Undergraduate

1. BRACHIAL PLEXUS
BIRTH PALSY

3. ?
Congenital or
acquired
About 1 / 1000
live births
Seen recently
in COVID-19
patients
A variety of
presentations
Properly assess
the amount of
injury

4. Non-traumatic injury:
•localized mass
•widespread inflammatory
process
•Parsonage-Turner
syndrome (idiopathic
neuritis)
Traumatic injury:
•obstetric injury
•motor vehicle accident
•contact sports
•penetrating injury from a
gunshot.

5.  One or more of the following tests could be used to diagnose the extent and
severity of a brachial plexus injury:
1. X-ray for the shoulder and neck
2. Electromyography (EMG)
3. Nerve conduction studies
4. Magnetic resonance imaging (MRI)
5. Computerized tomography (CT) myelography to present a detailed picture of
the spinal cord and nerve roots.

6. OBSTETRIC
BRACHIAL
PLEXUS INJURY

7.  Obstetric brachial plexus injury (OPBI) also known as birth brachial plexus injury
(BBPI) refers to injury noted in the perinatal period to all or a portion of the
brachial plexus.
 Risk factors:
 Technically difficult (57%) or breech (9%) deliveries
 Fetal macrosomia (weight >4 kg) (55%)
 Shoulder dystocia
 Multiparous mothers
 Prolonged labor
 Fetal hypotonia leading to loss of the normal cushioning effect of intact muscle tone

8. MECHANISM OF
INJURY
 The nerves of the brachial
plexus may be stretched,
compressed, or torn in a
difficult delivery.
 The result might be a loss of
muscle function, or even
paralysis of the upper arm.

10. Nerve root Pain distribution
Abnormality
Motor Sensory Reflex
C4-5
Neck, shoulder,
lateral arm
Deltoid, elbow
flexors
Lateral arm Biceps
C5-6
Neck, dorsal lateral
(radial) arm, thumb
Biceps, wrist
extensors
Lateral
forearm, thumb
Brachioradialis
C6-7
Neck, dorsal lateral
forearm, middle
finger
Triceps, wrist
flexors
Dorsal forearm,
long finger
Triceps
C7-8
Neck, medial
forearm, ulnar digits
Finger flexors Medial forearm,
ulnar digits
NA
C8-T1
Ulnar forearm Finger
intrinsics
Ulnar forearm NA

12. a. Preganglionic lesion
 It involves CNS which does not regenerate (poor
prognosis)
 Features:
 Horner’s syndrome (disruption of sympathetic
chain)
 Ptosis
 Anhidrosis
 Miosis
 Enophthalmos
 Motor deficits (flail arm).
 Sensory absent.
 Absence of a Tinel sign or tenderness to
percussion in the neck.
 Elevated hemidiaphragm (phrenic nerve).
 Winging of scapula due to paralysis of rhomboid
(dorsal scapular nerve) and serratus anterior
(long thoracic nerve) muscles.

13. b. Postganglionic lesion
 The function may either spontaneously
return with time (regeneration) or, when
loss of nerve continuity occurs, the nerve
can be repaired.
 Features:
 Motor deficit.
 Sensory deficits.

14. Group Name
Roots
Injured
Paralysis
(Weakness) Likely Outcome
I
Duchenne-Erb’s
Palsy (Upper
Erb’s)
C5,6
Deltoid and biceps
(Shoulder
abduction/external
rotation, elbow flexion)
Good spontaneous recovery
in over 80% of cases.
II
Intermediate
Paralysis
(Extended
Erb’s)
C5-7
Deltoid, biceps, and the
wrist and finger
extensors (As above
with drop wrist)
Good spontaneous recovery
in about 60% of cases.
III
Total palsy with
no Horner
syndrome C5-T1
Complete flaccid
paralysis
Good spontaneous recovery
of the shoulder and elbow in
30–50% of cases. A
functional hand may be
seen in many patients
IV
Total palsy with
Horner
syndrome
C5-T1
Complete flaccid
paralysis with Horner
syndrome
The worst outcome. Without
surgery, severe defects
throughout the limb are
expected

15. 3.
ACCORDING
TO ROOTS
INJURED
Upper-trunk palsy– Erb’s
palsy (C5-6)
Intermediate palsy–
Extended Erb’s palsy (C5-7)
Lower-trunk palsy–
Klumpke’s palsy (C8-T1)
Pan-plexus palsy– Whole-
arm type (C5-T1)

16.  It is the most common type of injury
 It has the best prognosis
 Clinical presentation:
 Waiter’s tip position
 Ipsilateral diaphragmatic paralysis may be present if
there is phrenic nerve involvement
 Winging of scapula may be present if denervation occurs
to rhomboid and serratus anterior muscles.
 Deep tendon reflexes: absent biceps and brachioradialis
reflexes.
 It has very good prognosis if biceps’ function returns
by 3 months of age.

