Klumpke's and Erb's Palsy
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Questions and Answers

A patient presents with Klumpke's paralysis following a fall. Which combination of nerve root and spinal cord levels are MOST likely involved?

  • C5 and C6 nerve roots; cervical spinal cord
  • C8 and T1 nerve roots; cervical spinal cord (correct)
  • C6 and C7 nerve roots; lumbar spinal cord
  • L4 and L5 nerve roots; sacral spinal cord

A patient with Klumpke's paralysis demonstrates a 'claw hand' deformity. Which muscular imbalance primarily contributes to this presentation?

  • Weakness of thenar muscles with overactivity of the hypothenar muscles
  • Loss of lumbrical function combined with the unopposed action of extrinsic finger flexors and extensors (correct)
  • Spasm of interossei muscles overpowering the long finger flexors
  • Impaired wrist flexor function with compensatory activation of wrist extensors

Following an injury resulting in Klumpke's paralysis, a patient exhibits severe edema and vasomotor dysregulation in the affected hand. Which nerve's involvement is MOST likely contributing to these autonomic symptoms?

  • Radial nerve due to its extensive sensory distribution
  • Axillary nerve due to its proximity to blood vessels
  • Median nerve due to its high concentration of autonomic fibers (correct)
  • Musculocutaneous nerve due to its superficial location

A therapist is evaluating a patient with Klumpke's paralysis. Weakness is noted during thumb adduction and finger abduction. This finding indicates involvement of which myotome levels?

<p>C8 and T1 (C)</p> Signup and view all the answers

Which of the following mechanisms of injury (MOI) is MOST likely to result in Klumpke’s paralysis?

<p>Falling from a height and grabbing something to catch oneself (A)</p> Signup and view all the answers

In Erb's palsy, which nerve roots of the brachial plexus are primarily affected?

<p>C5 &amp; C6 (C)</p> Signup and view all the answers

During palpation of the brachial plexus, discomfort and possible paresthesia should radiate towards which anatomical landmark?

<p>The coracoid process (C)</p> Signup and view all the answers

Which of the following mechanisms of injury (MOI) is LEAST likely to cause Erb's palsy?

<p>Direct blow to the neck without associated shoulder displacement (B)</p> Signup and view all the answers

The 'Waiter’s tip' deformity, characteristic of Erb’s palsy, presents with which combination of upper extremity positions?

<p>Arm adducted and internally rotated, elbow extended, forearm pronated, wrist and fingers flexed (A)</p> Signup and view all the answers

A patient with Erb's palsy exhibits weakness in shoulder abduction and elbow flexion. Which myotome levels are most likely affected?

<p>C5 and C6 (C)</p> Signup and view all the answers

Which of the following muscles is LEAST likely to be affected by Erb's palsy?

<p>Triceps Brachii (C)</p> Signup and view all the answers

If a patient with Erb's palsy also presents with scapular winging, which additional nerve is MOST likely to be injured?

<p>Long thoracic nerve (A)</p> Signup and view all the answers

A newborn presents with Erb's palsy after a difficult delivery. Which of the following scenarios during the delivery is LEAST likely to have contributed to this condition?

<p>Breech presentation requiring significant traction to deliver the lower extremities. (C)</p> Signup and view all the answers

A patient presents with miosis, ptosis, and anhidrosis on the face following a brachial plexus injury. What is the MOST likely underlying cause of these symptoms?

<p>Injury to the superior cervical ganglion or autonomic fibers innervating the eyes and face. (D)</p> Signup and view all the answers

A football player experiences immediate, sharp pain down their arm, along with tingling and weakness, after a helmet-to-helmet collision. Symptoms subside after a few minutes. This presentation is MOST consistent with which condition?

<p>Burner or Stinger (B)</p> Signup and view all the answers

What is the MOST important precaution to observe when treating a patient with a brachial plexus traction injury involving nerve regeneration?

<p>Avoiding tractioning or stretching the regenerating nerve. (A)</p> Signup and view all the answers

When treating edema associated with a brachial plexus traction injury, which technique is MOST appropriate?

<p>Employing nodal pumping and drainage techniques proximal to the edge of the edema. (B)</p> Signup and view all the answers

A patient is in the early stages of recovery from a brachial plexus traction injury. To prevent placing drag on the healing tissue, which manual therapy technique is MOST suitable?

