Obstretic brachial plexus palsyObstretic brachial plexus palsy

Dr. Gajanan Pandit

Mumbai Port Trust Hospital

AnatomyAnatomy

Anatomy VariationsAnatomy Variations

Pre Fixedrun from C4-C8

stretching injury

-Erb’s palsy

Post fixedrun from C6-T2

abduction injury

-Kumpke’s palsy

DefinitionDefinition

An injury to all or to a portion of a child’s brachial plexus nerve network occurring at the time of delivery.

ClassificationClassification

Pre/PostganglionicSupra/InfraclavicularNature of injury Level of injury

Risk factorsRisk factors

Cephalopelvic disproportion A large or a macrosomic baby Delivery-Premature/Breech/Instrumental Shoulder dystocia Primigravida Prolonged labour Congenital anomalies

Shoulder dystociaShoulder dystocia

TypesTypes

Erb-Duchenne Palsy (60%)Klumpke’s Palsy (5%)

+ Horner syndrome (1%)Mixed (35%)

Erb-Duchenne PalsyErb-Duchenne Palsy

William Smellie, a British obstetrician is credited with the first medical description of obstetric brachial plexus palsy.

1861- Benjamin Amand Duchenne coined term ‘obstetric palsy of the brachial plexus’

1874 - Wilhelm Heinrich Erb concluded his thesis on adult brachial plexus injuries

Risk FactorsRisk Factors

MaternalFoetalIntrapartum events Neonatal

Mechanism of injuryMechanism of injury

Bending or stretching of the neck in a direction away from the side of injury

Clinical presentationClinical presentation

waiter’s /porter's/policeman’s tip position

Affected nerves Affected nerves

Dorsal scapular, suprascapular, lateral pectoral, long thoracic, musculocutaneous, radial, median and phrenic nerves.

Sensory deficits Sensory deficits

Radial side of the deltoid, forearm and hand

Muscle weakness Muscle weakness

External rotators and abductors of the shoulder/arm.

Flexors of the forearm. Extensors of the fingers (C7). Diaphragm descent (C4).

Muscle weaknessMuscle weakness

• Moro, biceps and radial reflexes are absent on the affected extremity however,

• grasp reflex remains intact.

Klumpke’s Palsy Klumpke’s Palsy

1885 -Augusta Dejerine-Klumpke neurologist and neuroanatomist diagnosed total brachial plexus radicular paralysis with oculopupillary involvement in a patient

Risk FactorsRisk Factors

MaternalFoetalIntrapartum events Neonatal

Mechanism of injuryMechanism of injury

Pulling up of the arm above the head, so that stretch on the C8 and T1 roots

Affected nervesAffected nerves

Inferior trunk ( C8,T1)Radial nerve, ulna nerve, the

thoracodorsal nerve, median nerve and the medial pectoral nerve.

Sensory deficitsSensory deficits

Ulnar side of the forearm and hand

Muscle weaknessMuscle weakness

Pronators of the forearm Flexors of the wrist joint.

Horner syndromeHorner syndrome

Bernard-Horner syndrome and oculo-sympathetic palsy

Injury to cervical sympathetic ganglions. Enophthalmos, partial ptosis, swelling of

the lower eyelid, miosis , unhydrosis and heterochromia.

Loss of ciliospinal reflex.

ComplicationsComplications

Fracture of the clavicle Fracture of the humerus Subluxation of the cervical spine Cervical cord injury Facial nerve palsy Phrenic nerve palsy

Nerve InjuryNerve Injury

Avulsion :- Rupture :-Stretching :-Scarring :- Neuropraxia Axonotmesis Nerotonmesis

ManagementManagement

X-rays to exclude fractures and examination for phrenic nerve paresis are important.

Other investigations - Electromyography, NAP, SEP, Nerve conduction studies, CT myography and MRI.

ManagementManagement

Most cases of OBPI resolve spontaneously in ~ 4 months to 2 year4 months to 2 year after delivery.

To prevent contractures, physiotherapy using wrist splits after 7days immobilization.

Surgery if movement doesn’t return after 3 months and electrophysiology indicate a poor prognosis.

Opponens Pollicis

Flexor Pollicis LongusAdductor Pollicis

Pectoralis Major (lower)

Biceps

Flexor Pollicis Brevis

Extensor Digitorum SuperficialisExtensor Digitorum Profundus

Pronator Quadratus

Extensor Carpi Radialis Longus & Brevis

Frexor Carpi Radialis

Triceps

Extensor indices

Extensor DigitorumFlexor Carpi Ulnaris

Extensor Digiti MininiExtensor Carpi Ulnaris

Extensor Pollicis LongusAbductor Pollicis LongusExtensor Pollicis Longus

BrachialisPronator Teres

Pectoralis Minor

DeltoidSerratus Anterior

Rhomboid Major & MinorSupinator

C5SupraspinatusInfraspinatus

Pectoralis Major (upper)

T1 C8 C7 C6

LumbricalsBrevis

Abductor PollicisInterossei

NeurrorhaphyNeurrorhaphy

NeurolysisNeurolysis

NeuromaNeuroma

NeurotizationNeurotization

Botox InjectionBotox Injection

Nerve ConduitNerve Conduit

Tendon TransferTendon Transfer

Modified ‘Quad’Modified ‘Quad’

Tendon TransferTendon Transfer

Nerve DecompressionNerve Decompression

Bony ProceduresBony Procedures

Triangle TiltTriangle Tilt

Post op.Post op.

Thank you…..Thank you…..