Clinical Science IIIClinical Science III

Karen R. Voogt, DPTKaren R. Voogt, DPT

Fall 2011Fall 2011

Brachial Plexus Brachial Plexus InjuriesInjuries

BRACHIAL PLEXUS BRACHIAL PLEXUS INJURIESINJURIES

Specifically: Specifically: Obstetrical Brachial Obstetrical Brachial Plexus InjuryPlexus Injury

Usually result from Usually result from forcible extraction of forcible extraction of fetus by traction on fetus by traction on shoulder in a breech shoulder in a breech presentation, or from presentation, or from traction and tipping traction and tipping of the head in a of the head in a shoulder presentationshoulder presentation

BRACHIAL PLEXUS BRACHIAL PLEXUS INJURIESINJURIES

Incidence ranges .5-2/1000 birthsIncidence ranges .5-2/1000 births Contributing Factors:Contributing Factors:

Birth weight >3500g Birth weight >3500g Shoulder dystocia Shoulder dystocia Prolonged laborProlonged labor Maternal diabetes Maternal diabetes Infant sedationInfant sedation Breech deliveryBreech delivery

BPIBPI

Occurrence:Occurrence: 0.1% spontaneous deliveries0.1% spontaneous deliveries 1.2% breech presentation1.2% breech presentation 1.3% forceps deliveries1.3% forceps deliveries

BRACHIAL PLEXUS BRACHIAL PLEXUS INJURIESINJURIES

May produce lifelong effects:May produce lifelong effects: Total body Total body MultifactorialMultifactorial Progressive musculoskeletal Progressive musculoskeletal

impairmentimpairment Limb length deficitsLimb length deficits

BRACHIAL PLEXUS BRACHIAL PLEXUS INJURIESINJURIES

May have associated trauma:May have associated trauma: clavicle or humerus fracturesclavicle or humerus fractures facial nerve injuriesfacial nerve injuries shoulder subluxationshoulder subluxation torticollistorticollis hemi paralysis of the diaphragm hemi paralysis of the diaphragm

with phrenic nerve injury (C4)with phrenic nerve injury (C4)

BPI: pathologyBPI: pathology

May be upper or lower plexus or May be upper or lower plexus or bothboth

Roots, trunks, divisions , cords and Roots, trunks, divisions , cords and peripheral nerves can all suffer:peripheral nerves can all suffer: Neurotmesis: complete ruptureNeurotmesis: complete rupture Axonotmesis: disruption of axons while Axonotmesis: disruption of axons while

neural sheath remains intactneural sheath remains intact Neurapraxia: temporary nerve Neurapraxia: temporary nerve

conduction block with intact axonsconduction block with intact axons

BPI: pathologyBPI: pathology

Partial or complete rupture may Partial or complete rupture may evolve into a neuroma, mass of evolve into a neuroma, mass of fibrous tissuefibrous tissue

Hemorrhage into subarachnoid Hemorrhage into subarachnoid space space

May have combination of types of May have combination of types of lesionslesions

Transient or permanentTransient or permanent

BPI Neuronal RecoveryBPI Neuronal Recovery

Axon regeneration 1 mm per dayAxon regeneration 1 mm per day 4-6 months for upper arm4-6 months for upper arm 7-9 months for lower arm7-9 months for lower arm

Recovery is varied according to Recovery is varied according to damagedamage 2 years upper arm2 years upper arm 4 years lower arm4 years lower arm

ClassificationClassification

Mild: stretching of the nerve fibersMild: stretching of the nerve fibers Moderate: stretching and tearingModerate: stretching and tearing Severe: complete rupture with Severe: complete rupture with

avulsion of roots from spinal cordavulsion of roots from spinal cord Diaphragmatic and serratus anterior Diaphragmatic and serratus anterior

paralysis suggests avulsion paralysis suggests avulsion

Classification: Classification:

Erb’s Palsy, or Erb’s Palsy, or upperupper Involvement of the Involvement of the

upper brachial upper brachial plexus and 5th and plexus and 5th and 6th C-nerve roots 6th C-nerve roots (20% more common (20% more common than lower)than lower)

Klumpke’s Palsy or Klumpke’s Palsy or lowerlower Involvement of the Involvement of the

lower brachial lower brachial plexus and 7plexus and 7thth and and 88thth nerve roots nerve roots

Caused by traction Caused by traction on abducted armon abducted arm

Erb’s PalsyErb’s Palsy

Caused by the forceful Caused by the forceful separation of separation of head/shoulder head/shoulder biceps, deltoid, biceps, deltoid,

brachialis, brachialis, brachioradialis, brachioradialis, supinator, supra and supinator, supra and infraspinatus, infraspinatus, subscapularis, teres subscapularis, teres minor, serratus anterior minor, serratus anterior and rhomboids, long and rhomboids, long extensors of wrist, extensors of wrist, fingers and thumb may fingers and thumb may be involvedbe involved

