Brachial plexus birth injury

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

Last reviewed: 9 Apr 2025

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]

History and exam

Key diagnostic factors

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

Full details

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

Full details

Risk factors

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

Full details

Diagnostic tests

1st tests to order

clinical diagnosis
x-ray of chest and affected upper extremity

Full details

Tests to consider

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

Full details

Emerging tests

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

Treatment algorithm

ACUTE

newborns and infants

ONGOING

following initial treatment

Contributors

Authors

Mark J. Adamczyk, MD

Co-Director

Brachial Plexus Treatment Center

Vice-Chairman

Department of Pediatric Orthopedic Surgery

Akron Children's Hospital

Akron

Disclosures

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

Disclosures

SAR declares that she has no competing interests.

Peer reviewers

Whitney E. Muhlestein, MD

Peripheral Nerve Fellow

University of Michigan

Ann Arbor

Disclosures

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

Disclosures

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.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

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

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

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. Abstract

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

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.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Clavicle or humeral fracture
- Septic arthritis of the shoulder or proximal humeral osteomyelitis
- Spinal cord or brachial plexus tumor
More Differentials
Guidelines
- ACOG neonatal brachial plexus palsy: task force report
More Guidelines
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Brachial plexus birth injury

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

newborns and infants

following initial treatment

Contributors

Authors

Mark J. Adamczyk, MD

Disclosures

Stephanie A. Russo, MD, PhD

Disclosures

Peer reviewers

Whitney E. Muhlestein, MD

Disclosures

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

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice