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Brachial Plexus Injury | Symptoms, Treatment & Surgery

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Brachial Plexus Injury | Symptoms, Treatment & Surgery

Abstract

A brachial plexus injury (BPI), also known as brachial plexus lesion, is an injury to the brachial plexus, the network of nerves that conducts signals from the spinal cord to the shoulder, arm and hand. #DrRohitBhaskar #BhaskarHealth
BRACHIAL
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PLEXUS INJURY
PRESENTED BY
DR ROHIT BHASKAR
PHYSICAL THERAPIST
OTHER NAMES:
ErbDuchenne palsy/Klumke Brachial Birth Palsy
Obstetric Brachial Plexus Palsy
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BRACHIAL PLEXUS
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Proximal or Duchenne-Erb’s
paralysis -Injury to C5 &C6,
most common
Intermediate paralysis-
Injury to C7
Distal or Klumpke’s paralysis
- injury to C8 & T1,
extremely rare
Total brachial plexus
paralysis ( more often
than the Klumpke type)
BRACHIAL PLEXUS
Mechanism of injury
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Bending or stretching of the neck
in a direction away from the
side of injury.
KLUMPKE’S PARALYSIS
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MECHANISM OF INJURY:
Pulling up of the arm above the
head, so that stretch on the C8
and T1 roots
CLINICAL ASSESSMENT
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U.E is flail & dangling
Look for other extremities
U.R: arm held in IR,add, active abd not possible,
elbow extended forearm pronated, thumb
flexed.
Complete paralysis- vasomotor impairment, pale
& marble like color
Horner’s sign
Associated # [clavicle, humerus]
DIFFERENTIAL DIAGNOSIS
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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
MANAGEMENT
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CONSERVATIVE MANAGEMENT
SURGICAL MANAGEMENT
Protective phase
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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 or aeroplane position.
Avoid lying on the involved limb
Positioning, splinting, kinesiotapping, gentle
massage therapy
CONSERVATIVE MANAGEMENT
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PHYSIOTHERAPY cornerstone of conservative mngt.
Maintain PROM, Supple of muscle.
Improve Muscle strength
Stretch muscle groups to prevent contracture.
Facilitates normal movement patterns while inhibiting substitutions.
Sensory Awareness
Positioning (abd, ER, F/A flexion, wrist ex.)
Splinting
Kinesiotapping
Electrical Stimulation
Splinting
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-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
SPLINTING
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Air splints restraining uninvolved UE to
encourage involved UE
Aeroplane splint Erb’s palsy
BPI Treatment Intervention
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BPI Treatment Intervention
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Interventions
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Interventions
Interventions
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Scapular winging, Trumpet sign
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SURGICAL MANAGEMENT
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Towel test
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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
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.
TOWEL TEST
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Indication for surgical correction
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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.
Surgical Intervention
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Neurosurgery 5-10% OBPI
Nerve grafting
Neuroma dissection and removal
Neurolysis (decompression and
removal of scar tissue)
Direct end to end anastomosis
of nerve ends
Neurrorhaphy
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Neurolysis
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Neuroma Removal
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Neurotization
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Tendon Transfer
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Tendon Transfer
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Post op management
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
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Post op.
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PROGNOSIS for Erb’s Palsy
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Generally good for
spontaneous
recovery, although
may be incomplete
Depends on degree
of involvement
Majority of
spontaneous recovery
by 9 months
BPI Neuronal Recovery
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Axon regeneration 1 mm per day
4-6 months for upper arm
7-9 months for lower arm
Recovery is varied according to damage
2 years upper arm
4 years lower arm
Denervated muscle fibers survive for approximately
18 to 24 months.
PREVENTION
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Birthing facility has a duty to be sure that
their obstetric teams have continuing
education and skill training, so that they
have current knowledge and skills to deal
with these challenges when they occur.
Mother/patients proper education.
Good advance planning by the obstetrician.
Good judgment .
Proper history taking
DELIVERY MANUEVER
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EPISIOTOMY
McROBERT’S POSITION
SUPRAPUBIC PRESSURE
WOODS MANUEVER (woodscrew maneuver)
COMBINATION MANUEVER
GASKIN MANUEVER
RUBIN MANUEVER
MANUAL DELIVERY OF POSTERIOR ARM
Alarmer method
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Ask for help. This involves requesting the help of an
obstetrician, anesthesia and pediatrics for
subsequent resuscitation of the infant.
Leg hyperflexion (McRoberts' maneuver)
Anterior shoulder disimpaction (pressure)
Rubin maneuver/woodscrew
Manual delivery of posterior arm
Episiotomy
Roll over on all fours (GASKIN)
TRACTION
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Many doctors use traction (pulling on baby's head) or fundal
pressure (where the nurse climbs on the bed and jumps down
onto your stomach) before anything else and these are not only
the least effective techniques, but dangerous to mother and
baby.
TRACTION
McRoberts
Manuever
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The McRoberts maneuver (where mom's legs are brought up as far back
toward her stomach as possible, which realigns the pubic bone and can
slip baby's shoulder out) ) should be tried first and if failing
Suprapubic Pressure
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Suprapubic pressure (where the doctor or nurse makes a fist and pushes
hard
on the baby's shoulder just above the pubic bone) can be applied.
Gaskin Manuever
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The Gaskin Maneuver consists of having mom roll onto all fours (or assisting
if necessary). During the process, many babies become dislodged and pop
right out. If this doesn't happen, then the doctor actually has better access to
help wiggle the baby around until the shoulder releases and the rest of
baby is born (Woods or Rubin maneuver).
Rubin manuever
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Manual Delivery of Post arm
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Manual delivery of posterior arm: Insert hand into the vagina and flex
the posterior arm of the fetus, bringing it across the chest. The posterior
arm is then delivered over the perineum which allows the provider to
rotate the fetus to allow delivery of the anterior shoulder once the rotation
has disimpacted it from the pubic symphysis.
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PRESENTED BY
DR ROHIT BHASKAR
PHYSICAL THERAPIST
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THANK YOU
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