brachialplexus ppt.pptx

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Brachial Plexus

Injury



Brachial plexus palsy is defned as a accidparesis o an upper extremity due to traumaticstretching o the brachial plexus received atbirth, with the passive range o motion greaterthan the active range o motion

Arch is !hild "etal neonatal #d $%%&'(()"*(+-



Incidence )

• *% to $% times more common

• %.+ and $ per *%%% live births

• "ullterm newborn

%.&( / & 0 *%%% 1$%%*2

%.*- / $.+ 0 *%%%

Indian journal obstetrics $%%-'3&)$&434



Pathogenesis

5esult rom stretching o the brachial plexus, with its rootsanchored to the cervical cord, by extreme lateral traction.



5is6 actors)

7he ris6 actors or brachial plexus palsies maybe divided into three categories)

8eonatal 9aternal

:aborrelated actors



8eonatal 5is6 actors)

;igh birth weight ( > 4 kg )

:ow AP<A5 score at * min, + min = *% min Breach etal

position

Pediatr 8eurol $%%('&()$&+$3$



Age 1 > &+ years 2

!ephaloPelvic isproportion

<estational iabetes 9ellitus 1 results in

Macrosomia 2

B9IPost date gestation




:abour 5elated)

Increased duration of 2nd stage of labour

Induction of labour

Oxytocin augment

Vacuum extraction

Direct compression of fetal neck during delivery by forceps




Classification:

?everity

Anatomical location

!linical fndings



•

Avulsion – this means the nerve has been pulled out from the spinal cord andhas no chance to recover.

• Rupture – this means the nerve has been stretched and at least partially torn,

but not at the spinal cord.

• Neurapraxia – this means the nerve has been gently stretched or compressed

but is still attached (not torn) and has excellent prognosis for rapid recovery

• Axonotemesis – this means the axons (equivalents of the copper filaments in

an electric cable) have been severed. The prognosis is moderate.

• Neurotemesis – this means the entire nerve has been divided. The prognosis

is very poor.

• Neuroma – this refers to a type of tumor that grows from a tangle of divided

axons (nerve endings), which fail to regenerate. The prognosis will depend on

what percentage of axons do regenerate.



Classification !natomical "

• #roximal or $uchenne%rb&s paralysis ('nury to C * C+, most

common)

•

'ntermediate paralysis ( 'nury to C )

• $istal or -lumpe&s paralysis ( inury to C/ * T0,extremely rare)

• Total brachial plexus paralysis ( more often than the -lumpe

type)

• $uchenne%rbs type 1 Total brachial type 1 -lumpe type



Weak MovementSpinal CordSegment

Resulting Position

Shoulderabduction

C5 Adducted

Shoulderexternalrotation

C5Internallyrotated

Elbow fexion C5, C6 Extended

Supination C5, C6 Pronated

Wristextension

C6, C7 lexed

in!erextension

C6, C7 lexed

"iaphra!#ati c descent

C$, C5 Ele%ated

#rb Brachial Plexus Palsy



Total Brachial Plexus Palsy

Weak MovementSpinal cordsegment

Resulting position

Wrist

fexion

C7,C&,'( Extended

in!erfexion

C7,C&,'( Extended

in!erabduction

C&,'()eutral

position

in!er

adduction C&,'(

)eutral

position

"ilator o*iris

'( +iosis

ull lidele%ation

'( Ptosis



Attitude of the affected Upper Limb:

• Arms hangs by the side with,

• ?houlder / internaly rotated

• #lbow / extension

• "orearm / pronated with palm acing bac6wards 1tipsposition2

• ;and = fnger unctions preserved



Conservative Management:

• Baby@s arm is positioned in

• ?houlder / abduction = external rotation

• #lbow / exed

• "orearm / supinated

• rist / behind the nec6

•

7his position prevents contracture o ?ubscapularis,Pectoralis major

• Passive stretching



Total Brachial Plexus Injury:

Involves injury to all the roots 0 trun6s 0 cords o thebrachial plexus

It is o $ types depending on the level

Pre-ganglionic

Post-ganglionic



Pre-ganglionic Type:

7raction injury resulting in the avulsion o Pre ganglioniclevel o all the roots !+ to 7*

If T1 root at Pre ganglionic level is affected results in ;orner@s

syndrome 1 ptosis, hypohirdosis 0 anhidrosis, miosis =enopthalmos2

?erratus anterior = 5homboids muscles are paralysed

:esion is irrecoverable

:imb is unctionless



Post-ganglionic :

Post ganglionic level lesion at all roots !+ to 7*

?erratus anterior = 5homboids muscle unctions arepreserved

I lesion is axonotmesis / recovery is possible

I lesion is neuronotmesis / surgical exploration = repair maybe needed



Investigations:

• Chest X-ray / to rule out Phrenic 8. palsy

• CT with metriamide 1!7myelogram2

•

MRI / integrity o nerve roots

• Electromyography 3( hrs within delivery distinguishesb0w prenatal = BPI

etect signs o reinnervation

5oot avulsions 1(%C accuracy2



#lectromyographic 1#9<2 )

•

#valuation at approximately * and & months oage.

• ?igns o denervation 1i.e., fbrillations2 $ to &wee6s ater the injury.

• I fbrillations are absent, the li6ely lesion isneurapraxia,

• 8erve root avulsion and a poor outcome frststudy by diDuse fbrillations, unrecordable orscanty motor unit potentials, no muscle responsewith stimulation o motor nerves, and noimprovement on the second #9< examination.



Management:

!onservative management

?urgical management



!onservative 9anagement

9aintain Passive 5ange o movements1P5E92

9uscle strength

?tretch muscle groups to prevent contracture



Protective Phase)

Initial rest period of 7-10 days / to allow or reductiono hemorrhage = edema around thetraumatied nerves

No ROM or other interventions are initiated

7he involved F: is positioned across the abdomen

Avoid lying on the involved limb

Baseline examination / ater initial period oimmobiliation



Positioning)

Arm is positioned toward Abd, #5, elbow " =orearm ?upination on a pillow to child@s side /during sleeping



Splinting:

2esting night splints – prevent wrist * finger 3 contracture

4rist cocup – maintain neutral wrist alignment (-lumpe&s

#aralysis)

5tatue of liberty splint – prevent !dd * '2 contracture



?urgical )

8eurosurgeon

Plastic reconstructive surgeon

Pediatric orthopaedic surgeon



Indication or ?urgical !orrection)

• ?urgical exploration should be done within 4 months o lie

• #xploration and nerve grating or neurotiation i there is acomplete plexus palsy at & months or i there is a !+!4 palsy with absence o biceps at & months

• "ailure o recovery o elbow exion and shoulder abduction

rom the &rd to the 4th month o lie



?urgical 7echniGues)

• 8erve transer0neurotiation

• 8erve anastomosis

• 8erve reconstruction

• 8eurolysis

• 8euroma

• 8eurorrhaphy

• 7endon 7ranser



?pontaneous recovery in H%-+C by 3–4 months

o lie

At & months, the predictive value o regainedelbow exion or complete recovery was *%%C

--C o shoulder #5

-4C o orearm supination

brachialplexus ppt.pptx

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