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BRACHIAL PLEXUS
INJURY
Presented By;
Dr.Shahsad Aboobacker .(PT)
( MPT(Musculoskeletal & Sports). CMT. MIAP )
www.alshifaa...
BRACHIAL PLEXUS
…??
The brachial plexus contains the
neural connections between the
neck and brachial nerves.
www.alshifaa...
BRACHIAL PLEXUS
ANATOMY & PICTORIAL
REPRESENTATION
www.alshifaa.i
C5
C6
C7
C8
T1
Roots Trunks Divisions
Upper/
Superior
Middle
Lower/
Inferior
Posterior
Cords TerminalBranches
Musc. Cut-
M...
Dorsoscap
ular
Suprascapul
ar
Lateral
Pectoral
Long
Thoracic
Upper Subscapular Thoracodorsal Lower Subscapular
Medial Pect...
BRANCHES OF ROOTS
DORSAL SCAPULAR NERVE
 Root value- C5
 Supply – Rhomboid major &
minor muscle
Posterior view
LONG THORACIC
NERVE
Root value- C5,C6,C7
Supply – Serratus anterior
muscle
BRANCHES OF UPPER TRUNK
NERVE TO SUBCLAVIUS
Root value – C5,C6
SUPRASCAPULAR NERVE
Root value – C5,C6
LATERAL PECTORAL
NERVE
Root value-
C5,C6,C7
MEDIAL PECTORAL NERVE
Root value- C8,T1
MUSCULOCUTANEOUS
NERVE
Root value – C5,C6,C7
12-11
MEDIAN NERVE
MEDIAL BRACHIAL
CUTANEOUS NERVE
Root value- C8,T1
MEDIAL ANTEBRACHIAL
CUTANEOUS NERVE
Root value- C8,T1
12-13
ULNAR NERVE
Root value-(C7),C8,T1
UPPER SUBSCAPULAR
Root value-C5,C6
LOWER SUBSCAPULAR
Root value- C5,C6
NERVE TO
LATISSIMUS DORSI
(Thoracodorsal)
Root valu...
AXILLARY NERVE
RADIAL NERVE
DERMATOMES OF UPPER LIMB
TENDON REFLEXES
 Biceps brachii tendon reflexe (C5,C6)
 Triceps tendon reflex (C6,C7,C8)
 Brachioradialis tendon reflex...
ERBS POINT
 The region of the Upper trunk of the brachial plexus
is called Erb’s Point.
 Brachial Plexus (BRAY-key-el PLEK-sis)
 1874 Wilhelm H. Erb described brachial plexus
paralysis in adults which involve...
 A brachial plexus injury (Erb’s palsy) is a nerve
injury
 The nerves that are damaged control muscles in
the shoulder, ...
CAUSES
 Undue separation of the head from shoulder
- Birth Injury (Shoulder Dytocia)
-Forceps Delivery
-Vaccum Extractor ...
 Falling on Shoulder
o Excessive Stretching
o Direct Blow
o Shoulder Dislocation
o Tumour (Neuroma)
o Cervical Rib
CLASSIFICATION
1. Upper Root Injury (Erb’s palsy or Erb-Duchenne
palsy)
 C5/C6 with or without C7 involved
 Most common ...
2 . Lower root injury (Klumpke’s palsy)
 C8/T1 with or without C7 are injured.
 Isolated lower root injury least common ...
3 . Complete Injury (Erb-Klumpke Palsy)
 All nerve roots from C5 to T1 involved.
 2nd most common (20%).
 On examinatio...
However a commonly used one is
Leffert's classification system
which is based on etiology and level of injury:
 I Open (u...
UPPER BRACHIAL
PLEXUS INJURY
( ERB’S PALSY )
www.alshifaa.inf
MUSCLE INVOLVMENT
Shoulder Deltoid
Rhomboids
Supraspinatus
Infraspinatus
Teres Minor
Elbow Biceps Brachi , Supinator
Brach...
DISABILITY
1. Abduction & Lateral Rotation of the arm
2. Flexion & Supination of the forearm
3. Biceps & Supinator jerks a...
WAITER’S / POLICEMAN’S TIP POSITION
 Characteristic Position - Adduction & Internal
Rotation of the arm with forearm pron...
LOWER BRACHIAL
PLEXUS INJURY
( KLUMPKE’S PALSY )
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Site of Injury
 Lower Trunk of the Brachial Plexus
Nerve Root Involved
 Mainly C8 and T1
Muscle Paralysed
 Intrinsic Mu...
DEFORMITY
 Claw Hand
MCP Joint -Hyperextended
IP Joint - Flexion
DISABILITY
 Cutaneous Anaesthesia & Analgesia in a narrow zone
along the ulnar border of the forearm and Hand
 Horner’s ...
• Increase in angle between neck &
shoulder
•Traction (stretching or avulsion) of
upper Ventral Rami (e.g., C5,C6)
UBP Inj...
DIAGNOSIS
 Relies mainly on clinical examination
 No specific lab. Studies
 CT Myelography
 MRI
 Nerve conduction stu...
