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  • Injury to the brachial plexus during birth
    • usually a stretching injury from a difficult vaginal delivery
    • some rare cases reported following C-sections
  • Epidemiology
    • incidence
      • approximately 1 to 4 per 1,000 live births
      • decreasing in frequency due to improved obstetric care
    • often right sided or bilateral
    • risk factors
      • large for gestational age (macrosomia)
      • multiparous pregnancy
      • difficult presentation
      • shoulder dystocia
      • forceps delivery
      • breech position
      • prolonged labor
  • 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
  • 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 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 
        • C7 involvement
        • Klumpke's Palsy
  • Brachial plexus diagram 
 Narakas Classification
Group  Roots 
Group I (Duchenne-Erb's Palsy) C5-C6 Paralysis of deltoid and biceps. Intact wrist and digital flexion/extension.
Group II (Intermediate Paralysis)
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
      • 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
  • 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
    • 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 (neurotization)
      • 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
    • 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
  • failure of nerve reconstruction
    • important to discuss preoperatively with parents
  • phrenic nerve palsy
    • if persist may require diaphragm plication

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