<p>Applying a 'blocking' technique proximal to the lesion. (A)</p> Signup and view all the answers

A patient is 6 weeks post-surgery for a brachial plexus injury. Which of the following is the MOST appropriate approach for treating the affected muscles distal to the lesion?

<p>Using light strokes and gentle compressions. (A)</p> Signup and view all the answers

During PROM for a patient with a brachial plexus injury, which direction of joint movement is MOST recommended?

<p>In the direction that shortens the affected tissue and nerve. (C)</p> Signup and view all the answers

When taking a patient history for a brachial plexus traction injury, which question is MOST important to ascertain the progression of healing?

<p>Has any function been regained, and if so, at what rate? (D)</p> Signup and view all the answers

During the acute phase of recovery from a peripheral nerve injury, what is the primary focus of management?

<p>Focusing on healing and preventing complications, potentially with immobilization. (A)</p> Signup and view all the answers

In the context of peripheral nerve injuries and recovery, what does 'discriminative sensory re-education' primarily involve?

<p>Identifying objects using touch, first with visual cues and later without. (D)</p> Signup and view all the answers

During the chronic phase of peripheral nerve injury recovery, what is the main goal of therapeutic intervention?

<p>Training compensatory functions to manage persistent physical deficits. (B)</p> Signup and view all the answers

When managing edema in a patient with a brachial plexus injury, which of the following techniques is MOST appropriate?

<p>Using cool hydrotherapy and unidirectional stroking towards the heart. (D)</p> Signup and view all the answers

What is the MOST important consideration when performing PROM exercises for a patient with a brachial plexus injury?

<p>Avoiding any movements that could potentially traction the nervous tissue. (C)</p> Signup and view all the answers

Which of the following interventions is MOST appropriate for stimulating regained function in a patient recovering from a peripheral nerve injury?

<p>Utilizing facilitatory ROODS techniques to enhance motor recruitment. (C)</p> Signup and view all the answers

In the late stages of regeneration or with a permanent lesion following a brachial plexus injury, what is the primary goal of home care?

<p>Maintaining tissue health and function while preventing further complications. (B)</p> Signup and view all the answers

What type of hydrotherapy should be used with caution for home care in patients with peripheral nerve injuries and sensory function deficits?

<p>Gentle contrast hydrotherapy, ensuring tolerance to temperature changes. (C)</p> Signup and view all the answers

Flashcards

Klumpke's Paralysis

Injury to the lower brachial plexus (C8-T1 nerve roots), primarily affecting hand function.

Klumpke's MOI

Extension of the shoulder with cervical spine traction.

Claw Hand Deformity

Resting hand deformity with MCP extension and PIP/DIP flexion due to lumbrical loss.

Autonomic Symptoms in Klumpke's

Autonomic dysfunction like edema and vasomotor changes, common in Klumpke's due to median nerve involvement.

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Myotome Deficits in Klumpke's

Thumb extension and ulnar deviation (C8), finger abduction (T1).

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Erb's Palsy Definition

A paralysis/palsy affecting the upper brachial plexus, specifically C5 & C6 nerve roots. Primarily impacts shoulder and brachium function.

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Brachial Plexus Roots

C5-C8 and T1

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Brachial Plexus Trunks

Superior, Middle, and Inferior

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Brachial Plexus Palpation

Lateral edge of the clavicular head of SCM next to anterior scalene. Palpation may cause discomfort and paresthesia.

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Erb's Palsy MOI

Forcible separation of the head/neck and shoulder, tractioning C5-C6 nerve roots.

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Waiter’s Tip Deformity

Arm hangs limp in adduction and internal rotation, elbow extended, forearm pronated, wrist & fingers flexed.

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Muscles Affected in Erb's Palsy

Deltoid, Supraspinatus, Infraspinatus, Teres Minor, Biceps Brachii, Brachialis, Supinator

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Myotome Deficits in Erb's Palsy

Shoulder abduction (C5) and elbow flexion & wrist extension (C6).

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Horner's Syndrome

Pupil constriction (miosis), drooping eyelid (ptosis), recession of eyeball (enophthalmos), and lack of sweating on the face (anhidrosis).

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Cause of Horner's

Likely due to injury of the superior cervical ganglion/autonomic fibers innervating the eyes and face.

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Burner/Stinger Symptoms

Immediate pain or pain occurring hours after incident. Paresthesia, tingling, burning. Progressive weakness.

