PEMBEKALAN SEM 5

JANUARI 2023

REHABILITATION
Pediatric Brachial Plexus Injury
management and prognostic
estimation based on
Brachial plexopathy in Children

• Rare
• Cause depends on age group
– Infant : Neonatal BPI ( Birth BPI)
– School age : play accidents, Backpack
– Middle & High school : sport injury, motor vehicle
 Risk Factor for neonatal BPI

Mother Infant

• Pelvis, shoulder dystocia • Malposition

• Gestational • Macrosomia
• Diabetes mellitus
• Maternal obesity
 Etiology
Birth brachial plexus injury
• Shoulder dystocia
• Breech delivery (2% of cases)
• Forceps or vacuum delivery
Mechanism : lateral stretch
Pavlik harness-‐related brachial plexopathy
 Brachial Plexus Anatomy
Schematic
 Background
• 50-95% recover spontaneously
• Goal: normalization of limb function, with optimization of
nerve regeneration and mechanical increase of elbow
flexion and shoulder stabilization
• This can be achieved through aggressive rehabilitation and
surgical intervention
 Classification

• Nerve injured → Seddon Classification of Nerve Injury, commonly used

• BPI usual level at root or trunk ( very
proximal).
• More proximal muscles will be reinnervated
earlier
• Spontaneous recovery from reinnervation of
axonotmesis should be observed within 3-‐4
months after injury.
 Types of Neonatal BPI
Erb’s palsy Klumpke palsy
• More common • Rarely isolated
• C5,6
• C8,T1
• C7 in 50% of cases
• Arm held adducted, shoulder • Small muscles of hand and
internal rotated, pronated, with wrist (Claw hand)
wrist flexd and fingers flexed
(Waiter’s tip possition) • Up to 1/3 have Horner
• Biceps reflex (-‐), Moro refl with Syndrome
hand movement but no shoulder
Abd, Palmar grasp(+)
• 5% have ipsilateral diaphragmatic
involvement
 Prognosis
• In order to be able to predict prognosis you
need acurate objective data obtained from
meticulous clinical and supporting
examination.
 Prognosis
• 90% have normal examination by 12 months of age
• No signs of clinical improvement by 3 months did not recover
function adequately
• Continued not to show improvement by 6 months → no
chance of adequate functional recovery
• Onset of recovery within 2 weeks good prognosis
• Involvement of only the proximal plexus good prognosis
• Breech delivery associated with root avulsion

(Strombeck C, 2000)
 Differential diagnosis
• Unilateral Cerebral palsy
• Fracture
• Arthrogryposis
• Neuromuscular disease
 Classification of Clinical Presentation

Narakas classification
• Group 1 : C5 and C6
• Group 2 : C5, 6, 7
• Group 3 : near complete paralysis , but
with finger flexion present neonatally
• Group 4 : complete paralysis and
Horner syndrome
 Narakas classification rating at age of 6 weeks
Group Injured root Clinic Possible result
Narakas group 1 C5-‐6 Palsy of shoulder, Spontaneous recovery in >
(upper Erb’s palsy) no elbow flexion 80%

Narakas group 2 C5-‐7 = Narakas 1, with no Good hand, elbow,

(extended Erb’s wrist extension shoulder function in 60%

Narakas group 3 C5-‐T1 Total palsy, no Generally good hand

function, good shoulder &
Bernard-‐Horner sign
elbow function in 30-‐50%
Narakas group 4 C5-‐T1 Total palsy w Bernard- Complex recovery rate,
‐Horner sign. Atonic, distinct deficits in the
marmorate and cold function of the whole
extremity extremity are possible
 Clinical presentation
• The limb appear to be palsied or paralyzed
• Look for concomitant pathology
• Fracture : clavicle, humerus, cervical spine
• Contractures and pathological sign
• In the early days after birth, skeletal
injuries/fractures
• “Simian” hand deformity
 Initial Management
Medical treatment of brachial plexus palsy begins
with the following steps:
• diagnosis by neurologic examination
• identification of associated injuries
• education of the family about the disease and
therapy
• daily range of motion exercises
• monthly assessment of motor strength
• for infants with persistent weakness, referral to
Brachial Plexus Center before 2 months of age
 Clinical Examination
● Visual Inspection and general assessment

● Long Thoracic → proximal branch of the brachial plexus (C5, C6, and C7) → innervates serratus
anterior muscle

Chung KC, Yang LJ-S, McGillicuddy JE. Practical Management of Pediatric and Adult Brachial Plexus Palsies. Vol. 2, Brachial plexus injuries. Elsevier; 2012.
 Clinical Examination
● Dorsal scapular nerve → very proximal branch from C5 spinal root → innervate major and minor
rhomboid muscle

● Suprascapular nerve (C5,C6) → supraspinatus and infraspinatus muscle

Chung KC, Yang LJ-S, McGillicuddy JE. Practical Management of Pediatric and Adult Brachial Plexus Palsies. Vol. 2, Brachial plexus injuries. Elsevier; 2012.
 Clinical Examination
● Axillary nerve (C5,C6) → anterior division → anterior and lateral deltoid. Posterior division →
teres minor, posterior deltoid.

