Dr kanij erbs palsy presentation

ERB'S palsy

1. Brachial Plexus Injury In Newborn Dr Kanij Fatema Associate Professor Pediatric Neurology BSMMU

2. 13 days old girl came to the OPD with decreased movement of right arm There was history of prolong labour and normal vaginal delivery On examination, tone of the right upper arm was reduced Biceps jerk was absent Movement of the wrist joint was present

3. Video

4. Brachial Plexus Nerve roots from the fifth cervical through the first thoracic nerves form the three primary trunks of the brachial plexus Once formed, they divide promptly into anterior and posterior divisions The posterior divisions join to form the posterior cord , which gives rise to the upper and lower subscapular , thoracodorsal , axillary , and radial nerves

5. The anterior divisions of the fifth, sixth, and seventh nerves form the lateral cord , and the anterior divisions of the eighth cervical and first thoracic nerves form the medial cord The lateral cord subsequently gives rise to the musculocutaneous nerve and a branch to the coracobrachialis . The medial cord gives rise to the ulnar , medial antebrachial cutaneous , and medial brachial cutaneous nerves Additional branches from the lateral and medial cords unite to form the median nerve  

6. Brachial Plexus Injury Birth-related brachial plexus injuries occur in 0.5-5 infants per 1000 live birth The incidence ranges globally from 0.2-4% of live births According to the World Health Organization , prevalence is generally 1-2% worldwide , with the higher numbers being in underdeveloped countries Also known as Obstetrical brachial plexus injuries

7. Etiology Excessive traction to the affected extremity during breech delivery Traction to the head and neck during vertex delivery Shoulder dystocia Large birth weight (>4000 g) Can occur in the absence of fetal trauma One study showed that 50% of Erb’s palsy occur in normal-sized infants without trauma at delivery

8. May be associated with clavicle fracture in 10% of cases and humerus fracture in 10 % cases

9. Pathophysiology A first-degree injury, or neurapraxia , involves a temporary conduction block with demyelination of the nerve . Complete recovery occurs. Recovery may take up to 12 weeks A second-degree injury, or axonotmesis , results from a more severe trauma or compression The endoneurial tubes remain intact, and the recovery, therefore, is complete A third-degree injury ,the endoneurial tubes are not intact . The pattern of recovery is mixed and incomplete A fourth-degree injury results in a large area of scar at the site of nerve injury. No improvement in function is noted, and the patient requires surgery to restore neural continuity A fifth-degree injury is a complete transection of the nerve. Similar to a fourth-degree injury, surgery is required

10. Types Erbs Palsy (80–90 percent ) Klumpkes Palsy Total plexus involvement Bilateral involvement (10 to 20%) Brachial neuritis (rare, may be associated with DPT vaccinations) Recurrent inherited brachial plexus neuritis

11. Erb’s Palsy The most common form of brachial plexus 80–90 % of all cases Damage of the fifth and sixth cervical nerves or the upper trunk of the brachial plexus result in paralysis of the upper arm The deltoid ,biceps, brachialis , supinator , and extensors of the wrist and finger muscles are paralyzed

12. The infant typically lies with Humerus adducted and internally rotated The elbow extended Forearm pronated Wrist flexed The biceps reflex is absent

13. The most common associated (not causative) injuries include the following: Clavicular and humeral fractures Torticollis Cephalohematoma Facial nerve palsy Diaphragmatic paralysis

14. Workup Lab studies generally are not necessary for the diagnosis of brachial plexus palsy X ray arm( to exclude fracture) X ray chest ( to exclude paralysis of hemidiaphragm ) MRI of the plexus ( before surgery to determine the extent of injury) NCS and EMG (controversial)

15. Treatment Counseling Gentle handling (as the injury is painful and there is chance of extension of injury) Immobilization not recommended Passive range of motion ( to prevent contracture of the shoulder) : start after 10 to 14 days Surgery Botulinum toxin might be recommended to reduce contracture

16. Occupational therapy Throughout the first six months , OT is the mainstay of treatment As the child gets older, bimanual activities ( eg , swimming, basketball, wheelbarrow walking, climbing) should be encouraged Exercises are intended to : • Maintain joint mobility • Prevent contractures • Provide sensory input for sensory stimulati on

17. Therapy alone is usually sufficient for mild brachial plexus injuries Therapy also is a prerequisite for successful surgery , if surgery is necessary If contracture develops :Static and dynamic splinting of the arm is useful to reduce contractures to prevent further deformity Commonly prescribed splints include resting hand and wrist splints, elbow extension splints, dynamic elbow flexion and supinator splints

18. Surgery Surgery for newborn brachial nerve lesions is becoming more popular, especially when electrical physiologic and neuroimaging data indicate primary injury to the plexus and no nerve root evulsion Primary nerve reconstruction , followed by appropriate tendon transfers Surgical intervention may benefit 20–25 percent of all patients

19. Outcome Although quick recovery may be observed, complete recovery may take many months Good return of hand and arm function by 6 months is a good prognostic sign In a study (Waters, 1999), 80 to 90 percent of 66 patients with brachial plexus injuries experienced a spontaneous return of function

20. Klumpke’s paralysis Injury to the lower trunk of the plexus, involving the C8 and T1 This condition is rare(less than 1 %) Weakness of the forearm extensors, flexors of the wrist and fingers, and intrinsic muscles of the hand occurs Horner’s syndrome is often present as a result of involvement of the sympathetic fibers accompanying T1

21. The elbow is typically flexed The forearm is supinated The wrist is extended A clawlike deformity of the hand with hyperextension of the wrist and fingers The triceps reflex may be diminished, and the grasp reflex is usually absent

22. Total brachial plexus involvement 10 % of brachial palsy of newborn The arm hangs limply from the shoulder No muscle movement Tendon areflexia Decreased sensation over the arm and hand The outlook for recovery after complete brachial plexus injury is poorer than the o thers

23. Recurrent inherited brachial plexus neuritis Hereditary neuralgic amyotrophy Carried on chromosome 17q25.3 Autosomal dominant disorder The long thoracic nerve is involved Lumbar plexus involvement may be noted The condition is believed to be an immune complex disease that causes damage to blood vessel walls

24. Clinical features Pain Brachial plexus-innervated muscle weakness Tendon reflexes are reduced Scapular winging present Autonomic nerves are affected Short stature, hypotelorism , small face and palpebral fissures, prominent epicanthal folds, and syndactyly are part of the syndrome  

25. In most cases recovery occurs spontaneously NCV and EMG to detect axonal loss No specific treatment

26. In a nut shell

27. Take Home Message Brachial plexus injury in newborn is not uncommon Most of the newborns recover Occupational therapy is the cornerstone of therapy

28. Occupational therapy Video

29. Thank You