Clinical Science III Karen R. Voogt, DPT Fall 2011 Brachial Plexus Injuries
BRACHIAL PLEXUS INJURIES <ul><li>Specifically: Obstetrical Brachial Plexus Injury </li></ul><ul><li>Usually result from fo...
BRACHIAL PLEXUS INJURIES <ul><li>Incidence ranges .5-2/1000 births </li></ul><ul><li>Contributing Factors: </li></ul><ul><...
BPI <ul><li>Occurrence: </li></ul><ul><ul><li>0.1% spontaneous deliveries </li></ul></ul><ul><ul><li>1.2% breech presentat...
BRACHIAL PLEXUS INJURIES <ul><li>May produce lifelong effects: </li></ul><ul><ul><li>Total body  </li></ul></ul><ul><ul><l...
BRACHIAL PLEXUS INJURIES <ul><li>May have associated trauma: </li></ul><ul><ul><li>clavicle or humerus fractures </li></ul...
BPI: pathology <ul><li>May be upper or lower plexus or both </li></ul><ul><li>Roots, trunks, divisions , cords and periphe...
BPI: pathology <ul><li>Partial or complete rupture may evolve into a neuroma, mass of fibrous tissue </li></ul><ul><li>Hem...
BPI Neuronal Recovery <ul><li>Axon regeneration 1 mm per day </li></ul><ul><ul><li>4-6 months for upper arm </li></ul></ul...
Classification <ul><li>Mild: stretching of the nerve fibers </li></ul><ul><li>Moderate: stretching and tearing </li></ul><...
Classification:  <ul><li>Erb’s Palsy,  or upper </li></ul><ul><ul><li>Involvement of the upper brachial plexus and 5th and...
 
Erb’s Palsy <ul><li>Caused by the forceful separation of head/shoulder  </li></ul><ul><ul><li>biceps, deltoid, brachialis,...
Erb’s Palsy cont <ul><ul><li>Affected arm usually hangs at side with shoulder ADD/ IR and elbow extension, forearm pronati...
PROGNOSIS for Erb’s Palsy <ul><li>Generally good for spontaneous recovery, although may be incomplete  </li></ul><ul><li>D...
TREATMENT  <ul><li>Usually involves rest for 7 - 10 days (possibly splinting) </li></ul><ul><ul><li>Positioning/splinting ...
TREATMENT cont. <ul><li>Bimanual activities  </li></ul><ul><li>Balance reactions </li></ul><ul><li>Taping  </li></ul><ul><...
LOWER (Klumpke’s Palsy) <ul><li>Involvement of the lower brachial plexus and 7th and 8th (T1) C- nerve roots </li></ul><ul...
Klumpke’s Palsy <ul><ul><li>Resting position of forearm supination, paralysis of wrist flexors, extensors, intrinsic muscl...
BOTH (Erb - Klumpke) Total Brachial Plexus Injury <ul><ul><li>Infrequent occurrence </li></ul></ul><ul><ul><li>Avulsion of...
Mallet Scale
Surgical Intervention <ul><li>Neurosurgery 5-10% OBPI </li></ul><ul><ul><li>Nerve grafting </li></ul></ul><ul><ul><li>Neur...
Surgical Intervention <ul><li>Later surgeries: </li></ul><ul><ul><li>Soft tissue release </li></ul></ul><ul><ul><li>Reduct...
 
BPI Impairments of Body Structure and Function <ul><li>Abnormal muscle substitutions </li></ul><ul><li>Neglect due to incr...
BPI Activity Limitations <ul><li>Inability to grasp, reach </li></ul><ul><li>Limited bilateral activities ex-catch, carry ...
