|
https://upload.orthobullets.com/topic/4117/images/erb3.jpg
https://upload.orthobullets.com/topic/4117/images/screen_shot_2014-05-25_at_8.51.35_pm.jpg
https://upload.orthobullets.com/topic/4117/images/Brachial Plexus with sensory 566_moved.jpg
https://upload.orthobullets.com/topic/4117/images/34_moved.JPG
https://upload.orthobullets.com/topic/4117/images/erb2.jpg
Introduction
  • 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
 
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
      • 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 (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
Complications
  • failure of nerve reconstruction
    • important to discuss preoperatively with parents
  • phrenic nerve palsy
    • if persist may require diaphragm plication
 

Please rate topic.

Average 3.9 of 51 Ratings

Questions (16)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(OBQ12.160) Which of the following is the most common long term consequence of untreated brachial plexus birth palsy? Review Topic

QID: 4520
FIGURES:
1

Figure A

56%

(1945/3453)

2

Figure B

3%

(113/3453)

3

Figure C

9%

(327/3453)

4

Figure D

5%

(166/3453)

5

Figure E

25%

(867/3453)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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? Review Topic

QID: 4578
1

Claw hand

5%

(122/2457)

2

Fixed adduction and internal rotation at shoulder with elbow extension

8%

(205/2457)

3

Hyperextension of the MCP joints and flexion of the IP joints of the hand

5%

(128/2457)

4

Weakness in elbow flexion

3%

(78/2457)

5

Normal physical exam without deficits

77%

(1898/2457)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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?
Review Topic

QID: 3161
1

>90%

12%

(201/1696)

2

75%

7%

(115/1696)

3

50%

5%

(93/1696)

4

25%

12%

(196/1696)

5

<10%

64%

(1084/1696)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 618
1

Trapezius

5%

(50/1013)

2

Triceps

1%

(8/1013)

3

Biceps

92%

(937/1013)

4

Interossei

1%

(8/1013)

5

Flexor digitorum profundus

0%

(5/1013)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 3655
1

Loss of hand function with preserved shoulder function

21%

(475/2241)

2

Absent shoulder abduction and external rotation with intact wrist and digit flexion and extension

72%

(1624/2241)

3

Rotator cuff dysfunction, elevated hemidiaphragm, and absence of rhomboid function

1%

(22/2241)

4

Loss of shoulder and wrist function

1%

(23/2241)

5

Ptosis, myosis and anhydrosis

4%

(86/2241)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
ARTICLES (32)
VIDEOS (1)
GROUPS (1)
Topic COMMENTS (41)
Private Note