2. BRACHIAL PLEXUS
…??
The brachial plexus contains the
neural connections between the
neck and brachial nerves.
www.alshifaa.inf
Brachial Plexus
(BRAY-key-el PLEK-sis)
19. ERBS POINT
The region of the Upper trunk of the brachial plexus
is called Erb’s Point.
20. Brachial Plexus (BRAY-key-el PLEK-sis)
1874 Wilhelm H. Erb described brachial plexus
paralysis in adults which involved the upper roots and
described certain types of “delivery paralysis”
Otherwise Known as Erb’s Palsy
1885 Augusta Klumpke first described the clinical
picture resulting from injury to lower roots
( Klumpke’s Palsy ).
21. A brachial plexus injury (Erb’s palsy) is a nerve
injury
The nerves that are damaged control muscles in
the shoulder, arm, or hand and any or all of these
muscles may be paralyzed.
One or two of every 1,000 babies have this
condition. It is often caused when an infant's neck
is stretched to the side during a difficult delivery.
22. CAUSES
Undue separation of the head from shoulder
- Birth Injury (Shoulder Dytocia)
-Forceps Delivery
-Vaccum Extractor Delivery
-Breech delivery
-Cephalic presentation of large birth weight
infant (> 4 kgs)
-Previous child with BPI
-Prolonged maternal labour (> 60 minutes
during second stage)
-Multi-parity
-Intrauterine torticollis and Intrauterine malposition
23. Falling on Shoulder
o Excessive Stretching
o Direct Blow
o Shoulder Dislocation
o Tumour (Neuroma)
o Cervical Rib
24. CLASSIFICATION
1. Upper Root Injury (Erb’s palsy or Erb-Duchenne
palsy)
C5/C6 with or without C7 involved
Most common (73% to 86%)
If C7 involved, wrist flexed and fingers curled up in
“waiter’s tip “ position
If C4 involved, diaphragm paralysed.
Moro reflex: shoulder movement (-), Biceps (-); hand
movement (+); Grasp (+)
If C5/C6 injury, 90% full recovery by 3 months.
With C5/C6/C7- 65% full recovery.
25. 2 . Lower root injury (Klumpke’s palsy)
C8/T1 with or without C7 are injured.
Isolated lower root injury least common (0.6 to 2%).
Forearm is supinated, wrist and fingers hyperextended
with good elbow and shoulder function.
Horner’s syndrome with ptosis and miosis if associated
cervical sympathetic nerve injury.
Moro reflex: Shoulder movement(+), hand movement(-
); Grasp reflex(-).
Recovery < 50%, minimal if Horner’s syndrome
present.
26. 3 . Complete Injury (Erb-Klumpke Palsy)
All nerve roots from C5 to T1 involved.
2nd most common (20%).
On examination arm is flail and paralysed with total
sensory and motor deficit with or without miosis and
ptosis.
All reflexes are absent.
Outcome: Without associated Horner’s syndrome
<50% recovery, with associated Horner’s syndrome no
recovery without surgery
27. However a commonly used one is
Leffert's classification system
which is based on etiology and level of injury:
I Open (usually from stabbing)
II Closed (usually from motorcycle accident)
IIa Supraclavicular ( Preganglionic/Postgangionic )
IIb Infraclavicular
IIc Combined
III Radiation induced
IV Obstetric
IVa Erb's (upper root)
IVb Klumpke (lower root)
IVc Mixed
31. DISABILITY
1. Abduction & Lateral Rotation of the arm
2. Flexion & Supination of the forearm
3. Biceps & Supinator jerks are lost
4. Sensation are lost over a small area over the
lower part of the deltoid
32. WAITER’S / POLICEMAN’S TIP POSITION
Characteristic Position - Adduction & Internal
Rotation of the arm with forearm pronated
Forearm extension normal
Biceps reflex absent
This deformity is known as
Policeman’s tips hand or
Porter’s tip hand
34. Site of Injury
Lower Trunk of the Brachial Plexus
Nerve Root Involved
Mainly C8 and T1
Muscle Paralysed
Intrinsic Muscles of the hand(T1)
Ulnar Flexors of the wrist and Fingers(C8)
36. DISABILITY
Cutaneous Anaesthesia & Analgesia in a narrow zone
along the ulnar border of the forearm and Hand
Horner’s Syndrome : If the sympathetic fibers of the
1st thoracic root are also injured paralyzed hand
and ipsilateral ptosis and miosis.
37. • Increase in angle between neck &
shoulder
•Traction (stretching or avulsion) of
upper Ventral Rami (e.g., C5,C6)
UBP Injury – Erb’s Palsy LBP Injury – Klumpke’s Palsy
• Excessive upward pull of limb
• Traction (stretching or avulsion) of
lower ventral rami (e.g., C8, T1)
38. DIAGNOSIS
Relies mainly on clinical examination
No specific lab. Studies
CT Myelography
MRI
Nerve conduction studies
EMG
39. MANAGEMENT
Medical Management
a. The main aspect of medical management is
pain control.
b. Often treated in a similar way to neuropathic
pain with NSAID,
c. Tricyclic Antidepressants,
d. Anticonvulsants
e. Oral or transdermal opoids.
40. Surgical options
a. Nerve transfers
b. Nerve grafting
c. Muscle transfers
d. Free muscle transfers Neurolysis of scar
around the brachial plexus in incomplete
lesions.
e. Arthrodesis to stabilise joints
41. Physiotherapy Management
Electrical Stimulation
Splinting – To Prevent Contracture
o Pain control - TENS
o Maintaining ROM - Passive movements,
Exercise therapy
o Strengthen affected muscles –
Biofeedback
Exercise therapy
oManaging chronic oedema –
Compression Garments,
Advice, Massage therapy
Position of Patient
Child- Sitting Position with arm Slightly abducted
and forearm supinated
Infants – On the mothers loop , resting on pillow
Placement of electrode
Child – Inactive : Over the nape of neck
Active : over the motor points