2. 2. *Definition*Incidence*Risk factors*Classification*Investigation*Management*Prognosis
  3. 3. *Obstetrical brachial plexus palsy is defined as a flaccid paresis of an upper extremity due to traumatic stretching of the brachial plexus received at birth, with the passive range of motion greater than the active range of motion Arch Dis Child Fetal neonatal Ed 2003;88:F185-9
  4. 4. *Brachial palsy is a paralysis involving the muscles of the upper extremity that follows mechanical trauma to the spinal roots of C5 to T1 (the brachial plexus) during birth*Injuries are transient, with full return of function occuring in 70-92% of cases¹ 1.Plas Reconstr Surg 1994;93:675-80
  5. 5. 0.38 – 3 / 1000 (2001) Due to Advances in obstetrics0.19 – 2.5 / 1000 Indian journal obstetrics 2009;43:236-46
  6. 6. *The risk factors for brachial plexus palsies may be divided into three categories:1. Neonatal2. Maternal3. Labor-related factors
  7. 7. *High birth weight ( > 4 kg )*Low APGAR score at 1 min, 5 min & 10 min*Breach fetal position Pediatr Neurol 2008;38:235-242
  8. 8. *Age ( > 35 years )*Cephalo-Pelvic Disproportion*Gestational Diabetes Mellitus ( results in Macrosomia )*BMI*Post date gestation Pediatr Neurol 2008;38:235-242
  9. 9. *Increased duration of 2nd stage of labour*Induction of labour- Oxytocin augment*Operative vaginal deliveries- Vacuum extraction- Direct compression of fetal neck duringdelivery by forceps Pediatr Neurol 2008;38:235-242
  10. 10. *Based on,1. Severity2. Anatomical location3. Clinical findings
  11. 11. *Avulsion*Rupture*Neuroma*Neuropraxia
  12. 12. 1. Proximal or Duchenne-Erb’s paralysis (Injury to C5 & C6, most common)2. Intermediate paralysis ( Injury to C7 )3. Distal or Klumpke’s paralysis ( injury to C8 & T1, extremely rare)4. Total brachial plexus paralysis ( more often than the Klumpke type) Duchenne-Erbs type > Total brachial type > Klumpke type
  13. 13. *Group I, C5-C6 – paralysis of shoulder & biceps*Group II, C5-C7 – paralysis of shoulder, biceps & forearm extensor*Group III, C5-T1 – Complete paralysis of limb*Group IV, C5-Th1 – Complete paralysis of limb with Horner’s syndrome
  14. 14. *In 1874, Wilhelm Heinrich Erb described isolated upper brachial plexus palsy*The site of damage localized to the junction of C5 & C6*Due to,- Breech presentation with arms extended over the head- Excessive traction on the shoulder- # clavicle during vaginal delivery
  15. 15. 1. Deltoid2. Supraspinatus3. Infraspinatus4. Rhomboids5. Clavicular head of pectoralis major6. Teres minor7. Biceps8. Brachialis9. Extensor carpi radialis longus & brevis
  16. 16. *Arms hangs by the side with,*Shoulder – internaly rotated*Elbow – extension*Forearm – pronated with palm facing backwards (tips position)*Hand & finger functions - preserved
  17. 17. *Baby’s arm is positioned in,*Shoulder – abduction & external rotation*Elbow – flexed*Forearm – supinated*Wrist – behind the neck*This position prevents contracture of Subscapularis, Pectoralis major*Passive stretching
  18. 18. *Isolated injuries to the distal or lower portion of the brachial plexus is described by Klumpke*The site of damage localized to the junction of C8 & T1*Due to,- Stretching of lower plexus N. under and against coracoid process during forceful elevation or abduction of the arm- Excessive traction on the trunk
  19. 19. 1. Flexors of wrist2. Flexors of fingers (FDS & FDP)3. Intrinsic muscles of hand*If sympathetic trunk is involved results in ipsilateral Horner’s syndrome ( ptosis, hypohirdosis, miosis & enopthalmos)*Associated with delayed pigmentation of iris
  20. 20. *Involves injury to all the roots / trunks / cords of the brachial plexus*It is of 2 types depending on the level,1. Pre-ganglionic2. Post-ganglionic
  21. 21. *Traction injury resulting in the avulsion of Pre ganglionic level of all the roots C5 to T1*If T1 root at Pre ganglionic level is affected results in Horner’s syndrome ( ptosis, hypohirdosis / anhidrosis, miosis & enopthalmos)*Serratus anterior & Rhomboids muscles are paralysed*Lesion is irrecoverable*Limb is functionless
