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Questions and Answers
What is the name of the condition that involves weakness or paralysis of the muscles in the upper extremity due to nerve injury?
What is the name of the condition that involves weakness or paralysis of the muscles in the upper extremity due to nerve injury?
Brachial plexus injury
Brachial plexus injuries are always permanent and do not have the potential to heal.
Brachial plexus injuries are always permanent and do not have the potential to heal.
False
What is the estimated incidence of brachial plexus injury in newborns?
What is the estimated incidence of brachial plexus injury in newborns?
Describe the anatomy of the brachial plexus.
Describe the anatomy of the brachial plexus.
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What are the two main types of brachial plexus palsy discussed in the document?
What are the two main types of brachial plexus palsy discussed in the document?
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Erb-Duchenne palsy is characterized by the ______ position, where the arm is adducted, internally rotated, and the elbow extended.
Erb-Duchenne palsy is characterized by the ______ position, where the arm is adducted, internally rotated, and the elbow extended.
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Match the following clinical features to the corresponding brachial plexus palsy:
Match the following clinical features to the corresponding brachial plexus palsy:
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What is the primary cause of brachial plexus injury in newborns?
What is the primary cause of brachial plexus injury in newborns?
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Which of the following are factors that can increase the risk of shoulder dystocia?
Which of the following are factors that can increase the risk of shoulder dystocia?
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Describe the typical presentation of a newborn with a brachial plexus injury involving C8-T1.
Describe the typical presentation of a newborn with a brachial plexus injury involving C8-T1.
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A decreased grip strength on the affected side is a common sign of brachial plexus injury.
A decreased grip strength on the affected side is a common sign of brachial plexus injury.
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What is a claw hand deformity, and how does it occur in older children with brachial plexus injury?
What is a claw hand deformity, and how does it occur in older children with brachial plexus injury?
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What is the towel test, and how is it used to assess brachial plexus injury?
What is the towel test, and how is it used to assess brachial plexus injury?
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An absence of biceps recovery by 3 months of age is a sign that surgery may be needed for a brachial plexus injury.
An absence of biceps recovery by 3 months of age is a sign that surgery may be needed for a brachial plexus injury.
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What are some common treatment options for brachial plexus injury?
What are some common treatment options for brachial plexus injury?
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What are some examples of nerve transfers that might be used to address brachial plexus injury?
What are some examples of nerve transfers that might be used to address brachial plexus injury?
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Some treatment strategies focus on improving ______, particularly in cases of internal rotation contractures.
Some treatment strategies focus on improving ______, particularly in cases of internal rotation contractures.
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Which of the following tendon transfer procedures is used to improve elbow flexion?
Which of the following tendon transfer procedures is used to improve elbow flexion?
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Study Notes
Brachial Plexus Injury
- Brachial plexus is a network of nerves supplying the arms and hands.
- Injury results in weakness or paralysis of the upper extremities (UE).
- Injuries are often temporary, with full function returning in 70-92% of cases.
- Incidence ranges from 0.19-2.5/1000 to 0.38-3/1000 births.
- This is related to advancements in obstetrics.
Anatomy of Brachial Plexus
- Network of nerves extending from the cervical spinal cord to the arm and hand.
- Nerve roots include C5, C6, C7, C8, and T1.
- Branches form the musculocutaneous, ulnar, radial, and median nerves.
Causes of Brachial Plexus Injury
-
Fetal:
- Macrosomia (birth weight ≥ 4 kg)
- Breech presentation
-
Maternal:
- Diabetes during pregnancy
- Shoulder dystocia (shoulder impacted behind pubic bone)
- Small stature/cephalopelvic disproportion
- Prolonged labour
- Precipitous labour
- Use of assisted delivery such as forceps or vacuum
Shoulder Dystocia
- Difficult birth, one shoulder gets stuck behind the pubic bone.
- A rare condition, with occurrence between 0.6% to 1.4% of births with babies weighing 5 lb 8 oz to 8 lb 13 oz
- Rate increases to 5% to 9% for infants weighing more than 8 lb 13 oz at birth.
Classification of Brachial Plexus Injury - Severity
- Avulsion: Complete tear of nerve root
- Rupture: Partial tear of nerve root
- Neuroma: Scar tissue formation around the nerve
- Neuropraxia: Temporary nerve dysfunction
Classification of Brachial Plexus Injury - Grades
- Grade I: Paralysis of shoulder and elbow flexors (Erb-Duchenne) - Waiter's tip position. Spontaneous recovery 90%.
- Grade II: Paralysis of shoulder, elbow flexion, pronation/supination, wrist drop, and altered hand sensation. Spontaneous recovery 60%.
- Grade III: Total paralysis (C5, C6, C7, C8, T1), 40% spontaneous recovery. Surgery for extensive nerve repair and muscle transplantation may be required.
- Grade IV: Severe damage and sympathetic injury (Klumpke's, claw hand). Full spontaneous recovery is rare, surgery may be needed
Erb's Palsy
- Results from stretching of the 5th and 6th cervical nerves.
- Infant's arm held in the "waiter's tip" position (arm extended, internally rotated, and wrist flexed).
- Moro reflex and R hand grasp intact, but the affected arm is absent.
- Spontaneous resolution in 90% by 4 months of age. Nerve grafting might help for persistent deficits.
Klumpke's Palsy
- Injury to the inferior part of the brachial plexus (C8 and T1).
- Due to excessive abduction of the arm (hyper-abduction traction) during delivery.
- Less common than Erb's palsy.
- Motor loss in the small muscles of the hand (C8, T1). Sensory loss in the medial aspect of the upper limb.
Signs and Symptoms
- Weakness and loss of movement in the forearm and hand.
- Horner syndrome (unilateral ptosis, miosis, anhidrosis) may be present; drooping eyelid, constricted pupil, reduced sweating.
- Infant holds the arm in supination, elbow bent, and wrist extended.
- Decreased grip strength on the affected side.
- Sensory loss difficult to assess in newborns.
- Reflexes in the affected roots are absent.
- Claw hand (Older children) - Wrist extension, metacarpophalangeal joint hyperextension, and interphalangeal joint flexion.
Towel Test
- Developed to assess nerve function, particularly in infants.
- Child is supine with face covered with the towel.
- Shoulder, elbow, and hand motion needed to remove the towel.
- Important test to assess recovery and identify potential need for surgery for persistent deficits by 3 months of age if not successful.
Treatment
- Surgery: Tendon transfer, nerve transfer/neurotization, nerve anastomosis, nerve reconstruction.
- Therapy: Occupational therapy, hydrotherapy (water-based therapy), physical therapy, muscle strengthening exercises, and flexibility
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