The document provides an in-depth overview of the brachial plexus anatomy, including its formation from spinal nerve roots and the associated major nerves. It discusses various causes of brachial plexus injuries, such as trauma and obstetric palsy, detailing different types and presentations, including Erb's and Klumpke's palsies. Assessment techniques and potential motor and sensory deficits, as well as the implications of treatment, are also addressed, highlighting the complexity and significance of brachial plexus injuries.

1. BRACHIAL PLEXUS INJURY
PRESENTATION BY
Ashish Parashar
Lecturer, Physiotherapy
Debasis Rout
Lecturer, Occupational Therapy
COMPOSITE REGIONAL CENTRE FOR SKILL DEVELOPMENT, REHABILITATION &
EMPOWERMENT OF PERSONS WITH DISABILITIES (DIVYANGJAN), RAJNANDGAON
(Under the Administrative Control of NIEPID, Secunderabad)
Department of Empowerment of Persons with Disabilities (Divyangjan), MSJ&E, Govt. of India.
Old District Hospital Campus, Rajnandgaon, Chattishgarh-491441

2. • It is a complex network of nerves, which is responsible
for innervations of upper extremity.

3.  Formed by Ventral rami of spinal nerve roots C5, C6,
C7, C8 and T1
Pre fixed Post fixed
C4 Larger C4 Absent
T1 Reduced T1 Larger
T2 Absent T2 Present

4. 1. Roots: As each spinal nerves
exists from intervertebral
foramen they divide into
Ventral rami (roots of
brachial plexus) & dorsal
rami (innervates paraspinal
muscles).
2. Trunks: Roots runs in
between anterior & medial
scalene muscle where they
form trunks
• Upper trunk- C5& C6
• Middle trunk – C7
• Lower trunk- C8 & T1

5. 3. Divisions: Each trunk
behind clavicle divides into
• Anterior division
• Posterior division
4. Cords: Divisions combines
to form the cords, which are
named according to its
relation to Axillary artery.
• Lateral cord- anterior division
of upper & middle trunk
• Medial cord- anterior division
of lower trunk
• Posterior cord- posterior
division of all 3 trunks
Cords then divides and recombines
to form major nerves of upper
limb.

6. 5. Branches:
• Supraclavicular region- From roots & Trunks
• Infraclavicular region- from cords

7. Roots:
• Dorsal Scapular nerve- C5-
Rhomboidus
• Long thoracic nerve – C5,6,7-
Serratus anterior
• Nerve to Scalene & longus Colli-
C2-6- Scalene, Longus colli
• Branch to phrenic Nerve – C5-
Ipsilateral diaphragm
Trunks:
• Suprascapular nerve- C5,6-
Supraspinatus, Infraspinatus
• Nerve to subclavius- C5,6-
Subclavius

8. Lateral cord
• Lateral Pectoral Nerve-
C5,6,7- Clavicular head of
Pectoralis major muscle
• Musculocutaneous :
C5,6,7- Coracobrachalis,
biceps, most of brachialis,
it continues as lateral
cutaneous nerve of
forearm
• Lateral Root of Median
nerve - C5,6,7

9. Medial cord
• Medial pectoral nerve - C8,T1 :To Sternal
head of Pectoralis major muscle and
Pectoralis minor muscle
• Medial cutaneous nerve to arm -C8,T1-
supplies skin over front and medial side of
arm
• Medial cutaneous nerve to forearm -C8,T1
:Supplies skin over lower part of arm &
medial side of forearm
• Median root of median nerve C8-T1
• Ulnar C8-T1:
- Forearm- flexor carpi ulnaris, medial ½ of
FDP
- Palm – Interossei, 3rd & 4th lumbricals
- Hypothenar- Flexor digiti minimi, abductor
digiti minimi, Opponens digiti minimi
- Thenar – adductor pollicis, flexor pollicis
brevis
- Sensation medial 1½ finger