Scapular winging, Trumpet sign
BPI Treatment Intervention
BPI Treatment Intervention
Interventions
Interventions
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  1. 1. Clinical Science III Karen R. Voogt, DPT Fall 2011 Brachial Plexus Injuries
  2. 2. BRACHIAL PLEXUS INJURIES <ul><li>Specifically: Obstetrical Brachial Plexus Injury </li></ul><ul><li>Usually result from forcible extraction of fetus by traction on shoulder in a breech presentation, or from traction and tipping of the head in a shoulder presentation </li></ul>
  3. 3. BRACHIAL PLEXUS INJURIES <ul><li>Incidence ranges .5-2/1000 births </li></ul><ul><li>Contributing Factors: </li></ul><ul><ul><li>Birth weight >3500g </li></ul></ul><ul><ul><li>Shoulder dystocia </li></ul></ul><ul><ul><li>Prolonged labor </li></ul></ul><ul><ul><li>Maternal diabetes </li></ul></ul><ul><ul><li>Infant sedation </li></ul></ul><ul><ul><li>Breech delivery </li></ul></ul>
  4. 4. BPI <ul><li>Occurrence: </li></ul><ul><ul><li>0.1% spontaneous deliveries </li></ul></ul><ul><ul><li>1.2% breech presentation </li></ul></ul><ul><ul><li>1.3% forceps deliveries </li></ul></ul>
  5. 5. BRACHIAL PLEXUS INJURIES <ul><li>May produce lifelong effects: </li></ul><ul><ul><li>Total body </li></ul></ul><ul><ul><li>Multifactorial </li></ul></ul><ul><ul><li>Progressive musculoskeletal impairment </li></ul></ul><ul><ul><li>Limb length deficits </li></ul></ul>
  6. 6. BRACHIAL PLEXUS INJURIES <ul><li>May have associated trauma: </li></ul><ul><ul><li>clavicle or humerus fractures </li></ul></ul><ul><ul><li>facial nerve injuries </li></ul></ul><ul><ul><li>shoulder subluxation </li></ul></ul><ul><ul><li>torticollis </li></ul></ul><ul><ul><li>hemi paralysis of the diaphragm with phrenic nerve injury (C4) </li></ul></ul>
  7. 7. BPI: pathology <ul><li>May be upper or lower plexus or both </li></ul><ul><li>Roots, trunks, divisions , cords and peripheral nerves can all suffer: </li></ul><ul><ul><li>Neurotmesis: complete rupture </li></ul></ul><ul><ul><li>Axonotmesis: disruption of axons while neural sheath remains intact </li></ul></ul><ul><ul><li>Neurapraxia: temporary nerve conduction block with intact axons </li></ul></ul>
  8. 8. BPI: pathology <ul><li>Partial or complete rupture may evolve into a neuroma, mass of fibrous tissue </li></ul><ul><li>Hemorrhage into subarachnoid space </li></ul><ul><li>May have combination of types of lesions </li></ul><ul><li>Transient or permanent </li></ul>
  9. 9. BPI Neuronal Recovery <ul><li>Axon regeneration 1 mm per day </li></ul><ul><ul><li>4-6 months for upper arm </li></ul></ul><ul><ul><li>7-9 months for lower arm </li></ul></ul><ul><li>Recovery is varied according to damage </li></ul><ul><ul><li>2 years upper arm </li></ul></ul><ul><ul><li>4 years lower arm </li></ul></ul>
  10. 10. Classification <ul><li>Mild: stretching of the nerve fibers </li></ul><ul><li>Moderate: stretching and tearing </li></ul><ul><li>Severe: complete rupture with avulsion of roots from spinal cord </li></ul><ul><li>Diaphragmatic and serratus anterior paralysis suggests avulsion </li></ul>
  11. 11. Classification: <ul><li>Erb’s Palsy, or upper </li></ul><ul><ul><li>Involvement of the upper brachial plexus and 5th and 6th C-nerve roots (20% more common than lower) </li></ul></ul><ul><li>Klumpke’s Palsy or lower </li></ul><ul><ul><li>Involvement of the lower brachial plexus and 7 th and 8 th nerve roots </li></ul></ul><ul><ul><li>Caused by traction on abducted arm </li></ul></ul>
  12. 13. Erb’s Palsy <ul><li>Caused by the forceful separation of head/shoulder </li></ul><ul><ul><li>biceps, deltoid, brachialis, brachioradialis, supinator, supra and infraspinatus, subscapularis, teres minor, serratus anterior and rhomboids, long extensors of wrist, fingers and thumb may be involved </li></ul></ul>
