If you’ll recall from my BLOG REBOOT 2017 post this past Monday: my new plan to have focused blog days, my love for alliteration, the lack of days of the week that start with “D” in English, AND my love of German have brought us here:
Hallo und willkommen auf Diagnose Donnerstag !!!
(Hello and welcome to Diagnosis Donnerstag “Thursday”)
Since starting in pediatrics in the summer of 2016, there are A LOT of things that this PT has had to go back and review from school. This is so exciting for me & just reinforces the importance and value of being a lifelong student. #NerdAlert
Recently, I evaluated a VERY young little one (we are talking WEEKS people) and many friends and family wondered: WHAT could a physical therapist possibly be doing with a baby so young? So this “Donnerstag” we are going to explore:
Obstetric Brachial Plexus Injuries
(Trauma to the brachial plexus that occurs during birth)
Don’t fret! If my subtitled explanation just made you MORE confused, we are going to break it down. IF you are a PT, OT, or student of these noble professions 😉 , pull out a blank sheet of paper and draw the Brachial Plexus AS FAST AS YOU CAN —> GO!
OK, so the brachial plexus is a group of nerves that exit from your spinal chord in the neck and travel down the arm. Check out those yellow guys over there on the left.
These nerves are crucial for the control of your shoulder, elbow, wrist, and hand, and they also provide feeling to the arm.
As you can see, there is a lot of anatomy on the path these nerves travel from spinal chord to their ultimate destination in the hand.
OK, medical professionals, how did you do? To test myself in preparation for this blog, I tried my hand at a quick drawing, I guess all those repetitions preparing for the boards actually did stick…Thanks Dr. C 🙂
Back to our little ones: During birth and injury can occur. This usually happens during a difficult vaginal delivery with a higher incidence when babies are breech: traction, rotation, or compression on the newborn’s shoulder or neck can cause damage to their little brachial plexi. Most occur at the upper roots at the levels of C5 & C6 (exiting the neck at cervical vertebra 5 and 6).
As we just saw, these nerves are SO important for the function of the arm. When there has been injury, babies normally present with an Erb’s Palsy (damage to C5 & C6), with a characteristic “Waiter’s Tip” position.
Shoulder: Held in extension, internal rotation, adduction. Elbow: Extended. Forearm: Pronated. Wrist and fingers: flexed. Basically due to the paralyzation or weakness of the muscles innervated by C5 & C6.
PT student sidebar: how many of those muscles can you name? Rhomboids, levator scapularis, serratus anterior, subscapularis, deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, supinator, and the long extensors of the wrist, fingers, and thumb.
INTERESTINGLY: Grip is left intact but sensation loss may be present.
What does this mean for the little one? Limitations can vary GREATLY depending on the severity of the injury but can include:
- Difficulty Reaching
- Performing bilateral motor activities (dressing, tying shoes, drinking)
- Moving supine to prone (Rolling) and visa-versa
- Asymmetrical strengthening can lead to delayed balance reactions as they grow
- Creeping (also known as “crawling” in the non-PT world)
- Due to absent sensation: Neglect of limb or behaviors such as biting
This is where physical therapy comes in! Because:
The majority of infants diagnosed with OBPI require ONLY PT with no surgical intervention needed (Laurent & Lee, 1994)!
PT GOALS: The ideal outcome for a little one with OBPI is complete return of motor control and sensation with no activity limitations or participation restrictions. In addition therapy will focus on preventing secondary impairments of muscle contractures or joint injury.
Upon initial evaluation, the therapist will establish baseline function with the objective of the PT program to facilitate the highest functional outcome possible for the child. Directed active movement to increase strength and decrease compensatory movement is used. Education of the family is extremely important to include positioning techniques and modifications.
Outcomes and Prognosis: The majority of spontaneous recovery occurs by 9 months of age but continued recover may occur up to 2 years after the injury (Gilbert, 1993). However, it is difficult to determine true prognosis as many studies show varying numbers (research opportunity alert !?!) A recent study showed 66 – 73% of all infants with OBPI report a full recovery (Hoeksma et al, 2004)
Well, that was a lot for one night friends. Please if you have any questions let me know! OR if you have any topics you’d like covered during Diagnosis Donnerstag, shoot me a message or leave a comment below.
Read all about it:
Gilbert, A. Obstetrical brachial plexus palsy. In Tubiana, R (ed.). The Hand, Vol. 4. Philadelphia: WB Saunders, 1993, p.579.
Hoeksma, AF, ter Steeg, AM, Nelissen, RG, van Ouwerkerk, WJ, Lankhorst, GJ, & de Jong, BA. Neurological recovery in obstetric brachial plexus injuries: A historical cohort study. Developmental Medicine & Child Neurology, 46:76 – 83, 2004
Laurent, JP, & Lee, RT. Birth related upper brachial plexus injuries in infants: Operative and nonoperative approaches. Journal of Child Neurology, 9:111-117, 1994.