D.A.ASIR JOHN SAMUEL., ( Paed.Neuro)

Final Yr MPT

Under,

Mr. M.MANIKANDAN., MPT (Neuro)

Associate Professor

*Definition

*Incidence

*Risk factors

*Classification

*Investigation

*Management

*Prognosis

*Obstetrical brachial plexus palsy is defined as a

flaccid paresis of an upper extremity due to traumatic

stretching of the brachial plexus received at birth,

with the passive range of motion greater than the

active range of motion

Arch Dis Child Fetal neonatal Ed 2003;88:F185-9

*Brachial palsy is a paralysis involving the muscles

of the upper extremity that follows mechanical

trauma to the spinal roots of C5 to T1 (the brachial

plexus) during birth

*Injuries are transient, with full return of function

occuring in 70-92% of cases¹

1.Plas Reconstr Surg 1994;93:675-80

0.38 – 3 / 1000 (2001)

0.19 – 2.5 / 1000

Due to Advances in obstetrics

Indian journal obstetrics 2009;43:236-46

*The risk factors for brachial plexus palsies may

be divided into three categories:

1. Neonatal

2. Maternal

3. Labor-related factors

*High birth weight ( > 4 kg )

*Low APGAR score at 1 min, 5 min & 10 min

*Breach fetal position

Pediatr Neurol 2008;38:235-242

*Age ( > 35 years )

*Cephalo-Pelvic Disproportion

*Gestational Diabetes Mellitus ( results in Macrosomia )

*BMI

*Post date gestation

Pediatr Neurol 2008;38:235-242

*Increased duration of 2nd stage of labour

*Induction of labour

- Oxytocin augment

*Operative vaginal deliveries

- Vacuum extraction

- Direct compression of fetal neck during

delivery by forceps

Pediatr Neurol 2008;38:235-242

*Based on,

1. Severity

2. Anatomical location

3. Clinical findings

*Avulsion

*Rupture

*Neuroma

*Neuropraxia

1. Proximal or Duchenne-Erb’s paralysis (Injury to C5 &

C6, most common)

2. Intermediate paralysis ( Injury to C7 )

3. Distal or Klumpke’s paralysis ( injury to C8 & T1,

extremely rare)

4. Total brachial plexus paralysis ( more often than the

Klumpke type)

Duchenne-Erbs type > Total brachial type > Klumpke type

*Group I, C5-C6 – paralysis of shoulder & biceps

*Group II, C5-C7 – paralysis of shoulder, biceps &

forearm extensor

*Group III, C5-T1 – Complete paralysis of limb

*Group IV, C5-Th1 – Complete paralysis of limb with

Horner’s syndrome

*In 1874, Wilhelm Heinrich Erb described isolated upper

brachial plexus palsy

*The site of damage localized to the junction of C5 & C6

*Due to,

- Breech presentation with arms extended over the head

- Excessive traction on the shoulder

- # clavicle during vaginal delivery

1. Deltoid

2. Supraspinatus

3. Infraspinatus

4. Rhomboids

5. Clavicular head of pectoralis major

6. Teres minor

7. Biceps

8. Brachialis

9. Extensor carpi radialis longus & brevis

*Arms hangs by the side with,

*Shoulder – internaly rotated

*Elbow – extension

*Forearm – pronated with palm facing backwards (tips

position)

*Hand & finger functions - preserved

*Baby’s arm is positioned in,

*Shoulder – abduction & external rotation

*Elbow – flexed

*Forearm – supinated

*Wrist – behind the neck

*This position prevents contracture of Subscapularis,

Pectoralis major

*Passive stretching

*Isolated injuries to the distal or lower portion of the brachial

plexus is described by Klumpke

*The site of damage localized to the junction of C8 & T1

*Due to,

- Stretching of lower plexus N. under and against coracoid

process during forceful elevation or abduction of the arm

- Excessive traction on the trunk

1. Flexors of wrist

2. Flexors of fingers (FDS & FDP)

3. Intrinsic muscles of hand

*If sympathetic trunk is involved results in

ipsilateral Horner’s syndrome ( ptosis,

hypohirdosis, miosis & enopthalmos)