  22. 22. *Post ganglionic level lesion at all roots C5 to T1*Serratus anterior & Rhomboids muscle functions are preserved*If lesion is axonotmesis – recovery is possible*If lesion is neuronotmesis – surgical exploration & repair may be needed
  23. 23. Gravity EliminatedNo contration 0Contraction, no motion 1Motion ≤ ½ range 2Motion >½ range 3Full motion 4Against GravityMotion ≤ ½ range 5Motion >½ range 6Full motion 7 Journal of the American society for surgery of the hand 2003; 3:1, 41-54
  24. 24. Modified Mallet classification
  25. 25. S0 – No reaction to painful or other stimuliS1 – Reaction to painful stimuli, none to touchS2 – Reaction to touch, not to light touchS3 – Apparently normal sensation APMR,59:458-464,1978
  26. 26. M0 – No contractionM1 –Contraction with out movement (shoulder,elbow, wrist); slight movement of digitsM2 – Incomplete movement when suppressing, weakcomplete movement of digitsM3 – complete movement with apparently normalforce APMR 1978,59:458-464
  27. 27. *Chest X-ray – to rule out Phrenic N. palsy*CT with metrizamide (CT-myelogram)*MRI – integrity of nerve roots*Electromyography- 48 hrs within delivery distinguishes b/w prenatal & OBPI- Detect signs of reinnervation- Root avulsions (80% accuracy)
  28. 28. *Nerve Conduction Studies (NCV)- Sensory nerve conduction but absence of motor nerve conduction at 3 months – Avulsion injury*SSEP & MEP denotes the integrity of sensory & motor fibres
  29. 29. *EMG- Fibrillation potential- motor unit action potential (MUAP)*Nerve Conduction Studies- Sensory nerve action potential (SNAP)- Compound muscle action potential (CMAP).
  30. 30. *Fibrillation potential appear about 3 weeks after motor nerve injury*Minimal degree of nerve lesion – innervation ratio*MUAP loss occur immediately – moderate lesion Neurol Clin N Am 20 (2002) 423–450
  31. 31. *Absolutely abnormal – less than age based laboratory control values*Relatively abnormal - < 50% than the amplitude of homologous response recorded from contralateral side*Wallerian degeneration apparent 2-3 days on NCS Neurol Clin N Am 20 (2002) 423–450
  32. 32. *SNAPs & CMAPs are spared – minimal lesion SNAP amplitude decrease ( moderate) CMAP amplitude decrease (severe) Neurol Clin N Am 20 (2002) 423–450
  33. 33. *CMAP amplitudes are the most useful for quantifying the amount of axon loss suffered by a nerve*Prior to reinnervation, the CMAP amplitudes are the most reliable indicator of the amount of axon loss present, and the relationship is roughly one to one.*For example,*CMAP amplitude from symptomatic side – 5mV*CMAP amplitude from asymptomatic side – 10mV Neurol Clin N Am 20 (2002) 423–450
  34. 34. *CMAP amplitudes begin to decrease on day 2 or 3 and reach their nadir at day 7*SNAP amplitudes begin to drop on day 6 and reach their nadir around day 10 or 11*Fibrillation potential after day 21*MUAP loss occurs immediately - at least moderate in degree*Prolonged duration, increased polyphasia and, occasionally, heightened amplitude – during reinnervation (MUAP) Neurol Clin N Am 20 (2002) 423–450
  35. 35. *The length of nerve between the lesion site and the denervated muscle fibers*Advancement occurs at a rate of about 1 in/month*Denervated muscle fibers survive for approximately 18 to 24 months.* After this period of time has elapsed, the muscle fibers undergo degeneration and, from that point onward, can no longer be reinnervated Neurol Clin N Am 20 (2002) 423–450
  36. 36. 1. Supporting structures are spared2. Distance between the lesion and the denervated muscle fibers is short3. Lesion is incomplete Neurol Clin N Am 20 (2002) 423–450
  37. 37. *End organs of the sensory nerve fibers do not undergo degeneration,*There is no time limit on sensory nerve fiber regeneration.*If it requires more than 2 years for the sensory fibers to reach their end organs, reinnervation can still be successful Neurol Clin N Am 20 (2002) 423–450
  38. 38. *Conduction slowing- Neuropraxia- Axonotmesis*Conduction block- Neuronotmesis Neurol Clin N Am 20 (2002) 423–450
  39. 39. *No SNAP domain*CMAP domain includes,*Musculocutaneous NCS recording Biceps (Musc- biceps)*Axillary NCS recording deltoid (Ax-deltoid).*EMG domain includes those muscles contained within the C5 myotome.
