Brachial Plexus injury (BPI) Flashcards
(40 cards)
1
Q
Birth related brachial plexus injuries are referred to as
A
- Neonatal brachial plexus palsy (NBPP)
- obstetric brachial plexus injury (OBPI)
- perinatal brachial plexus injury (PBPI)
- brachial plexus birth palsy (BPBP)
- birth brachial plexus injury (BBPI)
- erb’s palsy
- klumpke’s palsy
2
Q
What is obstetric/perinatal brachial plexus palsy/injury
A
- almost always involves traction of the C5 and C6 nerve root
- resulting in weakness of shoulder function and elbow flexion
- traumatic birth, bigger babies can be a factor with this
3
Q
Incidence of BPP
A
- around 1 to 3 per 1000 live birth in US
- decreasing incidence
- majority of cases are erb’s palsy
- Involvement of C5 and C6 +/- C7 resulting in proximal muscle weakness
4
Q
Pathogenesis: perinatal brachial plexus injury
A
- stretching or avulsion of the brachial plexus by extreme lateral traction
- relationship between gross pathology and outcome
- can occur during difficult delivery, when the brachial plexus is stretched or torn
5
Q
Etiology of BPP/contributing factors durig pregnancy
A
- genetics: 2-3% recurrence risk for siblings (may be more to do with genetics of mothers hips
- teratogens: increased risk with maternal alcoholism (increased sugar levels)
- nutritional deficiency: lack of folic acid
6
Q
Degrees of injury with BPP
A
- most severe third degree: peripheral or central avulsion, rupture: neurotmesis
- Moderate or second-degree: injury characterized by damage of the axons and myelin sheath: axonotmesis
- Overstretch, distraction, or pull of the nerve(s) of the brachial plexus called: neuropraxia (stretched but not torn - child should recover full)
7
Q
Types of injury
Neuropraxia/stretch
A
- varies in degrees of intensity
- nerves in plexus compressed not torn due to swelling or bruising from birth trauma of shoulder
- stretch injuries will spontaneously recover in 1-2 years of age with 90-100% return of function
8
Q
Types of injury
Rupture
(not at the root)
A
- nerves are torn at either one or several places in the plexus requiring surgery for the nerves to recover
- some children dont get surgery - 75% return of function
9
Q
injury types
Avulsion at the root
A
- most severe injury
- nerves are pulled from the spinal cord as evidence by a totally flaccid extremity
- requires surgery and testing to make sure they did not stroke
10
Q
injury types
neuroma
A
- from a torn nerve that begins to heal
- scar tissue develops and puts pressure on the injured nerve and prevents signals from being transmitted between nerves and muscles
- neuroma injuries require treatment to heal
11
Q
insult prior to delivery?
A
- 50% of all BPI attributed to unavoidable intrapartum or antepartum events and not to actual management of the shoulder dystocia
- before acutal recognition of shoulder dystocia a significant degree of stretch pressure may have been applied to the FETAL brachial plexus
12
Q
examples of non-obstetric causes
A
- contact sports, especially wrestling and football
- high speed impact accidents: motorcycle, bicycle, car
- falls
- industrial accidents
- tumors of the neck
- viral disease
13
Q
Draw the brachial plexus
A
compare to online
14
Q
Risk factors for BPP
A
- birth weight >4500 g (7.8 lbs)
- prolonged labor and difficult delivery (take history from parents
- maternal diabetes Larger than average weight newborn
- breech
- hypotonia, sedation - mother is sedated = baby is sedated
- difficulty delivering the baby’s shoulder after the head has already come out
- flat contracted or platypelloid pelvis (doesnt round out)
- overdue baby
- prior birth of child greater than 8.5 lbs or child with BPI
- use of tolls or external assistance during delivery
- postdate destation
- disparity between fetal size and maternal pelvis size (small pelvis)
- short/small maternal size
- epidural
15
Q
platypelloid pelvis
A
- uncommon in both sexes
- pelvic inlet appears slightly flattened (kidney shaped)
- transverse diameter is greater than AP diameter
- sacral promontory pushed forwards
16
Q
what are the classifications of BPI
A
- upper erbs palsy C5, C6
- extended Erb’s C5, C6, C7
- total palsy with no horner syndrome C5, C6, C7, C8, T1
- Total palsy with horner syndrome C5, C6, C7, C8, T1
17
Q
Upper erb’s C5-C6
A
- shoulder abduction/ER, elbow flexion affected
- good spontaneous recovery expected in over 80% of cases
18
Q
Extended Erbs C5-C7
A
- shoulder abduction/ER and definite wrist drop
- good spontaneous recovery in about 60% of cases
- C7
19
Q
Total palsy with horner syndrome
C5-T1
A
- complete flaccid paralysis with horner syndrome
- the worst outcome
- without surgery, severe defects throughout the limb functon
- visual system involved
- need muscle transplant
20
Q
Horner syndrome 4 classic signs
A
- constricted pupil (miosis)
- dropping of the upper eyelid (ptosis)
- absence of sweating of the face (anhidrosis)
- sinking of the eyeball into the bony cavity that protects the eye (enophtalmos)
- relatively rare disorder
21
Q
Horners syndrome
