brachialplexus ppt.pptx
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Brachial Plexus
Injury
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Brachial plexus palsy is defned as a accidparesis o an upper extremity due to traumaticstretching o the brachial plexus received atbirth, with the passive range o motion greaterthan the active range o motion
Arch is !hild "etal neonatal #d $%%&'(()"*(+-
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Incidence )
• *% to $% times more common
• %.+ and $ per *%%% live births
• "ullterm newborn
%.&( / & 0 *%%% 1$%%*2
%.*- / $.+ 0 *%%%
Indian journal obstetrics $%%-'3&)$&434
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Pathogenesis
5esult rom stretching o the brachial plexus, with its rootsanchored to the cervical cord, by extreme lateral traction.
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5is6 actors)
7he ris6 actors or brachial plexus palsies maybe divided into three categories)
8eonatal 9aternal
:aborrelated actors
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8eonatal 5is6 actors)
;igh birth weight ( > 4 kg )
:ow AP<A5 score at * min, + min = *% min Breach etal
position
Pediatr 8eurol $%%('&()$&+$3$
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Age 1 > &+ years 2
!ephaloPelvic isproportion
<estational iabetes 9ellitus 1 results in
Macrosomia 2
B9IPost date gestation
Pediatr 8eurol $%%('&()$&+$3$
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:abour 5elated)
Increased duration of 2nd stage of labour
Induction of labour
Oxytocin augment
Vacuum extraction
Direct compression of fetal neck during delivery by forceps
Pediatr 8eurol $%%('&()$&+$3$
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Classification:
?everity
Anatomical location
!linical fndings
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•
Avulsion – this means the nerve has been pulled out from the spinal cord andhas no chance to recover.
• Rupture – this means the nerve has been stretched and at least partially torn,
but not at the spinal cord.
• Neurapraxia – this means the nerve has been gently stretched or compressed
but is still attached (not torn) and has excellent prognosis for rapid recovery
• Axonotemesis – this means the axons (equivalents of the copper filaments in
an electric cable) have been severed. The prognosis is moderate.
• Neurotemesis – this means the entire nerve has been divided. The prognosis
is very poor.
• Neuroma – this refers to a type of tumor that grows from a tangle of divided
axons (nerve endings), which fail to regenerate. The prognosis will depend on
what percentage of axons do regenerate.
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Classification !natomical "
• #roximal or $uchenne%rb&s paralysis ('nury to C * C+, most
common)
•
'ntermediate paralysis ( 'nury to C )
• $istal or -lumpe&s paralysis ( inury to C/ * T0,extremely rare)
• Total brachial plexus paralysis ( more often than the -lumpe
type)
• $uchenne%rbs type 1 Total brachial type 1 -lumpe type
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Weak MovementSpinal CordSegment
Resulting Position
Shoulderabduction
C5 Adducted
Shoulderexternalrotation
C5Internallyrotated
Elbow fexion C5, C6 Extended
Supination C5, C6 Pronated
Wristextension
C6, C7 lexed
in!erextension
C6, C7 lexed
"iaphra!#ati c descent
C$, C5 Ele%ated
#rb Brachial Plexus Palsy
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Total Brachial Plexus Palsy
Weak MovementSpinal cordsegment
Resulting position
Wrist
fexion
C7,C&,'( Extended
in!erfexion
C7,C&,'( Extended
in!erabduction
C&,'()eutral
position
in!er
adduction C&,'(
)eutral
position
"ilator o*iris
'( +iosis
ull lidele%ation
'( Ptosis
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Attitude of the affected Upper Limb:
• Arms hangs by the side with,
• ?houlder / internaly rotated
• #lbow / extension
• "orearm / pronated with palm acing bac6wards 1tipsposition2
• ;and = fnger unctions preserved
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Conservative Management:
• Baby@s arm is positioned in
• ?houlder / abduction = external rotation
• #lbow / exed
• "orearm / supinated
• rist / behind the nec6
•
7his position prevents contracture o ?ubscapularis,Pectoralis major
• Passive stretching
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Total Brachial Plexus Injury:
Involves injury to all the roots 0 trun6s 0 cords o thebrachial plexus
It is o $ types depending on the level
Pre-ganglionic
Post-ganglionic
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Pre-ganglionic Type:
7raction injury resulting in the avulsion o Pre ganglioniclevel o all the roots !+ to 7*
If T1 root at Pre ganglionic level is affected results in ;orner@s
syndrome 1 ptosis, hypohirdosis 0 anhidrosis, miosis =enopthalmos2
?erratus anterior = 5homboids muscles are paralysed
:esion is irrecoverable
:imb is unctionless
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Post-ganglionic :
Post ganglionic level lesion at all roots !+ to 7*
?erratus anterior = 5homboids muscle unctions arepreserved
I lesion is axonotmesis / recovery is possible
I lesion is neuronotmesis / surgical exploration = repair maybe needed
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Investigations:
• Chest X-ray / to rule out Phrenic 8. palsy
• CT with metriamide 1!7myelogram2
•
MRI / integrity o nerve roots
• Electromyography 3( hrs within delivery distinguishesb0w prenatal = BPI
etect signs o reinnervation
5oot avulsions 1(%C accuracy2
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#lectromyographic 1#9<2 )
•
#valuation at approximately * and & months oage.
• ?igns o denervation 1i.e., fbrillations2 $ to &wee6s ater the injury.
• I fbrillations are absent, the li6ely lesion isneurapraxia,
• 8erve root avulsion and a poor outcome frststudy by diDuse fbrillations, unrecordable orscanty motor unit potentials, no muscle responsewith stimulation o motor nerves, and noimprovement on the second #9< examination.
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Management:
!onservative management
?urgical management
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!onservative 9anagement
9aintain Passive 5ange o movements1P5E92
9uscle strength
?tretch muscle groups to prevent contracture
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Protective Phase)
Initial rest period of 7-10 days / to allow or reductiono hemorrhage = edema around thetraumatied nerves
No ROM or other interventions are initiated
7he involved F: is positioned across the abdomen
Avoid lying on the involved limb
Baseline examination / ater initial period oimmobiliation
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Positioning)
Arm is positioned toward Abd, #5, elbow " =orearm ?upination on a pillow to child@s side /during sleeping
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Splinting:
2esting night splints – prevent wrist * finger 3 contracture
4rist cocup – maintain neutral wrist alignment (-lumpe&s
#aralysis)
5tatue of liberty splint – prevent !dd * '2 contracture
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?urgical )
8eurosurgeon
Plastic reconstructive surgeon
Pediatric orthopaedic surgeon
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Indication or ?urgical !orrection)
• ?urgical exploration should be done within 4 months o lie
• #xploration and nerve grating or neurotiation i there is acomplete plexus palsy at & months or i there is a !+!4 palsy with absence o biceps at & months
• "ailure o recovery o elbow exion and shoulder abduction
rom the &rd to the 4th month o lie
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?urgical 7echniGues)
• 8erve transer0neurotiation
• 8erve anastomosis
• 8erve reconstruction
• 8eurolysis
• 8euroma
• 8eurorrhaphy
• 7endon 7ranser
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?pontaneous recovery in H%-+C by 3–4 months
o lie
At & months, the predictive value o regainedelbow exion or complete recovery was *%%C
--C o shoulder #5
-4C o orearm supination
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