Brachial plexus injuries MS

Children injured during birth may improve or recover by ___-___ months of age

3-4 mo. *see if they are developmentally on target

Most neuropraxis injuries recover spontaneously with a ____-____% return of function

90-100%

Recovery potential for a Class I (Neuropraixa) is _________

Full

Recovery potential for a Class II (Axonotemesis) is _________

Full

Neuroma definition

Tangle of divided axons, which fail to regenerate, prognosis dependent upon % of axonal regeneration, paresthesia with touch

What is the gradual progression of brachial plexus injuries from least to most?

Tearing of some axons to complete severing of the nerve

T/F: There is always a surgery done to treat brachial plexus injuries

False, not always necessary

Klumpke's Palsy is injury of the ________ brachial plexus

Lower

Where is damage to the brachial plexus when there is upward traction on the UE?

Lower plexus

Nerve conduction velocity studies

Measures how quickly impulses are conducted through a nerve

potential for recovery varies for _______ and ______ injuries

neuromas; neuropraxic

some brachial plexus injuries heal ___________

spontaneously

Recovery potential for a Class VI (Neurotemesis) is _________

Unpredictable

Symptoms of severe brachial plexus injuries

- Ability to use the fingers, but not shoulder/elbow muscles (cant position hand in space, some sort of bracing or AE) - Ability to use the arm but not fingers - Complete lack of movement and feeling (if cant move/feel arm, wont use it) - Severe pain

What are the impaired muscles in Erb's Palsy?

- Deltoid - Shoulder external rotators - Elbow flexors - Wrist extensors

Symptoms of mild brachial plexus injuries

- Feeling of electric shock, burning, shooting pain down the arm - Numbness and weakness (patchy weakness)

How does Klumpke's Palsy present?

- Forearm supination - Wrist extension - Finger flexion/clawing *no use of hand but have use of proximal UE, how to incorporate what they do have esp if infant

What are specific causes of brachial plexus injuries?

- MVA - Contact sports - Blunt trauma - Stab/gunshot wounds - Inflammatory processes (autoimmune - brachial plexitis) - Compression - Neuropathies - Birth-related or obstetric palsy

What do the degree of functional impairment and potential for recovery depend on, regarding surgical treatment options?

- Mechanism - Type - Complexity of the injury - Time of the injury

Brachial Plexus description

- Nerve network originating in cervical region - Branches into nerves that control movement & sensation in BUE *we know these feed into peripheral nerves

What are some treatment interventions for obstetric birth palsy?

- Prevention of fixed deformities - Gentle ROM exercises - Positional splinting between exercises - Caregiver education *Might do orthotic device Because little what else are you watching for? Milestones - are their reflexes on target, are they showing dimiinshed reflex response for UE What if caregiver cant do it? See them more frequently. If good caregiver see them less but if they arent able to do everything that needs to be done, see them more frequently

What are brachial plexus injuries? (result of what, AKA what, could be due to what)

- Result of traumatic injury, repetitive injury, tumors, or inflammation - Parsonage-Turner Syndrome - Birth injuries

How does Erb's Palsy present?

- Shoulder adduction - Shoulder internal rotation - Elbow extended - Forearm pronated - Wrist flexed -"waiters tip" position *Whatever is not working pulls them into this position If cant move arm, teach to locate arm, bring it in front, wrap hands, movemnt of both Ues, teach them PROM

Pain with brachial plexus injuries

- Some experience none - Some hypersensitive (anytime you ding a peripheral nerve, will go through hypersensitivity and have to use desensitization) - Pain on unaffected side due to overuse (bc that arm is doing too much) - Avulsion pain (burning & crushing)

What are some complications of brachial plexus injuries?

- Stiff joints - Pain - Loss of sensation - Muscle atrophy - Permanent disability ranging from weakness to complete paralysis (depends on age, injury type, location and severity. even with surgery this occurs)

What are the impaired muscles for Klumpke's Palsy?

- Wrist flexors - Long digital flexors - Intrinsic muscles

loss of sensation creates hazards during

ADLs *Talk about compensation, how not to injure the effected arm. If I have loss of sensibility in general, will take longer to heal. If hurting themselves, talk about that

Which brachial plexus injuries have no potential for recovery unless surgical reconnection is achieved?

Avulsion and rupture

What is the most serious of the severe brachial plexus injuries?

Avulsion of cervical nerve roots from SC *very dense presentation with lots of impairments

What is shoulder dystocia?

Brachial plexus nerves are stretched or torn due to impaction of the shoulder -prognosis for recovery depends on pattern, complexity and severity of injury

What roots are affected in Erb's Palsy?

C5-C6

What roots are affected in Klumpke's Palsy?

C8-T1

Electromyography

Checks the health of the nerves

Surgery after BPI: Neurolysis

Clearing scar tissue from the nerve *protected gliding so doesnt scar down. starts as soon as they wake up in recovery

Most common cause of mild brachial plexus injuries

Contact sports

surgery after BPI: Nerve graft

Damaged part is removed and replaced with sections of nerves cut from other locations in the body *Take surral nerve out of leg and sew it into distal nerve to bud and follow the same path

MRI

Determines if a nerve has been severed completely from SC

Why should surgical repairs occur within 3-6 months?