  40. 40. * SNAP- lateral antebrachial cutaneous NCS (LABC; 100%)- Median NCS recording from first digit (Med-D1; 100%), second digit (Med-D2; 20%) & third digit (Med-D3; 10%) sensory NCS.- Superficial radial NCS (S-Radial; 60%)*CMAP – Biceps & Deltoid*EMG domain includes those muscles belonging to the C6 myotome.
  41. 41. *SNAP- Med-D2 (80%)- Med-D3 (70%)- S-Radial (40%)*CMAP – EDC (Radial)*EMG domain includes muscles belonging to the C7 myotome Neurol Clin N Am 20 (2002) 423–450
  42. 42. *SNAP domain of the C8 APR includes Uln-D5*CMAP domain Ulnar NCS, recording abductor digiti minimi (Ulnar-ADM) and first dorsal interosseous (Uln-FDI)- Radial NCS, recording Extensor indicis proprius (Radial-EIP) motor NCS- To a lesser extent, the median NCS, recording abductor pollicis brevis (Median-APB)*EMG domain consists of those muscles belonging to the C8 myotome
  43. 43. *CMAP domain -Abductor pollicis brevis, the Median-APB NCS is a more reliable*EMG domain consists of those muscles belonging to the T1 myotome.* Abductor pollicis brevis*Flexor pollicis longus muscles are the most helpful in its assessment
  44. 44. *Fracture Pseudoparalysis*Congenital Varicella of the Upper Limb*Cerebral Palsy (Monoplegia)*Intrauterine Upper-Limb Nerve Compression by the Umbilical Cord or Amniotic Bands*Intrauterine Maladaption Palsy
  45. 45. *Surgical management*Conservative management
  46. 46. *Pediatric neurosurgeon*Plastic reconstructive surgeon*Pediatric orthopaedic surgeon
  47. 47. *Thomas and Dargassie developed towel test*Lefevre and Diament called it as hand to face test*In supine, the child face is covered with towel*Shoulder flexion, elbow flexion and extension and finger flexion and extension are needed for the test.*He/she passes the test if he/she then removes the towel from the face. Journal of Hand Surgery,2004,29B:2:155–158 – LOE-3B
  48. 48. *Absence of biceps recovery by 3 months of age is an indication of surgery*The infants that did not pass the towel test At 6 months also did not pass it at 9 months are the potential candidates for surgery Journal of Hand Surgery,2004,29B:2:155–158
  49. 49. *Surgical exploration should be done within 6 months of life*Exploration and nerve grafting or neurotization if there is a complete plexus palsy at 3 months or if there is a C5-C6 palsy with absence of biceps at 3 months*Failure of recovery of elbow flexion and shoulder abduction from the 3rd to the 6th month of life Plast. Reconstr. Surg. 2004;113: 54e-67e
  50. 50. *Nerve transfer/neurotization- Intercostal N.- Ulnar N.- Sural N.- Suprascpular N.- Axillary N.*Nerve anastomosis*Nerve reconstruction
  51. 51. *Neurolysis*Neuroma resection*Neurorrhaphy
  52. 52. *Internal rotation contracture- subscapularis release- Latissimus dorsi infraspinatus*Improving abduction- Trapezius / latissimus dorsi trasnfer to humeral head
  53. 53. *Improving forearm pronation- Flexor-pronator transfer (steindler procedure)*Improving elbow extension (in lower plexus injury)- Latissimus dorsi transfer*Improving elbow flexion- Flexorplasty – triceps, PM, Lats
  54. 54. *Immobilization- Cast 3-6 weeks- Night splint 3-6 months*Scar management- Tendon gliding- US massage
  55. 55. *Muscle reeducation- cues to perform previous action of transferred muscle- Taping / vibration over muscle belly- Biofeedback- NEMS-after 6 weeks*Functional performance
