Brachial Plexus Palsy

Definition
Brachial plexus palsy : Paralysis of the arm due to an injury to the brachial plexus. Upper (C5, C6): Erbs palsy Lower (C8, T1): Klumpkes palsy Total brachial plexus palsy : Erb-Duchenne-Klumkes palsy

Leffert Classification of Brachial Plexus Injuries

- Description - I Open (usually from stabbing) - II Closed (usually from motorcycle accident) - IIa Supraclavicular - preganglionic: - avulsion of nerve roots, usually from high speed injuries with other injuries and LOC; - no proximal stump, no neuroma formation (neg Tinel's) - pseudomeningocele, denervation of neck muscles are common - horner's sign (ptosis, miosis, anhydrosis) - postgangionic: - roots remain intact; - usually from traction injuries; - there are proximal stump and neuroma formation (pos Tinel's) - deep dorsal neck muscles are intact, and pseudomeningoceles will not develop; - Infraclavicular Lesion: - usually involves branches from the trunks (supraclavicular); - function is affected based on trunk involved; - Trunk Injured Functional Loss Upper biceps , shoulder muscles Middle Wrist and Finger Extension; Lower Wrist and Finger Flexion; - III Radiation induced - IV Obstetric - IVa Erb's (upper root) - waiter's tip hand; - IVb Klumpke (lower root);

Anatomy of Brachial Plexus

Sign
Erb palsy
Injury to C5 & C6 : paralysis 1. Deltoid (abduction) 2. Biceps, brachialis, supinator (elbow flexion) 3. Supra & infraspinatus (external rotation) Sensory loss : lateral upper arm, thumb Reflex loss : biceps, brachioradialis
extention

Flexion & pronation

flexion

Sign
Klumpkes palsy
Injury to C8 & T1 : paralysis : wrist , finger flexors & small muscles of the hand Sensory loss : med. side forearm & wrist > associated with Horners syndrom
Claw hand deformity

Horners syndrom

Sign
Combined paralysis
Injury to C5 T1 paralysis : shoulder & hand Arm : wasted, cold & dependent edema Horners syndrom Exteremely rare

Types of brachial plexus injury

A. B. C. D. Avulsion poor prognosis Rupture Neuroma Neuropraxia >> & good prognosis

Kinds of traumatic injury

1. 2. 3. 4. 5. 6. 7. 8. 9. A fall onto apex of the shoulder & the side of head A blow to the angle between the shoulder & the neck A fall on the front of the shoulder A blow to the anterior axilla Dislocation of the shoulder Gunshot & knife wounds to the axilla and supraclavicular Contusion caused by stretched during coma/GA, pressure by hematom Traction on the brachial plexus area Shoulder dystocia.

Indication for EMG

Highly sensitive but nonspesific To evaluate motor neuron dysfunction Confirme & extension clinical examination Useful in localizing of spesific lesion Distinguishing partial/complete lesion differentiating primary muscle or nerve pathology Useful for dd/ & presence of coexisting disease

Differential Diagnosis
Pseudoparalysis ec. Clavicle & humerus fr Osteomyelitis

TREATMENT
Depend on the type of nerve damage (avulsion/rupture surgical treatment) Vit. B1, B6, B12, E Anti Inflamasion drug Vasodilator All involved joint should be moved, full ROM several times a day ( fisioth/)