Brachial Plexus Lesions PDF

BRACHIAL PLEXUS LESIONS DR TIFFANY IDLEWINE, PT, DPT, OCS BP MECHANISM OF INJURY  Injury to brachial plexus can occur in many ways. These include, contact sports, motor vehicle accidents, or during birth. Grossly, it can be divided into:  Traumatic  e.g motor vehicle accident, c...

BRACHIAL PLEXUS LESIONS DR TIFFANY IDLEWINE, PT, DPT, OCS BP MECHANISM OF INJURY  Injury to brachial plexus can occur in many ways. These include, contact sports, motor vehicle accidents, or during birth. Grossly, it can be divided into:  Traumatic  e.g motor vehicle accident, contact sports  Non traumatic  e.g. obstetric palsy and Parsonage-Turner Syndrome Stretch Injury BP- TRACTION & IMPACT  The nerves of the brachial plexus are damaged due to the forced pull by the widening of the shoulder and neck. Impact Injury  Traction occurs from severe movement  Heavy impact to the shoulder is the second common and causes a pull or tension among the mechanism for brachial plexus injury. nerves.  Depending on the severity of the impact, lesions can  Upward traction occur at all nerves in the brachial plexus.  The location of impact also affects the severity of the  Results in the broadening of the angle between the arm and chest as occurs when the arm and injury, and depending on the location the nerves of shoulder are forced upward, with the nerves of the brachial plexus may be ruptured or avulsed. T1 and C8 are torn away.  Some forms of impact that cause injury to the brachial  Downward traction plexus are:  Shoulder dislocation  Tension of the arm which forces the angle of the neck and shoulder to become broader. This  Clavicle fractures tension is forced and can cause lesions of the  Hyperextension of the arm upper roots and trunk of the nerves of the  Delivery at birth brachial plexus  During the delivery of a baby, the shoulder of the baby may graze against the pelvic bone of the mother. During this process, the brachial plexus can experience damage which results in injury. This is very low compared to the other  Muscles Paralyzed UPPER TRUNK- ERB’S PARALYSIS  Mainly: biceps, deltoid, brachialis, and brachioradialis. Undue separation of the head from the shoulder, which is commonly  Partly: supraspinatus, infraspinatus, and encountered in: supinator  Birth injury  Deformity Fall on shoulder   Arm: Hangs by the side, adducted and medially During anesthesia rotated  Forearm: Extended and pronated Nerves Roots Involved  Mainly C5  The deformity is known as "Policeman's tip  Sometimes C6 hand" or "Porter's tip hand“ Disability  Abduction and lateral rotation of the arm.  Flexion and supination of forearm.  Biceps and supinator jerks are lost.  Sensations are lost over a small area over the lower part of the deltoid  LOWER TRUNK- KLUMPKE'S PARALYSIS Deformity  Claw hand (position of the hand) due to the unopposed action of Undue abduction of the arm, the long flexors and extensors of the fingers. as in clutching a tree branch  In a claw hand there is hyperextension at the with the hand during a fall metacarpophalangeal joints and flexion at the interphalangeal from a height, or sometimes in joints. a birth injury. Disability Nerve Roots Involved  Claw hand   Cutaneous anaesthesia and analgesia in a narrow zone along Mainly T1 the ulnar border of the forearm and hand.  Partly C8  Horner's syndrome: ptosis, miosis, anhydrosis, enophthalmos, and loss of ciliospinal reflex - may be associated. This is because of injury to sympathetic fibres to the head and neck that leave Muscles Paralyzed the spinal cord through nerve T1   Vasomotor changes: The skin areas with sensory loss is warmer Intrinsic muscles of the hand (T1) due to arteriolar dilation. It is also drier due to the absence of sweating as there is loss of sympathetic activity.  Ulnar flexors of the wrist  Tropic changes: Long standing case of paralysis leads to dry and and fingers (C8). scaly skin. The nails crack easily with atrophy of the pulp of fingers. AXILLARY NERVE INJURY LONG THORACIC NERVE INJURY Scap stabilizing shirt while nerve heals RADIAL NERVE PALSY- SATURDAY NIGHT PALSY MOI- SATURDAY NIGHT PALSY  It's possible that intoxicated people lose the reflexive ability to adjust their positions while they're sleeping. The classic scenario involves a person dozing off with their arm dangling over a chair or other hard surface, which causes compression in the axilla.  Likewise, a person who falls asleep on another person's arm and subsequently compresses their nerve is said to have "honeymoon palsy." Despite the fact that these are the more commonly known presentations, it is important to remember that Saturday night palsy can result from abnormal positioning or use of the limbs that can compress by a similar mechanism.  Using crutches improperly, wearing compressive clothing or accessories, wearing a blood cuff for an extended period of time, and more are examples of this SATURDAY NIGHT PALSY- CLINICAL PRESENTATION  The onset of symptoms may take several days following the initial insult, resulting in a delayed presentation.  Numbness, weakness, tingling, pain, or any combination of these symptoms may be reported by patients.  Physical examination may reveal a characteristic wrist drop caused by the loss of extensor muscle function controlled by the radial nerve branches and the preservation of flexor muscle function supplied by other nerves in the hand and arm.  As a result, the wrist and fingers cannot be extended at the metacarpophalangeal joints. The ability to extend the thumb is also lost, which makes it difficult to open the hand and grasp objects.  Any healthcare provider should be aware that patients can still extend their fingers at the level of the proximal and distal interphalangeal joints because the ulnar nerve controls these.  The triceps reflex, which is controlled by radial nerve innervation, may also be lost in patients.  Sensory deficits commonly affect the posterior or lateral upper arm, with symptoms distributing distally to affect the posterior forearm, posterior hand, and posterolateral aspect of the lateral three and a half digits. BURNERS AND/OR “STINGERS”  Burner’s syndrome is a common injury in contact sports and reflects an upper cervical root injury or a peripheral nerve dysfunction injury.  It is a transient nerve injury which occurs following over-stretching of the upper trunk of the brachial plexus or compression of the C5/C6 nerve root, depending on the mechanism of injury.  Recurrences are common and can lead to permanent neurologic deficits.  Burner’s syndrome tends to be a grade I or grade II nerve injury. CLASSIFICATION OF PERIPHERAL NERVE INJURIES  Grade I- Neuropraxia; a disruption of nerve function involving demyelination.  Axonal integrity is preserved, and remyelination follows within three weeks (hours or a couple of days)  Grade II- Axonotmesis; in which axonal damage and Wallerian degeneration occur. – couple of weeks  Grade III- Neurotmesis; complete nerve transection (neurotmesis), or permanent nerve damage Burners injuries mainly present as a grade I or II classifications EPIDEMIOLOGY OF BURNER’S  Burner’s syndrome is most commonly seen in collision  Immediate, acute traumatic onset of or contact sports such as American football, ice pain/burning/paresthesia/pins and hockey, and rugby. needles/weakness.  The incidence of this is thought to be rather high; involving  It is important to acquire details on the pain between 50 and 65% of collegiate American football quality, intensity, location and radiation. players.  Typically presents with symptoms circumferentially  This statistic is in fact quite likely higher than estimated radiating down the arm. due to a relatively high incidence of non-reporting by these same collegiate players.  Shaking of the upper extremity  Holding upper extremity close to their body   Atrophy or asymmetry in the neck- prolonged The majority of research has been completed with American football players. It occurs most commonly in  Shoulder depression linebackers and defensive backs while tackling. It may  Atrophy of deltoid or supraspinatus-prolonged also occur with running backs or linemen while blocking or being tackled.  Altered motor patterns when using the shoulder