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.
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. Alternative terms include neonatal brachial plexus palsy, obstetric brachial plexus palsy, and obstetric brachial plexus injury.
The most common type of BPBI is Erb palsy (C5 to C6 nerve involvement), accounting for about 45% of cases of BPBI. An additional injury to C7, referred to as extended Erb palsy, is discovered in roughly 20% to 30% of cases of BPBI. Total plexus involvement (C5 to T1), or global plexus palsy, represents about 20% of cases of BPBI. Klumpke palsy (C8 to T1) is the least common, comprising less than 1% of cases of BPBI.
History and exam
Key diagnostic factors
- paralysis of an arm
- observed decreased motion of an arm
- abnormal posture of the arm
Other diagnostic factors
- 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
- 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
1st investigations to order
- clinical diagnosis
- x-ray of chest and affected upper extremity
Investigations to consider
- ultrasound scan of the shoulder
- MRI/MRI myelogram
- CT/CT myelogram
- EMG/nerve conduction studies
- 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
newborns and infants
following initial treatment
- Clavicle or humeral fracture
- Septic arthritis of the shoulder or proximal humeral osteomyelitis
- Spinal cord or brachial plexus tumor
- ACOG neonatal brachial plexus palsy: task force report
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