Flashcards in ICL 4.4: UE Plexopathies Deck (35)
what is plexopathy?
plexopathy is a disorder affecting a network of nerves, blood vessels, or lymph vessels
typically occurs distal to roots and proximal to peripheral nerves (but not always)
the region of nerves it affects are at the brachial (upper) or lumbosacral (lower) plexus
usually diagnosed with history, PE, imaging, electrodiagnostics
symptoms include pain, loss of motor control, and sensory deficits
what can cause plexopathy?
traction, transection, obstetrical injuries, compression, hemorrhage
what innervates the FDP of the 2nd and 3rd fingers?
anterior interosseous nerve
what innervates the FDP of the 3rd and 4th fingers?
which nerve is related to wrist drop?
to double check that the neuropathy isn't effecting nerves higher up on the posterior cord you should check somewhere innervated by the axillary nerve like the deltoid
what part of the brachial plexus are you at when you're at the clavicle?
the divisions are sitting at the level of the clavicle
what is a traction plexopathy?
it's a pulling type of injury to the nerves of the brachial plexus; most common type of nerve injury
may be due to birth trauma*, sports, MVA/MCA
rhomboid and serratus anterior may help distinguish root from plexus injury (EDX)
many have associated pain syndromes
treatments can include meds* and surgery
what is Erb's palsy?
typically upper trunk plexus traction injury involving C5-C6 nerve roots
usually due to obstetrical injury but may also be sports related like during a tackle that pulls the neck away (Burner-Stinger syndrome)
"waiter's tip" = C5-C6 innervate proximal muscles of the shoulder
treat with rehab and splints in abduction, external rotation, flexion, supination, and wrist extension positions
which sport has the highest incidence for traction type injuries aka stingers?
football in the US but in the world it's rugby
what parts of the body are weakened with Erb's Palsy?
the kids will be ____ due to weakness of _____:
1. adducted: deltoid, supraspinatus
2. internally rotated: teres minor, infraspinatus
3. extended: biceps, brachioradialis
4. pronated: supinator, brachioradialis
5. wrist flexion: ECRL, ECRB
what is Klumpke's palsy?
traction injury to inferior trunk plexus = C8-T1 nerve roots
usually due to hyper-abduction injury; usually obstetrical but could also be due to MVA or falls
pts. present with distal weakness like loss of hand intrinsics which could cause claw hand deformity
affects anterior interosseous nerve and ulnar nerve innervated forearm muscles, distal radial innervated muscles but shoulder girdle is preserved
how do you treat Klumpke's palsy?
rehabilitation for incomplete lesions and surgical exploration w/ nerve root avulsion
what is a neoplastic plexopathy?
may involve brachial or lumbosacral plexus --> usually lower trunk of brachial plexus and painful***
may be associated with neurofibromas, schwanommas, sarcomas, neuromas
primary tumors are rare but secondary tumor from lung or breast can cause injury to plexus
may see Horner's syndrome
what is Horner's syndrome?
associated with neoplastic plexopathy
1. mitosis = constriction of pupils
2. ptosis = drooping eyelids
3. anhidrosis = no sweating
this is often because of Pankos tumors which have a predilection for your lower trunk of brachial plexus
which cancers are associated with a neoplastic plexopathy?
what is radiation plexopathy?
it's a progressive demyelination, connective tissue fibrosis, loss of vascular structures of the nerves
usually effects the superior trunk which then could continue down to the lateral cord
most commonly due to high frequency of radiation use and can occur anywhere from 1-30 years post exposure --> most common with breast cancer treatment
might have lack of sensation in median nerve distribution which is associated with hand intrinsic weakness
what is idiopathic brachial plexopathy also known as?
1. neuralgic amyotrophy
2. neuralgic amyotrophy
what is idiopathic brachial plexopathy?
can be idiopathic, inflammatory, immune-related, or worked out too much
usually there's a trigger like URI or overdoing it while working out
male > female
what is the clinical presentation of an idiopathic brachial plexopathy?
some kind of trigger followed by sudden onset of severe pain at the shoulder girdle specifically
pain might resolve in hours or up to weeks all on its own without treatment; doctors just help with symptoms and controlling pain and not losing strength in effected muscles
symptoms are all over, it doesn't just effect one specific nerve which is a hallmark of this --> most patients have bilateral involvement
which nerves are most commonly affected by idiopathic brachial plexopathy?
1. Long Thoracic (Serratus anterior)
2/3 may be bilateral
2. Suprascapular (supraspinatus, infrapinatus)
3. Axillary (Deltoid)
4. AIN (FPL-flexor pollicus longus, FDP – flexor digitorum profundus)
however IBP is known for effecting all over but these are the nerves that are most likely effected
how do you treat idiopathic brachial plexopathy?
steroids if it's inflamed
start rehab ASAP; goal is to prevent contractures
recovery is usually quick but can be up to 2-3 years on it's own
what is thoracic outlet syndrome?
there are 2 types: vascular or neurogenic
1. vascular = involves subclavian artery, subclavian vein, or axillary vein that could be compressing on plexus
2. neurogenic = may be due to compression by 1st cervical rib (costoclvaciular syndrome), scalenes (anterior and middle), pectoralis minor (pec minor syndrome), or a fibrous band on the plexus
it's dynamic so symptoms aren't always present
what part of the body is more commonly effected in thoracic outlet syndrome?
ulnar distribution is more common than median distribution
median motor is effected and ulnar sensory is effected and the reason is because of T1:
your lateral cord and medial cord contribute to form median nerve so a majority of your median motor is coming from T1
while your ulnar sensory is effected because your medial cord branches into the medial antebrachial nerve
what's the clinical presentation of vascular thoracic outlet syndrome?
1. Arterial involvement
Decreased color and temp
2. Venous involvement
what's the clinical presentation of neurogenic thoracic outlet syndrome?
pain and numbness along medial aspect of forearm and hand --> increase with overhead activity
discomfort in neck, clavicle and axilla
hand muscle wasting: Median thenar > Ulnar intrinsics
Adson’s test and Roos test
what is Adson's test?
used for thoracic outlet syndrome
passively abduct, extend and externally rotate patients arm while monitoring radial pulse
have pt rotate head toward the arm
decrease or loss of pulse may be related to compression of subclavian artery
this would be considered a vascular TOS
what is the Roos test?
used for neurogenic thoracic outlet syndrome
patient has both arms in 90o abduction-external rotation with shoulders and elbows in the frontal plane of the chest
patient then opens and closes hands slowly over a 3-min period
normal = forearm fatigue & minimal distress
abnormal = gradual increase in pain @ neck and shoulder progressing down the arm
1. paresthesia in forearm & fingers
2. venous compression with cyanosis & swelling
3. drop arms d/t marked distress
what is the treatment for thoracic outlet syndrome?
1. rehabilitation treatment
focus on ROM
stretching of muscles – anterior/middle scalenes, pec minor, trapezius and levator scapulae
strengthening of scapular stabilizers – upper/middle trap and rhomboids
2. surgical treatment = first rib or fibrous band resection
what is nerve root avulsion?
severe injury at the nerve root level where the root gets ripped off from the spinal cord -- traction injury that disrupts protective connective tissue support
usually traumatic like an accident
C8 and T1 are usually effected because they're less protection
will present as absent sensation or muscle contraction from muscle innervated by the roots involved = "flail shoulder"