OB 3rd Year 4 TH Class

Physiotherapeutic assessment
and treatment of acquired

pediatrics conditions
Obstetric Brachial Plexus Injury
12/23/2023 Yazachew 1
Brachial plexus injury
Yazachew 2
Outlines
 Objectives  Natural history of recovery
 Definition  Evaluation
 Incidence  Management
 Anatomical review  Outcomes
 Risk factors  Prognosis
 Clinical presentations  Summary
 Classification
12/23/2023 Yazachew 3
Objectives
At the end of this lesson, students will be able to:

 Define brachial plexus injury
 Know the incidence, prognosis, and risk factors of
brachial plexus injury
 Describe the assessment and role of physiotherapy
in managing brachial palsy
 Describe the outcomes of brachial plexus injury
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Brachial plexus palsy…
Introduction
Anatomy
 The brachial plexus (plexus brachialis) is a somatic
nerve plexus formed by intercommunications among
the ventral rami (roots) of the lower 4 cervical nerves
(C5-C8) and the first thoracic nerve (T1).
 It is responsible for the motor innervations of all of
the muscles of the upper extremity
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Anatomy…
12/23/2023 Yazachew 6
Definition
 Obstetric brachial plexus injury (OBPI), also known as
birth brachial plexus injury (BBPI), is unfortunately a
rather common injury in newborn children.
 Incidence varies between 0.15 and 3 per 1000 live
births in various series and countries.
12/23/2023 Yazachew 7
Causes and Risk factors
Foetal
 Macrosomia
 Breech
Maternal
 Diabetes in pregnancy
 Shoulder dystocia
 Small stature/cephalopelvic disproportion
 Primi or multiparity
 Prolonged second stage of labour
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Types
An avulsion- is when the nerve is torn from where it
attaches to the spinal cord.
No recovery is expected with an avulsion injury. It
cannot be repaired with surgery.
A rupture- is when the nerve is torn, but not from
where it attaches to the spinal cord.
This usually occurs beyond the vertebrae in the
neck. A rupture requires surgery to reconnect the
ends of the nerves.
12/23/2023 Yazachew 9
Neuroma- forms when torn nerve fibers have attempted

to re-grow and heal themselves, but scar tissue has
grown in and around the injury.
 This scar tissue makes it impossible for the nerve to
conduct electrical signals to the muscles.
 Surgery removes the scar tissue around the nerve and
between the ends of a completely ruptured nerve.
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 Axonotomesis- occurs when the fibers inside the

nerve have been broken but the nerve covering is still
intact.
 Recovery by re-growth of the nerve fibers is often very
good but it takes time (1mm per day) for the nerve to re-
grow.
12/23/2023 Yazachew 11
Neuropraxis- occurs when the nerve has been damaged
(e.g. sprained) but not torn. In this case, the nerve fibers
can recover on their own.
 Improvement in movement of the arm should be seen
within three months.
12/23/2023 Yazachew 12
Clinical Presentation
 Erb’s Palsy: C5 – C6
– Most common, fastest and most complete recovery
 Klumpke’s Palsy: C8-T1

 Total plexus injury: C5-T1
 Bilateral injuries
12/23/2023 Yazachew 13
Earbs’s Palsy
A) Erb's palsy or Erb–Duchenne palsy -is a form of

obstetric brachial plexus palsy.
 It occurs when there's an injury to the brachial plexus ,
specifically the upper brachial plexus at birth.
 The injury can either stretch, rupture or avulse the roots of the
plexus from the spinal cord.
 It is the most common birth related neuropraxia (about 48%).
12/23/2023 Yazachew 14
It is a lesion of C5 & C6 nerve roots (in
some cases C7 is involved as well) usually
produced
Injuries to the brachial plexus affects
movement and cutaneous sensations in the
upper limb.
12/23/2023 Yazachew 15
Clinical presentation of erb’s pulsy
 Shoulder = adduction and internal rotation,

 Elbow = extension
 Forearm = pronation and
 Wrist and fingers = flexion.
Buterbaugh KL 2016
12/23/2023 Yazachew 16
B) Klumpke’s Palsy
 Elbow slight flexion
Muscles involved
 Elbow extensors
 Wrist flexors
 Hand intrinsics and
 Finger flexors are involved
12/23/2023 Yazachew 17
Brachial palsy….
Associated complications
 A broken clavicle (collar bone)
 a broken humerus (upper arm bone), and
 Horner’s Syndrome
 cephalohaematoma
 facial nerve palsy
 Torticollis
 diaphragmatic paralysis
12/23/2023 Yazachew 18
Tests And Diagnosis
 There is no single test which can determine the extent

