Physical Medicine and Rehabilitation Department

Medical Faculty of Hasanuddin University SHORT CASE REPORT

Right Incomplete Brachial Plexus Injury (Upper

Trunk Lesion) Post Ganglionic Type

Presented by: Deasy Fatimah Aulia

 IDENTITY
• Name : Mr. S
• Age : 27 Years Old
• Sex : Male
• Address : Makassar
• Religion : Moeslem
• Occupation : Sailor
• Marital status : Married
• Insurance : BPJS
• Date of examination : January 31th 2022
• Patient referred from Orthopedic Department Wahidin Sudirohusodo Hospital with
Diagnose: Brachial Plexus Injury Dextra

CHIEF COMPLAINT : Weakness of right arm after motorcycle accident since May 2021
HISTORY OF PRESENT ILLNESS:
Late May 2021
He got motorcycle accident.
The mechanism of injury: he
was riding a motorcycle in a
sleepy condition so that he hit a
tree with his right shoulder and
neck hitting a tree trunk.
Taken to Bantaeng Hospital and he
felt pain on his right shoulder, could
not move nor feel any sensation on
his right arm and hand
ANAMNESIS
June 2021 Sept 2021 Okt 2021
Sometimes he feels
Patient routine The patient
stubbing radiating pain
treatment at underwent EMG-NCV
from shoulder to hand,
neurologist in Bantaeng and was diagnosed
NRS 2-3, disappears by
Then patient referred with BPI. Then patient
itself. He feels it since the
to physiotherapy in was refferd to
day of accident and the
Bantaeng for 3 months Orthopedic and
pain persist until now
planned to surgery
 Numbness and tingling sensation Because there was no Patient was referred to PMR doctor
 No complain of one-sided perspiration
improvement so that before surgery for 2 months but
or droopy eyelid. No history of
shortness of breath.
patient was referred patient stop therapy for 1 month
 No associated injury (brain injury/ spinal neurology department and now patient reconsult to PMR
cord ) RSWS doctor
 Bowel and bladder within normal limit
 ANAMNESIS
HISTORY OF PAST ILLNESS :
• No history of DM, HT, Malignancy

HISTORY OF FUNCTIONAL ABILITY :

• Patient is right-handed. After the accident, he did all the activities using his left arm. Patient was able to bath, groom, wearing clothes, buttoning
shirt, and eat by himself albeit longer. He still need help from his wife to prepare food for him. Patient was able to transfer bed to sit and sit to stand
independently. He can walk independently without ambulatory aid.

HISTORY OF HOBBY and WORK :

• Before the accident, he was a sailor who work in ship engine and his hobby was playing basketball. He loves to hang out with his friends. After the
accident he was on temporary leave from his job.

HISTORY OF PSYCHO SOCIAL ECONOMY :

•He accepts his condition. He has a good motivation of training, going for therapies and for surgery. No thoughts on suicidal or self-harm. Patient
hoped that he can regain better function of his elbow and hand. He realized that the chance of full recovery is very unlikely and consider to
change his profession.
•Patient is married. He comes from Bantaeng. He live with his wife and 1 son, while in Makassar he lived with his younger sister house. After the
accident he was on temporary leave from his job. He doesn’t do any jobs right now and just stay in Makassar for therapies and for surgery plan.
His wife is a teacher. Now family expenses were taken care by wife and support from his familiy . He has BPJS for his health insurance.

