Neonatology Book

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Brachial Plexus Injury from Birth Trauma

Aka: Brachial Plexus Injury from Birth Trauma, Brachial Birth Trauma, Brachial Birth Palsy
  1. Epidemiology
    1. Injuries may occur intrapartum prior to delivery: 50%
      1. Unrelated to Shoulder Dystocia or excessive traction
      2. Possibly from fetal Shoulder against Symphysis Pubis
      3. May be unavoidable
    2. Reference
      1. Gherman (1998) Am J Obstet Gynecol 178:423-7 [PubMed]
  2. General
    1. Follows difficult or prolonged delivery
  3. Mechanism of injury
    1. Upper plexus Injury
      1. Lateral flexion of neck against fixed head, Shoulder
    2. Lower plexus Injury
      1. Arm forced upward
  4. Types
    1. Duchenne-Erb Paralysis (Waiter's Tip Deformity)
    2. Klumpke's Paralysis (Clawhand Deformity)
    3. Whole Arm Paralysis (uncommon)
      1. Limb completely flaccid
      2. Hands dry and atrophic
      3. All reflexes absent
  5. Signs: General
    1. Arm motionless at side with elbow extended
    2. Moro Reflex absent on affected side
    3. Swelling above clavicle due to Hemorrhage
    4. Traumatic neuritis
      1. Tenderness to palpation
    5. Thoracic root injury
      1. Horner's Syndrome
  6. Differential Diagnosis: Pseudoparalysis
    1. Clavicle Fracture
    2. Upper Humerus Fracture
  7. Associated Conditions
    1. Phrenic Nerve palsy from Birth Trauma
    2. Horner's Syndrome
  8. Radiology: XRay Shoulder and XRay arm
    1. Assess for concurrent Fracture
  9. Management
    1. Prevent fixed soft tissue contractures
      1. Gentle repetitive range of motion Shoulder and elbow
      2. Supportive splints for wrist and fingers
    2. Reconstructive surgery for late deformities
  10. Prognosis
    1. Improvement in first week suggests full recovery
    2. No improvement by 6 months suggests permanent deficit
    3. No improvement expected after 2 years
    4. Older patients
      1. Underdevelopment of Upper extremity
      2. Humerus shortened
      3. Contractures and disuse atrophy
  11. Resources
    1. The National Brachial Plexus, Erb's Palsy Association
      1. http://www.nbpepa.org
  12. References
    1. Behrman (2000) Nelson Pediatrics, Saunders, p. 491-2
    2. Alfonso (2000) Semin Pediatr Neurol 7(1):4-14 [PubMed]
    3. Van Heest (1996) Pediatr Clin North Am 43(5):1113-33 [PubMed]

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