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  • 767.6 Injury to brachial plexus due to birth trauma
  • 953.4 Injury to brachial plexus

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  • G54.0 Brachial plexus disorders
  • P14.0 Erb's paralysis due to birth injury
  • S14.3XXA Injury of brachial plexus, initial encounter

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Description

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  • Paralysis of the arm
  • Weakness in the arm
  • Diminished reflexes, C5-C6 vertebrae
  • Arm hangs by side, internally rotated
  • Motor or sensory changes in the nerve distribution due to pressure from compression and stretch
    • Sensory changes in multiple peripheral nerves of the upper extremity from C5 and C6 nerve roots

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Essentials of Diagnosis

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  • Seddon’s classification
    • Neurapraxia (Class 1), 1st degree
    • Axonotmesis (Class 2), 2nd degree
    • Neurotmesis (Class 3)
      • 3rd degree, nerve fiber interruption
      • 4th degree, epineurium intact
      • 5th degree, complete transection of the nerve

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General Considerations

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  • Involved nerves include suprascapular, musculocutaneous, axillary
  • Must differentiate from more proximal and distal nerve compression, thoracic outlet syndrome (TOS), ulnar tunnel, cervical radiculopathy
  • Wallerian degeneration occurs below site of injury

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Signs and Symptoms

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  • Acute or chronic paresthesia
  • Sensory changes: hyposensitivity of hand
  • Hand clumsiness
  • Feeling of arm heaviness
  • Hand weakness, loss of grip-power and dexterity
  • Intrinsic muscle atrophy
  • Waiter’s tip sign
  • Loss of lateral-rotator, arm-flexor, and wrist-extensor musculature

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Functional Implications

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  • Feeling of arm being dead
  • Difficulty with hand function, hand clumsiness, and possible loss of strength during ADLs/IADLs

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Possible Contributing Causes

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  • During forceps delivery, infant has head traction
  • In the womb, sustained pressure over thoracic outlet
  • Falls with outstretched arms
  • Traction to the cervical spine
  • Trauma pulling arm into abduction
  • Ganglion or space-occupying lesion
  • Clavicle fracture
  • Glenohumeral dislocation

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Differential Diagnosis

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  • Thoracic outlet syndrome (TOS)
  • Cervical radiculopathy
  • Other potential entrapment sites include
    • Medial humeral groove
    • Arcade of Struthers
    • Medial intermuscular septum
    • Flexor digitorum profundus
    • Flexor carpi ulnaris
    • Just proximal to or within Guyon’s canal
    • Sensory and motor involvement between the abductor digiti minimi and flexor digiti minimi
    • Near hook of hamate: involves motor function only
    • Distal end of Guyon’s canal: involves sensory function only
  • Radial neuropathy
  • Median neuropathy
  • Carpal tunnel syndrome
  • Proximal ulnar nerve entrapment
  • Distal ulnar nerve entrapment cubital tunnel (Guyon’s Canal)
  • Klumpke paralysis
    • Traction of an abducted arm
    • Lower brachial plexus injury
    • Damage to C8 and T1 vertebrae
    • Loss of intrinsic muscles of the hand, wrist, finger flexors
  • Ulnar nerve palsy
  • Bishop deformity

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Imaging

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  • Diagnostic ultrasound imaging
    • Allows for dynamic imaging during arm movement
    • May show enlargement of brachial plexus nerves at entrapment site

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Diagnostic ...

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