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Updated: Dec 29 2023

Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy)

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  • 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
    • 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
          • return of elbow flexion by three months is associated with recovery in vast majority (up to 100%) of patients
      • 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
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