The document discusses brachial plexus injuries, which involve damage to the network of nerves between the neck and arm. It describes the anatomy of the brachial plexus and its branches. There are two main types of brachial plexus injuries - Erb's palsy, which involves the upper trunk and results in weakness of shoulder and arm muscles, and Klumpke's palsy, which involves the lower trunk and causes hand deformities. Causes include difficult childbirth and other stretching or trauma to the neck and shoulders. Management involves medical treatment of pain as well as potential surgical interventions and physical therapy.

1. BRACHIAL PLEXUS
INJURY
Presented By;
Dr.Shahsad Aboobacker .(PT)
( MPT(Musculoskeletal & Sports). CMT. MIAP )
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2. BRACHIAL PLEXUS
…??
The brachial plexus contains the
neural connections between the
neck and brachial nerves.
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Brachial Plexus
(BRAY-key-el PLEK-sis)

3. BRACHIAL PLEXUS
ANATOMY & PICTORIAL
REPRESENTATION
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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. 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. BRANCHES OF ROOTS
DORSAL SCAPULAR NERVE
 Root value- C5
 Supply – Rhomboid major &
minor muscle
Posterior view

7. LONG THORACIC
NERVE
Root value- C5,C6,C7
Supply – Serratus anterior
muscle

8. BRANCHES OF UPPER TRUNK
NERVE TO SUBCLAVIUS
Root value – C5,C6
SUPRASCAPULAR NERVE
Root value – C5,C6

9. LATERAL PECTORAL
NERVE
Root value-
C5,C6,C7
MEDIAL PECTORAL NERVE
Root value- C8,T1

10. MUSCULOCUTANEOUS
NERVE
Root value – C5,C6,C7

11. 12-11
MEDIAN NERVE

12. MEDIAL BRACHIAL
CUTANEOUS NERVE
Root value- C8,T1
MEDIAL ANTEBRACHIAL
CUTANEOUS NERVE
Root value- C8,T1

13. 12-13
ULNAR NERVE
Root value-(C7),C8,T1

14. UPPER SUBSCAPULAR
Root value-C5,C6
LOWER SUBSCAPULAR
Root value- C5,C6
NERVE TO
LATISSIMUS DORSI
(Thoracodorsal)
Root value-C6,C7,C8

15. AXILLARY NERVE

16. RADIAL NERVE

17. DERMATOMES OF UPPER LIMB

18. TENDON REFLEXES
 Biceps brachii tendon reflexe (C5,C6)
 Triceps tendon reflex (C6,C7,C8)
 Brachioradialis tendon reflex(C5,C6,C7)

19. ERBS POINT
 The region of the Upper trunk of the brachial plexus
is called Erb’s Point.

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.  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. 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.  Falling on Shoulder
o Excessive Stretching
o Direct Blow
o Shoulder Dislocation
o Tumour (Neuroma)
o Cervical Rib

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. 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. 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. 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. UPPER BRACHIAL
PLEXUS INJURY
( ERB’S PALSY )
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30. MUSCLE INVOLVMENT
Shoulder Deltoid
Rhomboids
Supraspinatus
Infraspinatus
Teres Minor
Elbow Biceps Brachi , Supinator
Brachioradialis , Brachialis
Wrist ECRL & ECRB
( C6 root)

31. 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

32. 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

33. LOWER BRACHIAL
PLEXUS INJURY
( KLUMPKE’S PALSY )
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34. 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)

35. DEFORMITY
 Claw Hand
MCP Joint -Hyperextended
IP Joint - Flexion

36. 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.

37. • 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)

38. DIAGNOSIS
 Relies mainly on clinical examination
 No specific lab. Studies
 CT Myelography
 MRI
 Nerve conduction studies
 EMG

39. 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.

40.  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

41. 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

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