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Brachial plexus injuries by Dr. Rashi Goel PT

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Brachial Plexus Injuries and their Management

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Brachial plexus injuries by Dr. Rashi Goel PT

  1. 1. Rashi Goel MPT Orthopedics in Hand Rehabilitation Manipal University Manipal, Karnataka 25/01/2014 1rashigoelphysio@gmail.com
  2. 2. STUDY OBJECTIVES • Anatomy review • Classification of nerve injury • Formation of Brachial Plexus • Causes • Classification • Clinical Features • Special Features • Pathomechanics • Mechanism of different injuries 25/01/2014 2rashigoelphysio@gmail.com
  3. 3. • Assessment • Management • OBPI • PNI management 25/01/2014 3rashigoelphysio@gmail.com
  4. 4. ANATOMY REVIEW • A typical peripheral nerve consists of -several axon bundles/fascicles 25/01/2014 4rashigoelphysio@gmail.com
  5. 5. 25/01/2014 5rashigoelphysio@gmail.com
  6. 6. PATHOPHYSIOLOGY OF INJURY • Nerve response to injury 25/01/2014 6rashigoelphysio@gmail.com
  7. 7. Classification of nerve injuries • Seddon- 1 to 3 • Sunderland- 1 to 5 • Mackinnon- 6th 25/01/2014 7rashigoelphysio@gmail.com
  8. 8. Classification of Peripheral Nerve injury Seddon Process Sunderland Neurapraxia Segmental demyelination First degree Axonotmesis Axon severed but endoneurium intact (optimal circumstances for regeneration) Second degree Axonotmesis Axon discontinuity, endoneurial tube discontinuity, perineurium and fascicular arrangement preserved Third degree Axonotmesis Loss of continuity of axons, endoneurial tubes, perineurium and fasciculi; epineurium intact (neuroma in continuity) Fourth degree Neurotmesis Loss of continuity of entire nerve trunk Fifth degree 25/01/2014 8rashigoelphysio@gmail.com
  9. 9. 25/01/2014 9rashigoelphysio@gmail.com
  10. 10. Neuropraxia • conduction block at the site of injury • no macroscopic injury to the nerve • Physical examination will not show a Tinel’s sign • Electrodiagnostic studies will show no conduction across the area of injury but normal conduction distal to the area of injury 25/01/2014 10rashigoelphysio@gmail.com
  11. 11. Second-degree injury • involves a rupture of the axon • endoneurium remains intact • possibility of recovery following Wallerian degeneration • A Tinel’s sign will be noted on examination 25/01/2014 11rashigoelphysio@gmail.com
  12. 12. Third-degree lesions • injury to the endoneurium • preservation of the perineurium • scarring will occur • Full recovery is unlikely 25/01/2014 12rashigoelphysio@gmail.com
  13. 13. Fourth-degree injury • Rupture of the fasciculi • Disruption of the perineurium • The nerve is in continuity • scarring will likely prevent regeneration • A Tinel’s sign will be present at the site of injury but will not advance 25/01/2014 13rashigoelphysio@gmail.com
  14. 14. Neurotmesis • Entire nerve trunk is ruptured • Axonal continuity cannot be re-stored 25/01/2014 14rashigoelphysio@gmail.com
  15. 15. Pathology Motor Sensory Treatment Recovery Neuropraxia First degree Anatomic & axonal continuity Complete paralysis Minimal loss Observation Complete Second degree Transection axon but endoneurium intact Complete paralysis Complete loss Observation Complete Axonotmesis Third degree Perineurium intact Complete paralysis Complete loss Surgical intervention Complete Fourth degree Epineurium intact Complete paralysis Complete loss Surgical intervention Complete Neurotmesis Fifth degree Loss of nerve trunk continuity, complete disorganization Complete paralysis Complete loss Surgical intervention Complete 25/01/2014 15rashigoelphysio@gmail.com
  16. 16. Mackinnon • 6th degree injury • Mixed pattern 25/01/2014 16rashigoelphysio@gmail.com
  17. 17. 25/01/2014 17rashigoelphysio@gmail.com
