Brachial Plexus Injury

Pediatric Rehabilitation
 Introduction
• The brachial plexus is a network of intertwined nerves that
control movement and sensation in the arm and hand.
• A traumatic brachial plexus injury involves sudden damage to
these nerves, and may cause weakness, loss of feeling, or
loss of movement in the shoulder, arm, or hand.
• The brachial plexus begins at the neck and crosses the upper
chest to the armpit. Injury to this network of nerves often
occurs when the arm is forcibly pulled or stretched.
• Mild brachial plexus injuries may heal without treatment.
More severe injuries may require surgery to regain function
of the arm or hand.
Anatomy
 Contd..
• Most traumatic brachial plexus injuries occur
when the arm is forcefully pulled or stretched.
• Many events can cause the injury, including
falls, motor vehicle collisions, knife and
gunshot wounds, and most commonly,
motorcycle collisions.
 Severity Of Injury
• Brachial plexus injuries vary greatly in severity,
depending upon the type of injury and the
amount of force placed on the plexus.
• The same patient can injure several different
nerves of the brachial plexus in varying
severity.
 Classification Of Injuries
i. Leffert classification of brachial plexus injury
ii. Millesi classification of brachial plexus injury
iii. Classification on anatomical location of injury
 Leffert Classification
1. I : Open (usually from stabbing)
2. II : Closed (usually from motorcycle accident)
• II a: Supraclavicular; preganglionic &
postganglionic
• II b :Infraclavicular
3. III :Radiation induced
4. IV :Obstetric
• Iv a: Erb's (upper root)
• Iv b: Klumpke (lower root)
 Millesi Classification
• I: supraganglionic/preganglionic.
• II: infraganglionic/postganglionic
• III: trunk.
• IV: cord.
 Classification On Anatomical Location
• Upper plexus palsy (Erb’s palsy in the OBPI
cases) involves C5-C6+/-C7roots.
• Lower plexus palsy (Klumpke’s palsy) involves
C8-T1 roots (and sometimes also C7)
• Total plexus lesions involve all nerve roots C5-
T1
 Erbs Palsy
• The region of the upper
trunk of the brachial
plexus is called Erb's
point.
• Injury to the upper
trunk causes Erb's
Paralysis.
 Causes
• Undue separation of the head from the
shoulder, which is commonly encountered in
1)birth injury
2) fall on shoulder
3)during anesthesia
 Risk Factors
• The use of forceps and/or vacuum extraction
tools during delivery
• Large infant size
• Small maternal size
• Excessive maternal weight gain
• Second stage of labor lasting over an hour
• Infants with high birth weight
• Infants in the breech position
 Nerve Roots Involved
• C5 & Partly C6
• Affected nerves : axillary nerve,
musculocutaneous, & suprascapular nerve.
 Muscles Paralysed
• Biceps
• Deltoid
• Brachilais
• Brachioradialis
• Partly Supraspinatus
• Infraspinatus
• Supinator
 Deformity
• Arm: Hangs by the side, it is adducted and
medially rotated
• Forearm: Extended and pronated
• The deformity is known as "Policeman's tip
hand" or "Porter's tip hand".
 Disability
• Abduction and lateral rotation of the arm
(shoulder).
• Flexion and supination of forearm.
• Biceps and supinator jerks are lost.
• Sensations are lost over a small area over the
lower part of the deltoid.
 Diagnosis
• History
• Physical examination
• Neurological examination
 Investigations:
• X ray
• MRI
• Ct scan
• EMG/ NCS
 Positioning
• When your baby is being picked up or carried,
give their arm support with your arm or body
so that the weight of the arm does not drag
on the shoulder.
• This can feel awkward to begin with but gets
easier with practice.
• You can also support your baby’s arm close to
their body with a toy when they are lying in
their cots.
 Dressing
• When dressing put the affected arm through
the sleeve first. This leaves the non-affected
arm to do the twisting and turning.

• When undressing take the non-affected arm

out first. The affected arm will then easily slip
out without any twisting.
 Sensory Stimulation
• Because your baby is unable to move their own arm they are
unable to experience the feel of other textures and parts of
their body as they do naturally with their other arm.
• It is therefore important to gently stroke and massage their
arm.
• Do not forget to open their hand fully and massage their
palm and fingers (they get a lot of sensory information from
their hands).
• You can also safely bend their elbow to help them touch
their face, mouth (they like to suck their fists), and their
other hand.
 Electrical Stimulation
• EMS of affected muscles for initiation of
activity
 Splintage
• Airoplane splint
Activity Exercises
 Surgery
• Indications for surgery is no clinical or EMG
evidence of biceps function by 6 months.
• This represents 10% to 20% of children with
obstetric palsies.
• The three most common treatments for Erb's Palsy
are:
i. Nerve transplants (usually from the opposite leg)
ii. Sub Scapularis releases
iii. Latissimus Dorsi Tendon Transfers.
 Klumpke paralysis
• Lower trunk of brachial plexuses
 Causes
• Undue abduction of the arm, as in clutching
something with the hand after a fall from a
height, or sometimes in birth injury.
 Nerve roots
• Mainly T1 and partly C8
 Muscles Affected
• Intrinsic muscles of the hand (T1)
• Ulnar flexors of the wrist and fingers (C8).
 Deformity
• Claw hand due to the unopposed action of the
long flexors and extensors of the fingers.
• In a claw hand there is hyperextension at the
metacarphalangeal joints and flexion at the
interphalangeal joints.
 Disability
• Claw hand
• Cutaneous anaesthesia and analgesia in a narrow zone
along the ulnar border of the forearm and hand.
• Horner's syndrome: Ptosis, miosis, anhydrosis,
enophthalmos
• Vasomotor changes: The skin areas with sensory loss is
Warner due to arteriolar dilation. it is also drier due to the
absence of sweating as there is loss of sympathetic
activity.
• Tropic changes: Long standing case of paralysis leads to
dry and scaly skin.The nails crack easily with atrophy of
the pulp of fingers.
 Diagnosis
• History
• Physical exam
• Neurological exam
 Treatment
• Splintage
• Passive ROM exercises
• EMS