10. Posterior cord
• Upper subscapular - C5,6,7- partly supply
subscapular
• Lower subscapular - C5,6,7- subscapular, teres
major
• Thoracodorsal – C6,7,8 -lattismus dorsi
• Axillary nerve - C5,6- Deltoid, teres minor,
Supplies skin over lower part of deltoid &
upper part of triceps
• Radial nerve –C5 –T1 Supplies triceps,
anconius, brachioradialis, brachialis, extensor
muscles of forearm
Median Nerve:
• Forearm- all flexor muscle of forearm except
flexor carpi ulnaris & medial ½ of FDP
• Thenar – flexor Pollicis brevis, abductor
pollicis brevis, Opponens Pollicis Brevis
• 1 st & 2 nd lumbricals
• Sensory – supplies thenar palmar skin, lateral
3 ½ digits.

11.  Road traffic injuries
 Various other accidents – in factories, building sites,
sports, severe falls
 Iatrogenic (ligatures, drills, mastectomies, resection of
1 st rib etc)
 Obstetric palsy
 Gunshot wounds
 Tumors
 Secondary compression from trauma (Callus, fibrous
band, scar)

12. Traction/Over stretching: The mechanism is violent traction of upper
limb against the body (like RTA, other accident etc.)
 Increased angle between head & neck Results in C5, C6, C7 root or
upper trunk disruption.
 When upper limb is abducted above level of head with considerable
force, can result in avulsion of C8,T1 roots or lower trunk
Compression:
 Fracture of clavicle and callus formation may lead to compression of
lower trunk
 Tumors
 Haemorrhage
 Direct blow to side of neck
Penetrating wounds/direct trauma:
 Includes stab/gunshot wound
 Direct blow to supraclavicular fossa over Erb’s point

15.  Preganglionic avulsion
injuries indicate that the
nerve root has been torn
from the spinal cord and
preclude the possibility of
recovery.
 Postganglionic lesions may
be either in continuity (root
and sheath intact) or
ruptured (root intact and
nerve sheath ruptured).

16. Avulsion of T1 root
Interruption of T1 sympathetic ganglion
 Ptosis (drooping or falling of upper eyelid)
 Miosis (constricted pupil)
 Anhidrosis (loss of sweating)

17. COMPLETE :
Typically, these cases present with avulsion of the C7, C8
and T1 roots and rupture of the C5 and C6 roots
INCOMPLETE :
 Upper plexus palsy- Affecting the C5, C6 +/- C7 roots
 lower plexus palsy affecting the C8 and T1 roots

18.  Erbs palsy :Affects the strength of deltoid,
biceps, brachialis, infraspinatus, supraspinatus,
and serratus anterior muscles. Also involved are
the rhomboids, levator scapulae, and supinator
muscles.
 The patient is unable to abduct or externally
rotate the shoulder. The patient cannot supinate
the forearm because of weakness of the
supinator muscle. Waiter’s Tip hand deformity.
 Sensory involvement is usually confined along
the deltoid muscle and the distribution of the
musculocutaneous nerve.

19.  The middle trunk offers a major neural contribution to
the radial nerve.
 Weakens the extensor muscles of the arm and
forearm, excluding the brachioradialis, which receives
primary innervation from the C6 nerve root.
 Sensory deficit occurs along the radial distribution of
the posterior arm and forearm and along the dorsal
radial aspect of the hand.

20.  Klumpke’s palsy : Affects motor control in the
fingers and wrist.
 The intrinsic muscles of the hand are only
slightly affected in a lesion involving a
prefixed plexus, whereas paralysis of the
flexors of the hand and forearm occurs in a
lesion to a postfixed plexus.
 Sensory deficit occurs along the ulnar border
of the arm, forearm, and hand.
 Horner’s syndrome : Ptosis (drooping or
falling of upper eyelid), miosis (constricted
pupil) ,anhidrosis (loss of sweating)

21.  Infraclavicular lesions include injuries to the cords or
the individual peripheral nerves of the brachial plexus

22.  Palsy in elbow flexion and a deficit of muscle pronators
in the forearm, wrist, and finger flexors.
 A proximal lesion injures the lateral pectoral nerve,
resulting in partial or total palsy of the upper portion
of the pectoralis major muscle.
 Sensory deficit occurs at the forearm and at the thumb
level.

