Brachial plexus injuries

incidence of brachial plexus injuries

-1.5 out of 1000 live births in the US -Right UE>Left UE -Males >Females

evaluation for brachial plexus injuries

-Active Movement Scale -Mallet -AROM/PROM -Sensation (dermatome screen) -Assisting Hand Assessment (AHA)

medical follow up 8-17 years

-Appointments: as needed -Evaluations/ treatments: muscles, x-ray, therapy, splinting, bone surgery

medical follow up 1-3 years

-Appointments: every 3-6 months -Evaluations/ treatment: muscles, shoulder joint, MRI, therapy, splinting, shoulder and muscle surgery

medical follow up 3-8 years

-Appointments: every 6 months -Evaluations/ treatments: muscles, shoulder joint, CT scan, therapy, splinting, shoulder and muscle surgery

botox treatment

-Balance muscle force -inhibits acetylcholine receptors thus the muscles will not contract. Last approximately 3 months -Earliest can be given is 6 months

risk factors for brachial plexus injuries

-Birth weight more the 8.8 las -Maternal diabetes -Maternal obesity or excessive weight gain -Previous births with brachial plexus injuries increases risk 14%

secondary surgery for brachial plexus injuries

-Capsular release of the shoulder -Glenohumeral joint reduction -Shoulder muscle transfers

PROM to prevent contractures

-External rotation should be performed in neutral (shoulder down at side) to protect anterior shoulder structures and prevent dislocation -Flexion of the shoulder, flexion and extension of the elbow, and all other planes in the forearm, wrist and hand

additional observation and assessment areas

-Horner's syndrome -Capillary refill -Asymmetry -ADLS -Academic performance -Pain

monitoring of position of scapula

-Medial border should be 3 to 4 finger widths from spine -Inferior border 4 to 5 finger widths from spine

tertiary surgery for brachial plexus injuries

-Muscle and tendon transfers in the forearm, wrist or hand -De-rotation osteotomies of the humerus and ulna

peripheral nerves off lateral cord

-Musculocutaneous nerve -Median nerve

OT interventions for brachial plexus injuries

-Preserve ROM to prevent deformity -Positioning -Provide sensory input -Correct abnormal posture -AROM and progressive resistive exercises- Use toys -Positioning (weight bearing vs non-weight bearing) -Bimanual play -Scapular stabilization exercises-pushing, swinging, crawling and climbing -ADLs -- adaptive equipment and compensatory techniques -Shoulder splint, elbow splint, kinesiotaping, CIMT cast

peripheral nerves off posterior cord

-Radial nerve -Axillary nerve

Klumpke's palsy

-Shoulder and elbow are functional -Wrist and hand affected, especially the ulnar nerve and median nerve. -These kiddos posture in elbow flexion, supination secondary to loss of pronator quadratus. -The biceps and supinator is intact and over power the pronator teres which is a C6,C7 (myotome)

peripheral nerves of medial cord

-Ulnar nerve -median nerve

education to family

-regarding sensation deficits and how to provide sensory stimulation -on how to pick up and hold the baby. *No pulling on the affected limb. *Make sure baby isn't laying on affected limb and watch head and neck position when carrying and holding the infant

nerve root innervation: ECU

C6-8

nerve root innervation: FCR

C6-8

nerve root innervation: EDC

C7-8

nerve root innervation: anconeus

C7-8

nerve root innervation: triceps

C7-8

nerve root innervation: APB

C7-T1

nerve root innervation: EIP

C7-T1

nerve root innervation: EPB

C7-T1

nerve root innervation: EPL

C7-T1

nerve root innervation: FDS

C7-T1

nerve root innervation: FPL

C7-T1

nerve root innervation: pronator quadratus

C7-T1

nerve root innervation: FCU

C8-T1

nerve root innervation: FDP

C8-T1

nerve root innervation: abductor digiti minimi

C8-T1

nerve root innervation: adductor pollicis

C8-T1

brachial plexus injuries prognosis

Most children show some recovery 66% of children fully recover Recovery based on level of injury

primary surgery for brachial plexus injuries

Nerve graft Nerve transfer -Timing is crucial -Monitor elbow flexion. -If baby is not showing signs of return elbow flexion they will start to consider surgery between 4 to 6 months. This is currently in the stages of debate and surgery may start sooner

trunks of brachial plexus

Upper -- C5, C6 Middle -- C7 Lower -- C8-T1 Exist between anterior and middle scalene and pass under clavicle

without intervention children are at risk for

contractures

Children will avoid use of the extremity. Immobility leads to _______ in the sensory and motor homunculus.

cortical maladaptive plasticity

Weight bearing increases ________________ input for more active movement/play

proprioceptive

neonatal brachial plexus injury

trauma to the brachial plexus that typically occurs at birth Poor positioning in utero can also lead to brachial plexus traction and compression injuries.

T/F Both upper and lower injuries can have difficulty tying their shoes and require adaptations.

true

T/F weight bearing on arm should be avoided early on

true

what type of plexus injuries affect reaching and using the arm overhead thus adaptive dressing techniques are needed?

upper plexus injuries

what type of plexus injury causes difficulty pulling the zipper up?

upper plexus injuries

Erb's palsy involves injury to what part of brachial plexus?

upper trunk C5, C6 and sometimes C7

when does intervention start for kids with brachial plexus injuries?

within first week following surgery education of family and caregivers

Erb's palsy

•Affects shoulder and scapular movements and elbow flexion. •If C7 is involved, elbow extension. •Scapula is held in protraction, shoulder rest internal rotation and elbow in extension. The wrist and hand are fine and able to function normally

Neuropraxia or Simple Stretch

The nerve is injured but not torn

rupture nerve injury

The nerve is torn but not where it attaches to the spine

T/F children with brachial plexus injuries may not meet need school based OT services

True -cognitively they are fine -child may or may not meet eligibility for Special Education, possibly school set up 504 accommodation plan

cords of brachial plexus

lateral, posterior, medial -formed from anterior and posterior divisions

what type of plexus injury causes difficulty fastening zippers and closures?

lower plexus

medical follow up birth to 1 year

-Appointments: every 1-2 months -Evaluations/ treatment: nerve recovery, shoulder joint, ultrasound, therapy, splinting, nerve surgery

types of brachial plexus injuries

-Erbs Palsy (C5, C6 and sometimes C7) 90% of cases -Klumpke's Palsy (C8, TI) 1 % of cases -Global (C5-T1) 10% of cases

what % of brachial plexus injuries are bilateral?

10-20%

nerve root innervation rhomboid major

C5-6

nerve root innervation: biceps

C5-6

nerve root innervation: brachioradialis

C5-6

nerve root innervation: deltoid

C5-6

nerve root innervation: infraspinatus

C5-6

nerve root innervation: rhomboid minor

C5-6

nerve root innervation: supraspinatus

C5-6

nerve root innervation: serratus anterior

C5-7

nerve roots of brachial plexus

C5-T1.

nerve root innervation: ECR

C6-7

nerve root innervation: pronator teres

C6-7

stabilize ______ during play

scapula

Klumpke's palsy is injury to what part of brachial plexus?

Lower trunk C8-T1

Horner's syndrome

SYMPATHETIC FIBERS C8 AND TI CAUSES DROOPY EYELID AND CONSTRICTED PUPIL

severe stretch with neuroma

Scar tissue has grown around the injury site placing pressure on the injured nerve and preventing the nerve from sending signals to the muscles

avulsion nerve injury

The nerve is completely torn away from the spine (most severe).

dermatomes

area of skin innervated by cutaneous branches of single spinal nerve

other mechanisms of brachial plexus injuries

trauma -car accident -sports injury -gunshot wound -viral infection