Obstetrical Brachial Plexus Palsy

Transcription

1 Obstetrical Brachial Plexus Palsy The Leeds Teaching Hospitals N H S N H S Tru s t

2

3 Obstetrical Brachial Plexus Palsy The Leeds Teaching Hospitals NHS Trust (LTHT) is a national centre for the treatment of Obstetrical Brachial Plexus Palsy (OBPP). This booklet has been prepared by clinicians at this hospital to help you and your family understand OBPP. If after reading this you have any other questions related to your child's condition please contact any member of the team. Each time you attend appointments please bring your information pack with you so that further material may be added. Who is involved in my child's care? There are three Consultant Plastic Surgeons working within a team of clinicians at this hospital who have specialist knowledge of caring for children with OBPP, Professor Simon Kay (SPK), Mr Waseem Saeed (WRS) and Miss Grainne Bourke (GB). All work in the Department of Plastic and Reconstructive Surgery in Chancellor's Wing, at St. James's University Hospital. The Brachial Plexus Team When you attend the hospital you will be seen by a variety of people which may include; Surgeons (Consultants, Specialist Registrars, Registrars, and Senior House Officers) Anaesthetists, Radiologists, Neurophysiologists, Nursing staff, Occupational Therapists, Physiotherapists, Specialist Physiotherapy Practitioner and Clinical Psychologists. Hospital contact details: St James's Hospital Beckett Street, Leeds, LS9 7TF Ward 27 3rd floor Chancellor's Wing Plastic Dressing Clinic 3rd floor Chancellor's Wing Children's Hand Clinic 1st floor Chancellor's Wing Clinical Psychology 3rd floor Chancellor's Wing Occupational Therapy Lower ground Chancellor's Wing Physiotherapy Lower ground Chancellor's Wing Consultants' secretaries Professor Kay Mr Saeed Miss Bourke The information contained within this booklet is also available on the internet at

4 How does this injury occur and how often does it occur? Obstetrical brachial plexus palsy affects about one in every 2000 live births. It is more common in larger babies, but can occur in babies of any birth weight. During birth, after the delivery of the baby's head, the baby's shoulder may become stuck in the mother's pelvis. At this stage it is very important for the baby to be delivered quickly to prevent brain damage from hypoxia (lack of oxygen). In order to free the shoulder, a variety of manoeuvres may be used and may result in damage to the nerves of the arm. The baby may also suffer a break in the collar bone or humerus (arm bone) during the delivery. What is the Brachial Plexus? The group of nerves that supply movement and feeling to the shoulder, arm and hand is called the brachial plexus. These nerves start in the spinal cord (in the neck) and are named after the lower cervical vertebrae (C5, C6, C7, and C8) and the first thoracic vertebrae (TI). They join and divide a few times before forming the major nerves of the arm. They are the pathways for electrical signals to go from the brain to the muscles and skin of the arm. Each one of these nerves supplies movement and feeling to specific areas in the arm.

5 The left brachial plexus Cervical & Thoracic Roots C5 C6 C7 C8 T1 Trunks Divisions Lateral Cord Medial Cord Posterior Cord Ulnar Musculocutaneous nerve Median Radial Major Nerves of the Arm If there is an injury to one or more of these nerves they are unable to transmit the electrical signals from the brain, and so the muscles that are controlled by the injured nerve will not work and the skin supplied by the injured nerve will loose feeling. Each nerve is made up of many nerve fibres which are contained in small bundles. These bundles are then surrounded by a protective sheath. When a nerve is injured this can damage the nerve fibres, the nerve bundles or even the surrounding sheath. The recovery of the nerve depends on which of these structures are damaged and how badly they are damaged. What kinds of injuries can occur and how are they treated? In obstetrical brachial plexus palsy the nerves are usually stretched but remain in one piece. The damage to the nerve and the recovery depends on how badly the nerve is stretched. If the nerve is simply stretched and bruised then the nerve fibres can recover on their own over days and weeks.this is called neurapraxia. If the individual nerve fibres are stretched and torn but remain organised within their bundles they can still recover, but only by regenerating from the torn end along the track formed by the original nerve fibre. During this process some fibres fail to regenerate accurately and fail to reach their original muscles and skin, meaning the recovery from this "axonotmesis" is less certain. The recovery may take many months as the nerve will only regrow at a rate of one millimetre a day. A-Normal Nerve B-Nerve in continuity C-Nerve Rupture D-Nerve Root Avulsion A B C D