HISTORY OF MEDICATION :
• Gabapentin 1x300 mg, Vit B complex 2x1
Status of
PHYSICAL EXAMINATIONS
Finding
Consciousness Composmentis
Vital sign BP : 120/70 mmHg
  Pulse : 89 x/minute
  RR : 20 x/minute
  Temp. : 36.5oC
Communication Good
Nutritional Status Body weight: 52 kg
  Body height : 160cm
  BMI : 20,31 kg/m2
Gait Pattern Normal Gait (No arm swing on the right side)

Balance  Static sitting balance : adequate

 Dynamic sitting balance : adequate
 Static standing balance : adequate
 Dynamic standing balance : adequate

• Supine to side lying: independent

Mobilization (Transfer, ambulation) • Supine to sit: independent
• Shifting on sitting: independent
• Sit to stand: independent
• Stand to walk: independent

Coordination Within normal limit

Pain severity NRS 2
Internal status Integument, head, neck, eyes, nose, ear, mouth, chest, abdomen are WNL
POSTURE
 MUSCULOSKELETAL STATUS
HEAD/NECK and TRUNK

 Look : Slight forward head, atrophy of supraspinatus and infraspinatus

muscles, upper trapezius muscle, pectoralis major muscle
 Feel: hypotonus on upper trapezius and supraspinatus muscles, spasm
of paracervical muscles and no tenderness.
 Move: no pain on movement, ROM MMT see the chart

ROM MMT
Movement Right Left Movement Right Left
Neck
Flexion 0-45 Flexion 5
Extension 0-45 Extension 5
Lateral Flexion 0-45 0-45 Lateral Flexion 5 5
Rotation 0-60 0-60 Rotation 5 5
Trunk
Flexion 0-85 Flexion 5
Extension 0-30 Extension 5
Lateral Flexion 0-35 0-35 Lateral Flexion 5 5
Rotation 0-45 0-45 Rotation 5 5
 MUSCULOSKELETAL STATUS
UPPER EXTREMITY

 Look : higher right shoulder, shoulder subluxation (2 finger), athrophy of right upper trapezius, supraspinatus,
infraspinatus, deltoid, biceps, pectoralis major, wrist extensor, thenar, hypothenar. No Scars, no redness, swelling.
 Feel : shoulder subluxation (2 finger), hypotonus on right upper trapezius and supraspinatus, infraspinatus, no
muscles tone of biceps, deltoid muscles. Pain radiating (+) from shoulder to hand. No tenderness, no warmth
Tinel sign positive on right shoulder region
 Move : Full range of motion
Range of Motion
Movement Right Left
Shoulder
Flexion 0-170o (P) 0-180o
Extension 0-60o 0-60⁰
Abduction 0-170o (P) 0-180o
Adduction 0-45o 0-45o
Internal rotation 0-70o 0-70o
External rotation 0-90o 0-90o
Elbow
Flexion 0-145o 0-145o
Extension 145-0o 145-0o
Forearm
Supination 0-90o 0-90o
Pronation 0-90o 0-90o
 Wrist

Flexion 0-80o 0-80o Other Fingers

Extension 0-70o 0-70o Abduction 0-20 0-20

Ulnar deviation 0-30o 0-30o Adduction 20-0 20-0

Radial deviation 0-20o 0-20o MCP Flexion 0-90 0-90

Thumb PIP Flexion 0-100 0-100

Abduction 0-70o 0-70o DIP Flexion 0-90 0-90

Adduction 70-0o 70-0o MCP Extension 0-30 0-30
MCP flexion 0-80o 0-80o IP Extension 0-10 0-10
IP flexion 0-20o 0-20o
 MUSCLES CHART
Nerve and Muscles Right Left
Long Thoracic Nerve
Serratus anterior 1 5
Dorsal Scapular Nerve
Rhomboid 1 5
Supra Scapular Nerve
Supraspinatus 1 5
Infraspinatus 1 5
Lateral Pectoral Nerve
Lateral Portion of Pectoralis Mayor 1 5
Medial Pectoralis Nerve
Medial Portion of Pectoralis Mayor 1 5
Pectoralis Minor 1 5
Upper Subscapular Nerve
Subscapularis 1 5
Lower Subscapular Nerve
Teres Mayor 1 5
Thoracodorsal Nerve
Latissimus Dorsi 1 5
Musculocutaneous Nerve
Biceps 0 5
Brachialis 0 5
Coracobrachialis 0 5

