9.4 Pediatric Brachial Plexopathy & Congenital Disorders

ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

9.4 Pediatric Brachial Plexopathy & Congenital Disorders

Key Takeaways Explain This Topic AI

Obstetric Brachial Plexus Palsy (OBPP) results from traction during delivery; Erb-Duchenne palsy (C5-C6) presents with a 'waiter's tip' posture, while Klumpke palsy (C8-T1) presents with a claw hand and ipsilateral Horner syndrome.

Primary surgical indication for OBPP nerve reconstruction (grafting or nerve transfer) is the absence of active biceps recovery (elbow flexion against gravity) by 3-6 months of age.

Osteogenesis Imperfecta (OI) stems from COL1A1/COL1A2 mutations affecting Type I collagen; Type I is mild with blue sclera, Type II is perinatal lethal, Type III is severe deforming, and Type IV is moderate.

Bisphosphonates (pamidronate, zoledronic acid) and intramedullary telescoping rodding (Fassier-Duval rods) are key medical and surgical treatments for bone fragility in OI.

Oligoarticular JIA (≤4 joints) carries a high risk of asymptomatic chronic anterior uveitis requiring mandatory slit-lamp eye screening every 3-4 months to prevent vision loss.

Last updated: July 2026

Obstetric Brachial Plexus Palsy (OBPP)

Obstetric Brachial Plexus Palsy (OBPP) occurs in 0.5-3 per 1,000 live births, caused by traction applied to the fetal head/neck during delivery. Risk factors include shoulder dystocia , birth weight >4,000 g, maternal diabetes, and breech presentation.

Clinical Subtypes and Postural Deformities
Erb-Duchenne Palsy (Upper Trunk Injury)

Nerve Roots : C5 and C6 (± C7).

Paralyzed Muscles : Deltoid, supraspinatus, infraspinatus, biceps brachii, brachialis, supinator.

Deformity Posture : "Waiter's Tip" posture — shoulder adducted and internally rotated, elbow extended, forearm pronated, wrist flexed.

Reflexes & Hand Function : Biceps reflex absent ; hand grasp and finger movement are completely intact (C8-T1 spared).

Klumpke Palsy (Lower Trunk Injury)

Nerve Roots : C8 and T1 .

Paralyzed Muscles : Hand intrinsics (interossei, lumbricals, thenar, hypothenar), wrist flexors, long finger flexors.

Deformity Posture : Claw hand deformity — supination of forearm, MCP joint hyperextension, IP joint flexion.

Horner Syndrome : Preganglionic sympathetic fiber involvement at T1 causes ipsilateral Horner syndrome ( ptosis, miosis, anhidrosis ). Indicates severe T1 root avulsion.

Total Brachial Plexus Palsy

Nerve Roots : C5 through T1 . Complete flaccid limb paralysis, total sensory loss, Horner syndrome.

OBPP Subtype Nerve Roots Involved Key Muscles Affected Characteristic Deformity Posture Associated Clinical Sign

Erb-Duchenne C5 - C6 (± C7) Deltoid, Biceps, Infraspinatus "Waiter's tip" (adducted, int. rotated) Intact hand grasp; absent biceps reflex

Klumpke C8 - T1 Hand intrinsics, finger flexors Claw hand (MCP hyperextension, IP flexion) Horner syndrome (ptosis, miosis, anhidrosis)

Total Plexus C5 - T1 Entire upper extremity Complete flaccid paralysis Sensory loss, Horner syndrome
Rehabilitation and Secondary Orthopedic Deformities

Spontaneous recovery occurs in 80-90% of infants within 3 months. Physical therapy uses daily passive range of motion (PROM) starting at 3 weeks to prevent shoulder internal rotation contractures (subscapularis contracture leading to glenohumeral dysplasia and posterior humeral head subluxation). Secondary reconstructive procedures for established joint deformities include latissimus dorsi or teres major to infraspinatus tendon transfers and humeral derotation osteotomies.

