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The brachial plexus is an arrangement of nerve fibers, running from the spine, formed by theventral rami of the lower four cervical and first thoracic nerve roots (C5-T1). It proceeds through the neck, the axilla (armpit region), and into the arm.

Function:
The brachial plexus is responsible for cutaneous and muscular innervation of the entire upper limb, with two exceptions: the trapezius muscle innervated by the spinal accessory nerve (CN XI) and an area of skin near the axilla innervated by the intercostobrachial nerve. Lesions can lead to severe functional impairment.

Excessive stretching Rupture injury Avulsion injuries Although injuries can occur at any time, many brachial plexus injuries happen during birth: the baby's shoulders may become impacted during the birth process causing the brachial plexus nerves to stretch or tear. Obstetric injuries may occur from mechanical injury involving shoulder dystocia during difficult childbirth, the most common of which result from injurious stretching of the child's brachial plexus during birth, mostly vaginal, but occasionally Caesarean section. Traumatic brachial plexus injuries brachial plexus injury may arise from several causes, including sports, high-velocity motor vehicle accidents, especially in motorcyclists Injury from a direct blow to the lateral side of the scapula is also possible. The brachial plexus may be injured by falls from a height on to the side of the head and shoulder, whereby the nerves of the plexus are violently stretched...The brachial plexus may also be injured by direct violence or gunshot wounds, by violent traction on the arm, or by efforts at reducing a dislocation of the shoulder joint".

Risk factors of brachial plexus injuries

Shoulder dystocia (the baby's shoulder being restricted on the mother's pelvis) Maternal diabetes Large gestational size Difficult delivery needing external assistance Prolonged labor Breech presentation at birth

SHOULDER DYSTOCIA (CAUSE)

1. An upper brachial plexus lesion, which occurs from excessive lateral neck flexion away from the shoulder. Most commonly, forceps delivery or falling on the neck at an angle causes upper plexus lesions leading to Erb's palsy.[6] This type of injury produces a very characteristic sign called Waiter's tip deformity due to loss of the lateral rotators of the shoulder, arm flexors, and hand extensor muscles. 2.Much less frequently, sudden upward pulling on an abducted arm (as when someone breaks a fall by grasping a tree branch) produces a lower brachial plexus lesion, in which the eighth cervical (C8) and first thoracic (T1) nerves are injured "either before or after they have joined to form the lower trunk. The subsequent paralysis affects, principally, the intrinsic muscles of the hand and the flexors of the wrist and fingers". This results in a form of paralysis known as Klumpke's paralysis

DIFFERENCE
Erb's Palsy
C5, C6 and sometimes C7 nerves are involved Often presents with arm straight and wrist fully bent (waiter's tip) May have good hand function but not full movement of the arm May have instability of the shoulder joint Often presents with weak biceps and deltoid muscles (unable to bend elbow or lift arm at the shoulder)

Klumpke's Palsy
Rare injury of the lower brachial plexus (usually following breech delivery with arm above the head) Nerves C8 and T1 are involved Hand muscles and finger flexors are paralyzed It is extremely rare to have a true / isolated Klumpke's Palsy. The term is sometimes loosely applied to cases of complete or global brachial plexus palsy.

The severity of brachial plexus injury is determined by the type of nerve damage.[1] There are several different classification systems for grading the severity of peripheral nerve and brachial plexus injuries. Most systems attempt to correlate the degree of injury with symptoms, pathology and prognosis. Seddon's classification, devised in 1943, continues to be used, and is based on three main types of nerve fiber injury, and whether there is continuity of the nerve. Neurapraxia: The mildest form of nerve injury. It involves an interruption of the nerve conduction without loss of continuity of the axon. Recovery takes place without wallerian degeneration. Axonotmesis: Involves axonal degeneration, with loss of the relative continuity of the axon and its covering of myelin, but preservation of the connective tissue framework of the nerve (the encapsulating tissue, the epineurium and perineurium, are preserved). Neurotmesis: The most severe form of nerve injury, in which the nerve is completely disrupted by contusion, traction or laceration. Not only the axon, but the encapsulating connective tissue lose their continuity. The most extreme degree of neurotmesis is transsection, although most neurotmetic injuries do not produce gross loss of continuity of the nerve but rather, internal disruption of the nerve architecture sufficient to involve perineurium and endoneurium as well as axons and their covering. It requires surgery, with unpredictable recovery.

Avulsion The nerve is torn away from its attachment at the spinal cord; the most severe type. An eyelid droop suggests an avulsion of the lower brachial plexus (Horner's Syndrome). Rupture The nerve is torn, but not at the spinal cord attachment. Neuroma Scar tissue has grown around the injury site, putting pressure on the injured nerve and preventing the nerve from sending signals to the muscles. Neurapraxia The nerve has been stretched and damaged but not torn.

paralyzed arm lack of muscle control in the arm,hand, or wrist lack of feeling or sensation in the arm or hand. typical patterns of weakness, depending on which portion of the brachial plexus is involved The cardinal signs of brachial plexus injury then, are weakness in the arm, diminished reflexes, and corresponding sensory deficits. Erb's palsy. "The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm". In Klumpke's paralysis, a form of paralysis involving the muscles of the forearm and hand, a characteristic sign is the clawed hand, due to loss of function of the ulnar nerve and the intrinsic muscles of the hand it supplies.