  18. 18. 1. Nerve trunks cross the flexor aspect of joints • Extension ROM < flexion so less tension during limb movements • Exceptions- ulnar n. at elbow & sciatic n. at hip 2. Nerve Trunk runs an undulating course in its bed, fasciculi in epineurium & nerve fibers inside fasciculi So length between any two fixed points > distance between these two points 25/01/2014 18rashigoelphysio@gmail.com
  19. 19. 3. During tension, perineurium because of elastic fibres imparts greater elasticity tan endoneurium & epineurium 4. Epineurial connective tissue cushions te nerve fibres against deforming forces 25/01/2014 19rashigoelphysio@gmail.com
  20. 20. Nerve roots Over stretching of nerve roots by transmitted forces during repetitive stress and traction injury is prevented by: 1. Dura mater is adherant to intervertebral foramen so resists displacement of the nerve when traction pulls the entire system outward 25/01/2014 20rashigoelphysio@gmail.com
  21. 21. 2. 4th , 5th , 6th , & 7th nerve roots securely attached to vertebral column so more prone for traction injuries Rest- more prone for avulsion 25/01/2014 21rashigoelphysio@gmail.com
  22. 22. BRACHIAL PLEXUS INJURY 25/01/2014 22rashigoelphysio@gmail.com
  23. 23. Incidence • 15- 25 years • 70%- secondary to motor vehicle accidents 25/01/2014 23rashigoelphysio@gmail.com
  24. 24. Anatomy of the Brachial Plexus • Ventral rami of spinal nerve roots C5 to T1 Pre fixed- Post fixed- C4 large C4 small/absent C5 reduced T1 reduced T1 larger T2 absent T2 present more vertical arrangement more horizontal 25/01/2014 24rashigoelphysio@gmail.com
  25. 25. 25/01/2014 25rashigoelphysio@gmail.com
  26. 26. Formation Typical arrangement • Ant rami of C5 + C6 = SPT (unite near lateral border of middle scalene) • C7 = MPT • C8 + T1 unite behind scalene anterior = IPT 25/01/2014 26rashigoelphysio@gmail.com
  27. 27. • At the lateral border of the first rib • just above or behind the middle third of the clavicle • trunks undergo anterior division posterior divisions 25/01/2014 27rashigoelphysio@gmail.com
  28. 28. 25/01/2014 28rashigoelphysio@gmail.com
  29. 29. 25/01/2014 29rashigoelphysio@gmail.com
  30. 30. 1. Undivided anterior primary rami 2. Trunks—upper, middle, lower 3. Divisions of the trunks—anterior & posterior 4. Cords—lateral, posterior, and medial 5. Branches—peripheral nerves derived from the cords 25/01/2014 30rashigoelphysio@gmail.com
  31. 31. A. Branches of Roots • 1. N. to serratus anterior- long thoracic n./ Nerve of Bell- C5,6,7 • 2. N. to rhomboideus- dorsal scapular n.- C5 – Also supplies levator scapulae – Rhomboideus major – Rhomboideus minor 25/01/2014 31rashigoelphysio@gmail.com
  32. 32. B. Branches of trunks • Upper trunk- 1.suprascapular n.- – Supraspinatus – Infraspinatus 2. Nerve to subclavius 25/01/2014 32rashigoelphysio@gmail.com
  33. 33. C. Braches of cords • A. Lateral Cord: C5,6,7 1. Lateral pectoral 2.Musculocutaneous 3.Lateral root of median 25/01/2014 33rashigoelphysio@gmail.com
  34. 34. • B. Medial Cord: C8,T1 1. Medial Pectoral 2. Medial cut. N. of arm 3. Medial cut. N. of forearm 4. Ulnar n. – C7 from communicating branch from lat root of median n. 5. Medial root of median 25/01/2014 34rashigoelphysio@gmail.com
  35. 35. • Posterior cord: 1. Upper & lower Subscapular- subscapularis & teres major- C5,6 2. Thoracodorsal N.- lattisimus dorsi- C6,7,8 3. Axillary/ Circumflex n.- deltoid & teres minor- C5,6 4. Radial n.- C5 to T1 25/01/2014 35rashigoelphysio@gmail.com
  36. 36. 25/01/2014 36rashigoelphysio@gmail.com
  37. 37. Horner’s syndrome Avulsion of T1 root Interruption of T1 Sympathetic ganglion • miosis (small pupil) • enophthalmos (sinking of the orbit) • ptosis (lid droop) • anhydrosis (dry eyes) 25/01/2014 37rashigoelphysio@gmail.com
  38. 38. Horner’s syndrome 25/01/2014 38rashigoelphysio@gmail.com
