Brachial Plexus Traction Injuries PDF

Erb’s Paralysis/Palsy Anatomy Upper brachial plexus ​ C5 & C6 nerve roots ​ Therefore affects mainly the shoulder and brachium The brachial plexus ​ Roots: C5-C8 & T1 ​ Trunks: Superior, Middle, Inferior ​ Divisions: Anterior, Posterior ​ Cords: Lateral, Posterior, Media...

Erb’s Paralysis/Palsy Anatomy Upper brachial plexus ​ C5 & C6 nerve roots ​ Therefore affects mainly the shoulder and brachium The brachial plexus ​ Roots: C5-C8 & T1 ​ Trunks: Superior, Middle, Inferior ​ Divisions: Anterior, Posterior ​ Cords: Lateral, Posterior, Medial ​ Branches: Musculocutaneous, Axillary, Radial, Median, Ulnar (& 11 other nerves) Palpation Palpation of the plexus: Palpate the lateral edge of the clavicular head of SCM. Directly next to that is the anterior scalene. Directly next to that is the brachial plexus. Palpation should cause the body to feel discomfort radiating under the clavicle towards the coracoid process and possibly some paresthesia in the hand. Palpation of affected tissue: Assess for flaccidity of muscles down the entire upper extremity. Exactly which muscles will indicate which cords/roots are affected. Upper roots will most affect the shoulder and brachium. Lower roots will most affect the distal upper limb, especially the hand. VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries Pathophysiology (Rattray/Ludwig; p825) MOI Occurs when the head/neck & shoulder are forcibly moved apart, tractioning the C5-C6 nerve roots ​ Contact sports ​ MVAs Obstetric procedures ​ Tractioning of newborn using forceps ​ Newborn shoulder caught behind pubis during delivery ​ Newborn neck forcibly stretched ​ Vacuum suction used during delivery VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries Signs & symptoms Can be any level of nerve injury, depending on the severity of force ​ Neurotmesis ​ Axonotmesis ​ Neuropraxia ​ Neuroma from resultant scar tissue Resting deformity called Waiter’s tip ​ Arm hangs limp in adduction and internal rotation ​ Elbow extended and forearm pronated ​ Wrist & Fingers flexed Motor deficits in Deltoid (C5-6) / Supraspinatus (C4-6) / Infraspinatus (C5-6) / Teres Minor (C5-6) / Biceps Brachii (C5-6) / Brachialis (C5-6) / Supinator (C5-7) Sometimes, scapular winging results if the injury also causes damage to the long thoracic nerve (C5-7) Myotome deficits in ​ C5 = shoulder abduction ​ C6 = elbow flexion & wrist extension Sensory deficits in ​ C5 dermatome ​ C6 dermatome VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries  Klumpke’s Paralysis/Palsy Anatomy Lower brachial plexus ​ C8 & T1 nerve roots (affects ulnar and median fibres) ​ Therefore affects the hand The brachial plexus ​ Roots: C5-C8 & T1 ​ Trunks: Superior, Middle, Inferior ​ Divisions: Anterior, Posterior ​ Cords: Lateral, Posterior, Medial ​ Branches: Musculocutaneous, Axillary, Radial, Median, Ulnar (& 11 other nerves) VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries MOI Same as for Erb’s Paralysis, it just ends up affecting the lower brachial plexus (C8 & T1) Typically, this involves extension of the shoulder with traction of the cervical spine. A commonly cited MOI is falling from a height and grabbing something to catch yourself Signs & symptoms Can be any level of nerve injury, depending on the severity of force ​ Neurotmesis ​ Axonotmesis ​ Neuropraxia ​ Neuroma from resultant scar tissue Resting deformity called Claw hand ​ Loss of lumbricals leads to MCP ext, PIP fle, DIP fle Affects ulnar and median nerve fibres, so can manifest as any such signs or symptoms ​ Ape hand, oath hand Leads to severe edema, trophic changes, vasomotor dysregulation The median nerve is particularly rich in autonomic fibres; hence, injury to those fibres leads to autonomic symptoms and signs Motor deficits in Opponens Pollicis / Adductor Pollicis / Lumbricals / PIM / DIM / FDS / FDP / Pronator teres / Pronator quadratus / FCR Thumb opposition / Thumb adduction / Finger abduction and adduction / MCP flexion, IP extension PIP & DIP flexion Myotome deficits in ​ C8 = Thumb extension, ulnar deviation ​ T1 = Finger abduction Sensory deficits in ​ C8 dermatome ​ T1 dermatome VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries  Horner’s Syndrome Quick note Horner’s syndrome is sometimes associated with Klumpke’s paralysis (Rattray/Ludwig, p.763) Horner’s syndrome is ​ Miosis - pupil constriction ​ Ptosis - drooping upper eyelid Enophthalmos (recession of eyeball into orbit) Anhidrosis on the face It’s very rare and poorly understood ​ Probably injury to the superior cervical ganglion / autonomic fibres innervating the eyes and face ​ Miosis is sympathetic inhibition Ptosis could be due to inhibition of the Superior Tarsal Muscle (Muller’s muscle) which is under sympathetic innervation Anhidrosis is sympathetic dysregulation (inhibition) since sudomotor output is a sympathetic function Burners or Stingers Quick note Another kind of over-stretch injury or compression injury that is similar to Erb’s Symptoms vary depending on severity of injury: Immediate, lancinating pain or pain occurring hours after incident Paresthesia, tingling, burning Progressive weakness right after injury, or may occur days later Symptoms may last only a few minutes or hours VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries Precaution - Brachial Plexus Traction Injuries These injuries are often conditions of nerve degeneration. Do not traction a regenerating nerve Treat edema with elevation, nodal pumping & drainage techniques, proximal to the edge of the edema Use segmental techniques proximal to the lesion – applied at right angles to the direction of the regenerating nerve Consider “blocking” with the ulnar border of the hand just proximal to the lesion to prevent placing drag on the healing tissue Do not work on lesion site until regeneration has passed that site – approx. 2 weeks post trauma or 3 weeks post surgery Flaccid or weakened muscles distal to lesion are treated with light strokes & gentle compressions PROM can be used to affected joints in the direction that shortens the affected tissue & nerve VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries History How has your healing progressed? ​ Has any function been regained? Which? At what rate? What is your sensory function like? Have you had treatments before or currently? ​ Which HCP? ​ How are they going? ​ Any adverse reactions? How are you with positioning and changing position on the table? Assessment AROM PROM MMT Myotome Dermatome Differential None - diagnosed by neurologist Management Guidelines - Recovery from peripheral nerve injury (from Class 1) (Therapeutic Exercise, Kisner & Colby, 6th ed. pg 389-390) Acute Phase Early after injury or surgery - emphasis on healing & preventing complications May be immobilized - time dictated by MD Splinting or bracing may be needed to prevent deformities Recovery Phase When reinnervation occurs - emphasis on retraining & re-education Motor retraining - eg. being able to hold muscle in shortened position Desensitization - eg. stroking the skin with different textures for sensory stimulation Discriminative sensory re-education - identification of objects with, then without, visual cues (stereognosis) Chronic Phase When the potential for recovery has peaked and there are significant physical deficits - emphasis on Training compensatory function May continue to wear splint or brace VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries Treatment Manage edema, if present ​ Elevation, cool hydro, unidirectional stroking, manual lymphatic drainage ​ Decrease contractures as long as it doesn’t traction the nervous tissue ​ Pillowing ​ Segmental work on tissues Tissue health on flaccid tissue ​ Light, segmental work ​ Unidirectional stroking that doesn’t traction nerve ​ Joint health will include PROM from neutral to short (ie, that doesn’t traction the nervous tissue) ​ Joint mobilisations if possible Stimulate any regained function Facilitatory ROODS Promote relaxation ​ Diaphragmatic breathing, non-noxious stimuli from massage Home Care (late stage regeneration or permanent lesion) Manage edema, if present Maintain tissue health ​ Gentle contrast hydro if sensory function permits ​ Self-massage Maintain function as much as possible ​ Use any regained function as much as possible ​ Facilitatory ROODS ​ Strengthening exercises for regained function PROM and visualisation on flaccid tissues, as long as PROM doesn’t traction nerve Sensory re-education ​ Use different sensory stimuli on affected tissues (towels, fabrics etc) VCMT Peripheral Nervous System Treatments. Class 2 - Brachial Plexus Traction Injuries