Surgical Decision-Making for Primary Nerve Repair

The definitive clinical indication for surgical referral (nerve grafting or Oberlin biceps nerve transfer) is absence of active biceps recovery (elbow flexion against gravity) by 3 to 6 months of age .

Osteogenesis Imperfecta (OI)

Osteogenesis Imperfecta (OI) ("brittle bone disease") is a genetic disorder of connective tissue marked by bone fragility, recurrent fractures, low bone mass, and short stature.

Molecular Etiology

Over 85-90% of cases are autosomal dominant mutations in COL1A1 or COL1A2 genes encoding Type I collagen —the primary structural protein of bone, dentin, sclera, and ligaments.

Sillence Classification (Types I through IV)

Type I (Mild, Non-Deforming) : Most common form. Quantitative reduction in normal Type I collagen. Features near-normal height, blue sclerae (thin scleral collagen showing choroidal veins), childhood fractures, joint hypermobility, conductive hearing loss, ± dentinogenesis imperfecta (DI).

Type II (Perinatal Lethal) : Most severe. Intrauterine fractures, crumpled ribs ("beaded ribs"), accordion femurs. Death occurs perinatally from respiratory insufficiency.

Type III (Severe, Progressively Deforming) : Most severe non-lethal form. Fractures present at birth, severe progressive limb deformities, marked short stature, triangular facies, kyphoscoliosis. Sclerae are blue at birth, turning white in childhood.

Type IV (Moderate, Deforming) : Moderate fragility/deformation. Sclerae are normal (white) . Short stature, recurrent fractures, DI common.

OI Type Severity Sclera Color Bone Deformity Collagen Defect
Type I Mild, non-deforming Blue Minimal / None Quantitative reduction
Type II Perinatal lethal Dark Blue Extreme / Intrauterine fractures Structural disruption (fatal)

Type III Severe, progressively deforming Blue at birth → White Severe, progressive deformities Structural disruption

Type IV Moderate, deforming Normal (White) Mild to moderate Structural disruption
Multidisciplinary Management

Bisphosphonate Pharmacotherapy : Intravenous pamidronate or zoledronic acid is standard of care. Inhibits osteoclasts, increases cortical bone density, reduces fracture frequency, and relieves bone pain.

Orthopedic Surgery : Intramedullary rodding with telescoping rods ( Fassier-Duval rods ) that elongate during growth to realign bones and prevent fractures.

Rehabilitation Precautions : Avoid rotational/torsional forces. Hydrotherapy provides low-impact strengthening without fracture risk.

Juvenile Idiopathic Arthritis (JIA)

Juvenile Idiopathic Arthritis (JIA) is chronic inflammatory arthritis lasting >6 weeks in a child under 16 years.

Clinical Subtypes

Oligoarticular JIA : Affects ≤4 joints in the first 6 months (~50% of cases). Presents in young girls (<6 years) affecting large joints (knees, ankles). High ANA positivity (70-80%).

Complication : Chronic Asymptomatic Anterior Uveitis . Risk of blindness without ocular pain or redness. Mandatory screening : Slit-lamp ophthalmologic exam every 3 to 4 months .

Polyarticular JIA : Affects ≥5 joints in the first 6 months. RF-positive or RF-negative. Symmetrical involvement of small and large joints.

Systemic JIA (Still Disease) : High-spiking ( quotidian ) fevers, evanescent salmon-pink maculopapular rash, lymphadenopathy, hepatosplenomegaly, serositis.

Complication : Macrophage Activation Syndrome (MAS) —life-threatening hyperinflammation with cytopenias, coagulopathy, extreme hyperferritinemia, and hepatosplenomegaly. Treated urgently with high-dose corticosteroids and IL-1 blockade (anakinra).

Rehabilitation Management

Medications : NSAIDs, intra-articular steroid injections (triamcinolone hexacetonide), DMARDs (Methotrexate), biologics (anti-TNF etanercept/adalimumab; anti-IL-1/IL-6 for systemic JIA).

Rehab Interventions : Resting wrist extension splints, active-assisted ROM during flares, resistive strengthening in remission, joint protection, low-impact exercise (swimming).