*Associated with delayed pigmentation of iris

*Involves injury to all the roots / trunks / cords of

the brachial plexus

*It is of 2 types depending on the level,

1. Pre-ganglionic

2. Post-ganglionic

*Traction injury resulting in the avulsion of Pre ganglionic

level of all the roots C5 to T1

*If T1 root at Pre ganglionic level is affected results in

Horner’s syndrome ( ptosis, hypohirdosis / anhidrosis,

miosis & enopthalmos)

*Serratus anterior & Rhomboids muscles are paralysed

*Lesion is irrecoverable

*Limb is functionless

*Post ganglionic level lesion at all roots C5 to T1

*Serratus anterior & Rhomboids muscle functions

are preserved

*If lesion is axonotmesis – recovery is possible

*If lesion is neuronotmesis – surgical exploration &

repair may be needed

Gravity Eliminated

No contration 0

Contraction, no motion 1

Motion ≤ ½ range 2

Motion >½ range 3

Full motion 4

Against Gravity

Motion ≤ ½ range 5

Motion >½ range 6

Full motion 7

Journal of the American society for surgery of the hand 2003; 3:1, 41-54

Modified Mallet classification

S0 – No reaction to painful or other stimuli

S1 – Reaction to painful stimuli, none to touch

S2 – Reaction to touch, not to light touch

S3 – Apparently normal sensation

APMR,59:458-464,1978

M0 – No contraction

M1 –Contraction with out movement (shoulder,

elbow, wrist); slight movement of digits

M2 – Incomplete movement when suppressing, weak

complete movement of digits

M3 – complete movement with apparently normal

force

APMR 1978,59:458-464

*Chest X-ray – to rule out Phrenic N. palsy

*CT with metrizamide (CT-myelogram)

*MRI – integrity of nerve roots

*Electromyography

-48 hrs within delivery distinguishes b/w prenatal &

OBPI

-Detect signs of reinnervation

-Root avulsions (80% accuracy)

*Nerve Conduction Studies (NCV)

-Sensory nerve conduction but absence of motor

nerve conduction at 3 months – Avulsion injury

*SSEP & MEP denotes the integrity of sensory &

motor fibres

*EMG

- Fibrillation potential

- motor unit action potential (MUAP)

*Nerve Conduction Studies

- Sensory nerve action potential (SNAP)

- Compound muscle action potential (CMAP).

*Fibrillation potential appear about 3 weeks after

motor nerve injury

*Minimal degree of nerve lesion – innervation ratio

*MUAP loss occur immediately – moderate lesion

Neurol Clin N Am 20 (2002) 423–450

*Absolutely abnormal – less than age based laboratory

control values

*Relatively abnormal - < 50% than the amplitude of

homologous response recorded from contralateral side

*Wallerian degeneration apparent 2-3 days on NCS

Neurol Clin N Am 20 (2002) 423–450

*SNAPs & CMAPs are spared – minimal lesion

SNAP amplitude decrease ( moderate)

CMAP amplitude decrease (severe)

Neurol Clin N Am 20 (2002) 423–450

*CMAP amplitudes are the most useful for quantifying the amount

of axon loss suffered by a nerve

*Prior to reinnervation, the CMAP amplitudes are the most reliable

indicator of the amount of axon loss present, and the relationship is

roughly one to one.

*For example,

*CMAP amplitude from symptomatic side – 5mV

*CMAP amplitude from asymptomatic side – 10mV

Neurol Clin N Am 20 (2002) 423–450

*CMAP amplitudes begin to decrease on day 2 or 3 and reach

their nadir at day 7

*SNAP amplitudes begin to drop on day 6 and reach their

nadir around day 10 or 11

*Fibrillation potential after day 21

*MUAP loss occurs immediately - at least moderate in degree

*Prolonged duration, increased polyphasia and, occasionally,

heightened amplitude – during reinnervation (MUAP)

Neurol Clin N Am 20 (2002) 423–450

*The length of nerve between the lesion site and the

denervated muscle fibers

*Advancement occurs at a rate of about 1 in/month

*Denervated muscle fibers survive for approximately 18 to 24

months.

