summary Obstetric Brachial Plexopathy is injury to the brachial plexus that occurs during birth usually as a result of a stretching injury from a difficult vaginal delivery. Diagnosis is made clinically and depends on the nerve roots involved. Treatment can be observation or operative depending on the nerve roots involved, the severity of injury, and the location of the nerve injury. Epidemiology Incidence approximately 1 to 4 per 1,000 live births decreasing in frequency due to improved obstetric care Anatomic location often right sided or bilateral Risk factors large for gestational age (macrosomia) multiparous pregnancy difficult presentation shoulder dystocia forceps delivery breech position prolonged labor Etiology Cause usually a stretching injury from a difficult vaginal delivery some rare cases reported following C-sections Associated orthopedic 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) clavicle and humerus fractures torticollis Anatomy Brachial plexus diagram Narakas Classification Group Characteristics Roots Group I (Duchenne-Erb's Palsy) Paralysis of deltoid and biceps. Intact wrist and digital flexion/extension. C5-C6 Group II (Intermediate Paralysis) Paralysis of deltoid, biceps, and wrist and digital extension. Intact wrist and digital flexion. C5-C7 Group III (Total Brachial Plexus Palsy) Flail extremity without Horner's syndrome C5-T1 Group IV (Total Brachial Plexus Palsy with Horner's syndrome) Flail extremity with Horner's syndrome C5-T1 Waters Classification of Glenohumeral Deformity Waters Classification of Glenohumeral Deformity Classification Radiographic features Type I < 5 degree difference in retroversion Type II > 5 degree difference in retroversion Type III Posterior humeral head subluxation < 35% anterior to scapular spine axis Type IV Presence of false glenoid Type V Flattening of humeral head, progressive/ complete humeral head dislocation Type VI Infantile posterior dislocation Type VII Proximal humeral growth arrest 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 Vojta reflexes pain with gentle shaking of a flail arm may indicate pseudoparalysis from infection or fracture rather than nerve palsy Hospital for Sick Children Active Movement Scale (AMS) muscle strength grading system full range of motion with gravity eliminated (score of 4) must be achieved before higher scores may be assigned Imaging Radiographs may be useful for evaluation of clavicle or humerus fractures limited utility in infant given minimal ossification of humeral head and glenoid axillary view to evaluate position of humeral head if patient is older and suspicion is high for joint subluxation Myelography/CT myelography/MRI may be used to distinguish between root avulsion and extraforaminal rupture EMG/NCV poor reliability and often underestimate the severity of injury Ultrasound allows for assessment of joint subluxation or dislocation Erb's Palsy (C5,6) - Upper Lesion Most common type Mechanism results from lateral flexion of the head towards the contralateral shoulder with depression of the ipsilateral 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 and brachialis 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 (C5-T1) Mechanism stretch, rupture, and avulsion injury Physical exam flaccid arm both motor and sensory deficits Imaging chest radiograph to look for ipsilateral hemidiaphragm paralysis from phrenic nerve injury Prognosis worst prognosis Treatment - General Nonoperative observation & daily passive exercises by parents indications first line of treatment for all obstetric brachial plexopathies while awaiting return of function key to treatment is maintaining passive motion while waiting for nerve function to return Operative microsurgical nerve grafting indications lack of antigravity biceps function between 3-9 months of age postganglionic injury with intact nerve roots with segmental injury to nerve outcomes improved outcomes are seen with shorter grafts (<10cm) nerve transfer or neurotization definition nerve transfer refers to fascicles from one nerve transferred into a nother nerve that supplies a muscle neurotization refers to placing nerve fascicles directly into a neuromuscular junction of a muscle indications lack of antigravity biceps function between 3-9 months of age preganglionic injury or avulsion of nerve roots Treatment - Shoulder Dislocation & Contractures Operative soft tissue procedures latissimus dorsi