BRACHIAL PLEXUS INJURY - Dr Rohit Bhaskar

BRACHIAL
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PLEXUS INJURY
PRESENTED BY
DR ROHIT BHASKAR
PHYSICAL THERAPIST

OTHER NAMES:
Erb–Duchenne palsy/Klumke Brachial Birth Palsy
Obstetric Brachial Plexus Palsy

BRACHIAL PLEXUS
◼ Proximal or Duchenne-Erb’s
paralysis -Injury to C5 &C6,
most common
◼ Intermediate paralysis-
Injury to C7
◼ Distal or Klumpke’s paralysis
- injury to C8 & T1,
extremely rare
◼ Total brachial plexus
paralysis ( more often
than the Klumpke type)
BRACHIAL PLEXUS

Mechanism of injury
◼ Bending or stretching of the neck
in a direction away from the
side of injury.

KLUMPKE’S PARALYSIS
◼ MECHANISM OF INJURY:
Pulling up of the arm above the
head, so that stretch on the C8
and T1 roots

CLINICAL ASSESSMENT
◼ U.E is flail & dangling
◼ Look for other extremities
◼ U.R: 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]

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

MANAGEMENT
◼ CONSERVATIVE MANAGEMENT
◼ SURGICAL MANAGEMENT

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

CONSERVATIVE MANAGEMENT
PHYSIOTHERAPY – cornerstone of conservative mngt.
◼ 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

Splinting
◼ -Resting night splints – prevent wrist &
finger F contracture
◼ -Wrist cock-up – maintain neutral wrist
alignment (Klumpke’s Paralysis)
◼ -Statue of liberty splint – prevent Add &
IR contracture

SPLINTING
◼ Air splints – restraining uninvolved UE to
encourage involved UE
◼ Aeroplane splint – Erb’s palsy

BPI Treatment Intervention

Interventions
Interventions

Interventions

Scapular winging, Trumpet sign

SURGICAL MANAGEMENT

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
◼ Lefevre and Diament called it as hand to face 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.

TOWEL TEST

Indication for surgical correction
◼ Surgical exploration should be done within
6 months of life
◼ Exploration and nerve grafting or
neurotization if there is a complete plexus
palsy at 3 months or if there is a C5-C6
palsy with absence of biceps at 3 months
◼ Failure of recovery of elbow flexion and
shoulder abduction from the 3rd to the
6th month of life.

Surgical Intervention
◼ Neurosurgery 5-10% OBPI
◼ Nerve grafting
◼ Neuroma dissection and removal
◼ Neurolysis (decompression and
removal of scar tissue)
◼ Direct end to end anastomosis
of nerve ends

Neurrorhaphy

Neurolysis

Neuroma Removal

Neurotization

Tendon Transfer

Post op management
◼ Immobilization
◼ Cast 3-6 weeks
◼ Night splint 3-6
months
◼ Scar
management
◼ Tendon gliding
◼ US massage
◼ Muscle reeducation
cues to perform
previous action of
transferred muscle
◼ -Taping / vibration over
muscle belly
◼ -Biofeedback
◼ -NEMS-after 6 weeks
◼ *Functional
performance

Post op.

PROGNOSIS for Erb’s Palsy
◼ Generally good for
spontaneous
recovery, although
may be incomplete
◼ Depends on degree
of involvement
◼ Majority of
spontaneous recovery
by 9 months

BPI Neuronal Recovery
◼ Axon regeneration 1 mm per day
◼ 4-6 months for upper arm
◼ 7-9 months for lower arm
◼ Recovery is varied according to damage
◼ 2 years upper arm
◼ 4 years lower arm
Denervated muscle fibers survive for approximately
18 to 24 months.

PREVENTION
◼ Birthing facility has a duty to be sure that
their obstetric teams have continuing
education and skill training, so that they
have current knowledge and skills to deal
with these challenges when they occur.
◼ Mother/patients proper education.
◼ Good advance planning by the obstetrician.
◼ Good judgment .
◼ Proper history taking

DELIVERY MANUEVER
◼ EPISIOTOMY
◼ McROBERT’S POSITION
◼ SUPRAPUBIC PRESSURE
◼ WOODS MANUEVER (woodscrew maneuver
◼ COMBINATION MANUEVER
◼ GASKIN MANUEVER
◼ RUBIN MANUEVER
◼ MANUAL DELIVERY OF POSTERIOR ARM

Alarmer method
◼ Ask for help. This involves requesting the help of an
obstetrician, anesthesia and pediatrics for
subsequent resuscitation of the infant.
◼ Leg hyperflexion (McRoberts' maneuver)
◼ Anterior shoulder disimpaction (pressure)
◼ Rubin maneuver/woodscrew
◼ Manual delivery of posterior arm
◼ Episiotomy
◼ Roll over on all fours (GASKIN)

TRACTION
◼ Many doctors use traction (pulling on baby's head) or fundal
pressure (where the nurse climbs on the bed and jumps down
onto your stomach) before anything else and these are not only
the least effective techniques, but dangerous to mother and
baby.
TRACTION

McRobert’s
Manuever
◼ The McRoberts maneuver (where mom's legs are brought up as far back
toward her stomach as possible, which realigns the pubic bone and can
slip baby's shoulder out) ) should be tried first and if failing

Suprapubic Pressure
◼ Suprapubic pressure (where the doctor or nurse makes a fist and pushes
hard
on the baby's shoulder just above the pubic bone) can be applied.

Gaskin Manuever
◼ The Gaskin Maneuver consists of having mom roll onto all fours (or assisting
if necessary). During the process, many babies become dislodged and pop
right out. If this doesn't happen, then the doctor actually has better access to
help wiggle the baby around until the shoulder releases and the rest of
baby is born (Woods or Rubin maneuver).

Rubin manuever

Manual Delivery of Post arm
◼ Manual delivery of posterior arm: Insert hand into the vagina and flex
the posterior arm of the fetus, bringing it across the chest. The posterior
arm is then delivered over the perineum which allows the provider to
rotate the fetus to allow delivery of the anterior shoulder once the rotation
has disimpacted it from the pubic symphysis.

PRESENTED BY
DR ROHIT BHASKAR
PHYSICAL THERAPIST

THANK YOU

BRACHIAL PLEXUS INJURY - Dr Rohit Bhaskar

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