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Burner/Stinger Injury

Over-stretch or compression injury, symptoms can last minutes or hours.

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Brachial Plexus Injury Precaution

Injuries are often nerve degeneration – avoid traction on regenerating nerves.

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Treating Edema (BPI)

Use elevation, nodal pumping & drainage techniques, proximal to the edge of the edema.

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Segmental Techniques (BPI)

Apply at right angles to the direction of the regenerating nerve.

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Flaccid/Weak Muscles (BPI)

Use light strokes & gentle compressions.

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AROM (Active Range of Motion)

Assessment of the range of motion a joint can achieve by the patient's own muscle activation.

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PROM (Passive Range of Motion)

Assessment of the range of motion a joint can achieve with external assistance.

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MMT (Manual Muscle Testing)

Manual Muscle Testing, a method for evaluating the strength of a muscle or muscle group.

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Myotome

A group of muscles primarily innervated by a single nerve root.

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Dermatome

Area of skin innervated by a single nerve root.

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Acute Phase (Nerve Injury)

Focuses on healing and preventing complications; immobilization may be used.

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Recovery Phase (Nerve Injury)

Focuses on retraining and re-education of motor and sensory functions as reinnervation occurs.

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Chronic Phase (Nerve Injury)

Focuses on training compensatory function when potential for recovery has peaked.

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Study Notes

Erb's Palsy Anatomy

  • Involves the upper brachial plexus
  • Affects C5 and C6 nerve roots
  • Primarily affects the shoulder and brachium

Brachial Plexus Components

  • Roots: C5-C8 & T1
  • Trunks: Superior, Middle, Inferior
  • Divisions: Anterior, Posterior
  • Cords: Lateral, Posterior, Medial
  • Branches: Musculocutaneous, Axillary, Radial, Median, and Ulnar nerves (plus 11 other nerves)

Palpation of the Plexus

  • Locate the lateral edge of the clavicular head of the SCM.
  • Find the anterior scalene next to the clavicular head.
  • The brachial plexus is located directly next to the anterior scalene.
  • Palpation may cause discomfort radiating under the clavicle towards the coracoid process.
  • There's potential for paresthesia in the hand.

Palpation of Affected Tissue

  • Assess flaccidity of muscles in the entire upper extremity.
  • Muscle flaccidity indicates which cords/roots are affected.
  • Upper roots primarily impact the shoulder and brachium.
  • Lower roots mainly affect the distal upper limb, especially the hand.

Pathophysiology of Erb's Palsy (MOI)

  • Occurs when the head, neck, and shoulder are forcibly separated, tractioning the C5-C6 nerve roots

Common Mechanisms of Injury

  • Contact sports
  • MVAs (Motor Vehicle Accidents)
  • Tractioning of newborn using forceps
  • Newborn shoulder caught behind the pubis during delivery
  • Forcibly stretching of newborn's neck
  • Vacuum suction during delivery

Signs and Symptoms of Erb's Palsy

  • Can vary in severity based on the extent of nerve injury
  • Possible nerve injuries include Neurotmesis, Axonotmesis, Neuropraxia, and Neuroma
  • Resting deformity is often called "Waiter's tip"

Waiter's Tip Presentation

  • Arm hangs limp in adduction and internal rotation.
  • Elbow is extended and forearm is pronated.
  • Wrist and fingers are flexed

Motor Deficits in Erb's Palsy

  • Deltoid (C5-6), Supraspinatus (C4-6), Infraspinatus (C5-6), Teres Minor (C5-6), Biceps Brachii (C5-6), Brachialis (C5-6), and Supinator (C5-7) can experience deficits.
  • Sometimes, scapular winging can occur due to damage to the long thoracic nerve (C5-7).

Myotome Deficits

  • C5: Shoulder abduction
  • C6: Elbow flexion and wrist extension

Sensory Deficits

  • C5 Dermatome
  • C6 Dermatome

Klumpke's Palsy Anatomy

  • Involves the lower brachial plexus, specifically C8 and T1 nerve roots impacting ulnar and median fibers
  • Predominantly affects the hand

Klumpke's Palsy MOI

  • Injury affects the lower brachial plexus (C8 & T1).
  • Usually involves shoulder extension with cervical spine traction
  • Falling from a height and grabbing something can cause this

Klumpke's Palsy Signs & Symtoms

  • Can vary in nerve injury level: Neurotmesis, Axonotmesis, Neuropraxia, Neuroma
  • Resting deformity called Claw hand, resulting from loss of lumbricals, leads to MCP extension, PIP flexion, and DIP flexion.
  • Affects ulnar and median nerve fibers.