and teres major transfer (Hoffer procedure) indication persistent internal rotation contracture or external rotation weakness without glenohumeral dysplasia technique pass tendons posteriorly around humerus to create external rotation forces pectoralis major and +/- subscapularis lengthening indication to lessen the internal rotation forces may be used in conjunction with tendon transfers arthroscopic release for internal rotation contractures bony procedures proximal humeral derotation osteotomy (Wickstrom) indication persistent internal rotation contracture or external rotation weakness with glenohumeral dysplasia arthrodesis indication non-functional deltoid with good function of hand and wrist Treatment - Elbow Flexion Contracture Nonoperative serial nighttime elbow extension splinting indications for elbow flexion contracture <40 degrees outcomes prevents progression, does not correct contracture serial elbow extension casting indications for elbow flexion contracture >40 degrees Operative anterior capsular release, biceps/brachialis tendon lengthening indications for severe, persistent contracture outcomes may have high recurrence rate Treatment - Forearm Operative indications residual supination contracture of the forearm technique biceps rerouting tendon transfer intact passive passive pronation forearm osteotomy with biceps rerouting tendon transfer limited passive forearm pronation Treatment - Wrist and hand Operative indications replace function for a paralyzed muscle force is preportional to cross-sectional area of the muscle amplitude is proportional to the length of the muscle technique tendon transfers wrist drop pronator teres to ECRB loss of finger extension FCR or FCU to EDC 2-5 thumb abduction EIP to abductor pollicis brevis Complications Initial nerve inury phrenic nerve palsy if persistent may require diaphragm plication Surgical complications shoulder tendon transfers radial and axillary nerve palsies Phrenic nerve palsy if persist may require diaphragm plication 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 anti-gravity by 3 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 C7 involvement Klumpke's Palsy
QUESTIONS 1 of 22 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.51) An infant is diagnosed with the most common brachial plexopathy. Which of the following correctly pair the muscle innervation and recovery timeline correlated with a good prognosis for full recovery? QID: 212947 Type & Select Correct Answer 1 Muscle innervated by the ulnar nerve; 3 months 4% (76/1782) 2 Muscle innervated by the anterior interosseous nerve; 4 months 3% (46/1782) 3 Muscle innervated by the musculocutaneous nerve; 1 year 7% (133/1782) 4 Muscle innervated by the axillary nerve; 1 year 5% (92/1782) 5 Muscle innervated by the musculocutaneous nerve; 3 months 80% (1423/1782) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ18.1) The most common obstetric brachial plexus injury will present with which of the following deficits? QID: 212897 Type & Select Correct Answer 1 Paralysis of deltoid and biceps; weak wrist and digit extension 64% (1075/1683) 2 Paralysis of deltoid and biceps 31% (523/1683) 3 Paralysis of FCR, FCU, FDS, FDP and interossei 3% (49/1683) 4 Flail extremity 1% (22/1683) 5 Flail extremity; myosis, ptosis, and anhydrosis 0% (5/1683) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.97) An infant first presents holding his limb in the position shown in Figure A. Birth history reveals that he was a large-for-gestational age infant and labor was prolonged. His orthopedist recommends passive stretching including shoulder abduction and external rotation. For which of the following scenarios is this an appropriate line of treatment? QID: 4732 FIGURES: A Type & Select Correct Answer 1 One-month-old infant with partial antigravity biceps strength. 84% (2788/3320) 2 Four-month-old infant with scapula winging and elevated hemidiaphragm. 3% (113/3320) 3 Seven-month-old infant with posterior glenoid dysplasia. 3% (96/3320) 4 Eight-month-old infant with recent anterior Z-lengthening of the subscapularis tendon. 5% (166/3320) 5 Five-month-old infant with recent ipsilateral latissimus dorsi and teres major transfer. 