23.  Isolated injuries to the medial cord are rare. Instead,
upper medio-ulnar injury results in palsy, which is total
in the distribution of the ulnar nerve and only partial in
the distribution of the median nerve.
 Motor deficits occur in the flexor pollicis longus muscle
and the flexor digitorum profundus muscle of the index
finger.
 Partial palsy of the lower portion of the pectoralis
muscle results in injury to the medial pectoral nerve.

24.  Involves the areas of distribution of the Radial, Axillary,
Subscapular, and Thoracodorsal nerves.
 The lesion results in weakness of the extensors in the
arm, with impairment of medial rotation and elevation
of the arm at the shoulder.

25.  Isolated injuries to the long thoracic nerve are rare
 Traumatic wounds or traction injuries to the neck
result in isolated weakness of the serratus anterior
muscle with winging of the medial border of the
scapula.
 Partial loss of scapular rotation during abduction or
flexion of the arm.

26.  Antero-medial shoulder dislocation is the most
frequent cause of isolated Axillary nerve lesions.
 Results in loss of active shoulder abduction.
 Sensory changes include an area of anaesthesia along
the deltoid muscle.

27. Assessment

28. Mostly
 Inability to move right upper limb/right
shoulder
 Difficulty in right hand movement
 Weakness of right upper limb

29. Nature and mechanisms of injury:
 High-speed, large-impact accidents i.e. fall from a speeding
motorcycle associated with preganglionic plexus injuries
 Slow-speed, small-impact accidents i.e. fall down a stairway
associated with postganglionic injuries
 Trauma, brief detail (Sharp/blunt/fracture/dislocation)
 Treatment taken
 Progression of deformity/Improvement of what function
 Physiotherapy/brace/splint
 Any occasional dislocation

30.  Disability
 Dominant hand
 Status of eating if right hand and hygiene if
left hand
 Sports status
 Driving

31.  Personal Hx: Smoking/alcohol/tobacco
 Medical Hx: Medication, surgery, Hakeem,
Chemotherapy, Radiotherapy, hospitalization
 Socioeconomic and family Hx: No. of Family members,
status of living, income

32. Area and nature of pain:
 constant burning, crushing pain with sudden shooting
paroxysms.
 91% experience pain for at least 3 years after their injury.
(Bruxelle and associates)
 Result of deafferentation of the spinal cord at the damaged
root level, leading to undampened excitation of the cells in
the dorsal horn of the spinal cord. That is received and
interpreted centrally as pain and is eventually felt in the
dermatomes of the avulsed nerve root.
 may also result from secondary injuries to bones or related
soft tissues.

33. Best to start with the patient stood with both arms and
torso exposed.
 Look at the face for Horner's syndrome
 Look for surgical scars
 muscle wasting – shoulder girdle, arm, forearm or
hand
 Deformity
 posture of the limb

34.  Winging of the scapula : weakness of the serratus
anterior muscle, (lesion of the long thoracic nerve)
 Atrophy of the Supraspinatus or Infraspinatus muscles
: Suprascapular nerve involvement
 Atrophy of the deltoid muscle: Axillary nerve lesion
 Atrophy of the deltoid muscle with Supraspinatus and
Infraspinatus muscles: upper trunk plexus lesion (C5-
C6)

35.  Forward head posture
 Increased upper thoracic spine kyphosis,
 Protraction and elevation of the scapulae
 An increase cervical spine inclination, and backward
bending at the atlanto-occipital junction.
 The forward head posture results in muscle imbalances
that can further result in entrapment of various nerves
of the brachial plexus in the area of the thoracic outlet

36.  Attitude or position of the upper
extremity and hand.
 Arm adduction and internal
rotation: Erb paralysis
 Pronation of the forearm with
flexion at the wrist and
metacarpophalangeal and
proximal interphalangeal joints:
Injury to the lower trunk of the
brachial plexus
 External deformities along the
clavicle : fracture of clavicale
(nonunions and malunions)
 Swelling or ecchymosis :
supraclavicular fossa

37.  Using standard goniometer: all joints of the shoulder
girdle and upper limb.
 Deficits of joint motion from immobility: contracture of
the joint capsule, adhesions in the joints, and
shortening of both muscle and tendons.

