Brachial Plexus Injury - An Introduction to the Physiotherapists

Brachial Plexus Injury - Basics, Assessment & Intervention concepts for Physiotherapists

1. Brachial Plexus Injury – An Introduction to the Physiotherapists

2. Brachial Plexus 15 cms long ,spinal column to axilla. Brachial plexus is responsible for cutaneous (sensory) and muscular (motor) innervation of the entire upper limb & pectoral girdle. It proceeds through the neck, the axilla and into the arm.

3. Brachial Plexus - Origin   Formed by ventral rami of spinal nerves C5-T1 Five ventral rami form    Roots / Trunks that separate into Divisions that then form Cords that give rise to Branches  Major nerves Axillary Radial Musculocutaneous Ulnar Median

4. Brachial Plexus: ROOTS 5 ANTERIOR PRIMARY RAMI of C5,C6,C7,C8,T1 Also, fibres are contributed by C4 and T2

5. Brachial Plexus: ROOTS 5 Prefixed plexus large contribution from C4 but not from T2 Postfixed plexus : large contribution from T2 but not from C4

6. Brachial Plexus: 5 parts Roots Trunks Divisions Cords Branches Really Tired - Drink Coffee - Roots, Trunks, Divisions, Cords

7. Brachial Plexus: 3 TRUNKS C5 and C6: Upper Trunk C7 : Middle Trunk C8 and T1: Lower Trunk UML– Upper Middle Lower

8. Brachial Plexus: 2 DIVISIONS Each trunk divides in to Ventral/Anterior division ..... to supply flexor aspect Dorsal/Posterior division......to supply extensor aspect AP – Anterior Posterior

9. Brachial Plexus: 3 CORDS Divisions join to form cords Ventral divisions of upper & middle trunks: Lateral cord Ventral division of lower trunk: Medial cord Dorsal divisions of all trunks: Posterior cord LORD MACAULAY PRABHU – LATERAL MEDIAL POSTERIOR

10. Brachial Plexus: BRANCHES from ROOTS Nerve to serratus anterior or long thoracic nerve ( C5, C6, C7) Nerve to Rhomboids or dorsal scapular nerve( C5)

11. Brachial Plexus: BRANCHES from TRUNK ONLY FROM UPPER TRUNK Suprascapular nerve( C5,6) Nerve to subclavius ( C5,6) 2S

12. Brachial Plexus: BRANCHES from Lateral cord 1. Lateral pectoral ( C5,6,7) 2. Musculo-cutaneous ( C5,6,7) 3. Lateral root of Median ( C5,6,7) LML

13. Brachial Plexus: BRANCHES from Medial Cord Medial pectoral ( C8, T1) Medial cutaneous nerve of arm (C8, T1) Medial cutaneous nerve of forearm ( C8, T1) Medial root of median nerve( C8, T1) Ulnar Nerve( C7,8, T1) M oney  M akes  M any  M en  U nhappy

14. Brachial Plexus: BRANCHES from Posterior Cord Upper subscapular (C5,6) Nerve to Latissimus dorsi or Thoracodorsal nerve ( C6,7,8) Lower subscapular (C5,6) Axillary nerve ( C5,6) Radial nerve ( C5,6,7,8, T1) ULTRA / ULNAR

15. Brachial Plexus Branches

16. Classification Based on, 1. Severity 2. Anatomical location 3. Clinical findings

17. Brachial Plexus Injuries

18. Based on severity Avulsion Rupture Neuroma Neuropraxia

19. Based on Anatomical Location 1. Proximal or Duchenne Erb’sparalysis (Injury to C5 & C6, most common) 2. Intermediate paralysis ( Injury to C7 ) 3. Distal or Klumpke’s paralysis ( injury to C8 & T1, extremely rare) 4. Total brachial plexus paralysis ( more often than the Klumpke type)

20. Based on Clinical Findings Group I, C5-C6 – paralysis of shoulder & biceps Group II, C5-C7 – paralysis of shoulder, biceps & forearm extensor Group III, C5-T1 – Complete paralysis of limb Group IV, C5-Th1 – Complete paralysis of limb with Horner’s syndrome

21. Mode of Brachial Plexus Injuries Road traffic accident Penetrating injuries Surgical complications Birth Injuries Domestic violence and accidents

22. Pre- Ganglionic Vs Post- Ganglionic

23. Pre –Ganglionic Type Traction injury resulting in the avulsion of Pre ganglionic level of all the roots C5 to T1 If the T1 root at Pre ganglionic level is affected results in Horner’s syndrome ( ptosis, hypohidrosis /anhidrosis, miosis & enophthalmos) Serratus anterior & Rhomboids muscles are paralysed Lesion is irrecoverable Limb is functionless