MANAGEMENT
 Medical Management
a. The main aspect of medical management is
pain control.
b. Often treated in a similar wa...
 Surgical options
a. Nerve transfers
b. Nerve grafting
c. Muscle transfers
d. Free muscle transfers Neurolysis of scar
ar...
Physiotherapy Management
 Electrical Stimulation
 Splinting – To Prevent Contracture
o Pain control - TENS
o Maintaining...
www.alshifaa.inf
Brachaial Plexus Injury
Brachaial Plexus Injury
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Brachial Plexus Injury
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Brachaial Plexus Injury

  1. 1. BRACHIAL PLEXUS INJURY Presented By; Dr.Shahsad Aboobacker .(PT) ( MPT(Musculoskeletal & Sports). CMT. MIAP ) www.alshifaa.info
  2. 2. BRACHIAL PLEXUS …?? The brachial plexus contains the neural connections between the neck and brachial nerves. www.alshifaa.inf Brachial Plexus (BRAY-key-el PLEK-sis)
  3. 3. BRACHIAL PLEXUS ANATOMY & PICTORIAL REPRESENTATION www.alshifaa.i
  4. 4. C5 C6 C7 C8 T1 Roots Trunks Divisions Upper/ Superior Middle Lower/ Inferior Posterior Cords TerminalBranches Musc. Cut- Median Ulnar Radial Axillary Lateral Posterior Medial Anterior Anterior Headless arrow towards RightHeadless arrow towards LeftAdd wAdd XAdd Y
  5. 5. Dorsoscap ular Suprascapul ar Lateral Pectoral Long Thoracic Upper Subscapular Thoracodorsal Lower Subscapular Medial Pectoral Medial Brachial Cutaneous Medial Antebrachial Cutaneous LLM "Lucy Loves Me" ULTRA MMMUM "Most Medical Men Use Morphine"
  6. 6. BRANCHES OF ROOTS DORSAL SCAPULAR NERVE  Root value- C5  Supply – Rhomboid major & minor muscle Posterior view
  7. 7. LONG THORACIC NERVE Root value- C5,C6,C7 Supply – Serratus anterior muscle
  8. 8. BRANCHES OF UPPER TRUNK NERVE TO SUBCLAVIUS Root value – C5,C6 SUPRASCAPULAR NERVE Root value – C5,C6
  9. 9. LATERAL PECTORAL NERVE Root value- C5,C6,C7 MEDIAL PECTORAL NERVE Root value- C8,T1
  10. 10. MUSCULOCUTANEOUS NERVE Root value – C5,C6,C7
  11. 11. 12-11 MEDIAN NERVE
  12. 12. MEDIAL BRACHIAL CUTANEOUS NERVE Root value- C8,T1 MEDIAL ANTEBRACHIAL CUTANEOUS NERVE Root value- C8,T1
  13. 13. 12-13 ULNAR NERVE Root value-(C7),C8,T1
  14. 14. UPPER SUBSCAPULAR Root value-C5,C6 LOWER SUBSCAPULAR Root value- C5,C6 NERVE TO LATISSIMUS DORSI (Thoracodorsal) Root value-C6,C7,C8
  15. 15. AXILLARY NERVE
  16. 16. RADIAL NERVE
  17. 17. DERMATOMES OF UPPER LIMB
  18. 18. TENDON REFLEXES  Biceps brachii tendon reflexe (C5,C6)  Triceps tendon reflex (C6,C7,C8)  Brachioradialis tendon reflex(C5,C6,C7)
  19. 19. ERBS POINT  The region of the Upper trunk of the brachial plexus is called Erb’s Point.
  20. 20.  Brachial Plexus (BRAY-key-el PLEK-sis)  1874 Wilhelm H. Erb described brachial plexus paralysis in adults which involved the upper roots and described certain types of “delivery paralysis”  Otherwise Known as Erb’s Palsy  1885 Augusta Klumpke first described the clinical picture resulting from injury to lower roots ( Klumpke’s Palsy ).
  21. 21.  A brachial plexus injury (Erb’s palsy) is a nerve injury  The nerves that are damaged control muscles in the shoulder, arm, or hand and any or all of these muscles may be paralyzed.  One or two of every 1,000 babies have this condition. It is often caused when an infant's neck is stretched to the side during a difficult delivery.
  22. 22. CAUSES  Undue separation of the head from shoulder - Birth Injury (Shoulder Dytocia) -Forceps Delivery -Vaccum Extractor Delivery -Breech delivery -Cephalic presentation of large birth weight infant (> 4 kgs) -Previous child with BPI -Prolonged maternal labour (> 60 minutes during second stage) -Multi-parity -Intrauterine torticollis and Intrauterine malposition
  23. 23.  Falling on Shoulder o Excessive Stretching o Direct Blow o Shoulder Dislocation o Tumour (Neuroma) o Cervical Rib
  24. 24. CLASSIFICATION 1. Upper Root Injury (Erb’s palsy or Erb-Duchenne palsy)  C5/C6 with or without C7 involved  Most common (73% to 86%)  If C7 involved, wrist flexed and fingers curled up in “waiter’s tip “ position  If C4 involved, diaphragm paralysed.  Moro reflex: shoulder movement (-), Biceps (-); hand movement (+); Grasp (+)  If C5/C6 injury, 90% full recovery by 3 months.  With C5/C6/C7- 65% full recovery.