Axillary Nerve
Deltoid 0 5
Teres Minor 0 5
Radialis Nerve
Supinator 1 5
Ext. Carpi Rad. Longus 2 5
Triceps 1 5
Brachioradialis 1 5
Ext. Carpi Ulnaris 2 5
Ext. Digitorum 2 5
Abd. Poll. Longus 4 5
Ext. Poll. Longus 4 5
Ext. Poll. Brevis 4 5
Median Nerve
Pronator Teres 1 5
Flexor Carpi Radialis 2 5
Palmaris Longus 1 5
Flex. Dig. Superficialis 3 5
Flex. Dig. Profundus 3 5
Flex. Poll. Longus 3 5
Pronator Quadratus 1 5
Lumbricals 1 5
Opp. Pollicis 4 5
Abd. Poll. Brevis 4 5
Flex. Poll Brevis 4 5
Ulnar Nerve
Flex. Dig. Profundus 3 5
Dorsal interossei 2 5
Palmar interossei 2 5
Lumbricales 2 5
Add. Pollicis 3 5
Flex. Carpi Ulnaris 3 5
Opp. Dig. Min 3 5
Abd. Dig. Min 3 5
Flex. Dig. Min 3 5
 MUSCULOSKELETAL STATUS
LOWER EXTREMITY
 Look : no deformity, no signs of inflammation, no muscle atrophy
 Feel : normotonus, no tenderness
 Move: no pain on movement, full ROM, normal muscle strength
Range of Motion Manual Muscle Test
Movement Right Left Movement Right Left
Hip
Flexion 0-110o 0-110o Flexion 5 5

Extension 0-20o 0-20o Extension 5 5

Abduction 0-45o 0-45o Abduction 5 5
Adduction 0-30o 0-30o Adduction 5 5
Internal rotation 0-40o 0-40o Internal rotation 5 5
External rotation 0-45o 0-45o External rotation 5 5
Knee
Flexi 0-135o 0-135 Flexion 5 5

Extension 135-0o 135-0o Extension 5 5

 MUSCULOSKELETAL STATUS
LOWER EXTREMITY

Ankle

Dorsiflexion 0-40o 0-40o Dorsiflexion 5 5

Plantarflexion 0-50o 0-50o Plantarflexion 5 5

Inversion 0-20° 0-20° Inversion 5 5

Eversion 0-20° 0-20° Eversion 5 5

Great toe

MTP flexion 0-70o 0-70o MTP flexion 5 5

IP flexion 0-60o 0-60o IP flexion 5 5

MTP extension 0-30o 0-30o MTP extension 5 5

IP extension 0-20o 0-20o IP extension 5 5

 NEUROLOGICAL STATUS
• Cranial nerve : normal

• Physiological reflex : BPR -/++TPR +/++

KPR ++/++ APR ++/++
Spasticity : -/-
Clonus : -/-

• Pathological reflex :
Babinski -/-
Hoffmann -/- Tromner -/-

• Sensory deficit:
Exteroceptive : sensory deficit (explained later)
Proprioceptive : impaired
 NEUROLOGICAL STATUS

Nerves Right Left Horner syndrome

C5 0% 100 % ■ Anhidrosis : -
C6 0% 100 % ■ Ptosis :-
■ Enopthalmus : -
C7 70% 100 %
■ Miosis :-
C8 90% 100 %
T1 90% 100 %
 FUNCTIONAL EXAMINATION
BARTHEL INDEX HAND PREHENSION
ACTIVITY SCORE MAX
SCORE
Feeding 5 10 Power grip

Bathing 5 5 - Cylindrical grasp : Inadequate/Adequate

Grooming 0 5 - Spherical grasp : Inadequate/Adequate
Dressing 5 10
- Hook grip : Inadequate/Adequate
Bowels 10 10

Bladder 10 10
Precision grip
Toilet use 5 10
- Pinch grip : Inadequate/Adequate
Transfers 15 15