24. Post – Ganglionic Type Post ganglionic level lesion at all roots C5 to T1 Serratus anterior & Rhomboids muscle functions are preserved If lesion is axonotmesis – recovery is possible If lesion is neuronotmesis – surgical exploration & repair may be needed

25. Traumatic Brachial Plexopathies Penetrating injury Infraclavicular plexus commonly affected Knife, gun shot etc Less common incident direct contact, hematoma pseudoaneurysm

26. Traumatic Brachial Plexopathies Closed traction injuries Supraclavicular injuries - forced separation of head and shoulder Infraclavicular injuries - forced separation of arm from the torso (hyper abduction) Root avulsion - more serious Ventral roots are more prone to injury- lesser calibers ,thinner dural sac

27. Tractional Brachial Plexus Injury

28. Obstetric Brachial Plexopathies Five pattern of injuries C5,C6(Erb’s palsy) C5-T1 with some finger flexion sparing C5-T1 with flail arm and Horner's syndrome C5-T1 with Horner (Klumpke’s palsy )

29. Plexopathies

30. Erb’s Paralysis Site of injury: upper trunk ; Erb’s Point 6 nerves meet C5 Root C6 Root Suprascapular nerve Nerve to subclavius Dorsal division Ventral division

31. Erb’s Paralysis: The Cause Undue separation of head and shoulder Birth injury Fall on shoulder During anesthesia Roots involved : C5, C6 Muscle paralysed : Biceps, deltoid, brachialis and brachioradialis , supraspinatus , infraspinatus and supinator

32. Erb’s Paralysis: Deformity- position of limb policeman’s tip or porter’s tip hand Arms: hangs by the side, adducted and medially rotated Forearm: extended and pronated Disability : abduction and lateral rotation of arm shoulder Flexion and supination of forearm Loss of biceps and supinator jerks Loss of sensations over the lower part of deltoid

33. Klumpke’s paralysis Site of injury: lower trunk of brachial plexus Cause of injury : undue abduction of arm as in clutching something after a fall from a height or birth injury Nerve roots involved: T1 and partly C8 Muscle Paralysed: intrinsic muscles of hand Ulnar flexors of wrist and fingers

34. Klumpke’s Paralysis Claw hand deformity Horner’s syndrome Ptosis, myosis,enophthalmos and loss of ciliospinal reflex

35. Injury to nerve to Serratus Anterior Nerve of Bell Cause : sudden pressure on shoulder from above carrying heavy load on shoulders Deformity : winging of scapula Disability: loss of pushing and punching, loss of overhead abduction at shoulder

36. Supraclavicular Brachial Plexopathies Burner syndrome (stinger syndrome) Forceful separation of head & shoulder ( lateral neck extension & shoulder depression after a blunt force to head & neck) Presented with unilateral sharp burning pain in neck radiating to arm Classical C6 distribution,C5 may also affected Male sports person Permanent neurological dysfunction is rare

37. Burner syndrome (Stinger syndrome)

38. Supraclavicular Brachial Plexopathies Rucksack palsy ( cadet palsy, pack palsy) Classical presentation –pain weakness associated with wearing a backpack Sensory involvement and most are due to demyelinating conduction block (neuropraxia) of brachial plexus

39. Cervical rib

40. Thoracic outlet syndrome

41. T horacic outlet syndrome Brachial plexus fibers compromised by a translucent band extending from rudimentary cervical rib to 1 st rib C8 and T1 fibers are mostly affected Presented with pain, paresthesia in the neck shoulder and along the medial border of hand Weakness of the muscles in the hand symptom & sign of vascular compromise

42. Supraclavicular Brachial Plexopathies Pancoast Syndrome Superior lobe carcinoma of lung, mainly NSCC Compression of T1 as only pleura separates lung from T1 Shoulder pain radiating in an ulnar distribution down the arm Shoulder pain worse at night Associated with Horner syndrome

43. Infraclavicular Brachial Plexopathies Crutch palsy : R adial nerve compression

44. Clavicular Brachial Plexopathies Midshaft clavicular fracture: Medial cord injury

45. Nonspecific Brachial Plexopathies Neuralgic Amyotrophy Frequently involves long thoracic, axillary and supraclavicular nerves Presenting feature: abrupt shoulder or upper arm pain, often nocturnal onset Pain abates after 7-10 days 50% associated with infection

46. Clinical Presentation U.E is flail & dangling Look for other extremities U.E: 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]

47. Trumpet Sign The term "trumpet sign" describes the child's typical pattern of bringing objects to the mouth ( ie , shoulder abduction accompanied by elbow flexion).