  25. 25. 2 . Lower root injury (Klumpke’s palsy)  C8/T1 with or without C7 are injured.  Isolated lower root injury least common (0.6 to 2%).  Forearm is supinated, wrist and fingers hyperextended with good elbow and shoulder function.  Horner’s syndrome with ptosis and miosis if associated cervical sympathetic nerve injury.  Moro reflex: Shoulder movement(+), hand movement(- ); Grasp reflex(-).  Recovery < 50%, minimal if Horner’s syndrome present.
  26. 26. 3 . Complete Injury (Erb-Klumpke Palsy)  All nerve roots from C5 to T1 involved.  2nd most common (20%).  On examination arm is flail and paralysed with total sensory and motor deficit with or without miosis and ptosis.  All reflexes are absent.  Outcome: Without associated Horner’s syndrome  <50% recovery, with associated Horner’s syndrome no recovery without surgery
  27. 27. However a commonly used one is Leffert's classification system which is based on etiology and level of injury:  I Open (usually from stabbing)  II Closed (usually from motorcycle accident) IIa Supraclavicular ( Preganglionic/Postgangionic ) IIb Infraclavicular IIc Combined  III Radiation induced  IV Obstetric IVa Erb's (upper root) IVb Klumpke (lower root) IVc Mixed
  28. 28. UPPER BRACHIAL PLEXUS INJURY ( ERB’S PALSY ) www.alshifaa.inf
  29. 29. MUSCLE INVOLVMENT Shoulder Deltoid Rhomboids Supraspinatus Infraspinatus Teres Minor Elbow Biceps Brachi , Supinator Brachioradialis , Brachialis Wrist ECRL & ECRB ( C6 root)
  30. 30. DISABILITY 1. Abduction & Lateral Rotation of the arm 2. Flexion & Supination of the forearm 3. Biceps & Supinator jerks are lost 4. Sensation are lost over a small area over the lower part of the deltoid
  31. 31. WAITER’S / POLICEMAN’S TIP POSITION  Characteristic Position - Adduction & Internal Rotation of the arm with forearm pronated  Forearm extension normal  Biceps reflex absent  This deformity is known as Policeman’s tips hand or Porter’s tip hand
  32. 32. LOWER BRACHIAL PLEXUS INJURY ( KLUMPKE’S PALSY ) www.alshifaa.inf
  33. 33. Site of Injury  Lower Trunk of the Brachial Plexus Nerve Root Involved  Mainly C8 and T1 Muscle Paralysed  Intrinsic Muscles of the hand(T1)  Ulnar Flexors of the wrist and Fingers(C8)
  34. 34. DEFORMITY  Claw Hand MCP Joint -Hyperextended IP Joint - Flexion
  35. 35. DISABILITY  Cutaneous Anaesthesia & Analgesia in a narrow zone along the ulnar border of the forearm and Hand  Horner’s Syndrome : If the sympathetic fibers of the 1st thoracic root are also injured paralyzed hand and ipsilateral ptosis and miosis.
  36. 36. • Increase in angle between neck & shoulder •Traction (stretching or avulsion) of upper Ventral Rami (e.g., C5,C6) UBP Injury – Erb’s Palsy LBP Injury – Klumpke’s Palsy • Excessive upward pull of limb • Traction (stretching or avulsion) of lower ventral rami (e.g., C8, T1)
  37. 37. DIAGNOSIS  Relies mainly on clinical examination  No specific lab. Studies  CT Myelography  MRI  Nerve conduction studies  EMG
  38. 38. MANAGEMENT  Medical Management a. The main aspect of medical management is pain control. b. Often treated in a similar way to neuropathic pain with NSAID, c. Tricyclic Antidepressants, d. Anticonvulsants e. Oral or transdermal opoids.
  39. 39.  Surgical options a. Nerve transfers b. Nerve grafting c. Muscle transfers d. Free muscle transfers Neurolysis of scar around the brachial plexus in incomplete lesions. e. Arthrodesis to stabilise joints
  40. 40. Physiotherapy Management  Electrical Stimulation  Splinting – To Prevent Contracture o Pain control - TENS o Maintaining ROM - Passive movements, Exercise therapy o Strengthen affected muscles – Biofeedback Exercise therapy oManaging chronic oedema – Compression Garments, Advice, Massage therapy Position of Patient  Child- Sitting Position with arm Slightly abducted and forearm supinated  Infants – On the mothers loop , resting on pillow Placement of electrode  Child – Inactive : Over the nape of neck Active : over the motor points
  41. 41. www.alshifaa.inf

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