6 If the nerve fibres and the outer protective sheath are stretched and torn it is more d i fficult for the nerve to repair itself. This is because the channel for the nerve fibres to regenerate and grow along is now lost. There is also scar tissue around the injured nerve which stops the nerve fibres from finding the right pathway. This is called neurotmesis or nerve rupture. As the nerve tries to recover it may form a scarred swelling or neuroma. This scar tissue cannot conduct electrical signals and so the pathway from the brain to the arm is interrupted. This type of injury may benefit from surgery to remove the scar tissue and repair the nerve ends. If the injury to the nerve occurs close to the spinal column the nerves to the arm actually become separated from the spinal cord. These nerves cannot repair themselves nor can they be directly rejoined to the spinal cord with surgery. This injury is called a nerve root avulsion. How can we decide the type of nerve injury and whether your child needs surgery? There is no special test to decide the severity of the nerve injury in your child. The most reliable method of assessing the condition is by examination of your child and their arm for movement. We use a system called the Toronto Scoring System which looks at and scores a number of movements in the arm. This scoring system is initially performed on your child at 12 weeks of age by our specialist physiotherapy practitioners and may be repeated regularly to watch and document progress and recovery. The movement in your child's arm at these stages will help us to determine what treatment your child requires. If your child has a very low score at 12 weeks (which indicates minimal movement of their arm) or if your child's arm movement doesn't improve over time, they are more likely to have a nerve injury that will require surgery to repair the damage. If your child regains the movement of their arm within the first few months then this means your child may not need to undergo primary nerve surgery. They will be reviewed in our Children's Hand Clinic on a regular basis as some children require secondary surgery at a later stage to improve the function of their arm. What happens if my child is to have surgery? The decision to operate on your child is usually made between 3 and 6 months of age. If your child is to have surgery they will be admitted to the children's ward the day before the surgery. This allows time for your child to meet, and be examined by, the team of doctors and nurses who will be involved in your child's care during your hospital stay. Accommodation is available on the ward for one parent and nearby at Eckersley House (if rooms are available) for the other parent. On the morning of surgery you and your child will be escorted to the operating suite. You will be able to stay with your child until they have gone to sleep. The surgery including the nerve grafting will take several hours. After the surgery your child will be placed in a cowl dressing (see section later) and there may also be some dressings around the legs to protect the sites if the sural nerves have been used.

7 What happens during surgery? All surgery is performed under a general anaesthetic and the surgeon will initially examine the nerves to establish the extent of the damage. If the nerves are found to be ruptured with a neuroma present, then the damaged part of the nerve is removed and is replaced with a segment of healthy nerve. The nerve that is used to bridge this gap is usually taken from the leg and is called the sural nerve. This is a small nerve which supplies some feeling over the outer edge of the foot. Taking this nerve from the leg does not damage the foot or ankle in any significant way. If there are a lot of nerves injured in the neck then it may be necessary to use other nerves as well as the sural nerves. If nerves have been avulsed from the spinal cord, then nerves from adjacent areas inside and around the plexus (which do less important jobs) will be transferred to supply function to the arm, such as bending the elbow and stabilising the shoulder. Sometimes if there is severe damage to a lot of nerves it is necessary to transfer or use nerves from the other arm. This is rarely necessary in OBPP. What will my child be like when they return from surgery? When your child returns to the ward they will initially be a bit drowsy. The nursing staff will regularly check on your child and give them pain relief and review their dressings. They will be allowed to feed as soon as they return to the ward.your child will usually only have to stay on the ward for a couple of days following their surgery. Prior to going home their leg dressings will be taken off and their legs will be checked before a smaller dressing is put back on. Why does my child need a cowl dressing on? The cowl dressing straps your child's arm across the abdomen and there is strapping around the head. This is to: Restrict movement of the arm and neck. Such movement can damage the delicate surgery to the nerves and tissues. Protect the wounds. How do I look after my child while the cowl is on? Care must be taken to ensure the strapping is always secure. Your child will not be able to have a bath while the cowl is on. Regular washing of exposed areas of skin will help maintain freshness and comfort. Care should be taken when feeding your child to avoid crumbs etc dropping into the cowl. Always use a bib, or some other protection at mealtimes and during play. Your child will need clothing in a larger size to fit over the cowl.

