My seminar While Pursuing Master of Physiotherapy (MPT) at Manipal University

1. D.A.ASIR JOHN SAMUEL., ( Paed.Neuro)
Final Yr MPT
Under,
Mr. M.MANIKANDAN., MPT (Neuro)
Associate Professor

2. *Definition
*Incidence
*Risk factors
*Classification
*Investigation
*Management
*Prognosis

3. *Obstetrical brachial plexus palsy is defined as a
flaccid paresis of an upper extremity due to traumatic
stretching of the brachial plexus received at birth,
with the passive range of motion greater than the
active range of motion
Arch Dis Child Fetal neonatal Ed 2003;88:F185-9

4. *Brachial palsy is a paralysis involving the muscles
of the upper extremity that follows mechanical
trauma to the spinal roots of C5 to T1 (the brachial
plexus) during birth
*Injuries are transient, with full return of function
occuring in 70-92% of cases¹
1.Plas Reconstr Surg 1994;93:675-80

5. 0.38 – 3 / 1000 (2001)
Due to Advances in obstetrics
0.19 – 2.5 / 1000
Indian journal obstetrics 2009;43:236-46

6. *The risk factors for brachial plexus palsies may
be divided into three categories:
1. Neonatal
2. Maternal
3. Labor-related factors

7. *High birth weight ( > 4 kg )
*Low APGAR score at 1 min, 5 min & 10 min
*Breach fetal position
Pediatr Neurol 2008;38:235-242

8. *Age ( > 35 years )
*Cephalo-Pelvic Disproportion
*Gestational Diabetes Mellitus ( results in Macrosomia )
*BMI
*Post date gestation
Pediatr Neurol 2008;38:235-242

9. *Increased duration of 2nd stage of labour
*Induction of labour
- Oxytocin augment
*Operative vaginal deliveries
- Vacuum extraction
- Direct compression of fetal neck during
delivery by forceps
Pediatr Neurol 2008;38:235-242

10. *Based on,
1. Severity
2. Anatomical location
3. Clinical findings

11. *Avulsion
*Rupture
*Neuroma
*Neuropraxia

12. 1. Proximal or Duchenne-Erb’s paralysis (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)
Duchenne-Erbs type > Total brachial type > Klumpke type

13. *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

14. *In 1874, Wilhelm Heinrich Erb described isolated upper
brachial plexus palsy
*The site of damage localized to the junction of C5 & C6
*Due to,
- Breech presentation with arms extended over the head
- Excessive traction on the shoulder
- # clavicle during vaginal delivery

15. 1. Deltoid
2. Supraspinatus
3. Infraspinatus
4. Rhomboids
5. Clavicular head of pectoralis major
6. Teres minor
7. Biceps
8. Brachialis
9. Extensor carpi radialis longus & brevis

16. *Arms hangs by the side with,
*Shoulder – internaly rotated
*Elbow – extension
*Forearm – pronated with palm facing backwards (tips
position)
*Hand & finger functions - preserved

17. *Baby’s arm is positioned in,
*Shoulder – abduction & external rotation
*Elbow – flexed
*Forearm – supinated
*Wrist – behind the neck
*This position prevents contracture of Subscapularis,
Pectoralis major
*Passive stretching

18. *Isolated injuries to the distal or lower portion of the brachial
plexus is described by Klumpke
*The site of damage localized to the junction of C8 & T1
*Due to,
- Stretching of lower plexus N. under and against coracoid
process during forceful elevation or abduction of the arm
- Excessive traction on the trunk

19. 1. Flexors of wrist
2. Flexors of fingers (FDS & FDP)
3. Intrinsic muscles of hand
*If sympathetic trunk is involved results in
ipsilateral Horner’s syndrome ( ptosis,
hypohirdosis, miosis & enopthalmos)
*Associated with delayed pigmentation of iris

20. *Involves injury to all the roots / trunks / cords of
the brachial plexus
*It is of 2 types depending on the level,
1. Pre-ganglionic
2. Post-ganglionic

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

22. *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

24. Gravity Eliminated
No contration 0
Contraction, no motion 1
Motion ≤ ½ range 2
Motion >½ range 3
Full motion 4
Against Gravity
Motion ≤ ½ range 5
Motion >½ range 6
Full motion 7
Journal of the American society for surgery of the hand 2003; 3:1, 41-54

26. Modified Mallet classification

27. 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

28. 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

29. *Chest X-ray – to rule out Phrenic N. palsy
*CT with metrizamide (CT-myelogram)
*MRI – integrity of nerve roots
*Electromyography
- 48 hrs within delivery distinguishes b/w prenatal &
OBPI
- Detect signs of reinnervation
- Root avulsions (80% accuracy)

30. *Nerve Conduction Studies (NCV)
- Sensory nerve conduction but absence of motor
nerve conduction at 3 months – Avulsion injury
*SSEP & MEP denotes the integrity of sensory &
motor fibres

31. *EMG
- Fibrillation potential
- motor unit action potential (MUAP)
*Nerve Conduction Studies
- Sensory nerve action potential (SNAP)
- Compound muscle action potential (CMAP).

