Rucksack paralysis

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Background

Brachial plexus surrounding the brachial artery.
Anatomical illustration of the brachial plexus with areas of roots, trunks, divisions and cords marked.
Dermatomes and cutaneous nerves - anterior
Dermatomes and cutaneous nerves - posterior
  • Brachial plexus injury as a consequence of carrying a heavy backpack frequently described in military population [1]
  • Seen also in boy scouts, hikers, mountaineering [2][3]
  • Also described secondary to wearing body armor [4]
  • Known by a variety of names: pack palsy,[5] backpack palsy, rucksack paralysis,[6] trekker's palsy, Pallbearer's palsy[7]
  • Decreased because of more ergonomically designed packs[8]

Clinical Features

  • Signs and symptoms vary depending on severity and location of injury
  • Most often present unilateral
  • Onset may be acute or subacute
  • Minor - electric shock, burning sensation shooting down the arm, numbness/weakness in arm
  • Severe - weakness/paralysis, numbness, severe pain
  • C5 injury:
    • weakness of deltoid and infraspinatus causes adducted, internally rotated shoulder
  • C6 injury:
    • weakness of biceps causes elbow extension
  • C7 injury:
    • weakness of extensor muscles causes wrist and digit flexion


Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

  • Typically clinical diagnosis
  • Electrodiagnostic studies EMG, NCV (non-emergent)
  • May consider CT, MRI

Management

  • Refrain from back use short term when patient resumes use a back with a frame and hip belt as this will reduce incidence of backpack palsy [9]
  • Surgical consultation (nonemergent, generally)
  • Physical therapy / occupational therapy

Disposition

  • Patients usually make full recovery
  • Outpatient treatment and follow-up with orthopedics if minor

See Also

External Links

References

  1. McCulloch, R., Sheena, Y., Simpson, C., et al. Brachial plexus palsy following a training run with a heavy backpack. J R Army Med Corps October 14, 2013 doi: 10.1136/jramc-2013-000139.
  2. Nylund T, Mattila VM, Salmi T, et al. Recovery of brachial plexus lesions resulting from heavy backpack use: a follow-up case series. BMC Musculoskelet Disord 2011;12:62.
  3. White HH. . Pack palsy: a neurological complication of scouting. Pediatrics 1968; 41:1001–3.
  4. Bhatt BM. ‘Top Cover Neuropathy’—Transient brachial plexopathy due to body armour. JRAMC 1990;136:53–4.
  5. Bom F. . A case of pack-palsy from the Korean War . Acta Psychiatr Neurol Scand 1953; 28:1–4.
  6. Daube JR. . Rucksack paralysis. JAMA 1969; 208:2447–52.
  7. Loni NK. . Pall-bearer's palsy . BMJ 1966; 2:808–9.
  8. De Luigi AJ, Pasquina P, Dahl E. Rucksack induced plexopathy mimicking a lateral antebrachial cutaneous neuropathy. Am J Phys Med Rehabil 2008;87:773–5.
  9. Knapik JJ, Reynolds KL, Harman E. Soldier load carriage: historical, physiological, biomechanical and medical aspects. Mil Med 2004; 169: 45-56.