38. Manual muscle testing: MRC grading
0: No visible or palpable contraction (None)
1: Visible or palpable contraction with no motion(Trace)
2: Full ROM gravity eliminated (Poor)
3: Full ROM against gravity (Fair)
4: Full ROM against gravity, moderate resistance (Good)
5: Full ROM against gravity, maximum resistance
(Normal)
 Repeated tests: for measuring improvement.
 Pinpointing the site and extent of the plexus lesion.

39.  Rhomboids (dorsal scapular nerve – C4,5)
◦ Push shoulder blades together
 Serratus anterior (long thoracic nerve - C5,6,7)
◦ The classic test is wall-press test.
◦ In BPI, the patient may be unable to lift the arm. The arm
should be supported by the examiner with one hand and the
patient asked to push forward as if trying to open a door. At
the same time the examiner should hold the lower pole of the
scapula with another hand.

40.  Supraspinatus (suprascapular nerve - C5,6)
◦ Test shoulder abduction in the scapular plane with the thumb
pointing downwards.
 Infraspinatus (suprascapular nerve - C5,6)
◦ Test external rotation with the shoulder in adduction and the
elbow flexed.

41.  Pectoralis major (lateral and medial pectoral nerves)
Clavicular head (C5,6)
 Atrophy would imply lateral cord injury.
 Ask the patient to touch their contralateral shoulder (and the
examiner palpates for evidence of contraction).
Sternocostal head (C7,8,T1)
• Atrophy would imply medial cord injury.
• Ask the patient to push against the hip (and the examiner
palpates the axillary fold).

42.  Latissimus dorsi (Thoracodorsal nerve – C6,7,8)
◦ While the arm is supported in a flexed position, ask the patient to
push down (while the examiner palpates for musle contraction).
 Subscapularis (upper and lower subscapular nerves –
C5,6,7)
◦ Belly-press sign. Ask the patient to bring the elbows forward while
pressing the belly. A flexed wrist relative to the normal side indicates
a positive sign.
 Deltoids (Axillary nerve – C5,6)
◦ Extend, abduct and flex the shoulder to test the posterior, middle
and anterior parts respectively.
 Teres minor (axillary nerve – C5,6)
◦ Test external rotation with the shoulder in abduction and the elbow
flexed.

43.  Elbow flexion (C5,6)
 Elbow extension (C7,8)
 Forearm supination (C6)
 Forearm pronation (C7,8)
 Wrist flexion/extension (C6,7)
 MCPJ flexion/extension (C7,8)
 Grip (C8)
 Fingers abduction (T1)

44.  Include light touch, temperature, deep pressure,
stereognosis, and two-point discrimination
 Establish normal sensation in an uninjured area (such
as forehead or sternum).
 First, assess the dermatomes (C5-lateral elbow; C6-
thumb tip; C7-middle finger tip; C8-little finger tip; T1-
medial elbow) and then if necessary such as in
infraclavicular BPI, examine according to the terminal
branch distribution.

45. Dermatome Nerve distribution

46.  Brachioradialis reflex: C6 nerve root level: signifies damage
in the C6 nerve root level, the upper trunk or posterior cord
of the brachial plexus, the radial nerve, or the
brachioradialis musculotendinous unit
 Biceps reflex: C5, and to a lesser extent, the C6 : indicates
damage to the C5 nerve root level, the upper trunk or
lateral cord of the brachial plexus, musculocutaneous
nerve, or biceps musculotendinous unit.
 Triceps reflex: C7 nerve root level: signifies damage to the
C7 nerve root, middle trunk or posterior cord of the
brachial plexus, radial nerve, or triceps musculotendinous
unit.