32. *Fibrillation potential appear about 3 weeks after
motor nerve injury
*Minimal degree of nerve lesion – innervation ratio
*MUAP loss occur immediately – moderate lesion
Neurol Clin N Am 20 (2002) 423–450

33. *Absolutely abnormal – less than age based laboratory
control values
*Relatively abnormal - < 50% than the amplitude of
homologous response recorded from contralateral side
*Wallerian degeneration apparent 2-3 days on NCS
Neurol Clin N Am 20 (2002) 423–450

34. *SNAPs & CMAPs are spared – minimal lesion
SNAP amplitude decrease ( moderate)
CMAP amplitude decrease (severe)
Neurol Clin N Am 20 (2002) 423–450

35. *CMAP amplitudes are the most useful for quantifying the amount
of axon loss suffered by a nerve
*Prior to reinnervation, the CMAP amplitudes are the most reliable
indicator of the amount of axon loss present, and the relationship is
roughly one to one.
*For example,
*CMAP amplitude from symptomatic side – 5mV
*CMAP amplitude from asymptomatic side – 10mV
Neurol Clin N Am 20 (2002) 423–450

36. *CMAP amplitudes begin to decrease on day 2 or 3 and reach
their nadir at day 7
*SNAP amplitudes begin to drop on day 6 and reach their
nadir around day 10 or 11
*Fibrillation potential after day 21
*MUAP loss occurs immediately - at least moderate in degree
*Prolonged duration, increased polyphasia and, occasionally,
heightened amplitude – during reinnervation (MUAP)
Neurol Clin N Am 20 (2002) 423–450

37. *The length of nerve between the lesion site and the
denervated muscle fibers
*Advancement occurs at a rate of about 1 in/month
*Denervated muscle fibers survive for approximately 18 to 24
months.
* After this period of time has elapsed, the muscle fibers
undergo degeneration and, from that point onward, can no
longer be reinnervated
Neurol Clin N Am 20 (2002) 423–450

38. 1. Supporting structures are spared
2. Distance between the lesion and the denervated
muscle fibers is short
3. Lesion is incomplete
Neurol Clin N Am 20 (2002) 423–450

39. *End organs of the sensory nerve fibers do not undergo
degeneration,
*There is no time limit on sensory nerve fiber regeneration.
*If it requires more than 2 years for the sensory fibers to
reach their end organs, reinnervation can still be successful
Neurol Clin N Am 20 (2002) 423–450

40. *Conduction slowing
- Neuropraxia
- Axonotmesis
*Conduction block
- Neuronotmesis
Neurol Clin N Am 20 (2002) 423–450

42. *No SNAP domain
*CMAP domain includes,
*Musculocutaneous NCS recording Biceps (Musc-
biceps)
*Axillary NCS recording deltoid (Ax-deltoid).
*EMG domain includes those muscles contained
within the C5 myotome.

43. * SNAP- lateral antebrachial cutaneous NCS (LABC; 100%)
- Median NCS recording from first digit (Med-D1; 100%),
second digit (Med-D2; 20%) & third digit (Med-D3; 10%)
sensory NCS.
- Superficial radial NCS (S-Radial; 60%)
*CMAP – Biceps & Deltoid
*EMG domain includes those muscles belonging to the C6
myotome.

44. *SNAP
- Med-D2 (80%)
- Med-D3 (70%)
- S-Radial (40%)
*CMAP – EDC (Radial)
*EMG domain includes muscles belonging to the C7 myotome
Neurol Clin N Am 20 (2002) 423–450

45. *SNAP domain of the C8 APR includes Uln-D5
*CMAP domain Ulnar NCS, recording abductor digiti minimi
(Ulnar-ADM) and first dorsal interosseous (Uln-FDI)
- Radial NCS, recording Extensor indicis proprius (Radial-EIP)
motor NCS
- To a lesser extent, the median NCS, recording abductor
pollicis brevis (Median-APB)
*EMG domain consists of those muscles belonging to the C8
myotome

46. *CMAP domain -Abductor pollicis brevis, the Median-APB NCS
is a more reliable
*EMG domain consists of those muscles belonging to the T1
myotome.
* Abductor pollicis brevis
*Flexor pollicis longus muscles are the most helpful in its
assessment