  39. 39. Two anatomical triangles 1. The interscalene triangle contains the roots of the plexus between • anterior and middle scalene muscles superiorly • first rib inferiorly 25/01/2014 39rashigoelphysio@gmail.com
  40. 40. 25/01/2014 40rashigoelphysio@gmail.com
  41. 41. 2. The posterior triangle of the neck contains the trunks of the plexus formed by • sternocleidomastoid muscle anteriorly • trapezius laterally • clavicle inferiorly 25/01/2014 41rashigoelphysio@gmail.com
  42. 42. 25/01/2014 42rashigoelphysio@gmail.com
  43. 43. • Roots and trunks- supraclavicular plexus. • Cords and branches- Infraclavicular plexus subjected to individual variations 25/01/2014 43rashigoelphysio@gmail.com
  44. 44. Rotator cuffs • Supraspinatus- • Infraspinatus- • Teres minor- • Subscapularis- 25/01/2014 44rashigoelphysio@gmail.com
  45. 45. Causes • Traumatic traction/ crush lesions • TOS • Obstetrical lesions • Lesions due to irradiation-post anaesthetic palsy, needle puncture & after tumor excision around neck or shoulder • Iatrogenic lesions • Tumors • Gunshots wounds25/01/2014 45rashigoelphysio@gmail.com
  46. 46. • 20 compression after trauma as clavicular malunion • Personage turner syndrome or brachial neuritis • Vascular lesions- aneurysm of subclavian artery or vein 25/01/2014 46rashigoelphysio@gmail.com
  47. 47. Five possible levels where nerve can get injured 1. Root 2. Trunks 3. Divisions 4. Cords 5. Branches / Peripheral nerve 4725/01/2014 rashigoelphysio@gmail.com
  48. 48. Classification 25/01/2014 48rashigoelphysio@gmail.com
  49. 49. Preganglionic and Postganglionic nerve lesions 25/01/2014 49rashigoelphysio@gmail.com
  50. 50. Postganglionic Preganglionic Location Distal to DRG Proximal to DRG Preservation SNAPs Abnormalities SNAPs & MAPs MAPs Repair Surgical repair/ Grafting Neurotization 25/01/2014 50rashigoelphysio@gmail.com
  51. 51. • Traumatic injuries- • Brachial plexus stretched b/w 2 points of attachment 1.Transverse processes proximally 2.Clavipectoral fascia junction distally 51 Pathomechanics 25/01/2014 rashigoelphysio@gmail.com
  52. 52. Traction apparatus with neutral axis at the C7 vertebra when arm is horizontal BP = Single cord with 5 separate points of attachment 5225/01/2014 rashigoelphysio@gmail.com
  53. 53. • When traction force falls through C7, traction is equally borne by all parts C5 - T1 • Deviation from neutral axis creates an unequal pull to one side or the other5325/01/2014 rashigoelphysio@gmail.com
  54. 54. • Traction imparted to arm elevated above horizontal- stress increased to lower roots of BP • Traction imparted to arm depressed below the horizontal- stress increased to upper roots of BP 5425/01/2014 rashigoelphysio@gmail.com
  55. 55. Mechanism • Closed trauma • Traction or compression • Traction- 95% of the injuries 25/01/2014 55rashigoelphysio@gmail.com
  56. 56. Root avulsions 25/01/2014 56rashigoelphysio@gmail.com
  57. 57. Root avulsions • 75% of supraclavicular lesions • Common at C7- T1 nerve roots • 2 Mechanisms- • 1.Peripheral - common • 2.Central - rare 25/01/2014 57rashigoelphysio@gmail.com
  58. 58. Peripheral Central when there is a traction force to the arm and the fibrous supports around the rootlets are avulsed occur from direct cervical trauma The epidural sleeve may be pulled out of the spinal canal, creating a pseudomeningocele The spinal cord is moved transversely or longitudinally, causing a sheering and spinal bending that results in an avulsion of nerve rootlets 25/01/2014 58rashigoelphysio@gmail.com
  59. 59. Mechanism of avulsion 25/01/2014 59rashigoelphysio@gmail.com
  60. 60. Injury patterns • Supraclavicular more involved- 75% • Double level injuries 25/01/2014 60rashigoelphysio@gmail.com
  61. 61. Mechanism 25/01/2014 61rashigoelphysio@gmail.com
  62. 62. Traction and abduction- C8,T1 25/01/2014 62rashigoelphysio@gmail.com