what happens
A
- interruption of the sympathetic nerve supply to the eye due to a lesion or growth
- lesions develops along the path of the eye to the region of the brain that controls the sympathetic nervous system (hypothalamus)
22
Q
Erbs paralysis
A
- affects the upper and lower arm
- usual have hand function C5, C6 maybe C7
- scapular involvement possible
- posturing: waiter’s tip position
23
Q
Klumpke paralysis
A
- affects the intrinsics of hand
- the infant may also have an eyelid droop on the opposite side
- C8-T1
- rarely in newborns
(may also have erbs)
24
Q
Total palsy
A
- C5-C8 and occasionally T1 involved
- flaccid arm
25
Shoulder dystocia
- a delivery that requires additional obstetric maneuvers following failure of gental downward traction on the fetal head to effect delivery of the shoulders
26
Brachial plexus injury without dystocia
- is a distinct entity
- BPI posterior shoulder is affected
- antecedent shoulder dystocia or c-section highly suggestive of an in utero mechanism
- neonates are smaller birth weight
- usually have a second stage of labor
## Footnote
shoulder dystocia is birth complication where shoulder gets stuck behind pubic boene
27
Leiden three item test
- active elbow extension at one month
- active elbow flexion at one month
- needle EMG of the biceps muscle. absent bicep motor unit potential at one month
28
Referrals after leiden three item test and decision rule
- prediction at one month of age > at 1 week and 3 months
- children without active elbow extension at one month should be referred
- children with active elbow extension as well flexion should not
- when there is elbow extension, but no active elbow flexion an EMG is neded; absence of MUPs in bicep muscle is reason for referral
29
active movement scale
| describe what it is
- created by the hospital for sick children in toronto to assess motor function in infants with brachial plexus injuries
- an infant is scored on 15 separate movements based on observational analysis
- a muscle grade score of 0 (no contraction) to 7 (full motion) is assigned based on motion elicited
- fifteen movements are evaluated from the affected shoulder to the handgood interrater reliability
30
Gilbert shoulder classification
- grade 0 = complete flail shoulder
- grade 1 (poor) is abducted equal to 45º, with no active external rotation
- grade 2 (fair) = abduction of less 90º with no external rotation
- Grade 3 (satisfactory) = abduction equal to 90º, with weak external rotation
- grade 4 (good) = abduction less than 120º with incomplete ER
- grade 5 (excellent) = abduction of greater than 120º with active ER
31
Pediatric outcomes data collection instrument
- established tool that measures upper extremity function, transfers and basic mobility, sports and physical function, comfort and pain, and happiness with physical condition
- may have further application as a tool to measure baseline function and postoperative functional gains for children with BPP
32
Interventions for BPP
- transitional movements
- protective reactions
- bimanual tasks
- strengthening with toys
33
Bone mineral density (BMD)
- BMD is significantly reduced in BPP children
- the retardation of bone accrual increases as the child height and weight decreases and the degree of paralysis increases
- weight bearing exercises significantly promoted BMD improvement when compared to traditional exercises in those children
34
Physical therapy interventions
| BPP
- ROM
- strengthening
- constrained induced movement therapy (CIMP)
- neuromuscular electrical stim
- joint mobilization (keep them as mobile as possible)
- aquatic therapy
- Kinesio taping
- serial casting: time, good results ith contractures
- orthosis may be used to encourage recover
35
Tasks to encourage movement
- infant only wrist flexion
- toddler has shoulder flexion to 65º, limited movement of fingers generalized strength is 3+
- school age 7-9
36
indications for use of botox with BPP
- internal rotation or adducted contracture: inject pectoralis and occasionally the Lat (subscapularis, teres minor, and teres major)
- limited active elbow flexion (inject triceps)
- limited active elbow extension: inject biceps, sometimes brachialis and brachioradialis
- pronation contraction: inject pronator teres
37
treatment for BPP
general treatment strategy is neurosurgical repair if antigravity deltoid and bicep movement is not available by 2 months of age
| mostly wait until they grow more muscle (mature muscle)
38
# BPI
Secondary surgery
- secondary surgeries are usually performed on children who are at least 18 months to 2 years
- this allows the children to mature and the injury to fully show itself, yet the child is still young enough to benefit from the reconstruction
39
surgeries for BPP
- mod quad
- tendon transfers
- tendon shortening or lengthening
- joint capsule tightening
- free nerve and muscle flaps
- and bony work
40
surgeries for resultant bony deformities
- triangle tilt surgery
- humeral osteotomy
- shoulder arthrodesis/fusion