47.  Loss of sensation and muscle control results in a loss of
gross and fine motor coordination
 Purdue pegboard test

48.  Disruption of the subclavian or axillary arteries occurs
in the presence of severe brachial plexus injuries,
particularly with associated fractures of the clavicle.
 vasomotor changes: dusky, cool skin indicating venous
insufficiency.
 Assesses the brachial and radial pulses.

49. Method:
Volumetric -submerges the patient’s hand in a lucite
container and measures the amount of water displaced
using a 500-ml graduated
Circumferential measurements of the hand and forearm
Rated from 1 to 3, with 1 being minimal edema and 3
being severe or pitting edema.

50.  Tinel’s sign : By tapping over the brachial plexus above the
clavicle
 It is an important clinical sign to determine the location of a
neuroma or to judge the regeneration of injured nerves.
 If the Tinel’s sign remains fixed at a point over a period of time
this implies retardation of progressive regeneration and
warrants surgical exploration.
 If the same advances from supra to Infraclavicular region and
then to the arm and the forearm, a wait and see attitude is
recommended.
 Presence of a localized tenderness, revealed by tapping above
the clavicle, possible neuroma resulting from disruption of part
of the plexus.(fourth- or fifth-degree nerve injury)

51. Self-care activities :
 Feeding
 Bathing
 Grooming
 Dressing

52.  X-ray:Cervical spine, clavicle, scapula, chest and
upper extremity.
 MRI
 Electromyography (EMG)
 Nerve conduction velocity (NCV)
 Strength Duration curve (S-D Curve)

53. Assessment

54.  Gestational age, birth weight, delivery history, Prolong
ed second stage of labor(over 60 minutes)
possible shoulder dystocia, include presentation, Fetal
macrosomia, Use of assistive techniques-forceps to aid
delivery. Maternal obesity, Gestational diabetes.
 Complications after birth: possible respiratory
issues (phrenic nerve:hemidiaphragm), possible Facial
Palsy, Horner’s Syndrome, torticollis
 Developmental history

55.  Position of head in relation to extremity
 Position of extremity in relation to rest of body. If possi
ble, observe in a variety of developmental positions
 Spontaneous movement
 Horner signs
 Check for evidence of circulatory issues

56. Important to assess total body control before focusing o
n affected extremity
 Muscle tone/bulk
 Quality of movement: head and trunk control
 Symmetry: include not only body symmetry but
also visual, auditory, oral symmetry

57.  Joint integrity: check for subluxations, joint
capsule tightness, glenohumeral changes
 Passive Range of Motion: take into account
physiological flexion, potential shoulder
subluxation or radial head dislocation, need to
promote scapulo‐humeral rhythm when testing
 Active Range of Motion: use of faces, toys, etc

58. Motor Assessment:- videotaping provides objective
documentation of motion on serial visits.
Motor assessment can be done by many measures –
 Active Motion Scale (AMS)
 Gilbert and Tassin Scale.
 Mallet score

59.  It is an eight-grade, ordinal scale.
 It is used to quantify UE strength by observing
spontaneous, active movements both without and
against gravity in 3 positions - supine, side-lying, &
sitting.
 It assesses 15 movement patterns –
Shoulder abd., add., flexion, ER & IR; Elbow flexion &
extension; FA supination & pronation; Wrist, finger &
thumb flexion & extension.

60. All these movement patterns can be elicited by “TOWEL TEST”

62. Commonly used to assess Elbow Function
Observation Muscle Grade
No contraction M0
Contraction with out movement M1
Slight or complete movement with weight
eliminated
M2
Complete movement against weight of the limb M3

64. Narakas Sensory Grading System
S0- No reaction to painful or other stimuli
S1 – Reaction to painful stimuli, none to touch
S2 – reaction to touch, not to light touch
S3 – Apparently normal sensation

65. Erb’s palsy:
 moro reflex is absent on
the affected arm.
 Asymmetric tonic neck
reflex
Klumpke: Absent palmar
reflex of the hand