  63. 63. Physical Examination (1) Posture (2) ROM of the cervical spine, shoulder, and upper extremity (3) motor strength (4) sensation (5) palpation (6) special tests (7) activities of daily living (8) vocational and avocational pursuits 25/01/2014 63rashigoelphysio@gmail.com
  64. 64. ROM • Active & Passive • Reflexes • Rule out Spinal Cord Injury- 1. Lower limb strength 2. Sensory 3. increased reflexes 4. pathological reflexes 25/01/2014 64rashigoelphysio@gmail.com
  65. 65. Motor testing • Spinal accessory- check trapezius • To be used for nerve transfer 25/01/2014 65rashigoelphysio@gmail.com
  66. 66. Motor strength • Posterior cord- Wrist extension Elbow extension Shoulder abduction 25/01/2014 66rashigoelphysio@gmail.com
  67. 67. • Lattisimus dorsi- palpate in post axillary fold and ask to cough • Pectoralis major- palpate as patient adducts his arm against resistance • Suprascapular nerve- shoulder ER and elevation- atrophy of infraspinatus • shoulder flexion, rotation, and abduction- rotator cuff or deltoid injury 25/01/2014 67rashigoelphysio@gmail.com
  68. 68. • preganglionic injury • long thoracic nerve C5-C7= scapular winging as the patient at-tempts to forward elevate the arm • dorsal scapular nerve C4-C5= atrophy of rhomboids and parascapular muscles 25/01/2014 68rashigoelphysio@gmail.com
  69. 69. Sensory Examination • Autonomous Zones • Deep pressure • light touch • Temperature • stereognosis • two-point discrimination 25/01/2014 69rashigoelphysio@gmail.com
  70. 70. Vascular Examination • Distal pulses • Thrills • Bruits • Rupture of axillary artery 25/01/2014 70rashigoelphysio@gmail.com
  71. 71. Special tests • Tinel’s sign 25/01/2014 71rashigoelphysio@gmail.com
  72. 72. Radiographic Evaluation • Cervical spine and shoulder • Chest X- Ray • Transverse process # of cervical vertebrae- root avulsion • Clavicle #, ribs # • Old rib #- intercostal nerves- for nerve transfer • Phrenic nerve- paralysis of diaphragm 25/01/2014 72rashigoelphysio@gmail.com
  73. 73. CT • Level of nerve root injury • 3 to 4 weeks after injury- pseudomeningocele for root avulsion • In acute trauma, CT/myelography remains the gold standard 25/01/2014 73rashigoelphysio@gmail.com
  74. 74. MRI • Adv. Over CT  Non invasive  non traumatic neuropathy-  Tumours  Radiation injury  Idiopathic BP neuritis  Vasculitic conditions • Oedema on T2 scan- zone of injury 25/01/2014 74rashigoelphysio@gmail.com
  75. 75. Histamine Test To differentiate pre & post ganglionic injuries Intact skin- triple response Preganglionic- normal response in area of skin that is anaesthetic Postganglionic- vasodilation, wheal formation but no flare response as this requires functioning axon in continuation with its cell body 25/01/2014 75rashigoelphysio@gmail.com
  76. 76. Management 25/01/2014 76rashigoelphysio@gmail.com
  77. 77. Neurolysis • Neurolysis is the surgical technique of freeing intact nerves from scar tissue 25/01/2014 77rashigoelphysio@gmail.com
  78. 78. Nerve Grafting • To bridge ruptured nerves 25/01/2014 78rashigoelphysio@gmail.com
  79. 79. Most frequently used donor nerve • Sural nerve- yield up to 30 cm of nerve • Antebrachial cutaneous • Radial sensory • Ulnar • Ant. tibial • Superficial peroneal • Saphenous 25/01/2014 79rashigoelphysio@gmail.com
  80. 80. 1. Attachment of a donor nerve to the ruptured distal stump, sacrificing the original function of the nerve for a more beneficial result in the upper limb 2. Restoration of motor or sensory function can be accomplished by neurotization Nerve transfer/ Neurotization 25/01/2014 80rashigoelphysio@gmail.com
  81. 81. • used in pre-ganglionic injuries • reinnervation of a denervated motor or sensory end Organ 25/01/2014 81rashigoelphysio@gmail.com
  82. 82. 5 possibilities for neurotization • Musculomuscular • Cutaneocutaneous • neurocutaneous • Neuromuscular • neuroneural Traumatic BPI 25/01/2014 82rashigoelphysio@gmail.com
