Brachial plexus injuries

TOS - Client education

Maintain good posture - Core strengthening Incorporate breaks into activities - Every 2 hours take 20min break Practice relaxation techniques Avoid repetitive movements, heavy lifts, and overhead activities Weight loss can relieve symptoms Avoid carrying heavy bags over the shoulder Stretch daily Perform exercises that keep shoulder muscles strong

Rupture

nerve stretched and partially torn; but NOT at spinal cord level

Axonotemesis

nerve axons severed; prognosis is moderate slow; incomplete recovery potential

Exercises for TOS

1. Corner Stretch Stand in a corner with hands at shoulder height, one on each wall Lean into the corner to feel a gentle stretch across the chest Hold 5 seconds 2. Lateral Neck Stretch Put left hand on head and right hand behind back Pull head toward left shoulder until you feel a gentle stretch on the right side of neck Hold 5 seconds and switch positions 3. Reverse Shoulder Rolls Shrug shoulders up, back, and then down in a circular motion 4. Neck Retraction ("chin tucks") Pull head straight back, keeping jaw level Hold 5 seconds

Types of TOS

1. Neurogenic (neurological) Compression of the brachial plexus Majority of TOS cases 2. Vascular Compression or arteries or veins under the clavicle 3. Nonspecific "Disputed" or "common" thoracic outlet syndrome Chronic pain in the area of the thoracic outlet that worsens with activity Specific cause not determined

what is the brachial plexus

A nerve network originating in the cervical neck region Branches to form nerves that control movement and sensation in the UEs Radial, median, and ulnar nerves originate from the brachial plexus

Causes of TOS

Anatomical defects: Extra cervical rib, abnormally tight fibrous band connecting the spine to the ribs, and long necks Poor posture: Drooping the shoulders or holding the head in a forward position Bulky musculature: Traumatic event History of previous injury Repetitive activity: Overuse or overload Typing, assembly, or overhead lifting Athletics Poor body mechanics: Pressure on your joints Obesity Carrying oversized bag or backpack Pregnancy: Joints loosen

Thoracic Outlet Syndrome (TOS)

Compressive neuropathy (compression of brachial plexus and/or subclavian artery and vein) - Injury, disease, or a congenital problem More common in women Pain in the neck/shoulder region and numbness distally Can involve muscle weakness Most improve with conservative treatment Extreme cases require surgery

Prognosis for TOS

Conservative approaches successfully resolve symptoms for most patients Surgery can be successful in 50% to 80% of patients At least 5% of patients have symptoms that return after surgery Risk of "double-crush" - Once you have an initial crush, anywhere along that nerve can potentially have another crush

Dejerine-Klumpke (Klumpke's) Palsy - specific deformity

Deformity = forearm supination, wrist extension, and finger flexion (or clawing)

Erb-Duchenne (Erb's) Palsy - specific deformity

Deformity = shoulder adducted/internally rotated, elbow extended, forearm pronated, and wrist flexed

Symptoms of Vascular TOS

Discoloration of hand Blood clot under clavicle Arm pain and swelling Throbbing lump near clavicle Lack of color (pallor) in fingers or entire hand Weakened pulse

Rehabilitation for TOS

Improve range of motion Strengthen the shoulder muscles Increase strength Endurance building - increase time or level of activity Promote better posture Pain control - cold or heat Relaxation techniques - deep breathing Use of medications Weight loss Lifestyle changes

Roos Stress Test

In a seated position, abduct/externally rotate shoulders and flex elbows Repeatedly open and close your hands for three minutes Reproduction of symptoms or a feeling of heaviness and fatigue can indicate the presence of TOS

Treatments for BPI

Initial "watch and wait" Surgery if injury is severe or no improvement within 3-6 months (Because of the risk of muscle atrophy and nerve degeneration, surgical repairs should ideally occur within 3-6 months of injury)

Dejerine-Klumpke (Klumpke's) Palsy

Injury of the lower brachial plexus (C8-T1 roots) Lack Moro and grasp reflex Impaired muscles = wrist flexors, long digital flexors, and intrinsic muscles

Erb-Duchenne (Erb's) Palsy

Injury to the upper brachial plexus (C5-C6 roots) Most cases of birth palsy Impaired muscles = deltoid, external rotators of the shoulder, elbow flexors, and wrist extensors

What is obstetric brachial plexus palsy?