of the brachial plexus injury.
 Instead, a child’s arm movement will be assessed and
monitored over a period of time by doctors and
physiotherapist.
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 If your child is being considered for surgery, MRI
(magnetic resonance imaging) may be used to
diagnose avulsions of the brachial plexus.
 It has been found that MRI can define the integrity of
nerve roots where they leave the spinal cord
12/23/2023 Yazachew 20
Managment
 Although spontaneous recovery is known, there is a large
subset which does not recover and needs primary or secondary
surgical intervention.
 In case of global involvement, involvement of the hand ,upper
limb, there is no real dispute about indication of surgery.
 A long term physiotherapy is indicated in most of the cases.
12/23/2023 Yazachew 21
Physiotherapy Assessment
 Subjective
– Delivery history
– Movement and improvements since birth
– Positions/activities throughout the day
 Objective
– Gross and fine motor activity
– ROM
– Sensation
 Modified Mallet Score
 Secondary impairments
 ICF-CY form
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Mallet Score
 Most commonly used and validated
 Assesses ability to perform ADLs with functional
movements
12/23/2023 Yazachew 23
Physiotherapy treatment
 Physical therapy is an option for treating torticollis in a

non-invasive and cost-effective manner.
 While outpatient infant physiotherapy is effective,
home therapy performed by a parent or guardian is just
as effective in reversing the effects of congenital
torticollis.
12/23/2023 Yazachew 24
 Stretching the neck and trunk muscles actively.
Parents can help promote this stretching at home with
infant positioning.
 Stretching the muscle in a prone position passively.
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Range of motion exercises for arms
 They should be performed slowly and should be held at

the end range for at least 10 seconds
 The exercises should be done three times a day
 They can be performed by well trained parents at home
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shoulder exercises
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Shoulder exercise ...
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Elbow
12/23/2023 Yazachew 29
12/23/2023 Yazachew 30
Active exercises
 The modified constraint movement therapy is an effective
method on improving the arm function in children with OBPI.
• RCT by
Abdel et al .2013
12/23/2023 Yazachew 31
Weight bearing – prone
Ibrahim et al 2011.
12/23/2023 Yazachew 32
Active...
 Place the baby on their
side with their affected
arm highest.
 This position makes
reaching easier because
the baby does not have
to lift his arm against
gravity
12/23/2023 Yazachew 33
Active...
12/23/2023 Yazachew 34
Sensery education
 To increase your baby’s body awareness you can:

 rub variety of texture against the childes arm
• bath towel for rough sensation
• gentle stroke or massage
• resting baby's arm on mothers breast during feeding
• bringing child's hand to mouth
12/23/2023 Yazachew 35
Electrical nerve stimulation
Helps in;
 Strengthen muscles
 Increase local blood circulation
 Improve sensory recovery
Elnaggar et al. 2016
12/23/2023 Yazachew 36
Prognosis
 Time is the most important factor in the recovery of brachial
plexus injuries.
 The rate of recovery of this injury dictates the final outcome.
 The faster the return of muscle function, the greater

likelihood of complete recovery.
 physiotherapist will rate child’s progress.
 The majority of children with brachial plexus injuries

recover with physiotherapy alone.
12/23/2023 Yazachew 37
Brachial plexus palsy
Good prognostic factors

 Recovery of antigravity elbow flexion*
 Early intervention
 Post-ganglionic injury
12/23/2023 Yazachew 38
Poor prognostic factors
 Lack of biceps function by 3 months
 Phrenic nerve and Horner’s syndrome
 Complete nerve transection
 Shoulder dystocia
 Pre-ganglionic injury
12/23/2023 Yazachew 39
THANK YOU!
12/23/2023 Yazachew 40

OB 3rd Year 4 TH Class

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Physiotherapeutic assessment

and treatment of acquired

Obstetric Brachial Plexus Injury

At the end of this lesson, students will be able to:

 Obstetric brachial plexus injury (OBPI), also known as

birth brachial plexus injury (BBPI), is unfortunately a

rather common injury in newborn children.

 Incidence varies between 0.15 and 3 per 1000 live

births in various series and countries.

Neuroma- forms when torn nerve fibers have attempted

 Axonotomesis- occurs when the fibers inside the

 Klumpke’s Palsy: C8-T1

A) Erb's palsy or Erb–Duchenne palsy -is a form of

 It occurs when there's an injury to the brachial plexus ,

specifically the upper brachial plexus at birth.

plexus from the spinal cord.

 It is the most common birth related neuropraxia (about 48%).

 Shoulder = adduction and internal rotation,

 There is no single test which can determine the extent

 Although spontaneous recovery is known, there is a large

subset which does not recover and needs primary or secondary

 In case of global involvement, involvement of the hand ,upper

limb, there is no real dispute about indication of surgery.

 A long term physiotherapy is indicated in most of the cases.

 Physical therapy is an option for treating torticollis in a

 They should be performed slowly and should be held at

 The modified constraint movement therapy is an effective

method on improving the arm function in children with OBPI.

 To increase your baby’s body awareness you can:

Elnaggar et al. 2016

 The faster the return of muscle function, the greater

 The majority of children with brachial plexus injuries

Good prognostic factors

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