4% (131/3320) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ13.12) A 3-month-old infant holds his limb in the position seen in Figure A. Examination reveals winged scapulae, and absent rhomboid, rotator cuff and latissimus dorsi function. Which is the most appropriate treatment plan? QID: 4647 FIGURES: A Type & Select Correct Answer 1 Instruct the parents to perform passive shoulder abduction and external rotation, and elbow flexion exercises and reassess at 6 months of life. 62% (1687/2701) 2 Neuroma resection and sural nerve grafting 5% (139/2701) 3 Neuroma resection and direct brachial plexus repair 6% (169/2701) 4 Nerve transfer to biceps and brachialis branches of the musculocutaneous nerve using fascicles from median and ulnar nerves. 24% (661/2701) 5 Latissimus dorsi transfer 1% (33/2701) L 5 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ12.160) Which of the following is the most common long term consequence of untreated brachial plexus birth palsy? QID: 4520 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 57% (2385/4154) 2 Figure B 3% (136/4154) 3 Figure C 9% (390/4154) 4 Figure D 5% (192/4154) 5 Figure E 24% (1012/4154) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ12.218) A newborn child born via a difficult breech delivery is found to have a brachial plexus birth palsy. While initially born with a flail limb, the child regained elbow flexion at 10 weeks. At age 18 months (1.5 years old), which of the following deficits is most likely to be seen on physical exam? QID: 4578 Type & Select Correct Answer 1 Claw hand 5% (149/3147) 2 Fixed adduction and internal rotation at shoulder with elbow extension 8% (267/3147) 3 Hyperextension of the MCP joints and flexion of the IP joints of the hand 5% (159/3147) 4 Weakness in elbow flexion 3% (98/3147) 5 Normal physical exam without deficits 78% (2441/3147) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ11.232) A 3-month-old is brought to clinic for evaluation of a right upper extremity abnormaility present since birth. Which of the following physical exam findings is associated with the best functional outcome? QID: 3655 Type & Select Correct Answer 1 Loss of hand function with preserved shoulder function 20% (589/2905) 2 Absent shoulder abduction and external rotation with intact wrist and digit flexion and extension 73% (2128/2905) 3 Rotator cuff dysfunction, elevated hemidiaphragm, and absence of rhomboid function 1% (34/2905) 4 Loss of shoulder and wrist function 1% (35/2905) 5 Ptosis, myosis and anhydrosis 4% (106/2905) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ10.73) An infant is born with total brachial plexus palsy and Horner’s syndrome after a difficult vaginal delivery. What is the prognosis for spontaneous recovery of motor function in the involved arm by 3 months? QID: 3161 Type & Select Correct Answer 1 >90% 12% (281/2310) 2 75% 7% (151/2310) 3 50% 6% (134/2310) 4 25% 11% (249/2310) 5 <10% 64% (1484/2310) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.232) Which of the following muscles would be affected if a 6-month-old child sustains a birth-related brachial plexopathy affecting C5 nerve root? QID: 618 Type & Select Correct Answer 1 Trapezius 5% (86/1660) 2 Triceps 1% (22/1660) 3 Biceps 92% (1522/1660) 4 Interossei 1% (9/1660) 5 Flexor digitorum profundus 1% (14/1660) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07PE.35) In obstetrical brachial plexus palsy, which of the following signs is associated with the poorest prognosis for recovery in a 2-month-old infant? QID: 6095 Type & Select Correct Answer 1 Persistent inability to bring the hand to the mouth with the elbow stabilized at the side 20% (109/535) 2 Persistent inability to actively abduct the arm past 90 degrees 5% (25/535) 3 Persistent inability to externally rotate the shoulder past 20 degrees 2% (12/535) 4 Persistent unilateral ptosis, myosis, and anhydrosis 70% (376/535) 5 History of clavicle fracture at birth 1% (7/535) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07PE.10) An 18-month-old boy with obstetric brachial plexus palsy is being evaluated for limited right shoulder motion. Physical therapy for the past 6 months has failed to result in improvement of the contracture. Which of the following studies is necessary prior to any shoulder reconstruction? QID: 6070 Type & Select Correct Answer 1 Electromyography 58% (712/1238) 2 MRI of the shoulder joint 36% (450/1238) 3 MRI of the brain 3% (31/1238) 4 Radiograph of the elbow 3% (31/1238) 5 Aspiration of the right shoulder 1% (7/1238) L 5 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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