Patient Presentation
A term female was born by Cesaarean section to a G1P1 female after prolonged labor, failure to progress and a difficult extraction. The Apgar scores were 8 and 9, but the infant was noticed to not be moving her right arm very well.
The pertinent physical exam showed respirations of ~30/minute, and a heart rate ~150 beats/minute. Her weight was 3.890 kg (75%),with a head circumference of 32 cm (10%) and length of 54 cm (90%). She was pink and had caput and molding of her head making the head circumference and length probably not entirely accurate. Her eyes were normal with reactive pupils. She was holding her head turned to the left and her arm at her side with an extended elbow and pronation of the forearm. She would move her fingers and wrist spontaneously. There were no spontaneous movements of her elbow or shoulder. She did not like being handled in general and especially with examination of her head or arm. The rest of her examination was normal.
The diagnosis of a brachial plexus injury or possible fracture was made. The radiologic evaluation had normal radiographs of the right upper extremity and the chest without any obvious fracture. The infant was swaddled and she fed vigorously. She cried much less once these were done. Orthopaedic consultation at about 4 hours of age already showed her improving with spontaneous movement of her arm including abduction at the shoulder and flexion of the elbow. The biceps flexion increased when activated. She now would also hold her head in midline and cried less with examination of her head. By 24 hours of age, she was holding her arm in a normal elbow hyperflexed position and was moving her shoulder more. She still would become fussy with some handling of that area but was easily consoled. Her examination continued to improve and by followup with her pediatrician at 1 week of age, she had a normal examination and was not overly fussy with examination. There were no concerns from the parents nor the orthopaedic surgeon at her followup appointment at 1 month of age.
Discussion
Brachial plexus birth palsy (BRBP) is a flaccid paralysis due to injury of one or more brachial plexus roots during the delivery process. It is more common in infants who have shoulder dystocia (strongest risk factor), fetal macrosomia (especially > 4500 grams), prolonged labor, labor induction or mechanical assistance and maternal gestational diabetes. Up to 15 to 20% (or higher in some studies) do not have an identifiable risk factor. BRBP has an incidence of about 0.9/1000 live births. It occurs more on the right side than left but bilateral BRBP can occur.
The brachial plexus is a combination of ventral nerve roots mainly from C5 to T1 (although with anatomic variation other adjacent nerve roots can also be involved, and different combinations can also occur). They combine into trunks that branch anteriorly and posteriorly and provide motor and sensory function to the upper extremity. C5 and C6 mainly innervate the shoulder and elbow flexion and extension. C7 is its own trunk and is involved with elbow extension. C8 and T1 innervate mainly the hand.
Most cases (~60%) involve C5-C6 known as Erb palsy or Waiter’s tip, where patients have “…the shoulder internally rotated, elbow extended, and wrist flexed and pronated.” When C7 is also involved with C5-C6 then this is called Erb palsy extension and occurs in 20-30% of patients. These have more shoulder and finger involvement. Klumpke palsy involves C8-T1 and fortunately occurs only in about 1% of patients as patients have more severe problems affecting the hand and wrist. Horner syndrome can also occur with C8-T1 palsies. The Horner syndrome classic triad is ipsilateral ptosis, miosis and anhidrosis of the eye. About 15-20% have total plexus palsies involving C5-T1.
There are three types of injuries. Neuropraxia occurs with a stretching or compression injury resulting in focal demyelination but there is no disruption of the axon. Axonotmesis happens when the axons are severed but the epineurium remains contiguous. Neurotmesis injuries have the entire nerve disrupted and therefore, the problem is more severe and spontaneous recovery is very unlikely.
Learning Point
Observation of the infant is important as it provides a great deal of information: how much does the patient move the arm, what parts of the arm are moved and what is the position of the head all can provide good information. An infant with a C5-C6 injury usually has a characteristic position with “…the shoulder in abduction and internal rotation, elbow in extension contrasting with the usual physiologic hyperflexion at this age, forearm in pronation and wrist in extension…. the grasping reflex is present and finger function is preserved.” Note that the phrenic nerve can be involved with C5-C6 injuries so respiratory status also needs to be assessed. Fortunately, most patients have transitory problems with 65-90% having recovery. Studies report 65% complete recovery, 20-30% with some functional problems and 10-15% with considerable functional problems. On physical examination the biceps functionality is one of the most important to assess. Patients who regain biceps function usually have a higher lesion and also less severe lesion, therefore it is used as a marker for many treatment decisions, and can be easily reassessed.
The speed of resolution is one of the most helpful prognostic factors also. The earlier the patient recovers some or all function, the better the outcome. The most common situation is a patient who has total resolution within the first month. Treatment is usually monitoring early on with possible physical therapy to decrease risk of muscle imbalances and potential stiffness, subluxation or other similar problems especially in the shoulder joint. Orthoses and other treatments are also sometimes used. Most patients recover at least some function by 2-3 months of age. Timing of surgical interventions depends on the actual problem and severity with potential surgery occurring as early as 3 months but potentially at older ages. Note that in the initial hours to days, the patient may have pain with movement/handling and therefore some immobilization such as swaddling and/other pain control may be needed for comfort.
Questions for Further Discussion
1. What problems are associated with fetal macrosomia?
2. What are indications for an instrumented delivery or Cesarean section?
3. How are neonatal clavicle and humerus fractures treated?
Related Cases
- Symptom/Presentation: Upper Extremity Trauma
- Age: Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Brachial Plexus Injuries and Peripheral Nerve Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Duff SV, DeMatteo C. Clinical assessment of the infant and child following perinatal brachial plexus injury. J Hand Ther. 2015;28(2):126-133; quiz 134. doi:10.1016/j.jht.2015.01.001
Abid A. Brachial plexus birth palsy: Management during the first year of life. Orthop Traumatol Surg Res. 2016;102(1 Suppl):S125-132. doi:10.1016/j.otsr.2015.05.008
Lin JS, Samora JB. Brachial Plexus Birth Injuries. Orthop Clin North Am. 2022;53(2):167-177. doi:10.1016/j.ocl.2021.11.003
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, Unive
You must be logged in to post a comment.