Less than 1% of live births Most common when there is difficulty delivering the baby's shoulder Shoulder becomes impacted on the mother's pubic bone causing the brachial plexus nerves to stretch or tear (shoulder dystocia)** The prognosis for recovery depends on the pattern, complexity, and severity of injury

Diagnosis of BPI

Multiple modalities are utilized: History taking and clinical examination Electrodiagnostic studies Imaging studies Some evaluations repeated on a regular basis to track progression of recovery

Mild BPIs

Often occur during contact sports Brachial plexus gets stretched "Stingers" or "burners" Symptoms: A feeling of electric shock, burning, or shooting pain down the arm Numbness and weakness Usually lasts only a few seconds or minutes But may linger for days or longer

Symptoms of BPI

Pain Some experience no pain Others are hypersensitive Pain on the unaffected side due to overuse of the uninjured arm ***Avulsion pain (a burning, crushing type of pain) in the distribution of the injured nerves Loss of sensation Muscle weakness Paralysis

General Symptoms of TOS

Pain and tingling in the neck and shoulders - Carrying something heavy may worsen pain (traction) Pain, numbness, and tingling in the ring/small fingers and ulnar forearm - Could be in thumb/index/middle fingers and radial forearm Signs of poor circulation Weakness of the muscles in the hand

Adson's Maneuver

Palpate radial pulse Turns head toward symptomatic side while you extend the shoulder and arm slightly away from the body Monitor radial pulse on the extended arm Diminished pulse or reproduction of symptoms = positive (+) test for TOS

Wright Test

Palpate radial pulse In a seated position, abduct and externally rotate the shoulder and arm Monitor radial pulse on the hyperabducted arm Diminished pulse or reproduction of symptoms = positive (+) test for TOS

Treatment for Obstetric Birth Palsy

Prevention of fixed deformities - Low loads of sustained stretch Gentle range of motion exercises Positional splinting between exercises Caregiver education

Severe BPIs

Result from injuries that tear or rupture the nerves Most serious is avulsion of cervical nerve roots from spinal cord (unable to repair*) Signs and symptoms: - Ability to use the fingers, but not the shoulder or elbow muscles - Ability to use the arm but not the fingers - Complete lack of movement and feeling (flail) - Severe pain

what are BPIs

Result of traumatic injury, repetitive injury, tumors, or inflammation Parsonage-Turner Syndrome (brachial plexitis) Birth injuries

What is the prognosis?

Site and type of brachial plexus injury determines prognosis ***Avulsion and rupture injuries have no potential for recovery unless surgical reconnection is made Potential for recovery varies for neuromas and neuropraxic injuries Most neuropraxic injuries recover spontaneously with a 90-100% return of function (mostly in adults*)

Is there any treatment?

Some brachial plexus injuries heal spontaneously Children injured during birth may improve or recover by 3-4 months of age*** Treatment for brachial plexus injuries routinely includes occupational therapy and, in some cases, surgery

Complications of BPI**

Stiff joints due to muscular paralysis Pain results from nerve damage Loss of sensation creates hazards during ADLs Muscle atrophy while waiting nerve regeneration Permanent disability ranging from weakness to complete paralysis - Dependent upon age and injury type, location and severity of the injury - Even with surgery, some people experience permanent disability

Symptoms of Neurological TOS

Wasting of intrinsics/hypothenar eminence - Wasting of thenar eminence Numbness or tingling in fingers Pain in neck and shoulder Ache in arm or hand Weakening grip Decreased hand function

Neuroma

a tangle of divided axons, which fail to regenerate; prognosis dependent upon percentage of axonal regeneration

Neuropraxia

nerve gently stretched or compressed; but still attached; excellent prognosis for rapid recovery full recovery potential

Upward traction on UE =

damage to lower plexus

Downward traction on UE =

damage to the upper plexus

Neurotemesis

entire nerve divided; prognosis very poor

Avulsion

nerve pulled out of spinal cord; no chance to recover

Brachial plexus injury

term for conditions that impair function of the brachial plexus Severity determined by the type of damage done to the nerves Categorized by type of nerve trauma Majority are caused by trauma