Upper Limb Orthotics/Brachial Plexus Lesion (Klumpke's Palsy)

Describe your case study

For example:

The patient is a 25 year old female who suffered a crush injury at work. She works as a PE teacher at a high school, an air compressor fell off a shelf onto her arm where she was trapped. The patient has a fixed focal dystonia which has resulted in a flexion contracture the right wrist and digits.

The resting position of the wrist is 45 degrees of flexion, however, on manipulation this can be corrected to 22 degrees flexion. The digits are fully flexed (100 degrees) and the thumb is in an abducted (45 degrees) and flexed position (80 degrees).

The patient is currently undergoing botulism toxin treatment to try to reduce the contracture.

The patient would like to be able to return to work, playing basketball and complete self-care activities.

Introduction

Located in the shoulder region of one’s body, the brachial plexus is a network of nerve fibers responsible for cutaneous and muscular innervation of the upper limb. Injuries to this area, also known as lesions, can cause severe functional impairment (Moore, 2007). Klumpke’s Palsy, also known as Dejerine – Kumpke Palsy, is a medical condition where injury to the brachial plexus, specifically the severing of the lower trunk C8 and T1 nerves, leads to the paralysis of the arm (Totora & Anagnostakos, 1990).

Anatomy

Klumpke’s Palsy mainly affects the intrinsic muscles of the hand (the interossei, thenar and hypothenar muscles) and the flexors of the wrist and fingers (the flexor carpi ulnaris and ulnar half of the flexor digitorum profundus) (Rowland, 2010) Furthermore, the forearm pronators and wrist flexors may also be affected, although it is less common. A classic visual presentation of Klumpke’s palsy is the “claw hand”where the forearm is supinated and the wrist and fingers are flexed, similar to those of a bird’s claw.

Etiology

Klumpke’s Palsy is results from difficulties in childbirth, most commonly from a traumatic vaginal delivery where the newborn’s shoulders become impacted and the brachial plexus nerves stretch or tear (Hill, 2008). In addition, the risk is greater the smaller the mother and the heavier the weight of the newborn being delivered is (Pham, 2011).

Orthotic Treatment Options

Treatment options for Klumpke’s Palsy differ depending on the severity exhibited by the patient. In most cases, an introduction of a passive range of motion program is recommended with a further combination of occupational therapy (OT) and Physical Therapy (PT) (Maria, 2005). In more severe cases surgical intervention will be required (Maria, 2005).

In terms of Orthotic treatments, it’s main treatment is to assist in movements where muscle weakness is exhibited. (Ruchelsman et al, 2008). Early orthoses will usually focus on wrist extensions and progress to wrist supination (Maria, 2005). Both static and dynamic orthoses are then prescribed and may be used separately or concurrently, depending on the patient’s movement and functional goals (Ruchelsman et al, 2008).

References

Pham CB, Kratz JR, Jelin Ac, Gelfand AA. Child neurology: brachial plexus birth injury: what every neurologist needs to know. Neurology. 2011. 77:695-697.

Hill A. Neurological problems of the newborn. In: Bradley WG et al. Neurology in Clinical Practice, 5th ed. Philadelphia, PA: Butterworth-Heinemann; 2008;

Ruchelsman, D. E., Pettrone, S., Price, A. E., & Grossman, J. A. (2008). Brachial plexus birth palsy: An overview of early treatment considerations. Bulletin of the NYU hospital for joint diseases, 67(1), 83-89. http://0-web.b.ebscohost.com.alpha2.latrobe.edu.au/ehost/pdfviewer/pdfviewer?sid=37d6c644-d5a0-4d31-b021-aa7795d182f0%40sessionmgr114&vid=2&hid=125 Moore, K.L.; Agur, A.M. (2007). Essential Clinical Anatomy (3rd ed.). Baltimore: Lippincott Williams & Wilkins. pp. 434–5. ISBN 978-0-7817-6274-8.

Maria, B. (2005). Clinical management in child neurology: Birth brachial plexus palsy. (3rd ed., Vol. 84, pp. 546-550). BC Decker Inc. Retrieved from http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/CHILD NEUROLOGY/docs/ch84.pdf

Tortora, G.J., & Anagnostakos, N.P. (1990). Principles of Anatomy and Physiology (6th ed.). New York: Harper & Row. ISBN 0-06-046694-4. pp.370–374

Page 512: Lower Radicular Syndrome (Klumpke Paralysis) in: Pedley, Timothy A.; Rowland, Lewis P.; Merritt, Hiram Houston (2010). Merritt's neurology. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-9186-3.