  83. 83. 1. Intercostal n.- combinations of musculocut., long thoracic, radial, or median n. 2. Spinal accessory n.- suprascapular/ musculocutaneous n. 3. Phrenic n.- for axillary n. 4. Plexo-plexal transfers 5. Motor branches of C3- C4 cervical plexus 6. Contralateral C7 transfers- for median n. 7. N. to long head of triceps- Ant. Br. Of axillary n. 8. Fascicles or branch from ulnar,median and radial nerves25/01/2014 83rashigoelphysio@gmail.com
  84. 84. 25/01/2014 84rashigoelphysio@gmail.com
  85. 85. 25/01/2014 85rashigoelphysio@gmail.com
  86. 86. Muscle Transplantation • Indications- 1.Failed neurolysis or nerve grafting 2.Chronic root avulsion for >1 year with no neural regeneration 3.To enhance function in addition to nerve reconstruction 25/01/2014 86rashigoelphysio@gmail.com
  87. 87. • Muscles- 1.Lattisimus dorsi 2.Rectus femoris 3.Gracilis 4.Gastrocnemius 25/01/2014 87rashigoelphysio@gmail.com
  88. 88. Double free muscle transfer • To restore elbow and hand function • Advantage of length of gracilis muscle and proximal location of its neurovascular bundle to gain early reinnervation of the transferred muscle while allowing wrist and hand function 25/01/2014 88rashigoelphysio@gmail.com
  89. 89. 25/01/2014 89rashigoelphysio@gmail.com
  90. 90. 25/01/2014 90rashigoelphysio@gmail.com
  91. 91. Pre- operative care • Universal sling, envelope sling, or hemisling patients who have an upper trunk or complete • Prevent inferior glenohumeral subluxation, which results from paralysis of deltoid, supraspinatus, and infraspinatus muscles • head of humerus be held in a normal or slightly elevated position in the glenoid 25/01/2014 91rashigoelphysio@gmail.com
  92. 92. 25/01/2014 92rashigoelphysio@gmail.com
  93. 93. Completed Universal Arm Splint 25/01/2014 93rashigoelphysio@gmail.com
  94. 94. 1. Light weight 2. Inexpensive 3. Maintain elbow in flexion 4. Allow for a variety of elbow flexion positions 5. Independent application 6. Client will be able to perform bilateral, midline tasks 7. Adjustable by user 8. Easy to clean and maintain 25/01/2014 94rashigoelphysio@gmail.com
  95. 95. • A long MCP extension splint for patient who has weak wrist extension & trace finger extension 25/01/2014 95rashigoelphysio@gmail.com
  96. 96. • Paralysis of wrist extensors • Passive flexed resting stance of the wrist • Resting hand splint to prevent overstretching of weak and finger extensor muscles in night 20°dorsiflexion 25/01/2014 96rashigoelphysio@gmail.com
  97. 97. • Initial post injury period – PROM • Digit mobility • Self-ROM exercises 25/01/2014 97rashigoelphysio@gmail.com
  98. 98. Electrical stimulation • for denervated muscles – direct current – Infinite duration (≥ 300 ms) 9825/01/2014 rashigoelphysio@gmail.com
  99. 99. Motor response • Rheobase The smallest amplitude of current flowing for an infinite duration that produces a minimal but perceptible response. • Chronaxie The shortest stimulus time at twice the rheobase that will produce a minimal perceptible response. 9925/01/2014 rashigoelphysio@gmail.com
  100. 100. • Denervated muscle Chronaxie longer than 20 to 30 milliseconds, most often closer to 100 milliseconds • Normally innervated muscle Less than 1 millisecond 10025/01/2014 rashigoelphysio@gmail.com
  101. 101. Immediate postoperative care • Shoulder girdle is immobilized 3-6 weeks • Cast / Splint for distal nerves or tendon corrections • Hemi-sling continued till evidence of -reinnervation of the supraspinatus muscle -restoration of the integrity of GH joint -can be discontinued thereafter 10125/01/2014 rashigoelphysio@gmail.com
  102. 102. 25/01/2014 102rashigoelphysio@gmail.com
  103. 103. • PROM - 4 to 6 times a day , 10 to 20 reps - within the ranges restricted by the surgeon • Immediately if no functioning free muscle or tendon transfers have been performed • To minimize stiffness in these joints and to promote neural mobility and gliding 10325/01/2014 rashigoelphysio@gmail.com