* After this period of time has elapsed, the muscle fibers

undergo degeneration and, from that point onward, can no

longer be reinnervated

Neurol Clin N Am 20 (2002) 423–450

1. Supporting structures are spared

2. Distance between the lesion and the denervated

muscle fibers is short

3. Lesion is incomplete

Neurol Clin N Am 20 (2002) 423–450

*End organs of the sensory nerve fibers do not undergo

degeneration,

*There is no time limit on sensory nerve fiber regeneration.

*If it requires more than 2 years for the sensory fibers to

reach their end organs, reinnervation can still be successful

Neurol Clin N Am 20 (2002) 423–450

*Conduction slowing

- Neuropraxia

- Axonotmesis

*Conduction block

- Neuronotmesis

Neurol Clin N Am 20 (2002) 423–450

*No SNAP domain

*CMAP domain includes,

*Musculocutaneous NCS recording Biceps (Musc-

biceps)

*Axillary NCS recording deltoid (Ax-deltoid).

*EMG domain includes those muscles contained

within the C5 myotome.

* SNAP- lateral antebrachial cutaneous NCS (LABC; 100%)

- Median NCS recording from first digit (Med-D1; 100%),

second digit (Med-D2; 20%) & third digit (Med-D3; 10%)

sensory NCS.

- Superficial radial NCS (S-Radial; 60%)

*CMAP – Biceps & Deltoid

*EMG domain includes those muscles belonging to the C6

myotome.

*SNAP

- Med-D2 (80%)

- Med-D3 (70%)

- S-Radial (40%)

*CMAP – EDC (Radial)

*EMG domain includes muscles belonging to the C7 myotome

Neurol Clin N Am 20 (2002) 423–450

*SNAP domain of the C8 APR includes Uln-D5

*CMAP domain Ulnar NCS, recording abductor digiti minimi

(Ulnar-ADM) and first dorsal interosseous (Uln-FDI)

- Radial NCS, recording Extensor indicis proprius (Radial-EIP)

motor NCS

- To a lesser extent, the median NCS, recording abductor

pollicis brevis (Median-APB)

*EMG domain consists of those muscles belonging to the C8

myotome

*CMAP domain -Abductor pollicis brevis, the Median-APB NCS

is a more reliable

*EMG domain consists of those muscles belonging to the T1

myotome.

* Abductor pollicis brevis

*Flexor pollicis longus muscles are the most helpful in its

assessment

*Fracture Pseudoparalysis

*Congenital Varicella of the Upper Limb

*Cerebral Palsy (Monoplegia)

*Intrauterine Upper-Limb Nerve Compression by

the Umbilical Cord or Amniotic Bands

*Intrauterine Maladaption Palsy

*Surgical management

*Conservative management

*Pediatric neurosurgeon

*Plastic reconstructive surgeon

*Pediatric orthopaedic surgeon

*Thomas and Dargassie developed towel test

*Lefevre and Diament called it as hand to face test

*In supine, the child face is covered with towel

*Shoulder flexion, elbow flexion and extension and finger

flexion and extension are needed for the test.

*He/she passes the test if he/she then removes the towel from

the face.

Journal of Hand Surgery,2004,29B:2:155–158 – LOE-3B

*Absence of biceps recovery by 3 months of age is an

indication of surgery

*The infants that did not pass the towel test At 6 months also

did not pass it at 9 months are the potential candidates for

surgery

Journal of Hand Surgery,2004,29B:2:155–158

*Surgical exploration should be done within 6 months of life

*Exploration and nerve grafting or neurotization if there is a

complete plexus palsy at 3 months or if there is a C5-C6 palsy

with absence of biceps at 3 months

*Failure of recovery of elbow flexion and shoulder abduction

from the 3rd to the 6th month of life

Plast. Reconstr. Surg. 2004;113: 54e-67e

*Nerve transfer/neurotization

- Intercostal N.

- Ulnar N.

- Sural N.

- Suprascpular N.

- Axillary N.

