Physiotherapy Following Brachial Plexus Birth Palsy(BPBP)

N.SARANYA. PT Dr. S.RAJA SABAPATHY, MS M Ch DNB FRCSDepartment of hand therapyGANGA HOSPITALCOIMBATORE.

Birth Palsy It is a low velocity injury

Partial injuries to the roots are common

When fully ruptured, the distance between the roots to be bridged is not much and some regeneration is possible

Useful function of the affected muscles will return in most cases

Problem : Co - ContractionsAdductors with Abductors

Internal Rotators with External Rotators

Elbow Flexors with Abductors of shoulder

The other problem: Recovery of one group of muscles earlier and better then its antagonist muscle

Unopposed action of this group causes contractures

All this is super imposed on growth

PrimaryEffectsSecondaryEffectsTertiaryEffects

Classical Deformity

Role of PhysiotherapistPre operative Immediate post operativeLong term follow up

Aim of PhysiotherapyTo Maintain Joint Range of MotionTo Prevent DeformitiesTo obtain an optimal Functional Outcome After Surgical Intervention Sensory re-educationSplintingParent / Patient satisfactionEnhance ADL

AssessmentPersonal historyPrevious history of treatmentClinical1. Modified Mallet score2. Strength 3. Sensory4. stereo gnosis5. Motor grading6. ROM

Proforma

Early Physiotherapy

Horizontal

BoneVertical Muscle Surgical Options

Postoperative Physiotherapy

Shoulder external and internal rotation exercises

Active assisted shoulder abduction

Stretching of shoulder abductors

Strengthening of shoulder abductors

Passive movements of distal joints

Home program

Overhead pulley exercisesPicking up of objects and placing over headFinger ladder exercisesWand exercises promoting shoulder abductionTo encourage eating, bathing, buttoningSwimming the best exercise.

Statue of Liberty Splint

Age - 2y 1mPreoperative Postoperative 1 y

Age - 1 yr 4mPreoperative Postoperative 4 m

Results Preoperative average abduction- 81degrees (Range:20-150 degrees)

Postoperative average abduction- 144degrees (Range: 80-180 degrees)

Increase in abduction range-63degrees (Range:20-110 degrees)

Results

Mallet score improves by an average of 2.5 points

Overall symmetry of the movements at limb in improved

What can not be expected Total correction of Internal Rotation Deformity at the Shoulder

SHEAR Deformity Scapula Hypoplasia Elevation And Rotation Nath RK, Lyons AB, Melcher SE, Paizi M. Surgical correction of the medial rotation contracture in obstetric brachial plexus palsy. J Bone Joint Surg 2007, 89B: 1638-44.

Triangular Tilt Operation

Osteotomy of the clavicle (middle third and distal third junction )Osteotomy of the acromion at the site where it narrows.Shaving of the protruding medial border of the scapula. Anterior capsular release/ Posterior capsuloraphy

Immobilization

Post op Physiotherapy1st weekMaintain the splint all the time remove only during exercises and gentle cleaningGravity eliminated rotation of the shoulder jointElbow bending and straighteningHand mobilization

2nd weekMaintain the splint all the time remove only during exercises and gentle cleaningContinue all exercise in 1st weekADD: Gentle passive shoulder abduction to 120degree

3rd week

Maintain the splint all the time remove only during exercises and gentle cleaningAdduction of armGentle passive shoulder abduction to 140degreeActive abduction as much as toleratedActive and passive external rotation by keeping arm side of body and elbow flexed to 90degreeElbow and hand mobilization

4th week

Passive shoulder abduction to 180degreesActive shoulder abduction as much as possible, increase range every day.Passive external rotation of shoulder by keeping the arm by side of chest and elbow fixed to its full rangeEncourage active external rotation as much as possible.

After 4 weeks

During day time remove the splint for few hoursStart with 2hrs/day during 5th week; 5hrs/day during 6th week, 8hrs/day in 7th week and 12 hrs in 8th week.Continue all exercisesExercise can be made more aggressive.

After 8 weeksNo splint required during dayNight splint to be continued for 6 months More aggressive physiotherapy.

Triangular Tilt ResultsPre opPost op

Triangular Tilt ResultsPre opPost op

Pre-opPost-op

Mallet scoreMallet score improves by an average of 2.5 points

T H A N K Y O U F O R Y O U R T I M E & P A T I E N C E

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