BRACHIAL PLEXUS INJURY IN

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BRACHIAL PLEXUS INJURY IN
NEONATES LOURDES
ASIAIN February 2005
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BACKGROUND
1764 Obstetrical brachial palsy described by
Smellie. 1874 Wilhelm H. Erb described
brachial plexus paralysis in adults which
involved the upper roots and described certain
types of delivery paralysis. He credited
Duchenne for describing the brachial palsy
following delivery in affected newborns. 1885
Augusta Klumpke first described the clinical
picture resulting from injury to lower roots.

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EPIDEMIOLOGY
Incidence of brachial plexus palsy is reported to
affect 0.5 to 1.9 per 1000 live births (Bar et
al 2001) 90 Erb palsy Most common on the right
side because the most common delivery
presentation is left occiput anterior vertex.
Associated with pre and gestational
diabetes older maternal age increased BW,
LGA Newborns with BP injuries have a higher
incidence of low Apgar scores of less than 7 at
1 and 5 mins and of asphyxia than matched
controls
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EPIDEMIOLOGY
Brachial plexus palsy occurs in 26 of cases of
shoulder Dystocia Both Shoulder dystocia and
brachial plexus palsy are more common in LGA
babies and Infants of diabetic mothers Infants
of diabetic mothers have a higher incidence of
permanent impairment In infants of diabetic
mothers, the macrosomic process affects the trunk
but not the head (large biacromial diameter) The
head shoulder disproportion is difficult to
predict in Utero.
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EPIDEMIOLOGY
Clavicular fractures are often associated with
shoulder dystocia , but the incidence of brachial
palsy in these Cases is only 11. Clavicular
fracture more mobility of shoulder
Not always associated with difficult delivery
(Intrauterine Maladaption palsy). Cases of in
utero origin supported by EMG findings if
denervation at birth.
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ANATOMY
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ANATOMY
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Brachial plexus is comprised of a group of nerves
arising form the nerve roots C5-T1. The uppper
(C5-C6) roots innervate the deltoid,
spinati,biceps, brachioradialis, biceps supinator
and flexor muscles of the forearm. The lower
roots (C7-T1) innervate the intrinsic muscles of
the hand. The phrenic nerve, arising from C3-C5
can be involved resulting in ipsilateral
diaphragmatic paralysis causing a decrease in
thoracic space, tidal volume and vital
capacity. Involvement of the sympathetic nerves
from T1 that give rise to the sup cervical symp
ganglion can result in Horner Synd.
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HORNER SYNDROME
Ptosis Miosis and anhydrosis
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Stretch, tear, compression or avulsion of
the nerves usually after forceful lateral
deviation of the head from the shoulders
during delivery. Recent studies suggest
intrinsic forces (uterine contractions).

PATHOGENESIS
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Clinical Manifestations Asymmetric Moro
reflex Erb palsy caused by the disruption of the
upper brachial plexus. Posture of adduction and
inward rotation at the shoulder with extension
and pronation at the elbow and flexion of the
fingers WAITERS TIP Klumpke absent grasp
reflex of the hand
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Clinical Manifestations
If phrenic nerve is involved, as mentioned
earlier respiratory distress may be present.
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DIFFERENTIAL DIAGNOSIS
Cervical Injury Cervical Spine
injury Dislocation of upper extremity/fractures
of upper extremity Intrauterine maladaptation
palsy
The physical findings of BP palsy are so unique
so it is difficult to mistaken if for other
diagnosis.
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DIAGNOSTIC WORKUP
Evaluation can be undertaken by multiple modes of
Imaging. EMG MRI Chest X ray Real time
UltraSonography
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MANAGEMENT
The majority of patients with brachial plexus
palsy Dx at birth will recover from neurologic
deficit. Those who do not recover during 3-6month
period will Require surgical intervention. 1-2
week rest of affected limb Early referral to
upper extremity clinic and PT Caregivers should
be instructed on how to handle baby No traction
of affected arm, no pressure under axila. Baby
to be carried in football hold
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MANAGEMENT
Surgical

• Exploration
• Neurolysis
• Excision of scar tissue
• Nerve grafting (local end to end anastomosis or
  remote
• nerve transplant)
• Surgical plication in case of diaphragmatic
  involvement
• Special considerations in post surgical care
• Edema of neck and compromise of airway
• Injury to vagal and laryngeal nerves
• Risk for meningitis

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PROGNOSIS
Study by Noetzel et al (2001) followed 80
patients with BP injury who did not recover by 2
weeks of age. Used the BMRC scales for
evaluating muscle strength and found Complete
recovery in 66 Mild impairment in 11 Moderate
weakness was seen in 9 Severe weakness in
14 When associated with phrenic nerve palsy and
diaphragmatic paralysis, there is more likelihood
of need for surgery for recovery.
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REFERENCES

• Brachial plexus palsy in neonates
• John B Cahil, Medlink
• Brachial plexus injury and obstetrical risk
  factors. Int J Gynecol Obst 200173 (1) 21-5
• Brachial plexus injuries, emedicine Aug 2004

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