BRACHIAL PLEXUS INJURY IN NEONATES LOURDES ASIAIN February 2005. BACKGROUND. 1764 Obstetrical brachial palsy described by Smellie.
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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
Brachial plexus palsy occurs in 26% of cases of shoulder
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
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.
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 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.
Miosis and anhydrosis
usually after forceful lateral deviation of the head from
the shoulders during delivery. Recent studies
suggest intrinsic forces
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 = WAITER’S TIP
Klumpke= absent grasp reflex
of the hand
If phrenic nerve is involved, as mentioned earlier
respiratory distress may be present.
Cervical Spine injury
Dislocation of upper extremity/fractures of upper
Intrauterine maladaptation palsy
The physical findings of BP palsy are so unique so it is
difficult to mistaken if for other diagnosis.
Evaluation can be undertaken by multiple modes of
Chest X ray
Real time UltraSonography
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
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.
John B Cahil, Medlink
Brachial plexus injury and obstetrical risk factors. Int J Gynecol Obst 2001;73 (1) 21-5
Brachial plexus injuries, emedicine Aug 2004