Due to the risk of muscular atrophy and nerve degeneration *Arms may atrohpy, nerve may not generate as well, watch closely in 3-6 months, careful of how to report to physician - sooner to surgery the better if they need it

What is the most common occurrence of obstetric brachial plexus injury?

During difficult delivery of the baby's shoulder -become impacted on mothers pubic bone -less than 1% of live births

Neurotamesis definition

Entire nerve divided, prognosis very poor

Diagnosis of brachial plexus injuries: multiple modalities used

History/physical exam, electrodiagnostic studies (to find delay of signal), imaging studies (like for someone with tumor) -some evals repeated on regular basis to track recovery -provides insight into the severity of the injury and prognosis

What is the first approach for treatment?

Initial watch and wait: milder injuries will improve over several months, appointments for 3-6 mo. to monitor progress *keep them from getting deformity

What happens to the brachial plexus in mild brachial plexus injuries and what is that called?

It gets stretched -called a "stinger" or "burner" (flail arm until nerve bounces back)

Surgery after BPI: Muscle transfer

Less important muscle/nerve is transferred to arm *Take flexor carpi radialis, make it wrist extensor

surgery after BPI: Nerve transfer

Less important nerve, still attached to the SC, is connected to the avulsed nerve *Leave nerve attached to origin and plug into muscle that needs innervation

What reflexes are diminished with Klumpke's Palsy?

Moro and grasp

Why may the joints be stiff?

Muscular paralysis

Axonotemesis definition

Nerve axons severed, prognosis is moderate

What will pain most likely result from?

Nerve damage *differ depending on severity and location of injury

Neuropraxia definition

Nerve gently stretched or compressed, still attached, excellent prognosis for rapid recovery *initial signs and symptoms wont be as dense as a rupture or avulsion

Avulsion definition

Nerve pulled out of SC, no chance of recovery *wont recover without surgery

Rupture definition

Nerve stretched and partially torn (but not at SC), patchy presentation

Recovery potential for a Class IV (Axonotemesis) is _________

Neuroma-in-continuity *Nerve is not torn, irritation, partial tearing fill in with the hyperactive, signals delayed but still getting through

Class I of nerve injury: _________, classes II-IV of nerve injury: __________, classes V-VI of nerve injury: __________

Neuropraxia, axonotemesis, neurotemesis *if complete transsection, recovery is not good

Recovery potential for a Class V (Neurotemesis) is _________

None

After the initial watch and wait period, what treatment is executed?

OT to regain maximum function, maintain flexibility, prevent deformity, and address pain *Keep on target with milestones, prevent deformity, education on how limb positioned at rest, incorporate into bimanual activites Baby will cry if in pain. OPAS scale - observed pain scale for children. Objectify level of pain when they cant tell you

Severe brachial plexus injuries result from what injuries?

Ones that tear or rupture the nerves

Symptoms of brachial plexus injuries in general

Pain, loss of sensation, muscle weakness, paralysis *may have total paralysis. you have to move body part for them so dont get stuck in deformity

Surgery after BPI: Joint fusion

Permanently joining the ends of two bones to increase stability and strength *fuse into position of function

CT myelography

Produces a detailed picture of SC and nerve roots

What are the 3 nerves that the brachial plexus branches off into?

Radial, median, ulnar

There will be muscle atrophy while the nerves are _______

Regenerating

surgery after BPI: Capsule release

Removing scar tissue/releasing contractures *Surgeon invaded this space, created more scarring via passive motino or could do passive motion machine

Surgery after BPI: Correction of the arm (osteotomy)

Separating and reattaching bone to change alignment *Stiff and contracted and humeral head impinging in shoulder joint, restructure size and shape of the bone so it isnt painful

Surgery after BPI: Tendon transfer

Shifting a functioning tendon to a new location *Nonfunctional tendon - trasnfer to other body part. Wrist flexor unimportant is palmaris longus, may take that and attach to other tendon, etc

What two things determine the prognosis of brachial plexus injuries?

Site and type

Recovery potential for a Class III (Axonotemesis) is _________

Slow, incomplete

If injury is severe or there is no improvement in 3-6 months, what treatment is utilized?

Surgery

Why do we use assessments and re-assessments frequently with this population?

To track progress of nerve regeneration and muscle function

The majority of brachial plexus injuries are caused by _____________

Trauma

How is brachial plexus injury severity determined?

Type of damage done to the nerves -categorized by type of nerve trauma

Erb's Palsy is injury to the _______ brachial plexus

Upper -most cases of birth palsy

Where is damage to the brachial plexus when there is downward traction on the UE?

Upper plexus

How long do mild brachial plexus injuries last?

Usually a few seconds or minutes, may linger for days or longer

BPI (brachial plexus injury) definition

term for conditions that impair function of the brachial plexus *sensory loss, motor loss, can also present with more global distribution (myotome or dermatome involvement)

Is OT routinely involved for this popn?

yes