(Pendleton 942)Pendleton, Heidi McHugh. Pedretti's Occupational Therapy: Practice Skills for Physical Dysfunction, 6th Edition. C.V. Mosby, 052006.

An infant with the "claw hand" posture

An example of a pair of hand orthotics for Klumpke's Palsy

Functional Aims and Goals

The main functional goal of an orthotic treating Klumpke’s Palsy is to correct the common symptom of “claw hand”; the forearm is supinated and the wrist and fingers are flexed, forming a hand posture that is visually similar to a bird claw. The correct this posture the fingers must be placed straight with the thumb facing somewhat perpendicular, forming a rough “L” shaped posture. Furthermore, the wrist has to be in a neutral position to prevent the wrist flexors from activating.

Design

Force Diagram

Material Used Low temperature thermoplastic Brown wrapping paper (for tracing) Soft foam/EVA (Used for Padding) 2cm and 4cm Velcro hook and strap

Manufacturing process

1.) Create a template for the hand orthotic. Trace client’s hand onto a piece of tracing paper. Patient’s hand should be in neutral with his/her fingers extended and flat. The client’s thumb should be extended at a comfortable angle. Make sure approximately 2/3 of the client’s forearm is included in the tracing.

2.) Verify template. If needed, place the cut out template on patient’s hand for verification. Make adjustments accordingly.

3.) Trace template onto sheet of Low Temperature Thermoplastic (LTT). Allow an extra 2-3cm margin to cover the circumference of the client’s hand and forearm.

4.) Cut the LTT template with shears.

5.) Heat up the LTT in a hot water bath to soften it.

6.) Place client’s hand and forearm in optimal molding position. Client’s hand should be similar to the tracing template. Ask client to maintain hand position during the molding process (please refer to figure 1 for hand molding shape).

7.) Mold LTT onto patient.

8.) Trim excess materials.

9.) Form crease marks on the thumbhole and the lateral sides of the phalanges (Left side of the index finger and right side of the pinky finger).

10.) Flare the distal end.

11.) Check the fit of the device on client. Make adjustments accordingly.

Critique of Fit

The Client

Client is a 6-month-old male with who had a “traumatic” vaginal delivery. Specifically, the infants’ arm was extended above the head during the delivery, leading to the surgeons having to pull the patient out of the womb or suffer being strangled and suffocated by the umbilical chord due to the initial awkward position the patient was in.

Subjective Assessment

Upon interviewing the parents of the client, the patient has no prior history of chronic pain. Patient has no prior history of medication. The patient’s parent’s goal is to fix the “hand deformity” that is exhibited in the patient’s right hand.

Objective Assessment

A physical examination was completed and revealed that there is deficiency exhibited in the small muscles of the right hand. Furthermore, the patient’s right wrist is in extreme extension (probably due to unopposed wrist extensors), his MCP in hyperextension (due to loss of intrinsic hand muscles), and flexion of the IP joints (due to loss of intrinsic hand muscles). This forms a hand shape like that of a bird’s talon, which is a classic visual presentation of a “claw hand” formation that is a common symptom of a lower brachial palsy lesion, also known as Klumpke Palsy. This diagnosis is further confirmed by the patent exhibiting the Horner’s syndrome, which is the combination of visual presentation of drooping of the eyelids (ptosis) and constriction of the pupil (miosis)

Diagnosis

Patient is diagnosed with Klumpke Palsy.

Orthotic Goals

The goal of the orthotic is to function as a night splint for the infant, with hopes of slowly correcting the “claw hand” symptom that is exhibited commonly with infants who have Klumpke palsy.

Presenting The Device

The night splint is made of Low Temperature Thermoplastic (LTT). 4 straps (distal end of forearm, wrist, fingers/phalanges and around the thumb) were used to secure the patient’s hand, with padding added for comfort. The partial thumbhole and the distal part of the phalanges are flared to prevent unnecessary friction and contact.

One issue that the night splint has is that the splint is pinching the patient at the wrist. This problem probably stemmed from the molding process capturing the contour of the patient’s hand too intricately. To remedy this problem in the future I will expand the LTT at the wrist slightly right after the molding process to give the patient more space for the wrist to fit into the night splint.

Outcome measures

There are a variety of outcome measures available for the upperlimb functional ability. Choose an appropriate measure (if you are having trouble finding some the TAC website for clinical resources here may be useful.

Complete this for your client (using your clinical knowledge and judgement) for before and after the client receives the orthosis. Choose activies that you believe the client would have improved on and video your client undertaking these whilst wearing their orthoses. Outline your finding. Provide images of the completed Outcome measure on your wikipage.

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