Erb’s Palsy contErb’s Palsy cont

Affected arm usually Affected arm usually hangs at side with hangs at side with shoulder ADD/ IR and shoulder ADD/ IR and elbow extension, elbow extension, forearm pronation forearm pronation and wrist flexion and and wrist flexion and finger flexion finger flexion (“waiter’s tip” (“waiter’s tip” position) position)

Moro, biceps and Moro, biceps and radial reflexes are radial reflexes are absent - intact graspabsent - intact grasp

May have sensory lossMay have sensory loss

PROGNOSIS for Erb’s PROGNOSIS for Erb’s PalsyPalsy

Generally good for Generally good for spontaneous spontaneous recovery, although recovery, although may be incomplete may be incomplete

Depends on degree Depends on degree of involvementof involvement

Majority of Majority of spontaneous spontaneous recovery by 9 recovery by 9 monthsmonths

TREATMENT TREATMENT

Usually involves rest for 7 - 10 days Usually involves rest for 7 - 10 days (possibly splinting)(possibly splinting) Positioning/splintingPositioning/splinting Gentle ROMGentle ROM Stimulation of muscle function Stimulation of muscle function Encourage active movementEncourage active movement Weight bearingWeight bearing Sensory inputSensory input

TREATMENT cont.TREATMENT cont.

Bimanual activities Bimanual activities Balance reactionsBalance reactions Taping Taping BotoxBotox Electrical Electrical

stimulationstimulation

LOWER (Klumpke’s LOWER (Klumpke’s Palsy)Palsy)

Involvement of the lower brachial Involvement of the lower brachial plexus and 7th and 8th (T1) C- nerve plexus and 7th and 8th (T1) C- nerve rootsroots caused by traction on abducted armcaused by traction on abducted arm Incidence .6-2% of all OBPIIncidence .6-2% of all OBPI

Klumpke’s PalsyKlumpke’s Palsy

Resting position of forearm supination, Resting position of forearm supination, paralysis of wrist flexors, extensors, paralysis of wrist flexors, extensors, intrinsic muscles of hand (claw- hand intrinsic muscles of hand (claw- hand deformity)deformity)

Sensory loss of ulnar border of Sensory loss of ulnar border of hand/forearmhand/forearm

T1 involvement T1 involvement may see associated paralysis of sympathetic may see associated paralysis of sympathetic

nerves with a Horner’s Syndromenerves with a Horner’s Syndrome

BOTH (Erb - Klumpke)BOTH (Erb - Klumpke)Total Brachial Plexus Total Brachial Plexus

InjuryInjury Infrequent Infrequent

occurrenceoccurrence Avulsion of Avulsion of

plexus/rootsplexus/roots Recovery limited Recovery limited

after avulsion/ruptureafter avulsion/rupture Loss of sensationLoss of sensation Surgical indicationSurgical indication

Mallet ScaleMallet Scale

Surgical InterventionSurgical Intervention

Neurosurgery 5-Neurosurgery 5-10% OBPI10% OBPI Nerve graftingNerve grafting Neuroma dissection Neuroma dissection

and removaland removal Neurolysis Neurolysis

(decompression and (decompression and removal of scar removal of scar tissue)tissue)

Direct end to end Direct end to end anastomosis of nerve anastomosis of nerve endsends

Surgical InterventionSurgical Intervention

Later surgeries:Later surgeries: Soft tissue releaseSoft tissue release Reduction of gleno-Reduction of gleno-

humeral joint humeral joint dislocationdislocation

Transfer of muscles Transfer of muscles osteotomiesosteotomies

BPI Impairments of Body BPI Impairments of Body Structure and FunctionStructure and Function

Abnormal muscle substitutionsAbnormal muscle substitutions Neglect due to increased function and Neglect due to increased function and

ease of movement of opposite armease of movement of opposite arm Soft tissue contractureSoft tissue contracture Scoliosis, pelvic obliquityScoliosis, pelvic obliquity Abnormal bone growthAbnormal bone growth Flattening of humeral head, short Flattening of humeral head, short

clavicleclavicle Positional torticollisPositional torticollis

BPI Activity LimitationsBPI Activity Limitations

Inability to grasp, reachInability to grasp, reach Limited bilateral activities ex-catch, carryLimited bilateral activities ex-catch, carry Decreased ability for ADLsDecreased ability for ADLs Compromised developmental Compromised developmental

activities/delayactivities/delay Decreased balance reactions/protective Decreased balance reactions/protective

responsesresponses Neglect, self –abuseNeglect, self –abuse Later-shoulder pain, arthritisLater-shoulder pain, arthritis

Scapular winging, Scapular winging, Trumpet signTrumpet sign

BPI Treatment BPI Treatment InterventionIntervention

BPI Treatment BPI Treatment InterventionIntervention

InterventionsInterventions

InterventionsInterventions