66.  X-ray:
All newborns with possible injuries should have x‐rays
of the cervical spine and involved extremity to rule
out clavicular and humeral fractures.
 MRI
 EMG
 NCV

70. Client
Neuropraxia
compressional
injury
Neurotemesis
(Tear injury )
Assess
ment
Axonotmesis
Root
avulsion
No
surgery
Surgery
Mandatery
rehabilitation
services

71.  Early diagnosis and follow-up, if possible, within two to
three weeks after the child’s birth [21]
 Conservative treatment should involve a
multidisciplinary team, composed of physiatrists,
clinical neurophysiologist, neurosurgeons, occupational
therapists, and physiotherapists

72.  Electrical stimulation/electrostimulation is a
complementary means or technique used in conservative
therapies for the rehabilitation of brachial plexus palsy
[4,19], that promotes gaining muscle tone/strength on the
affected muscles, and significant improvements in the
mobility of the injured limb.
 These therapies aim to ensure the conditions needed for
the functional recovery of the limb following nerve
regeneration, which implies the prevention of muscle
shrinkage, sagging, joint deformities, and muscle
contractures [20,21]
 Most studies reveal that conservative treatment performed
by therapists significantly reduces injuries, removing the
need for surgical intervention [28,29].

73.  There are different tools that are used as means and/or
complementary techniques to the
conservative/surgical treatment of neonatal brachial
plexus palsy, such as electrostimulation, botulinum
toxin injection, thermoplastic splints, posterior and
anterior temporary splints (for physiological
positioning, facilitating functional motor function, and
preventing vicious postures. and constraint induced
movement therapy [20,21].

74.  Constraint induced movement therapy demonstrates
that performing activities at home for one hour a day
can improve mobility, functional capacity, speed, range
of motion, and hand manipulation ability [23].

75.  Surgical nerve reconstruction may be necessary for
rehabilitating patients with neonatal brachial plexus palsy,
especially children who do not show spontaneous recovery
during the first months of life [17].
 When surgical intervention is required, both primary and
secondary microsurgeries are available. Primary
microsurgery techniques include recession and
reconstruction of the neuroma, neurolysis, and nerve
transfer [16,20,22]. Studies reveal that, as a primary
surgery for neonatal brachial plexus palsy, neurolysis
combined with nerve transfer produces good results [34].

76.  In situations where the lesion affects the suprascapular
nerve, shoulder function is impaired (abduction and
external rotation). Grafts extracted from the proximal
C5 root stump or the accessory nerve are often used to
reconstruct the suprascapular nerve. The use of the
phrenic nerve has also been shown to provide a similar
level of recovery to the use of the median nerve,
increasing the number of graft options available to
recover suprascapular nerve function [24].

77.  In Erb’s palsy, affecting shoulder abduction and
external rotation, elbow flexion, and forearm
supination, and when there is no evidence of
spontaneous recovery, surgery is a valid treatment
option
 The Oberlin’s procedure involves the transfer of the
ulnar nerve to the cutaneous nerve and is an effective
way of recovering the elbow function, improving elbow
flexion and leading to increased functional use of the
affected limb [25].

78.  well-known classification is useful to understand the nature
of the injury
◦ Neuropraxia—reversible rapidly in weeks, rarely reaches the
surgeon
◦ Externally intact looking nerves (Sunderland type two or three
injury — axonotomesis) —not to be resected in the neck but distal
transfers may be needed if progress is poor
◦ Neuroma in continuity—represents a post ganglionic lesion
(Sunderland Type III and IV axonotomessis) and requires surgical
repair after excision of the neuroma. Rarely is the neuroma
conductive, if it is a neurolysis may suffice
◦ Rupture—Post Ganglionic lesion (neurotomessis sunderland typeV),
amenable to intra plexal nerve repair
◦ Avulsion—Pre Ganglionic lesion, typically that root has to be
abandoned as a source of regenerating axon.

79.  Tendon transfers using available muscles
 Trapezius transfer to stabilize shoulder
 Shoulder and wrist arthrodesis to improve
posture
 Free Functional muscle transfer—can always
be attempted as the donor muscle is
uninjured and has never been denervated.