8 What do I need to look for while the cowl dressing is on? The cowl slipping and your child's head coming out of the dressing. The cowl being too tight or rubbing against the skin. Any red or sore areas around the cowl. Any problems with the wounds which you may notice by the dressings becoming discoloured, moist or starting to smell. This surgery is very specialised and your local hospital may not be able to help. Therefore, if you notice any of these problems occurring then please contact Ward 27 for advice before taking any other course of action. Staff are available 24 hours a day on or What follow up will my child have? One week following your child's operation: Your practice nurse will check your child's leg wound. The absorbable stitches that are used sometimes need trimming at the top and bottom of the scar. If you have any concerns about anything at all, staff are on duty 24 hours a day on the ward so please do not hesitate to contact them for advice. Three to four weeks following your child's operation: You will return to hospital to the Children's Plastics Dressing Clinic where the cowl will be removed. This should not cause your child too much distress. You may bathe your child or give them a gentle wash at the hospital, as s/he will be ready for this after being in the cowl. The nails may also be quite long, and need trimming. Their neck and leg areas will be checked and should be well healed. The absorbable sutures used may need further trimming. You will see the Physiotherapist and recommence passive exercises on your child's arm. At this stage you will not harm the nerve surgery by handling your child or performing their exercises (unless you are specifically told so by medical staff). What will I notice when the cowl is removed? Their arm may feel slightly stiff. This will improve over the following few weeks as you regularly perform their passive exercises. The skin under the plaster can be a little dry or sore, especially in the skin folds, i.e. armpits, inside of the elbows, around the neck and ears. This usually does not need any special treatment other than bathing, drying and moisturising. The scar areas may appear slightly reddened and raised and we may recommend at this stage that you start to massage these areas.

9 The active movement of your child's arm will be the same or slightly worse than it was before surgery. This is due to the length of time it takes for nerves to recover and it will take from several months to a few years before the full outcome of surgery becomes apparent. Three months following your child's operation: They will attend the Children's Hand Clinic and be seen by a multi-disciplinary team. Will my child need surgery again? Your child will be regularly assessed and their progress monitored in the Children's Hand Clinic. Sometimes they may need secondary operations especially around their shoulder to improve the movement of their arm. This type of surgery usually takes place years after the early nerve surgery. Physiotherapy for Obstetrical Brachial Plexus Palsy Physiotherapy should be started early for the child with a brachial plexus palsy and your child may have already seen a local physiotherapist soon after they were born. When your child attends this hospital for assessment they will meet our specialist physiotherapy practitioner in OBPP. She will assess the movement of your child's arm using a special scoring system and will also demonstrate the passive range of movement exercises that you need to perform on your child's arm. Why do I need to perform exercises on my child's arm? The aim of these exercises is to reduce any joint stiffness occurring as a result of the lack of active movement of your child's arm. The exercises keep the muscles and joints flexible and ready to work if and when the nerves and muscle function improve. Physiotherapy exercises will also encourage any active movement and improve the strength of your child's arm. Your child will be regularly reviewed by the Physiotherapy Practitioner in our Multi Disciplinary Team (MDT) clinic to monitor how your child is progressing. Sometimes as your child gets older there may be weakness of some muscle groups and imbalances may occur. These may require specific exercises, or splinting by the Occupational Therapist. Passive Range of Movement Exercises for Children with OBPP These exercises should be performed with your child lying flat on a firm surface. Their changing mat is an ideal place. Unless otherwise directed by your Physiotherapist each exercise should be:- Initially performed every nappy change and then reduced to at least three times a day. Performed slowly and gently Held for 10 seconds at the end of each exercise Repeated 5 times

10 It is extremely important that you do not attempt to perform these exercises until you have been instructed by a Physiotherapist. They will inform you of which specific exercises are appropriate for your child. A: Shoulder exercises 1. Elevation Gently hold your child's forearm and lift their arm up above their head. Keep the arm close to their ear. 2. Lateral Rotation This is the most important exercise. Bend your child's elbow to 90 o whilst holding the elbow in at the side. Rotate the arm out to the side towards the mat. It is important that you do both of their arms together. This allows you to compare the affected arm with the unaffected arm and to ensure that your child doesn't roll and limit their movement. 3. Posterior capsule stretch Place one hand onto your child's shoulder and with your other hand grasp your child's forearm and take it across their chest so that their elbow and shoulder are held at 90 o. Then apply a downward pressure onto their forearm. B: Elbow exercises 1. Flexion and Extension Grasp your child s forearm and gently bend and straighten their elbow fully.

11 2. Pronation and Supination Bend your child's elbow to 90 o, grasp firmly around your child's wrist and rotate their forearm so that their palm turns towards their face and then towards their feet. It is important that you hold onto the forearm and not their wrist. C: Wrist, Finger and thumb exercises 1. Wrist extension Grasp your child's hand and bend their wrist backwards. 2. Finger extension Hold your child's fingers and straighten all of their joints fully. NB: exercises 1 and 2 may be combined. 3. Thumb extension Grasp your child's thumb and straighten it fully making sure that you stretch the space between their thumb and index finger.

