Obstetric Brachial Plexus Palsy

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Obstetric Brachial Plexus Palsy

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Obstetric Brachial Plexus Palsy

  1. 1. Obstretic brachial plexus palsy Dr. Gajanan Pandit Mumbai Port Trust Hospital
  2. 2. Anatomy
  3. 3. Anatomy Variations  Pre Fixed run from C4-C8 stretching injury -Erb’s palsy  Post fixed run from C6-T2 abduction injury -Kumpke’s palsy
  4. 4. Definition  An injury to all or to a portion of a child’s brachial plexus nerve network occurring at the time of delivery.
  5. 5. Classification  Pre/Postganglionic  Supra/Infraclavicular  Nature of injury  Level of injury
  6. 6. Risk factors  Cephalopelvic disproportion  A large or a macrosomic baby  Delivery-Premature/Breech/Instrumental  Shoulder dystocia  Primigravida  Prolonged labour  Congenital anomalies
  7. 7. Shoulder dystocia
  8. 8. Types  Erb-Duchenne Palsy (60%)  Klumpke’s Palsy (5%) + Horner syndrome (1%)  Mixed (35%)
  9. 9. Erb-Duchenne Palsy  William Smellie, a British obstetrician is credited with the first medical description of obstetric brachial plexus palsy.  1861- Benjamin Amand Duchenne coined term ‘obstetric palsy of the brachial plexus’  1874 - Wilhelm Heinrich Erb concluded his thesis on adult brachial plexus injuries
  10. 10. Risk Factors  Maternal  Foetal  Intrapartum events  Neonatal
  11. 11. Mechanism of injury  Bending or stretching of the neck in a direction away from the side of injury
  12. 12. Clinical presentation  waiter’s /porter's/policeman’s tip position
  13. 13. Affected nerves  Dorsal scapular, suprascapular, lateral pectoral, long thoracic, musculocutaneous, radial, median and phrenic nerves.
  14. 14. Sensory deficits  Radial side of the deltoid, forearm and hand
  15. 15. Muscle weakness  External rotators and abductors of the shoulder/arm.  Flexors of the forearm.  Extensors of the fingers (C7).  Diaphragm descent (C4).
  16. 16. Muscle weakness • Moro, biceps and radial reflexes are absent on the affected extremity however, • grasp reflex remains intact.
  17. 17. Klumpke’s Palsy  1885 -Augusta Dejerine-Klumpke neurologist and neuroanatomist diagnosed total brachial plexus radicular paralysis with oculopupillary involvement in a patient
  18. 18. Risk Factors  Maternal  Foetal  Intrapartum events  Neonatal
  19. 19. Mechanism of injury  Pulling up of the arm above the head, so that stretch on the C8 and T1 roots
  20. 20. Affected nerves  Inferior trunk ( C8,T1)  Radial nerve, ulna nerve, the thoracodorsal nerve, median nerve and the medial pectoral nerve.
  21. 21. Sensory deficits  Ulnar side of the forearm and hand
  22. 22. Muscle weakness  Pronators of the forearm  Flexors of the wrist joint.
  23. 23. Horner syndrome  Bernard-Horner syndrome and oculo- sympathetic palsy  Injury to cervical sympathetic ganglions.  Enophthalmos, partial ptosis, swelling of the lower eyelid, miosis , unhydrosis and heterochromia.  Loss of ciliospinal reflex.
  24. 24. Complications Fracture of the clavicle Fracture of the humerus Subluxation of the cervical spine Cervical cord injury Facial nerve palsy Phrenic nerve palsy
  25. 25. Nerve Injury  Avulsion :-  Rupture :-  Stretching :-  Scarring :- Neuropraxia Axonotmesis Nerotonmesis
  26. 26. Management X-rays to exclude fractures and examination for phrenic nerve paresis are important. Other investigations - Electromyography, NAP, SEP, Nerve conduction studies, CT myography and MRI.
  27. 27. Management Most cases of OBPI resolve spontaneously in ~ 4 months to 2 year after delivery. To prevent contractures, physiotherapy using wrist splits after 7days immobilization. Surgery if movement doesn’t return after 3 months and electrophysiology indicate a poor prognosis.
  28. 28. Opponens Pollicis Flexor Pollicis Longus Adductor Pollicis Pectoralis Major (lower) Biceps Flexor Pollicis Brevis Extensor Digitorum Superficialis Extensor Digitorum Profundus Pronator Quadratus Extensor Carpi Radialis Longus & Brevis Frexor Carpi Radialis Triceps Extensor indices Extensor Digitorum Flexor Carpi Ulnaris Extensor Digiti Minini Extensor Carpi Ulnaris Extensor Pollicis Longus Abductor Pollicis Longus Extensor Pollicis Longus Brachialis Pronator Teres Pectoralis Minor Deltoid Serratus Anterior Rhomboid Major & Minor Supinator C5 Supraspinatus Infraspinatus Pectoralis Major (upper) T1 C8 C7 C6 Lumbricals Brevis Abductor Pollicis Interossei
  29. 29. Neurrorhaphy
  30. 30. Neurolysis
  31. 31. Neuroma
  32. 32. Neurotization
  33. 33. Botox Injection
  34. 34. Nerve Conduit
  35. 35. Tendon Transfer
  36. 36. Modified ‘Quad’
  37. 37. Tendon Transfer
  38. 38. Nerve Decompression
  39. 39. Bony Procedures
  40. 40. Triangle Tilt
  41. 41. Post op.
  42. 42. Thank you…..

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