  56. 56. *Maintain- PROM- Supple of muscle- Muscle strength*Stretch muscle groups to prevent contracture
  57. 57. *Initial rest period of 7-10 days – to allow for reduction of hemorrhage & edema around the traumatized nerves*No ROM or other interventions are initiated*The involved UL is positioned across the abdomen*Avoid lying on the involved limb*Baseline examination – after initial period of immobilization
  58. 58. Maintain ROM- Facilitates normal movement patterns while inhibiting substitutions- Lift 10 toy/ball & put in doll house/basket – shoulder F.- Paralysis & contracture of Rhomboids disturbs normal 6:1 humeroscapular rhythm in first 30º of shoulder mvt.- Stabilize the scapula & assist active F as child reaches for a toy Developmental Medicine & child Neurology 2001,43:419-426 – LOE-4A
  59. 59. - Hand to mouth- Transferring objects- Weight shifting on propped UE in prone & quadruped- Sitting with hands in front or back- Creeping- Reaching for toys placed at variety of angles & heights Developmental Medicine & child Neurology 2001,43:419-426 – LOE-4A
  60. 60. - In side-lying on uninvolved arm to avoid stresses on involved arm & to free the weak arm to reach & play with toys in front of them- Joint compression in weight bearing- Restraining uninvolved arm & encouraging involved arm
  61. 61. - Up to 65% of children with incomplete OBPI have limited ROM (Dev Med & Child Neurol 2004,46:76-83)- Prevent Scapulohumeral adhesion by restraining/stabilizing the scapula during reaching & allowing muscles to stretch in initial 30º of Abd.- Beyond 30º scapula must rotate along with humeral ER- Botox improves AROM & benefits lasted upto 6 wks Pediatric Rehabilitation 2001,4:29-36 – LOE-2B
  62. 62. - Sensory loss can lead to neglect or self-mutilation- Parents should be cautioned about risk of self mutilation such as biting an insensate area- Sensory perception can be enhanced by placing objects of different textures & temperatures in hand- Playing games such as finding toys under sudsy water/rice/sand- Blindfolding & having her name familiar objects placed in hand
  63. 63. - Arm is positioned toward Abd, ER, elbow F & forearm Supination on a pillow to child’s side – during sleeping
  64. 64. - Resting night splints – prevent wrist & finger F contracture- Wrist cock-up – maintain neutral wrist alignment (Klumpke’s Paralysis)- Statue of liberty splint – prevent Add & IR contracture
  65. 65. *Air splints – restraining uninvolved UE to encourage involved UE*Aeroplane splint – Erb’s palsy
  66. 66. *ES of denervated muscles prevents muscle atrophy*May be used after neurosurgery Archives of Physical Medicine & Rehabilitation 1998,79:458-464 – LOE-4A
  67. 67. *The upper plexus palsies are generally less severe*Poor prognostic factors include- total or lower plex-opathy- Horner’s syndrome- Root avulsions and- Associated fractures (e.g., ribs, clavicle, humerus)- Group IV ( according to Naraks grading) Clin Plast Surg 1984;11:181-7 – LOE -3A Clin Orthop Relat Res 1991;264:39-47
  68. 68. *Spontaneous recovery in 70-95% by 3–4 months of life*At 3 months, the predictive value of regained elbow flexion for complete recovery was 100%* 99% of shoulder ER*96% of forearm supination Developmental Medicine and Child Neurology; Jun 2010; 52, 6;529-534 – LOE-2B
  69. 69. *Physical Therapy for Children – 3rd Ed * Suzan K. Campel*Physiotherapy in Paediatrics – 3rd Ed * Roberta B. Shepherd