12 Exercises when playing Your physiotherapist will advise you on which playing exercises are appropriate for your child. These exercises may be performed as often as you like and are to be done in addition to the stretching passive range of movement exercises. Dependent upon the extent of your child's injury you may have to assist the affected arm with these exercises. Reaching exercises 1. Place your child on the floor and suspend or hold a toy above them. Encourage your child to reach for the toy especially with their affected arm. 2. Lay your child on their side with the affected arm uppermost. You may need to support your child in this position by placing cushions or rolled up towels at their back and in front of them. Put toys in front of them to encourage activity of the affected arm. Support / weight bearing exercise 1. Place your child on the floor on their front with their arms forward, initially you may need a rolled up towel under their chest to support them. Encourage them to put weight through their affected arm and then progress this exercise by encouraging them to reach for a toy with each arm.

13 Co-ordination/two handed exercise 1. Place you hands on your child's arms and encourage them to reach for a toy in front of them with both hands (assist the affected arm as necessary). You can also do clapping with them to encourage the use of both hands. This can be done with your child lying on their back or in a sitting position. Sensation exercises 1. To aim to increase awareness and sensation of your child's arm, stroke and massage their arm or rub the skin with various textures. Velvet or fleecy materials may be used for soft sensations and coarser materials like a bath towel for rough sensations. Encourage your child's awareness of their arm by involving it in all activities e.g. bringing their hand to their mouth and face or clapping their hands together. Handling your child When handling your child special care and attention does not have to be given to the affected arm and you should not be afraid to touch or handle your child's arm. However, it is important that you teach family and friends to not pull or lift your child by their affected arm.

14 Occupational Therapy What is Occupational Therapy? Occupational Therapy aims to promote the maximum level of functional independence for your child. They will assess your child's abilities and difficulties in daily and school life and liaise, if required, with appropriate personnel at your child's school, local hospital or Social Services. Your child may also be referred for a splint in order to support or gain the best possible function of their arm. Where will I see them? Your child may first be referred by the Doctors or the Physiotherapist whilst attending the Children's Hand Clinic. Your child may be seen in that clinic or may be asked to attend the Occupational Therapy Department as an out-patient. If you live a distance from St James's Hospital, then a referral can be made to your local Occupational Therapist with your consent. What does Occupational Therapy involve? Your child may require a thermoplastic splint for their affected arm. This will be made by the Occupational Therapist and you will be given instructions on how to care for it. Advice may be given to assist your child with personal activities of daily living such as washing, dressing and feeding. Advice may be given about suitable play activities to promote functional independence and dexterity. Provision of specialist equipment to assist your child's independence in daily living tasks may be recommended. Provision of relevant information on local resources and liaison on your behalf with community services if appropriate. Clinical Psychology During the course of your child's treatment you or your child may meet one of the Clinical Psychologists. The birth of a baby with OBPP can be a traumatic and distressing time and you may go through a range of emotional reactions. In time, your child may also need to adjust to the effects of their injury. The psychologists in the team are all used to seeing families in this situation and understand that it takes time to adjust. When will I see them? This may be in Children's Hand Clinic, on the ward or at a Clinical Psychology outpatient appointment, and could be at any stage as needed, from soon after the birth to much later on in the process. Sometimes another member of the team may suggest that a referral to us would be helpful, or you could request to see us yourself.

15 Some of the reasons why children and families see one of the Psychologists: Parents: Adjusting to OBPP. - The birth - Being given the diagnosis - The loss of arm function and the potential impact of this - Waiting for any recovery Having to think through surgical options at a time when it may be difficult to make decisions. Coping with the surgical process. For support through the course of recovery. Children: Coping with the loss of arm function. Coping with looking different. Dealing with the reactions of others (including questions, staring, teasing or bullying). Thinking through surgical options. Feeling anxious about undergoing surgery. What to expect when you or your child sees the Psychologist: You will usually see the psychologist for about an hour, but this may be shorter if you are seen in Children's Hand Clinic or as an inpatient and have other treatments to fit in. You may be offered a series of appointments depending on what you decide with your psychologist. You will always see the same psychologist. The content of each session will depend on the reason for your referral. Whatever the circumstances, your psychologist will want to listen to what you have to say and to understand the difficulties that you are experiencing. S/he will discuss the possible next steps with you. S/he might suggest gathering more information to get a clearer picture of your situation or to offer you help with your problems (e.g. this may involve filling out some questionnaires). Your views are important. Your psychologist will ask for your consent before doing anything more. Your psychologist will also give you information about confidentiality at your appointment. If you are not sure whether you need to see a Psychologist, talking to another member of the team may help you decide, or you could see one of the psychologists for a discussion about appointments and what they may involve.

