BP Injury

Question 1

What is the cut off for releases and tendon transfers at the GHJ

Answer 1

4-5 years

Question 2

What is the desired age for secondary orthopedic procedures to address GH dysplasia (like a lat transfer)

Answer 2

2-4 years old

Question 3

What is the cutoff for ALL nurve surgeries

Answer 3

15 months

Question 4

What is the cutoff for non-surgical management of GH dysplasia and dislocation (botox of IR muscles and casting)

Answer 4

9 months

Question 5

For the botox and cast solution to GH dislocation, what is the position of the arm?

what muscles are botoxed?

Answer 5

ER + Abduction

Internal Rotators

Question 6

What is the age range where the majority of nerve surgeries take place?

Answer 6

6-12 months

Question 7

What is the age where the majority of BP injury patients have shoulder dislocations

Answer 7

3-6 months

Question 8

what is the desired age for surgical intervention for infants with global BPBI (C5-T1 + Horner)

Answer 8

3 months

Question 9

What is the desired age for an initial eval with a speciality clinic (for BP injuries)

Answer 9

1 month

(because at this point clavical and humeral fxs are healed enough to evaluate pt)

Question 10

What is the modified mallet classification

Answer 10

For 3+

Assesses gross UE function

Question 11

What kind of cells regrow peripheral nerves

Answer 11

Schwann cells

Question 12

What is the normal rate of nerve regrowth in the PNS

Answer 12

1mm per day or 1 inch per month

Question 13

A child just had a peripheral nerve repair, and now they cant move their arm at all…

Answer 13

Normal, must give it time to regrow

Question 14

Nerve surgeries:

Intraplexal vs extraplexal

Answer 14

Intra-plexal- moving a nerve from one part of the BP to a different muscle

Example: Oberlins transfer: move the ulnar N to the bicep

Extra plexal: Bring in nerve tissue from elsewhere
example: sural nerve

Question 15

What kind of orthosis works best to treat brachial plexus injuries

Answer 15

Hero strap

Question 16

How well does CIMT work for BPI?

Answer 16

Very well!

Question 17

What is the most important stretch/ROM for BPI patients for preventing posterior humeral head dislocation and is the least tolerated by patients

Answer 17

ER + adduction

Question 18

When we stretch into composite wrist and finger extension we need what hand positioning

Answer 18

No hyperext of MP joint and neutral position of PIP and DIP

Question 19

When using extension + supination ROM on BPI patients where should we rotate the wrist from

Answer 19

Rotate from the forearm, proximal to the wrist to avoid intercarpal ligament stretch

Avoid elbow hyperext

Question 20

What ROMs are included in the BPI HEP

Answer 20

Shoulder ER + add

Shoulder ER + abd

shoulder abd

Elbow ext and supination

Composite wrist and finger extension

Question 21

When under ________ ROM is available it’s recommended an ultrasound be ordered to check for BPI/ Fx

Answer 21

Under 60 of ER/adduction

Question 22

What are the Narakas grades of BP injury

Answer 22

1. Upper trunk palsy (erb)
2. Extended upper trunk palsy
3. global palsy
4. global palsy + Horner’s

Question 23

What is the preferred imaging for primary nerve surgery planning

Answer 23

MRI

note: 1 year status post secondary shoulder surgery to check for GHJ integrity

Question 24

How do we test sensation in a child under 3

Answer 24

Distract them and pinch the dermatome and see if they notice

Question 25

What are the 3 parts of horners sign

Answer 25

Partial ptosis Miosis Facial anhidrosis

Question 26

Maternal risk factors for BPI

Answer 26

Advanced age 35+ Pelvic anatomy High BMI Infections Gestational diabetes Primiparity

Question 27

BP Cutoffs

Answer 27

1 month: earliest they can be seen for eval 3 months: desired age for nerve surgery 9 months: latest they can get non surgical Botox+ casting 15 months: cut off for nerve surgery 2-4: desired age for tendon transfer 4-5: cut off for tendon transfer

Question 28

Transfer vs grafting

Answer 28

Transfer heals faster but has less fibers

Question 29

What muscles degrade faster without intervention?

Answer 29

Smaller muscles like interossei of hand

Question 30

Clavicle fractures heal in… Humeral fractures heal in….

Answer 30

21 days 6 weeks

Question 31

If shoulder forward flexion only occurs with ___, this is the pec major working, not the deltoid

Answer 31

With internal rotation and adduction

Question 32

Shoulder abduction only occurring with lifting off the table (in supine) indicates what

Answer 32

Pec major subbing in for deltoids

Question 33

Shoulder stays mostly adducted Whole arm is off the mat Cubital fossa pointing at body (shoulder IR) No active shoulder abduction

Answer 33

Signs that the pec major is substituting for the deltoids Signs of a C5/C6 injury (or more levels)

Question 34

What substitution will you see for shoulder ER in infants with C5/C6

Answer 34

Shoulder retraction instead of ER

Question 35

How will babies with C5/C6 substitute for elbow flexion

Answer 35

Unopposed elbow extension causes rebounding into elbow flexion

Question 36

When less than 60 degrees of ER/adduction is available....

Answer 36

We should recommend an ultrasound to check GH joint

Question 37

T or F: you need to assess adduction/ER and abduction/ER separately

Answer 37

T

Question 38

To stretch shoulder abduction in these patients you must ________

Answer 38

must block the scapula

Question 39

When stretching wrist pronation/supination where do we want to stretch from?

Answer 39

Don't turn the forearm from the hand because then you're stretching the carpal joints too!

Question 40

____________ is the major limiting factor in BP surgery

Answer 40

Nerve regrowth

Question 41

T or F: For BP injury patients we need to "wait and see" and "protect arm and follow up with your pediatrician"

Answer 41

F, need early specialty referral

Question 42

3 months is the desired age for what?

Answer 42

Nerve surgeries for global BPBI (C5+T1 + Horners)

Question 43

at 3-6 months, this is when the majority of ___________

Answer 43

Majority of BPBI patients have shoulder dislocations

Question 44

at the age of 6-12 months, this is when the majority of ____________ take place

Answer 44

primary nerve surgeries note: Nerve transfers can be done later in this timeframe, whereas nerve grafting needs to be done earlier

Question 45

at 9 months, this is the cut off for

Answer 45

Non-surgical management of GH dysplasia

Question 46

15 months is the cutoff for

Answer 46

all primary nerve surgeries

Question 47

2-4 years old is the desired age for

Answer 47

Secondary orthopedic procedures like a tendon transfer

Question 48

4-5 years old is the cutoff for

Answer 48

tendon transfers and releases at the GHJ