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Brachial plexus injury
- 1. Brachial plexus injury Dr.Chandan Verma(PT) Assistant professor (Mahatma Gandhi Physiotherapy College, Jaipur)
- 2. Contents :- anatomy Etiology Mechanism of injury Classification Clinical features Investigation Management
- 3. Brachial plexus,amajor source of motor and sensory supply to the shoulder girdle,the Upper trunk and the whole of Upper limb.
- 4. The brachialplexus (plexus brachialis) is a somatic nerve plexus formed by intercommunications among the ventral rami (roots) of the lower 4 cervical nerves (C5-C8) and the first thoracic nerve (T1). The plexus is responsible for the motor innervation of all of the muscles of the upper extremity, with the exception of the trapezius(SAN & C3,C4) and levator scapula(C3,C4 & C5DSN).
- 6. Avulsion The nerveis 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. Types of Brachical Plexus Injury
- 7. Risk factor ofBrachial Plexus Injury 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 Over half of brachial plexus Injuries have no known risk factors
- 13. Injury ofbrachial plexus Upper trunk injury 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) •Includes about 75 percent of all brachial plexus
- 17.
- 18. Horner Syndrome •Result ofnerve damage affecting the eye including constriction of the pupil (miosis) and eye drooping (ptosis) •Sometimes seen with nerve root avulsions of the brachial plexus Global Palsy •All five nerves of the brachial plexus are involved (C5-T1) Presents with no movement at the shoulder, arm or hand •May have no sensations throughout the arm
- 19. Investigation Ct-scan MRI X-ray of cervical spine Chest X-ray Electromyography
- 20. Management It may include- 1.Conservative 2. surgical
- 21. Conservative treatment- Aims- tomaintain the rom of the extremit to strengthen the remaining functional muscle to protect the denervated dermatome To manage pain
- 22. Conservative Treatment-dividedinto three stages 1. Early stage 2. Intermediate stage 3. Late stage
- 23. 1. In earlystage- Nsaids and opioid drugs are useful during the early stage but do not appear to help with neuropathic pain which requires antiepileptic or antidepressants. Splinting- to avoid soft tissue contracture. Passive range of motion to prevent contracture. To control oedema-limb elevation with supportive orthosis -gentle effleurage -cOmpressive Elastic bandage
- 24. 2. Intermediate stage-(afterthree weeks) Exercises to re-educate movement should be initiated. Weaker movement are repeated with self resistive movement. PNF movement can be used to strengthen the various muscle group. Electrical stimulation for the paralyzed muscle. Technique like icing and brushing can be effective. Tens can be used to reduce pain.
- 25. Late stage-(after 2years) In this period,most of the recovery Would have takes place. If the recovery is still,it may be necessary to plan for the possible reconstructive surgery.
- 26. Aeroplane splintfor erb’s palsy-this maintains the shoulder in abduction and external rotation,elbow in 90° flexion,forearm in supination and wrist in a few degree of extension.
- 27. For klumpkepalsy a dynamic splint is given to maintain the wrist and metacarpo- phalaNgeal joint in flexion, inter-Phalangeal Joint in slight flexion and the thumb in flexion and opposition.
- 28. Surgical treatment Neurolysis Removal ofthe constrictive scar tissue surrounding the nerve. Neuroma Excision When the neuroma is large it must be removed and the nerve is then reattached either with end-to-end techniques or with nerve grafts. Nerve Grafting When the gap between the nerve ends is so large that it is not possible to have a tension-free repair using the end-to-end technique, nerve grafting is used. Neurotization This is used generally in those cases where there is an avulsion. Donor nerves are used for the repair. The parts of the roots still attached to the spinal cord can be used as donors for avulsed nerves. Isolated Nerve Transfers •Isolated transfer may be completed up to 12-18 months of age •A nearby healthy nerve is attached to the damaged nerve, closer to the target muscle Additional procedures are available to improve the overall function of the affected limb. Procedures include: •Arthroscopic surgery and other minimally invasive techniques •Tendon transfers •Muscle transfers
- 29. Physiotherapy treatment aftersurgery Proper splint to stabilize the transplanted muscle Electrical stimulation Biofeedback exercises Self assisted and functional movement Relaxed passive movement, active assisted movement, progresses to resisted exercises Active exercises and gripping exercises
- 31.