Mobility 15 15
- Pad to side grip : Inadequate/Adequate

Stairs 10 10 - Three jaw chuck grip : Inadequate/Adequate

TOTAL 80 100
- Lumbrical grip : Inadequate/Adequate
SCORE

Barthel Index : Independently

FUNCTIONAL EXAMINATION
The Brachial Assessment Tool (BrAT)
FUNCTIONAL STATUS
FUNCTIONAL STATUS

0
SUPPORTIVE EXAMINATION
Thorax and Shoulder X-Ray (From Bantaeng)
SUPPORTIVE
EXAMINATION

EMG NCV
(08/10/2021)
 MEDICAL DIAGNOSIS

Right Incomplete Brachial Plexus Injury (Upper Trunk

Lesion) Post Ganglionic Type
 FUNCTIONAL DIAGNOSIS
Health Condition
Right Incomplete Brachial Plexus Injury (Upper Trunk Lesion) Post
Ganglionic Type

Body Functions and Body Structures

Structure of shoulder region: muscle atrophy, joint; shoulder Activities
subluxation
Carrying out daily routine Participation
Structure of upper extremities
Lifting and carrying object Recreation and leisure
Touch function
Sensory function
Fine hand use Religion and spiritually
Hand and arm use
Sensory of Pain
Mobility of joint functions
Stability of joint functions
Muscles power functions
Control of voluntary movement functions

Environmental Factors: Personal Factors:

Immediate family Age
Health services systems and Self motivation
policies
 PROGNOSIS
Ad Vitam : Ad bonam

Ad Sanationam : dubia ad bonam

Ad Functionam :dubia ad malam

• The prognosis for moderate to severe injuries of the brachial plexus is not as good as for mild injuries but is still largely
positive. A combination of surgery and follow-up physical therapy can greatly improve the resulting function . (Gina
Jansheski, M.D. Brachial Plexus Prognosis)
• When the delay for operation was more than 6 months, it affected the outcome significantly
• The upper type showed better functional recovery (44%) than the whole type.
• If the muscles innervated by upper roots could gain a strength of M1 before 9 months after injury, and muscles
innervated by lower roots reached M1 before 12 months
• The muscular power at 24 months was almost the same as the final results (Nagano et al, Brachial plexus injuries. Prognosis of
postganglionic lesions, Arch Orthop Trauma Surgery)
NO PROBLEM
PROBLEM LIST GOALS
1 Weakness at upper extremity dextra Short Goal :
1. Explain the patient and families about
her condition, prevent the patient and
family from depression
2 Hand function 2. Improve Hand Function
3. Prevent progression of shoulder
subluxation
4. Prevent skin injury
3 Muscle atrophy and sensoric defisit
5. Maintain muscle throphy and ROM
prepare for nerve transfer
4 Prevent progression of shoulder subluxation
LongTerm Goal:
6. Prevent complication (edema and joint
stiffness at right extremity)
5 7. Occupational adjustment
Prevent wound skin 8. Increase quality of life
9. Prevent muscle atrophy from occurring
more quickly
10. Prevent further subluxation of the
shoulder
11. Patient can do ADL independently
PROGRAM
Medikamentosa : -
Non medikamentosa
1. Operatif : Surgery plan for nerve transfer
2. Non Operatif :
• Physical Therapy :
- ES 20 Hz, 30min, 3x/ weeks at supraspinatus,
deltoid, biceps, wrist extensor
- Passive ROM exercise
- Motoric reeducation
• OT :
- Fine Motor Exercise
- Sensoric reeducation
- ADL training
- Hand coordination with adaptation one-handed
activity
• OP : Shoulder sling, resting splint
• Home education:
- Maintain skin moisturizer, washing skin daily
- Inspect skin routinely
- Educate to support the right arm when sitting
position with arm rest of chair or pillow
- Find a propriate job
 PLANNING
• Planning Diagnosis: - EMG Evaluation after surgery

• Planning Monitoring : - Clinical sign (ROM, MMT, NRS, Barthel Index,

BraT Score )

• Planning Education : Explain to the patient about the condition and

consequences, daily inspection of hand area
THANK
YOU