The examination will consist of:

Thorough medical history and physical examination X-rays Magnetic resonance imaging (MRI) MRI involves the use of a powerful magnetic field, radiofrequency pulses and a computer to produce detailed images of internal body structures. Myelogram Special dye that absorbs X-rays is injected into the spinal fluid. The resulting X-ray or computer topography (CT) picture shows whether spinal roots are injured at the spinal cord level. Electromyogram (EMG or electromyography) A thin needle electrode is inserted into the muscles that appear to be affected by a nerve injury. An instrument records the electrical activity in the muscle at rest and as the muscle moves (contracts). Nerve conduction study This test, performed with an EMG, measures how quickly nerves are carrying electrical signals to the muscles or skin.

Treatment for brachial plexus injuries includes occupational or physical therapy and, in some cases, surgery. Some brachial plexus injuries may heal without treatment. Many infants improve or recover within 6 months, but those that do not have a very poor outlook and will need further surgery to try to compensate for the nerve deficits.

There is a Main role of physiotherapy in brachial plexus injury.

Acute Phase Rehabilitation Program

Physical Therapy
At onset of injury, nonsteroidal anti-inflammatory drugs (NSAIDs), early mobilization, and moist heat packs are the favorable methods of treatment for acute injuries. In the subacute phase, a gradual progression from ROM activity to cervical and shoulder muscle strengthening is recommended.

Medical Issues/Complications

If symptoms persist (eg, persistent weakness, chronic neurapraxia) regardless of therapy, further consideration for additional imaging and referral should be undertaken.

Surgical Intervention Consultations

Surgical intervention is rarely needed, is injury-specific, and should be directed by a neurosurgical or orthopedic spine surgeon. Neurosurgery spine/orthopedic spine

Other Treatment

Manipulation is not recommended as a first line intervention, but it may be a helpful adjunct after full medical assessment has been completed.

Recovery Phase Rehabilitation Program

Physical Therapy
In the recovery phase, cervical muscle strengthening and conditioning should be continued. Strength-training programs are used to fully recover the strength that the athlete had prior to the injury. Training should be focused on muscles supporting the injured brachial plexus nerve, such as the shoulders and the surrounding cervical spine region. The neck also should be protected (eg, use of cervical neck rolls, cervical pillows) until strength is regained.

Consultations

If needed, continue follow-up care with a neurologist, and/or spine specialist.

Maintenance Phase Rehabilitation Program

Physical Therapy
Continued maintenance of cervical muscle strength, conditioning, and protection is recommended.

For infants you must teach the caregiver how to handle and position, the baby for daily activities. For older children and adults with brachial plexus injuries, physical therapists should improve or

maintain the movement in patients' arms, wrists, hands, and fingers, as well as keep their muscles in these areas as strong as possible. Also, the therapist must make sure that the patient with a brachial plexus injury regains or keeps sensation in the affected areas. The physical therapist should prevent contraction of the joints and other deformities that could happen as a result of a brachial plexus injury.

During the acute phase, the physical therapist concentrates on early movement and icing. The physical therapist helps patients improve range of motion to strengthen cervical muscles. In the

recovery

phase the therapist provides exercises and treatment to strengthen

cervical muscles to the prior level of functioning before the injury occurred. Emphasis is placed on muscles supporting the injured brachial plexus nerve. Treatment for the maintenance phase includes a continuation of cervical muscle strengthening and conditioning. The frequency of treatment sessions with a physical therapist varies among patients based on the severity of the injury, but each session should not be longer than 60 minutes. When tightness occurs, superficial heating of the area with special techniques should be used for 15 minutes, followed by massage before treatment. Treatment should be temporarily halted if the patient develops an infectious disease, open wound, or fever.

THE EXERCISES

MOVEMENT OF HAND AND WRIST. The following hand and finger exercises are safe to do while the affected arm is in a sling following exploratory (primary) surgery, provided you don't have any other injuries in these areas. Please refer to your physician if in doubt.

While your arm is immobilised in the sling, You must not move the shoulder or elbow but it is important to keep the wrist and hand moving to stop them stiffening up. Use your other hand to assist the movements. As with all exercise, take care not to over do it. All these movements should be repeated a number of times.

Wrist in mid position. Fingers curled under as in diagram. Lift the back of your hand up with your other hand. Hold for approx. 30 secs. Hold fingers and wrist straight. Bend wrist towards the little finger, then towards the thumb. Use your other hand to assist the movement. Fingers; Support below the finger joint to be exercised. Bend your finger at the knuckle assisting the movement with your other hand. Then bend the middle joint. Repeat for each finger..

As above; Bend your finger tip using your other hand to assist. Repeat for each finge

Bend your fingers 90 degrees to the palm, then straighten using your other hand.

Support below the thumb joint to be exercised. Bend the bottom joint of your thumb assisting the movement with your other hand.

STRETCHES FOR BRACHIAL PLEXUS INJURIES

Place your elbow on a solid object, for example, a thick book. Straighten your elbow over the book. Perform stretch with palm up and your palm down. Using your other arm to help, bend your elbow as far as you can. Push your elbow firmly into the bed. Keeping your elbow firmly anchored, push your hand out to the side. range of motion exercises may also recommend stints and braces, which are meant to help people have greater movement in their arms and hands.

Recovery depends on the location and severity of the injury in the brachial plexus. In general, sports-related brachial plexus injuries have a good chance of full recovery with physical therapy. Most cases of nerve injury in infants have a good chance of full recovery unless the nerves are torn from the plexus. Severe cases may require surgery.