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Introduction
  • Injury to the brachial plexus during birth
    • usually a stretching injury from a difficult vaginal delivery
    • some rare reported in C-sections
  • Subtypes includes
    • Erb's Palsy (upper trunk C5-6)
      • Most common type 
    • Klumpke's Palsy (lower trunk C8-T1)
    • Total plexus injury
  • Epidemiology
    • incidence
      • approximately 1 to 4 per 1,000 live births
      • decreasing in frequency due to improved obstetric care
  • Pathophysiology
    • mechanism 
      • condition associated with
        • large for gestational age
        • multiparous pregnancy
        • difficult presentation
        • shoulder dystocia
        • forceps delivery
        • breech position
        • prolonged labor
  • Associated conditions
    • glenohumeral dysplasia 
      • increased glenoid retroversion, humeral head flattening, posterior humeral head subluxation
        • develops in 70% of infants with obstetric brachial plexopathy
        • caused by Internal rotation contracture (loss of external rotation)
    • elbow flexion contracture 
      • etiology is unclear, likely due to persistent relative triceps weakness (C7) compared with biceps (C5-6)
  • Prognosis 
    • 90% of cases will resolve without intervention 
      • spontaneous recovery may occur for up to 2 years
    • prognostic variables for spontaneous recovery
      • favorable 
        • Erb's Palsy
        • complete recovery possible if biceps and deltoid are M1 by 2 months
        • early twitch biceps activity suggests a favorable outcome  
      • poor 
        • lack of biceps function by 3 months
        • preganglionic injuries (worst prognosis)
          • avulsions from the cord, which will not spontaneously recover motor function
            • loss of rhomboid function (dorsal scapular nerve)
            • elevated hemidiaphragm (phrenic nerve)
        • Horner's syndrome (ptosis, miosis, anhydrosis)
          • less than 10% recover spontaneous motor function 
        • C5-C7 involvement
        • Klumpke's Palsy
Anatomy
  • Brachial plexus diagram 
Classification
 
 Narakas Classification
Group  Roots 
Characteristics
Group I (Duchenne-Erb's Palsy) C5-C6 Paralysis of deltoid and biceps. Intact wrist and digital flexion/extension.
Group II (Intermediate Paralysis)
 C5-C7
Paralysis of deltoid, biceps, and wrist and digital extension. Intact wrist and digital flexion. 
Group III (Total Brachial Plexus Palsy)
 C5-T1 Flail extremity without Horner's syndrome
Group IV (Total Brachial Plexus Palsy with Horner's syndrome)
 C5-T1 Flail extremity with Horner's syndrome
 
Presentation General
  • Symptoms
    • lack of active hand and arm motion  
  • Physical exam
    • upper extremity exam
      • arm hangs limp at side in an adducted and internally rotated position
      • decreased shoulder external rotation 
      • affected shoulder subluxates posteriorly
    • provocative testing
      • stimulate neonatal reflexes including Moro, asymmetric tonic neck and Votja reflexes
    • Toronto Scale muscle strength grading system
      • 0 - no motion
      • 1- motion present but limited
      • 2- normal motion
Erb's Palsy (C5,6) - Upper Lesion
  • Mechanism
    • results from excessive abduction of head away from shoulder, producing traction on plexus
      • occurs during difficult delivery in infants
  • Physical exam 
    • adducted, internally rotated shoulder; pronated forearm, extended elbow (“waiter’s tip”)
    • C5 deficiency
      • axilllary nerve deficiency
        • deltoid, teres minor weakness
      • suprascapular nerve deficiency
        • supraspinatus, infraspinatus weakness 
      • musculocutaneous nerve deficiency
        • biceps weakness 
    • C6 deficiency
      • radial nerve deficiency
        • brachioradialis, supinator weakness 
  • Prognosis
    • best prognosis for spontaneous recovery
Klumpke's Palsy (C8,T1) - Lower lesion
  • Mechanism
    • rare in obstetric palsy
    • usually arm presentation with subsequent traction/abduction from trunk 
  • Physical exam
    • deficit of all of the small muscles of the hand (ulnar and median nerves)
    • “claw hand”
      • wrist in extreme extension because of the unopposed wrist extensors
      • hyperextension of MCP due to loss of hand intrinsics
      • flexion of IP joints due to loss of hand intrinsics
  • Prognosis
    • poor prognosis for spontaneous recovery
    • frequently associated with a preganglionic injury and Horner's Syndrome
Total Plexus Palsy
  • Physical exam
    • flaccid arm
    • both motor and sensory deficits
  • Prognosis
    • worst prognosis
Treatment 
  • Nonoperative
    • observation & daily passive exercises by parents 
      • indications
        • first line of treatment for most obstetric brachial plexopathies
      • technique
        • key to treatment is maintaining passive motion while waiting for nerve function to returr
    • Elbow Flexion Contracture
      • Serial nighttime extension splinting
        • for contracture <40 degrees
        • prevents progression, does not correct contracture
      • Serial extension casting
        • for contracture >40 degrees
  • Operative
    • early surgical attempt at nerve restoration
      • microsurgical nerve repair or nerve grafting 
        • indications
          • complete flail arm at 1 month of age
          • Horner's syndrome at 1 month of age
          • lack of antigravity biceps function between 3-6 months of age
      • neurotization (nerve transfer)   
        • indications
          • root avulsion at 3 months of age
        • donor nerves
          • sural
          • intercostal
          • spinal accessory
          • phrenic
          • cervical plexus
          • contralateral C7
          • hypoglossal
    • posterior glenohumeral dislocation - late surgery
      • open reduction and capsulorrhaphy
        • indications
          • early recognition with minimal glenoid deformity
      • proximal humeral derotation osteotomy 
        • indications
          • late recognition, no glenoid present
    • Internal rotation contractures and glenohumeral joint dysplasia - late surgery
      • latissimus dorsi and teres major transfer to rotator cuff
        • indications 
          • persistent external rotation and abduction weakness, internal rotation contractures, and mild-to-moderate glenohumeral joint dysplasia
      • pectoralis major and +/- subscapularis lengthening
        • indications
          • <5 years of age
      • proximal humeral derotation osteotomy
        • indications
          • > 5 years of age
    • forearm supination contractures - late surgery
      • biceps tendon transfers
        • indications
          • supination contractures with intact forearm passive pronation
      • forearm osteotomy (radius +/- ulna) +/- biceps tendon transfer
        • indications
          • supination contractures with limited forearm passive pronation
    • elbow flexion contractures - late surgery.    
      • Consider Anterior capsular release, biceps/brachialis tendon lengthening for severe, persistent contracture
      • May have High recurrence rate
 
 

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