81.  Nerve Reconstruction
 Management of Late Deformity
 Fixing Shoulder Subluxation and Dislocation
 Tendon Transfers

82.  Results vary depending on multiple parameters
 Age of patient-younger patients get better results
 Time between injury and surgery-earlier the better-first 3
months is the best period
 Extent of injury-partial plexus injuries have superior
results, especially upper plexus injuries
 Rehab facility-people on good rehab programmes show
greater functionality and weight tolerance.

83.  Babhulkar and Thatte-analyzed a small
subset of the data in Bombay Hospital
over a 4 year period where at least 2 years
(approx.)

84.  When the delay for operation was more than 6 months, it
affected the outcome significantly.
 Patients with upper trunk injury showed maximum number of
good results (70%) while those with global plexopathy showed
good outcome in only 20%, fair in 36% and poor in 44%.
 In global plexopathy, those having preganglionic injury had the
worst outcome in the group. Outcome was inversely
proportional to number of avulsed roots.
 Pre-ganglionic injuries showed significantly poorer outcome
than post-ganglionic injuries
 Outcome with primary coaptation without nerve graft had
significantly better result than the patients where the nerve
graft was used.

86.  Positioning and handling
 Sensory stimulation
 Range of motion exercises

87.  Presence of a clavicular fracture is associated with
osseous deformity;
 Restriction of shoulder external rotation, due to
contracture of subscapularis and the anterior
shoulder capsule - in extreme cases this can lead
to posterior subluxation of the shoulder;
 Restriction of scapulo-humeral angle due to
contracture of latissimus dorsi and teres major;
 Loss of full elbow extension, exacerbated by
dislocation of the radial head through forced
supination;
 Loss of full supination;
 Loss of pronation;
 Loss of full extension of wrist and fingers;
 Loss of thumb abduction and opposition.

88.  Shoulder Exercises
 A Gently grasp your baby’s forearm and hold their shoulder
blade down firmly with the palm of your hand. Then raise their
arm slowly up over their head keeping the arm close to the ear
and hold.

89.  Shoulder Exercises
B- This exercise resembles a ‘high five’. Raise your baby’s
shoulder out half way and bend the elbow to 90°.
Maintaining this position, rotate the baby’s arm back so
that the arm touches the bed and hold.

90.  Shoulder Exercise
C-Bend both your baby’s elbows to 90° and keep
elbows tucked into the side of your baby’s body. Turn
the forearms out to the side and down towards the
surface and hold. This is probably the most important
exercise.

91.  Elbow Exercises
A-Keep your baby’s palm turned up, hold above and below the
elbow, gently but firmly straighten your baby’s elbow and hold.
Then bend your baby’s elbow and hold

92.  Elbow Exercises
B-Keep your baby’s elbow bent at 90° with their upper
arm against the body. Start with your baby’s palm
turned down, then turn your baby’s forearm up until
the palm is facing upwards and hold. Then, turn your
baby’s forearm until the palm is facing down and hold.

93.  Wrist and Finger Exercises
A -Hold your baby’s wrist in one hand and their hand in
your other hand. Gently bend their wrist backwards and
hold, then straighten their fingers and hold.
B- Use the same wrist position as above and straighten
their thumb and hold.

94.  Positioning and Handling
 If your baby’s arm is very floppy it should be well
supported with the hand, elbow and shoulder in
the neutral position. Often a towel under the
affected arm during sleep helps to keep the arm
in the neutral position.
 Move your baby’s arm gently for washing,
dressing and skin care. It is helpful to dress the
affected arm first and undress it last. When
washing and drying, particular care should be
taken with skin folds.
 When handling, feeding and cuddling your baby,
the affected arm should be well supported.

95.  Activity Exercises
◦ Side lying
 Place your baby on their side with their affected
arm highest. Place a large rolled up towel snugly at
the child’s back and another at their front. Put
toys in front of them to encourage activity of the
uppermost affected arm. This position makes
reaching easier because your baby does not have
to lift their arm against gravity.