Other Signs & Symptoms

  • Ape hand, oath hand
  • Severe edema, trophic changes, vasomotor dysregulation
  • Injury to fibres leads to autonomic symptoms and signs.

Klumpke's motor deficits

  • Opponens Pollicis / Adductor Pollicis / Lumbricals / PIM / DIM / FDS / FDP / Pronator teres / Pronator quadratus / FCR deficits
  • Thumb opposition / Thumb adduction / Finger abduction deficit
  • MCP flexion, IP extension, PIP & DIP flexion deficits

Klumpke's Myotome Deficits

  • C8: Thumb extension, ulnar deviation
  • T1: Finger abduction

Klumpke's Sensory Deficits

  • C8 dermatome
  • T1 dermatome

Horner's Syndrome

  • Sometimes associated with Klumpke's paralysis
  • Involves Miosis (pupil constriction), Ptosis (drooping upper eyelid), Enophthalmos (recession of eyeball into orbit), and Anhidrosis on the face
  • Believed to be caused by injury to the superior cervical ganglion or autonomic fibers innervating the eyes and face
  • It's rare and poorly understood

Burners or Stingers

  • Over-stretch or compression injury similar to Erb's palsy
  • Symptoms vary depending on injury severity: immediate, lancinating pain, paresthesia, progressive weakness
  • Symptoms are short lived

Precautions for Brachial Plexus Traction Injuries

  • These injuries often involve nerve degeneration.
  • Avoid tractioning a regenerating nerve.
  • Treat edema with elevation and nodal pumping/drainage techniques.
  • Apply segmental techniques proximal to the lesion at right angles to the direction of the regenerating nerve.
  • Block with the ulnar border of the hand just proximal to the lesion to avoid placing drag on the healing tissue.
  • Do not work on the lesion site until regeneration has passed (approx. 2 weeks post-trauma or 3 weeks post-surgery).
  • Treat flaccid or weakened muscles distal to the lesion with light strokes & gentle compressions.
  • Use PROM to affected joints in the direction that shortens the tissue & nerve.

History Questions for Patient

  • How has healing progressed?
  • Any regained function?
  • Sensory function details?
  • Previous or current treatments?
  • HCP information and treatment effectiveness?
  • Adverse reactions to treatments?
  • Positioning and table adjustments?

Assesment

  • AROM
  • PROM
  • MMT
  • Myotome
  • Dermatome

Differential Diagnosis

  • Neurologist confirms diagnosis

3 Phases of Management Guidelines - Recovery from Peripheral Nerve Injury

Acute Phase

  • Focus on healing & preventing complications soon after the injury
  • Immobilization time will be dictated by MD
  • Splinting/bracing may avoid deformities

Recovery Phase

  • Motor retraining is key when Reinnervation occurs
  • Desensitization & Discriminative sensory re-education can be performed

Chronic Phase

  • Occurs when recovery peaks, focus shifts to compensatory function.
  • Splint or brace use may continue.

Treatment for Brachial Plexus Injuries

  • Manage edema
    • Elevation, cool hydro, unidirectional stroking, manual lymphatic drainage
  • Decrease contractures
    • Pillowing and Segmental work on tissues can help
  • Tissue health on flaccid tissue:
    • Light, segmental work.
    • Unidirectional stroking without traction.
    • Joint health: PROM from neutral to short; joint mobilizations if possible
  • Stimulate regained function: Facilitatory ROODS
  • Promote relaxation: Diaphragmatic breathing, non-noxious stimuli from massage

Home Care for late stage of regenation period

  • Manage edema
  • Maintain tissue health: Gentle contrast hydro, if able and self-massage
  • Maintain function: Use regained function, Facilitatory ROODS & Strengthening exercises
  • PROM and visualization on flaccid tissues
  • Sensory re-education: Using different sensory stimuli (towels, fabrics, etc.)

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Description

This quiz covers Klumpke's and Erb's palsy, focusing on nerve involvement, muscular imbalances, autonomic symptoms, and mechanisms of injury. It also includes nerve root involvement, spinal cord levels and myotome levels.

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