Brachial Plexus Palsy Flashcards
Neonatal brachial plexus palsy (NBPP)
Traction/stretching of brachial plexus during labour or delivery
NBPP causes
Endogenous (maternal) force - uterine contractions and maternal pushing
Exogenous (clinician applied) forces - downward lateral traction
Shoulder dystocia
Delivery of the upper shoulder is blocked by symphysis pubis
The ipsilateral brachial plexus stretches when additional downward pressure is applied to baby’s head
Erb’s Palsy - upper trunk C5,6
Most common
Classic posture - waiters tip
- Shoulder in IR+ADD, elbow extension, forearm pronated, wrist and fingers flexed
Loss of passive ROM
Loss fo active ROM = scapular protraction and elevation, shoulder flexion and ER, elbow flexion, supination, wrist and finger extension
Loss of sensation - C5,6 dermatome - radial arm and hand
Klumpke’s Palsy - lower trunk C8,T1
Problem with contraction of dilators of the iris and elevators of the eyelid
Miosis/contraction of the pupils in the affected eye
Ptosis - drooping eyelid in the affected eye
What are the 4 types of nerve injury that may occur in neonatal brachial plexus palsy?
Avulsion
Neurotmesis/rupture
Axonotmesis/neuroma
Neuroapraxia/block
Avulsion
Location = preganglionic root - most severe lesion type
Complete discontinuity of neural connective tissue between spinal cord and PNS
Symptoms - loss of motor and sensory function of nerve
Surgical repair not possible
Neurotmesis/rupture
Location - postganglionic lesion - further down plexus
Rupture of the nerve and myelin sheath, Schwann cells and endometrium - severe
Symptoms - loss of motor and sensory function of nerve, pain and dysesthesias
Surgical repair is possible
Axonotmesis/neuroma
Location - postganglionic
Axons and myelin damaged but the endometrium, perineurium and epineurium remain intact
Signs and symptoms - lost motor and sensory function of the nerve
Nerve regrowth may occur without surgery
Neurapraxia/block
Location - post ganglionic
Injury - mild - pressure on nerve, causes ischemia, neural lesion, body responds with oedema, partial or complete action potential conduction block across lesion
Signs and symptoms - mild - temporary loss of motor and sensory function, numbness, tingling and burning sensations
Full spontaneous recovery in 6-8 weeks
Initial treatment
Pain management - care of UL (3 S’s)
Maintain and improve ROM (3 P’s)
Active ROM in sidling, supine, prone, sitting - reaching for toys
passive ROM in Mallet directions to prevent contracture in affected muscles and stiffness in associated joints
What are the 3 S’s?
Alert parents to be aware of poor SENSATION
Teach parents to carefully SUPPORT a flaccid arm/hand
Teach SAFE positioning during sleep and play
What are the 3 P’s?
POSITIONING to avoid contractures
PASSIVE facilitation/mobilisation into limited ROM
PROMOTE active movements as soon as able
Older child assessment
MSK examination
Secondary posture changes
Sensory - perceptual
Neuro-motor/development status
Older child treatment
Increase focus on 3P’s, continue 3S’s
Gross Motor - gradually introducing prone position when awake to promote symmetry if shoulder stable, then 4 point kneel etc
Fine Motor - reaching and hand function during ADL’s, play and learning
Facilitate postural control - supporting, protecting, weight shifting
Facilitate sensory function - warm baths or gentle massages can provide sensory stimulation to affected muscle groups
Interaction with hands - textures, bimanual play