17.  It occurs when the proximal C5-6
involvement is extended to the C7 root.
 Clinical presentation:
 elbow and wrist extension are also
compromised; hence a wrist drop can be
seen.
 deep tendon reflexes: Absent biceps,
brachioradioalis and triceps reflexes.
 It has poor prognosis.

18.  It is the least common type of injury
 Clinical presentation:
 Patients will typically maintain
shoulder and elbow strength but will
lose hand function.
 Patients also typically have hand
numbness in at least the ring finger
and small finger.
 Deep tendon reflexes: Absent grasp
reflex.
 Horner’s syndrome.
 It has poor prognosis.

19.  Occurs with extreme force
 All levels of the nerves and trunk are
damaged
 Flail limb and Horner’s syndrome
 It has the worst prognosis with a
probability for shoulder and posterior
radial subluxation or dislocation as well
as poor bone growth

20. LOOKS
EASY,
BUT WHY
SO
COMPLICAT
ED?
 20 - 30% develop residual neurologic
deficits with associated impact on
upper-limb function.
 The majority resolve spontaneously,
with 92% of the restoration taking place
during the first 3 months.

21. MAYBE..
The imbalance that occurs during re-
innervation of the muscles.
Anomalous re-innervation
Deltoid-biceps co-contraction
The internally rotated posture of the
shoulder causing gravity to flex the
elbow.
Flexion positioning of the limb by
therapists and families

22. ERB ENGRAM

23. The active shoulder function is
dependent upon:
1. the glenohumeral relationship
2. the integrity of the shoulder
capsule
3. the strength and physical
properties of the muscles
4. the nervous system
As muscles are reinnervated in an
asymmetric fashion, muscle
imbalances occur in the shoulder that
will virtually always lead to bone
deformations in this group.

25. A)
ASSESSMEN
T
History
•General observation
•Specific observation
Informal Evaluation
•Muscle tone
•Reflex tesing
•Range of motion
•Muscle testing
•Flexibility testing
•Manipulative skills
•Long and round measurements
•Sensory testing
Formal Evaluation

26. The appearance of prolonged,
polyphasic and low-amp indicates
re-innervation.
A decrease in the number of
fibrillation potentials and
positive sharp potentials is
typically seen in denervated
muscles – is a sign of
regenerating axons have reached
the motor end plates.
Seen several weeks before the
onset of voluntary muscle
contraction and signify that a
further period of observation is in
order.

28. B)
TREATMEN
T
 Treatment of OPBI focuses on:
1. Promoting nerve recovery.
2. Preventing joint contractures.
3. Maintaining range of motion is the
upper extremities and neck.
4. Improving muscle strength.
5. Addressing alignment and postural
control.
6. Facilitating development of
efficient and functional motor
patterns.

29. •Rest
•Moist heat
•Massage
•Stretching
•ROM exercises
•Facilitation of muscle contraction
•PNF
•Faradic stimulation
•Facilitation of righting and equilibrium reactions
•Sensory awareness
•Positioning and splinting
a. Conservative treatment
•Indications:
•Infant cannot bend elbow against gravity at 6 months of
age.
•Infant cannot move wrist and fingers at 6 months of age.
•No improvement of the arm strength during the 1st 2-3
months of treatment.
•Complications:
•Phrenic nerve injury.
•Injury to the lung and major blood vessels.
•Wound infection.
•Additional brachial plexus injury.
b. Surgical treatment
Methods of ttt:

30. ERB
ENGRAM
PROTOC
OL
 The major goals of physiotherapy are to
ensure optimal conditions for recovery of
motor function and learning process.
 The infant’s actions are monitored using
manual guidance and verbal feedback.
 The task can be modified to be correctly
achievable.
 Guiding correct shoulder alignment and
scapular movements passively as the child
attempts reaching.
 Encouraging grasping and releasing with
forearm in supination.

31. PRACTICA
L
GUIDELIN
ES FOR
DAILY
CARE
 Should be explained for the caregiver including:
 The correct position of the baby's arm during the
first three weeks, and avoid:
 More than 90° between the neck and the affected
shoulder.
 Arm hanging backwards, or above the shoulder.
 Pulling the child up by the arms and picking him up
by lifting him under his armpits.
 Sleeping on tummy.
 Lifting and carrying.
 Dressing and undressing:
 When dressing, put affected arm in the sleeve first.
 When undressing, remove affected arm from sleeve
last.
 Use a wrap over vest or a vest with a wide neck.
 Repetition of the exercises 2 times per day.

32. • Shoulder elevation / depression or protraction/retraction.
• Shoulder flexion 0-90 degrees using pectoral
musculature.
• Shoulder abduction 0-45 degrees using supraspinatus
musculature.
• Elbow flexion with forearm pronated bringing hand to
mouth and/or hands to midline.
• Finger flexion/extension with wrist in flexion then later
with wrist in extension.
First motions to return are:
• Full shoulder flexion/abduction using deltoid
musculature.
• Supination (children do not actively perform this motion
until 11 months of age).
• External rotation.
• Full elbow extension using triceps.
Last motions to return are: