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 sublux
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 wi
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 fu
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

Group
Group I (Duchenne-Erb's Palsy)
Group II (Intermediate Paralysis)
Group III (Total Brachial Plexus Palsy)
Group IV (Total Brachial Plexus Palsy with
Horner's syndrome)
Narakas Classification
Roots Characteristics
Paralysis of deltoid and biceps. Intact wrist an
C5-C6
flexion/extension.
C5-C7 Paralysis of deltoid, biceps, and wrist and dig
wrist and digital flexion.
C5-T1 Flail extremity without 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
muscle strength grading system
M0 - no contraction
M1 - contraction without movement
M2 - contraction with slight movement
M3 - complete movement
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
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 co
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
Clarke's pectoral transfer and Steindler's flexoplasty
indications
lack of elbow flexion
Anterior capsular release, biceps/brachialis tendon lengthening
For severe, persistent contracture

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palsy