  104. 104. Edema control • Decongestive massage • Compression sleeves / garments • Elevation 10425/01/2014 rashigoelphysio@gmail.com
  105. 105. Scar management • Scar massage • Elastomer pads • Gel sheeting 25/01/2014 105rashigoelphysio@gmail.com
  106. 106. Electrical stimulation • 3 to 6 weeks after surgery • Allow time for the nerve transfers to heal with considerably less danger of rupture • Direct-current (galvanic) stimulator • Electrodes placed over the muscle directly • Current longer than chronaxie 10625/01/2014 rashigoelphysio@gmail.com
  107. 107. • As the muscle reinnervates, the chronaxie slowly decreases • The time at which muscle recovery begins is thus detectable by changes in the stimulation parameters When the chronaxie decreases to 20 milliseconds or shorter, voluntary contractions of the muscle begin • Stimulate for 30 to 60 moderately strong contractions • Visible contractions 25/01/2014 107rashigoelphysio@gmail.com
  108. 108. 108 Stimulation unit for home use 25/01/2014 rashigoelphysio@gmail.com
  109. 109. Re-education of muscle 10925/01/2014 rashigoelphysio@gmail.com
  110. 110. Extraplexal Re-education • Voluntary MUPs on EMG / Visible contraction • Successful contractions produced by replicating nerve function 11025/01/2014 rashigoelphysio@gmail.com
  111. 111. Activation of muscles neurotized • Intercostals / Phrenic nerve – can be activated using breathing techniques 11125/01/2014 rashigoelphysio@gmail.com
  112. 112. • Spinal accessory - Elevation of the scapula • Contralateral C7 - mirroring motions 25/01/2014 112rashigoelphysio@gmail.com
  113. 113. • For all recovering muscles • Start with short sessions to avoid hyperventilation and fatigue 11325/01/2014 rashigoelphysio@gmail.com
  114. 114. Methods 1.Biofeedback using visual/ tactile clues 2.Gravity-eliminated exercises 3.Progressive strengthening techniques 11425/01/2014 rashigoelphysio@gmail.com
  115. 115. Biofeedback • Useful when active contractions appear • Portable biofeedback for home use • In later stages, Visual & palpatory monitoring Use of opposite hand or a mirror • Neuromuscular reeducation 11525/01/2014 rashigoelphysio@gmail.com
  116. 116. • Neuromuscular electrical stimulation • For visualization • Sensation of contraction • Start with strong amplitude of evoked contraction to give sense of the muscle contracting and then decrease the strength of stimulus 11625/01/2014 rashigoelphysio@gmail.com
  117. 117. 11725/01/2014 rashigoelphysio@gmail.com
  118. 118. Gravity-eliminated exercise • To attain maximum range possible in gravity eliminated position • Light weights can be used 11825/01/2014 rashigoelphysio@gmail.com
  119. 119. Strengthening • Against gravity • Biofeedback- to monitor improvement in muscle contraction • Starting weights - 0.1 to 0.25 kg • Use isometric, concentric, or eccentric contractions • Motivate & Encourage 11925/01/2014 rashigoelphysio@gmail.com
  120. 120. Pain management • Difficult areas • Nerve pain 12025/01/2014 rashigoelphysio@gmail.com
  121. 121. Sensory re-education • Surgical reconstruction of sensation using 1.Intercostal sensory 2.Contralateral C7 3.Cervical plexus branches 12125/01/2014 rashigoelphysio@gmail.com
  122. 122. Patient education • Pressure sores , Injury from sharp objects, heat & cold • Routine inspection of the skin • Re-education has a role only once some perception starts • Semmes-Weinstein monofilaments - 4.31 12225/01/2014 rashigoelphysio@gmail.com
  123. 123. References 1. Brachial Plexus Injuries by Robert D. Leffert 2. Brachial Plexus Palsy by H. kawai & H. Kawabata 3. Physical Therapy of shoulder by Robert Donatelli 4. The HAND Fundamentals of therapy by Morrin & Conolly 5. Various research articles 25/01/2014 123rashigoelphysio@gmail.com

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