16 Support Groups You may wish to speak to other families that have children with obstetrical brachial plexus palsy for advice and support. The Erb's Palsy Group has been running successfully for over 13 years and is registered as a charity. The aims of the group are to offer help to parents and professionals by: Giving support to parents, adults and children. Putting parents in contact with each other. Producing quarterly newsletters. Helping obtain medical information. Advising on benefits and aids for the children. Holding annual events for families. Producing many information sheets on OBPP and treatments available. Holding annual education days for professionals. To get further information you can visit their website on Alternatively you can contact Karen Hillyer by mail, phone or at:- 60 Anchorway Road, Coventry, CV3 6JJ Tel: or info@erbspalsygroup.com

17 Glossary of Terms A variety of terms and acronyms are used by medical staff. This glossary aims to help you understand this language:- ADL Anterior Avulsion injury Brachial Plexus Activities of Daily Living - things that you do on a day to day basis eg. wash your face. the front of the body or part. the nerve is pulled out from the spinal cord. Surgery cannot reattach this nerve to the spinal cord and is therefore aimed at nerve transfers. network of nerves that provide the movement and feeling to the arm. C5, C6, C7, C8, T1 names given to different levels of your spine which your nerves leave from. 'C' is the cervical (neck) bones and the 'T' stands for the thoracic (chest) bones. The numbers relate to the level that the nerve leaves from. Cervical Vertebrae bony parts of your neck. Distal any point of the body furthest from the head eg. the hand is distal to the elbow. Horner's Syndrome this is characterised by drooping of the eyelid and a small pupil on the same side as the injured arm. This occurs following damage of the T1 nerve. Lateral Medial towards the side of the body. situated towards the midline of the body. Multidisciplinary Te a m (MDT) a group of people which will include clinicians from different areas ie: doctors, nurses, physiotherapists, occupational therapists, clinical psychologists. Nerve grafts Nerve transfers Neurapraxia a nerve is taken out from somewhere else in your body (e.g. the sural nerve from your leg) and reattached to bridge the gap between the damaged nerves in your arm. a nerve is redirected from elsewhere in your body to the healthy distal part of your nerve eg. intercostal nerves (from your chest) to musculocutaneous nerve (in your arm) that supplies the biceps muscle. the nerve is damaged but intact, and heals without surgery.

18 Glossary of Terms cont. OPD PDC Posterior Proximal Rupture Outpatient Department. Plastics Dressing Clinic. the back of the body or part. any point of the body nearest to the head eg. the elbow is proximal to the hand. the nerve is completely torn in the neck and can be operated on by means of nerve grafts.

19 Questions There will be times when you think of questions that you want to ask the clinicians when you attend the hospital. Please feel free to use the space below to write these down ready for your next appointment.

20 Further appointments Please feel free to use the space below to write your further appointments at this hospital. If for whatever reason you are unable to attend any of your appointments please contact the relevant person as soon as possible (contact numbers are found at the front of this information booklet). Appointments can always be rearranged or cancelled and given to someone else. If you forget to attend any of your appointments please phone us as soon as possible and we will advise you on how to obtain a further appointment. If you move or change telephone numbers then please inform your consultant's secretary so that your records can be updated for future appointments. Clinic Date Time

21 Other Information Other information about your injury (section to include details of operation, follow up letters, correspondence to other clinicians).

22 Authors Many thanks to all of the people invoved in the formation of this booklet. Joy Barrowclough Maggie Bellew Helene Boonin Grainne Bourke Paul Brown Jane Haworth Fiona Jones Simon Kay Yvonne Lewis Chris Maddison Sarah Taplin Staff nurse Consultant Clinical Psychologist Senior Occupational Therapist Consultant Plastic, Hand and Reconstructive Surgeon Chief Medical Artist Chartered Clinical Psychologist Physiotherapy Practitioner in Hand Surgery Consultant Plastic, Hand and Reconstructive Surgeon Senior Sister Sister, Children's Dressing Clinic Associate Improvement Facilitator Acknowledgements We would like to thank the Physiotherapy, Occupational Therapy and Plastic Surgery Staff at the Royal Children s Hospital, Melbourne who kindly gave us permission to reproduce some of the figures and text used in this booklet.

23 MID