● Lateral pectoral nerve (C5, C6) → pectoralis major

Chung KC, Yang LJ-S, McGillicuddy JE. Practical Management of Pediatric and Adult Brachial Plexus Palsies. Vol. 2, Brachial plexus injuries. Elsevier; 2012.
 Clinical Examination
● Medial pectoral nerve → pectoralis minor and sternal head of the pectoralis major.

● Upper and lower subscapular nerve (C5,C6) → Subscapularis muscle

Chung KC, Yang LJ-S, McGillicuddy JE. Practical Management of Pediatric and Adult Brachial Plexus Palsies. Vol. 2, Brachial plexus injuries. Elsevier; 2012.
 Clinical Examination
● Lower subscapular nerve → innervates lower half of the subscapularis muscle (teres major)

● Thoracodorsal nerve (C7,C8) → innervates latissimus dorsi muscle

Chung KC, Yang LJ-S, McGillicuddy JE. Practical Management of Pediatric and Adult Brachial Plexus Palsies. Vol. 2, Brachial plexus injuries. Elsevier; 2012.
 Assessment
• Muscle strength : m-‐MRC,AMS
• Arm function : Mallet scale
• Pain : VAS, WBS
• Functional activity & Participation : ICF
• Depression

Write reports in a patient’s chart and

compare results over different periods of
time
 Assessment of strength
• Formal strength testing
• Other measures of muscle performance :
– Movement against gravity
– Reflex responses
– Functional performance
 ROM
• Normal movement of each body part maintains mobility of
the joints and soft tissue
• Limitation of ROM is of greatest importance when it
interferes with normal movement or activities
• It is Easier to prevent tightness by frequently repeating
an activity or movement than to correct limitations
after they developed
• Perform ROM exercise full arc several times a day
• Use available ROM in functional activities
throughout the day
 Manual muscle testing
DESCRIPTION GRADE
Functional (F) Normal for age or only slight
impairment or delay
Weak Functional (WF) Moderate impairment or delay that
affects activity pattern, base of
support, or control against gravity,
or decreases functional exploration
Nonfunctional (NF) Severe impairment or delay,
activity pattern has only
elements of correct muscular
activity
No function (0) Cannot do activity

Hislop, Montgomery: Daniels & Worthingham’s Muscle testing 7th edition, 2002
 Muscle grading
Muscle Strength
Deltoid
Shoulder external rotators
Shoulder internal rotators
Biceps
Triceps
Wrist flexors
Wrist extensors
Finger flexors
Finger extensors
 Joint Movement Grading
quantitative documentation of the joint
movement
Observation Central Grade Numerical Score
No joint movement 0 0
Flicker of movement 0+ 0.3
Less than half range 1- 0.6
Half range of movement 1 1.0
More than half range 1+ 1.3
Good but not full range 2- 1.6
Full range of movement 2+ 2.0
Joint Movement Central Grade Numerical Score
Shoulder adduction
Shoulder abduction
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
Finger flexion
Finger extension
Total Numerical Score
• By recording these objective data for muscle
strength and joint movement, a patient's
progress can be followed through a series of
examinations.
 Mallet
scale

Minimal age
3years
 Conservative treatment

• early therapeutic intervention is important

• initial evaluation as a team ( PMR Dr, PT, OT)
• PRM DR/PT/OT instruct parents / caregiver on home exercises
programe several times a day at home
• Regular PT/OT at hospital or clinic
• Regular assessment by PRM DR
• SPLINTING
 PMR MANAGEMENT
Therapeutic exercises designed to :
– improve muscle strength
– preserve flexibility and mobility of joints
– protect joint integrity
Splints to
– improve joint position/stability /function
– to stretch a tight muscle
• NMES not necessary if the child is steadily improving
 Therapeutic exercise
is the only treatment necessary under these
conditions:
• The infant can bend the elbow against gravity
and move the wrist and fingers by 3 months of
age.
• Muscle strength continues to improve
 Conservative treatment for the child
3 years and older
• Recommendations for adaptive tools
• Instructions for alternative techniques for ADL’s to help increase
the child’s independence in various skills, such as self-‐feeding or
dressing
• Recommend community activities like swimming, dance, martial
arts, musical instruments or adaptive bicycles. These activities
can be motivating for children of various ages and levels of
severity
 Electrodiagnosis
• Early electrodiagnosis
• Fibrilation potentials (sign of denervation ) at 2-3
weeks after injury indicate a longer course of
recovery
• Track reinnervation process
• Guide surgical decision making
• Some authors feel that EMG does not provide
prognostic information
 Treatment
• Passive ROM
• Passive stretching
• Active functional guided exercise
 RECONSTRUCTIVE SURGERY

Nerve procedure : before age of 10 months

• Neurolysis
• Direct suture
• Nerve grafting
• Nerve Transfer
• Neuroma excision
 Reconstructive surgery
After 10 months : Muscle procedures
• Tendon transfer : move insertion to a more
advanteous position
• Muscle transfer :
– free functioning muscle transfer
– SAHA procedure
 Presurgery & post surgery PMR
• Assessment of the Muscles or nerves that can be
used : MMT, Intact innervation ( EMG)
• Training & isolation of muscles used before
transfer procedure
• Training of the transferred muscle or neurotized
muscle after the procedure in the new function
– What to do : Biofeedback, NMES , functional training
• Splinting
THANK YOU