*Nerve anastomosis

*Nerve reconstruction

*Neurolysis

*Neuroma resection

*Neurorrhaphy

*Internal rotation contracture

-subscapularis release

-Latissimus dorsi infraspinatus

*Improving abduction

-Trapezius / latissimus dorsi trasnfer to humeral

head

*Improving forearm pronation

-Flexor-pronator transfer (steindler procedure)

*Improving elbow extension (in lower plexus injury)

-Latissimus dorsi transfer

*Improving elbow flexion

- Flexorplasty – triceps, PM, Lats

*Immobilization

-Cast 3-6 weeks

-Night splint 3-6 months

*Scar management

-Tendon gliding

-US massage

*Muscle reeducation

-cues to perform previous action of transferred

muscle

-Taping / vibration over muscle belly

-Biofeedback

-NEMS-after 6 weeks

*Functional performance

*Maintain

-PROM

-Supple of muscle

-Muscle strength

*Stretch muscle groups to prevent contracture

*Initial rest period of 7-10 days – to allow for

reduction of hemorrhage & edema around the

traumatized nerves

*No ROM or other interventions are initiated

*The involved UL is positioned across the abdomen

*Avoid lying on the involved limb

*Baseline examination – after initial period of

immobilization

Maintain ROM

-Facilitates normal movement patterns while inhibiting

substitutions

-Lift 10 toy/ball & put in doll house/basket – shoulder F.

-Paralysis & contracture of Rhomboids disturbs normal

6:1 humeroscapular rhythm in first 30º of shoulder mvt.

-Stabilize the scapula & assist active F as child reaches for

a toy

Developmental Medicine & child Neurology 2001,43:419-426 – LOE-4A

-Hand to mouth

-Transferring objects

-Weight shifting on propped UE in prone & quadruped

-Sitting with hands in front or back

-Creeping

-Reaching for toys placed at variety of angles & heights

Developmental Medicine & child Neurology 2001,43:419-426 – LOE-4A

-In side-lying on uninvolved arm to avoid stresses on

involved arm & to free the weak arm to reach & play

with toys in front of them

-Joint compression in weight bearing

-Restraining uninvolved arm & encouraging involved

arm

- Up to 65% of children with incomplete OBPI have limited

ROM (Dev Med & Child Neurol 2004,46:76-83)

- Prevent Scapulohumeral adhesion by restraining/stabilizing

the scapula during reaching & allowing muscles to stretch in

initial 30º of Abd.

- Beyond 30º scapula must rotate along with humeral ER

- Botox improves AROM & benefits lasted upto 6 wks

Pediatric Rehabilitation 2001,4:29-36 – LOE-2B

- Sensory loss can lead to neglect or self-mutilation

- Parents should be cautioned about risk of self mutilation such as

biting an insensate area

- Sensory perception can be enhanced by placing objects of

different textures & temperatures in hand

- Playing games such as finding toys under sudsy water/rice/sand

- Blindfolding & having her name familiar objects placed in hand

-Arm is positioned toward Abd, ER, elbow F &

forearm Supination on a pillow to child’s side –

during sleeping

-Resting night splints – prevent wrist & finger F

contracture

-Wrist cock-up – maintain neutral wrist alignment

(Klumpke’s Paralysis)

-Statue of liberty splint – prevent Add & IR

contracture

*Air splints – restraining uninvolved UE to

encourage involved UE

*Aeroplane splint – Erb’s palsy

*ES of denervated muscles prevents muscle atrophy

*May be used after neurosurgery

Archives of Physical Medicine & Rehabilitation 1998,79:458-464 – LOE-4A

*The upper plexus palsies are generally less severe

*Poor prognostic factors include

- total or lower plex-opathy

- Horner’s syndrome

- Root avulsions and

- Associated fractures (e.g., ribs, clavicle, humerus)

- Group IV ( according to Naraks grading)

Clin Plast Surg 1984;11:181-7 – LOE -3A

Clin Orthop Relat Res 1991;264:39-47

*Spontaneous recovery in 70-95% by 3–4 months of life

*At 3 months, the predictive value of regained elbow flexion for

complete recovery was 100%

* 99% of shoulder ER

*96% of forearm supination

Developmental Medicine and Child Neurology; Jun 2010; 52, 6;529-534 – LOE-2B

*Physical Therapy for Children – 3rd Ed

*Suzan K. Campel

*Physiotherapy in Paediatrics – 3rd Ed

*Roberta B. Shepherd