96. ◦ Lying on their back
 Place your baby on the floor and then suspend
or hold a toy above them. Encourage them to
reach upwards particularly with the affected
arm. Your baby must be able to reach the toy
and you may need to gently hold back the
unaffected arm at times. This encourages
reaching skills

97. ◦ Lying on their tummy
 Place your baby on the floor on their tummy with
their arms forward. Encourage them to lean on the
affected arm and reach for a toy with the opposite
arm. Then reverse the exercise so they are
reaching for the toy with their affected arm. This
allows practice of both supporting and reaching
with the affected arm. If your baby’s arm is very
floppy a small towel/roll may be used under their
chest to help support their weight.

98.  Sitting
 When sitting for short periods in an inclined position,
e.g. a car seat, if your baby’s arm falls backwards you
will need to support the arm with a small blanket or
towel. In sitting place your hands on your baby’s arm
or elbows and assist them in a two handed activity
such as reaching for a toy or clapping. This
encourages coordination between the unaffected and
the affected arms.

99.  Classroom management;
 Access to PE and sport;
 leisure activities;
 Confidence;
 Self-esteem;
 The need for secondary surgical intervention in the
future.

100. Clavicular fracture FIGURE OF “8” BANDAGE /
CAST
Shoulder external rotation AEROPLANE SPLINT
Restriction of scapulo-
humeral angle
SCAPULAR FIXATION
SPLINT
Loss of full elbow
extension
TRICEP ASSIST SPLINTING
Loss of full supination SERPENT SPLINT
/SUPINATOR ASSIST
Loss of pronation SERPENT SPLINT
Loss of full extension of
wrist and fingers
COCKUP SPLINT
Loss of thumb abduction
and opposition
THUMB SPIKA

101.  The use of temporary immobilizing splints is indicated for
children with impaired wrist function, which can help improve
hand function and prevent wrist drop, thus promoting wrist
extension. Some splints are used during sleep, and other more
functional ones are used during awake time activities
 If a patient has the ability to flex the fingers and thumb but is
unable to actively extend the fingers a dynamic splint with an
outrigger could help. A night resting splint will also maintain a
good hand resting position. The physiotherapy service can
provide any necessary splints

102.  Thermoplastic splints, posterior and anterior
temporary splints (for physiological positioning.
 Anterior and posterior fist or hand splints control and
prevent, at the fist level, extreme ulnar flexion and
deviation.
 Anterior splints can simultaneously control thumb
adduction, and posterior splints allow more freedom
of the child’s palm)

104.  ERBS PALSY-
 B/L Over head activity
 BASKET THE BALL (play )
 Lets go selling in a over head basket (play )
 Remove your tee( activity ) etc…
 WRIST DROP-
 Pushing the wall
 Rolling a bread
 Making the puppet to dance
 RADIAL CLAW HAND
 Putty activity
 Play carrom
 Water colour
 APE HAND-
 Throwing a ball
 Catching a ball hold the glass till filled
 LOSS OF SHOULDER ABDUCTION –
 Flap like a bird
 fly like an aeroplanene etc.

105.  Obvious truncal asymmetries;
 Residual unsightly scarring;
 Poor body image;
 Peer pressure;

106.  Maintain joint range of movement
 Use static splinting to maintain good resting
position of the hand
 Encourage active exercises for muscle groups that
are working
 Maximize function if necessary by modification of
activities and possibly dynamic splinting
 OT for assessment and improvement of
independent ADLs
 Check balance and posture, if necessary treat
appropriately
 Once there is evidence of recovery start
progressing exercise to incorporate gravity
eliminated exercises and active assisted exercises
 If appropriate discuss early return to work and
hobbies

107.  All patients with brachial plexus injury need early
referral to a person specializing in treating it
 Patients get better results with earlier referral
 All patients can be offered some modality of treatment
irrespective of time of referral
 No patient must be abandoned without offering
treatment and rehabilitation.