50. *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

53. *Surgical management
*Conservative management

55. *Pediatric neurosurgeon
*Plastic reconstructive surgeon
*Pediatric orthopaedic surgeon

56. *Thomas and Dargassie developed towel test
*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.
Journal of Hand Surgery,2004,29B:2:155–158 – LOE-3B

57. *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

58. *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
Plast. Reconstr. Surg. 2004;113: 54e-67e

59. *Nerve transfer/neurotization
- Intercostal N.
- Ulnar N.
- Sural N.
- Suprascpular N.
- Axillary N.
*Nerve anastomosis
*Nerve reconstruction

60. *Neurolysis
*Neuroma resection
*Neurorrhaphy

61. *Internal rotation contracture
- subscapularis release
- Latissimus dorsi infraspinatus
*Improving abduction
- Trapezius / latissimus dorsi trasnfer to humeral
head

62. *Improving forearm pronation
- Flexor-pronator transfer (steindler procedure)
*Improving elbow extension (in lower plexus injury)
- Latissimus dorsi transfer
*Improving elbow flexion
- Flexorplasty – triceps, PM, Lats

63. *Immobilization
- Cast 3-6 weeks
- Night splint 3-6 months
*Scar management
- Tendon gliding
- US massage

64. *Muscle reeducation
- cues to perform previous action of transferred
muscle
- Taping / vibration over muscle belly
- Biofeedback
- NEMS-after 6 weeks
*Functional performance

66. *Maintain
- PROM
- Supple of muscle
- Muscle strength
*Stretch muscle groups to prevent contracture

67. *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
*Avoid lying on the involved limb
*Baseline examination – after initial period of
immobilization

68. Maintain ROM
- Facilitates normal movement patterns while inhibiting
substitutions
- Lift 10 toy/ball & put in doll house/basket – shoulder F.
- Paralysis & contracture of Rhomboids disturbs normal
6:1 humeroscapular rhythm in first 30º of shoulder mvt.
- Stabilize the scapula & assist active F as child reaches for
a toy
Developmental Medicine & child Neurology 2001,43:419-426 – LOE-4A

69. - Hand to mouth
- Transferring objects
- Weight shifting on propped UE in prone & quadruped
- Sitting with hands in front or back
- Creeping
- Reaching for toys placed at variety of angles & heights
Developmental Medicine & child Neurology 2001,43:419-426 – LOE-4A

70. - In side-lying on uninvolved arm to avoid stresses on
involved arm & to free the weak arm to reach & play
with toys in front of them
- Joint compression in weight bearing
- Restraining uninvolved arm & encouraging involved
arm

71. - Up to 65% of children with incomplete OBPI have limited
ROM (Dev Med & Child Neurol 2004,46:76-83)
- Prevent Scapulohumeral adhesion by restraining/stabilizing
the scapula during reaching & allowing muscles to stretch in
initial 30º of Abd.
- Beyond 30º scapula must rotate along with humeral ER
- Botox improves AROM & benefits lasted upto 6 wks
Pediatric Rehabilitation 2001,4:29-36 – LOE-2B

72. - Sensory loss can lead to neglect or self-mutilation
- Parents should be cautioned about risk of self mutilation such as
biting an insensate area
- Sensory perception can be enhanced by placing objects of
different textures & temperatures in hand
- Playing games such as finding toys under sudsy water/rice/sand
- Blindfolding & having her name familiar objects placed in hand

73. - Arm is positioned toward Abd, ER, elbow F &
forearm Supination on a pillow to child’s side –
during sleeping

74. - 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

75. *Air splints – restraining uninvolved UE to
encourage involved UE
*Aeroplane splint – Erb’s palsy

76. *ES of denervated muscles prevents muscle atrophy
*May be used after neurosurgery
Archives of Physical Medicine & Rehabilitation 1998,79:458-464 – LOE-4A

78. *The upper plexus palsies are generally less severe
*Poor prognostic factors include
- total or lower plex-opathy
- Horner’s syndrome
- Root avulsions and
- Associated fractures (e.g., ribs, clavicle, humerus)
- Group IV ( according to Naraks grading)
Clin Plast Surg 1984;11:181-7 – LOE -3A
Clin Orthop Relat Res 1991;264:39-47

79. *Spontaneous recovery in 70-95% by 3–4 months of life
*At 3 months, the predictive value of regained elbow flexion for
complete recovery was 100%
* 99% of shoulder ER
*96% of forearm supination
Developmental Medicine and Child Neurology; Jun 2010; 52, 6;529-534 – LOE-2B

80. *Physical Therapy for Children – 3rd Ed
* Suzan K. Campel
*Physiotherapy in Paediatrics – 3rd Ed
* Roberta B. Shepherd