  13. 14. Erb’s Palsy cont <ul><ul><li>Affected arm usually hangs at side with shoulder ADD/ IR and elbow extension, forearm pronation and wrist flexion and finger flexion (“waiter’s tip” position) </li></ul></ul><ul><ul><li>Moro, biceps and radial reflexes are absent - intact grasp </li></ul></ul><ul><ul><li>May have sensory loss </li></ul></ul>
  14. 15. PROGNOSIS for Erb’s Palsy <ul><li>Generally good for spontaneous recovery, although may be incomplete </li></ul><ul><li>Depends on degree of involvement </li></ul><ul><li>Majority of spontaneous recovery by 9 months </li></ul>
  15. 16. TREATMENT <ul><li>Usually involves rest for 7 - 10 days (possibly splinting) </li></ul><ul><ul><li>Positioning/splinting </li></ul></ul><ul><ul><li>Gentle ROM </li></ul></ul><ul><ul><li>Stimulation of muscle function </li></ul></ul><ul><ul><li>Encourage active movement </li></ul></ul><ul><ul><li>Weight bearing </li></ul></ul><ul><ul><li>Sensory input </li></ul></ul>
  16. 17. TREATMENT cont. <ul><li>Bimanual activities </li></ul><ul><li>Balance reactions </li></ul><ul><li>Taping </li></ul><ul><li>Botox </li></ul><ul><li>Electrical stimulation </li></ul>
  17. 18. LOWER (Klumpke’s Palsy) <ul><li>Involvement of the lower brachial plexus and 7th and 8th (T1) C- nerve roots </li></ul><ul><ul><li>caused by traction on abducted arm </li></ul></ul><ul><ul><li>Incidence .6-2% of all OBPI </li></ul></ul>
  18. 19. Klumpke’s Palsy <ul><ul><li>Resting position of forearm supination, paralysis of wrist flexors, extensors, intrinsic muscles of hand (claw- hand deformity) </li></ul></ul><ul><ul><li>Sensory loss of ulnar border of hand/forearm </li></ul></ul><ul><ul><li>T1 involvement </li></ul></ul><ul><ul><ul><li>may see associated paralysis of sympathetic nerves with a Horner’s Syndrome </li></ul></ul></ul>
  19. 20. BOTH (Erb - Klumpke) Total Brachial Plexus Injury <ul><ul><li>Infrequent occurrence </li></ul></ul><ul><ul><li>Avulsion of plexus/roots </li></ul></ul><ul><ul><li>Recovery limited after avulsion/rupture </li></ul></ul><ul><ul><li>Loss of sensation </li></ul></ul><ul><ul><li>Surgical indication </li></ul></ul>
  20. 21. Mallet Scale
  21. 22. Surgical Intervention <ul><li>Neurosurgery 5-10% OBPI </li></ul><ul><ul><li>Nerve grafting </li></ul></ul><ul><ul><li>Neuroma dissection and removal </li></ul></ul><ul><ul><li>Neurolysis (decompression and removal of scar tissue) </li></ul></ul><ul><ul><li>Direct end to end anastomosis of nerve ends </li></ul></ul>
  22. 23. Surgical Intervention <ul><li>Later surgeries: </li></ul><ul><ul><li>Soft tissue release </li></ul></ul><ul><ul><li>Reduction of gleno-humeral joint dislocation </li></ul></ul><ul><ul><li>Transfer of muscles osteotomies </li></ul></ul>
  23. 25. BPI Impairments of Body Structure and Function <ul><li>Abnormal muscle substitutions </li></ul><ul><li>Neglect due to increased function and ease of movement of opposite arm </li></ul><ul><li>Soft tissue contracture </li></ul><ul><li>Scoliosis, pelvic obliquity </li></ul><ul><li>Abnormal bone growth </li></ul><ul><li>Flattening of humeral head, short clavicle </li></ul><ul><li>Positional torticollis </li></ul>
  24. 26. BPI Activity Limitations <ul><li>Inability to grasp, reach </li></ul><ul><li>Limited bilateral activities ex-catch, carry </li></ul><ul><li>Decreased ability for ADLs </li></ul><ul><li>Compromised developmental activities/delay </li></ul><ul><li>Decreased balance reactions/protective responses </li></ul><ul><li>Neglect, self –abuse </li></ul><ul><li>Later-shoulder pain, arthritis </li></ul>
  25. 27. Scapular winging, Trumpet sign
  26. 28. BPI Treatment Intervention
  27. 29. BPI Treatment Intervention
  28. 30. Interventions
  29. 31. Interventions
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