48. Differential Diagnosis 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

49. Investigations X-rays of the chest - to rule out clavicular or humeral fracture MRI of the shoulder- may demonstrate shoulder dislocation; presence of pseudo meningocele indicates avulsion injury of the affected spinal roots CT Scan of the shoulder- may demonstrate shoulder dislocation; presence of pseudomeningoceles indicates avulsion injury of the affected spinal roots EMG/Nerve conduction studies- presence of fibrillation potentials indicate denervation

50. Outcome Measures Narakas Classification Grouping Toronto Muscle Grading Toronto score Active movement scale Modified Mallet scale for shoulder Gilbert's and Raimondi's scale for evaluation of elbow function Gilbert-Raimondi Hand Score Narakas Motor & Sensory Grading System

51. Narakas Classification Grouping

52. Toronto Muscle Grading

53. Active Movement Scale (AMS)

54. Toronto score used to predict recovery in infants with brachial plexus birth palsy. If the score is less than 3.5 at 3 months of age, poor recovery is expected. Referral to a tertiary centre is therefore required. This group of children may require early surgical intervention. If the score is greater than 3.5, reasonable recovery is likely. Max. score : 10

55. Modified Mallet scale for Shoulder function

56. Gilbert's and Raimondi's scale for evaluation of elbow function

57. Gilbert-Raimondi Hand Score

58. Narakas Motor Grading System M0 – No contraction M1 –Contraction with out movement (shoulder, elbow, wrist); slight movement of digits M2 – Incomplete movement when suppressing, weak complete movement of digits M3 – complete movement with apparently normal force APMR 1978,59:458-464

59. Narakas Sensory Grading System S0 – No reaction to painful or other stimuli S1 – Reaction to painful stimuli, none to touch S2 – Reaction to touch, not to light touch S3 – Apparently normal sensation APMR,59:458-464,1978

60. Towel 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. If child fails, surgery was indicated Journal of Hand Surgery,2004,29B:2:155–158 – LOE-3B

61. Towel Test 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 Journal of Hand Surgery,2004,29B:2:155–158

62. Microsurgical Procedures Nerve graft: Depending upon the nerve injury, it may be possible to repair a rupture by "splicing" a donor nerve graft from another nerve of the child.

63. Microsurgical Procedures Nerve transfer: In some cases, it may be possible to restore some function in the arm by using a nerve from another muscle as a donor.

64. Other Surgical Procedures Release of joint contractures: Thickened soft tissues around the shoulder and elbow joints can be released to allow more motion.

65. Other Surgical Procedures Tendon transfer: To improve the ability to raise the arm, a functioning tendon is moved from its normal attachment in the body and reattached in the affected area

66. Protective phase 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

67. Conservative Management 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

68. Physiotherapy Management 1 st 6 months of treatment is directed specifically at the prevention of fixed deformities. Exercise therapy should be administered daily to maintain ROM and improve muscle strength. Parents must be taught to actively maintain ROM and keep the functioning muscles fit. Exercises should include bimanual or bilateral motor planning activities.

69. Shoulder ROM Exercises

70. Elbow ROM Exercises

71. Wrist & Hand ROM Exercises

72. Task-specific activities

73. Sensory Retraining

74. Positioning Twist Strap Positioning with Sand bag

75. Electrical Stimulation

76. Kinesio Taping to different muscle groups

77. Tendon Gliding Execises

78. Constraint induced movement therapy

79. Functional Electrical Stimulation

80. Fine Motor Activities

81. Bimanual Strengthening Activities

82. Statue of Liberty Splint

83. Aeroplane Splint

84. External Rotation strap splint

85. Flail Arm Splint (For Total BPI)

86. Knuckle bender splint

87. Cock –up splint

88. Mirror therapy

89. Play therapy

90. Hydrotherapy

91. Biofeedback & Mental Imagery (Post surgical)

92. Robotics & EMG

93. Bioness Wireless hand rehab system that delivers low-level electrical stimulation to activate the nerves that control the muscles in the hand and forearm

94. Virtual Reality therapy

95. MyoPro

96. Plexus Arm & Hybrid Prosthesis

97. Bionic Reconstruction Prosthesis

98. Physiotherapy plan of care

99. THANK YOU