Brachial plexus birth injury

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Evidence last reviewed: 16 Feb 2026

Topic last updated: 19 Mar 2024

Brachial plexus birth injury presents in a newborn with decreased movement of the involved arm, most commonly in the "waiter tip" position.

Around 70% to 80% of children recover fully. Children without full recovery by 3 months are likely to have some residual impairment, most commonly to the shoulder, elbow, or forearm.

Early referral to a brachial plexus birth injury clinic is imperative for oversight of the infant’s care. This facilitates serial exams and timely surgical intervention if recovery is inadequate.

Physical or occupational therapy, including home exercises, is recommended for all children with brachial plexus birth injuries to maintain motion and prevent contracture while the nerves reinnervate muscles affected by the initial injury.

Nerve or musculoskeletal reconstruction may be needed to improve function in babies or children with incomplete recovery.

Definition

Brachial plexus birth injury (BPBI) is a paralysis of the upper extremity due to an injury at the time of birth to the nerves that control movement and sensation to the upper extremity. BPBI is often associated with delivery complicated by shoulder dystocia.[1][2][3] Alternative terms include neonatal brachial plexus palsy, obstetric brachial plexus palsy, and obstetric brachial plexus injury.[4]

The most common type of BPBI is Erb palsy (C5 to C6 nerve involvement), accounting for about 45% of cases of BPBI.[5][6] An additional injury to C7, referred to as extended Erb palsy, is discovered in roughly 20% to 30% of cases of BPBI.[6][7] Total plexus involvement (C5 to T1), or global plexus palsy, represents about 20% of cases of BPBI.[6][8] Klumpke palsy (C8 to T1) is the least common, comprising less than 1% of cases of BPBI.[7][9]

História e exame físico

Principais fatores diagnósticos

paralysis of an arm
observed decreased motion of an arm
abnormal posture of the arm

Detalhes completos

Outros fatores diagnósticos

crepitance of clavicle or humerus
Horner syndrome
tachypnea, respiratory distress, feeding difficulties, failure to thrive
lack of full range of passive movement
hyperreflexia, persistent primitive reflexes, abnormal muscle tone, or abnormal body posture

Detalhes completos

Fatores de risco

shoulder dystocia
large fetal size (>4000 g)
maternal diabetes (especially type 1) or gestational diabetes mellitus
maternal obesity
breech presentation
atypical second phase of labor
assisted delivery

Detalhes completos

Investigações diagnósticas

Primeiras investigações a serem solicitadas

clinical diagnosis
x-ray of chest and affected upper extremity

Detalhes completos

Investigações a serem consideradas

ultrasound scan of the shoulder
MRI/MRI myelogram
CT/CT myelogram
EMG/nerve conduction studies

Detalhes completos

Novos exames

three-dimensional proton-density MRI to assess the brachial plexus
volumetric MRI and EMG assessment of rotator cuff muscles
ultrasound evaluation of the brachial plexus

Algoritmo de tratamento

AGUDA

newborns and infants

CONTÍNUA

following initial treatment

Colaboradores

Autores

Mark J. Adamczyk, MD

Co-Director

Brachial Plexus Treatment Center

Vice-Chairman

Department of Pediatric Orthopedic Surgery

Akron Children's Hospital

Akron

Declarações

MJA declares that he has no competing interests.

Stephanie A. Russo, MD, PhD

Co-Director

Brachial Plexus Treatment Center

Pediatric Hand and Peripheral Nerve Surgery

Akron Children’s Hospital

Akron

Declarações

SAR declares that she has no competing interests.

Revisores

Whitney E. Muhlestein, MD

Peripheral Nerve Fellow

University of Michigan

Ann Arbor

Declarações

WEM declares that she has no competing interests.

Tim Hems, MA, DM, FRCS(Eng), FRCSEd(Orth)

Consultant Hand and Orthopaedic Surgeon

Queen Elizabeth University Hospital

Glasgow

Declarações

TH declares that he has written a number of publications over the last few years which highlight the lack of evidence that nerve repair surgery improves outcome in brachial plexus birth palsy.

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Referências

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Principais artigos

American College of Obstetricians and Gynecologists. Neonatal brachial plexus injury. 2014 [internet publication].Texto completo

Royal College of Obstetricians and Gynaecologists. Shoulder dystocia: green-top guideline no 42. March 2012 [internet publication].Texto completo

Smith BW, Daunter AK, Yang LJ, et al. An update on the management of neonatal brachial plexus palsy-replacing old paradigms: a review. JAMA Pediatr. 2018 Jun 1;172(6):585-91. Resumo

Vuillermin C, Bauer AS. Boston Children's Hospital approach to brachial plexus birth palsy. J Pediatr Orthop B. 2016 Jul;25(4):296-304. Resumo

Pondaag W, Malessy MJA. Evidence that nerve surgery improves functional outcome for obstetric brachial plexus injury. J Hand Surg Eur Vol. 2021 Mar;46(3):229-36.Texto completo Resumo

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais
- Clavicle or humeral fracture
- Septic arthritis of the shoulder or proximal humeral osteomyelitis
- Spinal cord or brachial plexus tumor
Mais Diagnósticos diferenciais
Diretrizes
- ACOG neonatal brachial plexus palsy: task force report
Mais Diretrizes
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Brachial plexus birth injury

Summary

Definition

História e exame físico

Principais fatores diagnósticos

Outros fatores diagnósticos

Fatores de risco

Investigações diagnósticas

Primeiras investigações a serem solicitadas

Investigações a serem consideradas

Novos exames

Algoritmo de tratamento

newborns and infants

following initial treatment

Colaboradores

Autores

Mark J. Adamczyk, MD

Declarações

Stephanie A. Russo, MD, PhD

Declarações

Revisores

Whitney E. Muhlestein, MD

Declarações

Tim Hems, MA, DM, FRCS(Eng), FRCSEd(Orth)

Declarações

Créditos aos pareceristas

Declarações

Referências

Principais artigos

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais

Diretrizes

Conectar-se ou assinar para acessar todo o BMJ Best Practice

Conectar-se ou assinar para acessar todo o BMJ Best Practice

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