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Brachial plexus birth palsies occur in varying degrees and can have lifelong physical and psychological impact for patients as well as their families.
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The best method for diagnosing and following infants with brachial plexus birth palsy is serial physical examinations.
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Muscular balance about the shoulder is critical for external rotation and internal rotation to promote the development of a normal glenohumeral joint and to perform activities of daily living.
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Assessment of midline function is
Evaluation and Management of Brachial Plexus Birth Palsy
Section snippets
Key points
Assessment tools
The Toronto Test Score was proposed by Michelow and colleagues14 as a scoring system to determine surgical indications and provide an assessment tool following nerve reconstruction procedures. Five upper extremity functions (shoulder abduction, elbow flexion, wrist extension, digit extension, and thumb extension) are graded on a scale from 0 to 2, where 0 is no function, 1 is partial function, and 2 is normal function. If a child has a combined score of less than 3.5 by 3 months of age or
Classification
Brachial plexus birth palsies are classified based on which nerve roots are affected. The classic Erb palsy is an injury that involves the C5 and C6 nerve root levels and is the most common injury pattern, accounting for approximately 60% of cases. An extended Erb palsy involves the C5, C6, and C7 nerve roots and accounts for approximately 20% to 30% of cases. When all nerve roots are injured, C5-T1, this is termed a global or total brachial plexus palsy and accounts for 15% to 20% of cases.
Nonsurgical treatment
Initial treatment of all brachial plexus birth palsies that do not coexist with a fracture is passive range of motion. Typically neonatal clavicle and humerus fractures heal within 3 weeks, so therapy is begun at 3 to 4 weeks in these cases. Ensuring the infant has full passive range of motion is critical to prevent contractures and/or joint deformity from occurring. Therefore, exercises should be performed multiple times a day at home with formal therapy sessions used as needed for education
Microsurgery
The timing of microsurgical intervention, when needed, remains one of the most controversial topics surrounding the care of infants with brachial plexus birth palsy. Most authors agree that infants with global plexus palsies and Horner syndrome should undergo microsurgical intervention at approximately 3 months of age9, 21 (Gilbert). However, no consensus is present for the remaining 70% to 80% of patients who have a typical Erb palsy or extended Erb palsy. Some authors advocate microsurgical
Summary
Brachial plexus birth palsy continues to be common despite advancements in obstetric care. These injuries can be permanent with lifelong consequences. The diagnosis is made by serial physical examinations without the need for additional advanced modalities. Treatment is begun shortly after birth by performing passive range of motion and tactile stimulation. Microsurgical procedures, tendon transfers, and osteotomies may be recommended to improve function of the child’s limb; however, the
References (46)
- et al.
Brachial plexus injury: a 23-year experience from a tertiary center
Am J Obstet Gynecol
(2005) - et al.
Current concepts in the management of brachial plexus birth palsy
J Hand Surg Am
(2010) - et al.
Obstetrical brachial plexus lesions
J Hand Surg Br
(1991) - et al.
Clinical electromyography correlation in infants with obstetric brachial plexopathy
J Hand Surg
(2007) - et al.
Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to supraclavicular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve
J Hand Surg
(2004) - et al.
Nerve transfer to biceps muscle using a part of ulnar nerve for C5-6 avulsion of the brachial plexus: anatomical study and report of four cases
J Hand Surg
(1994) Long-term evaluation of brachial plexus surgery in obstetrical palsy
Hand Clin
(1995)- et al.
Magnetic resonance imaging and clinical findings before and after tendon transfers about the shoulder in children with residual brachial plexus birth palsy
J Shoulder Elbow Surg
(2006) - et al.
Arthroscopic treatment of internal rotation contracture and glenohumeral dysplasia in children with brachial plexus birth palsy
J Shoulder Elbow Surg
(2010) Rotation osteotomy of the humerus for Erb’s palsy in children with humeral head deformity
J Hand Surg Am
(2002)
The epidemiology of neonatal brachial plexus palsy in the United States
J Bone Joint Surg Am
Obstetrical brachial plexus injuries: incidence, natural course and shoulder contracture
Clin Rehabil
Brachial plexus birth palsy: a 10 year report on the incidence and prognosis
J Pediatr Orthop
Cause and effect of obstetric (neonatal) brachial plexus palsy
Acta Paediatr Scand
Upper extremity size differences in brachial plexus birth palsy
Hand (N Y)
Management of obstetric brachial plexus lesions: state of the art and future developments
Childs Nerv Syst
Obstetric brachial plexus palsy – risk factors and predictors
Ortop Traumatol Rehabil
Obstetric brachial plexus injuries: evaluation and management
J Am Acad Orthop Surg
Variations of the ventral rami of the brachial plexus
J Korean Med Sci
Orthopaedic management in cerebral palsy
The natural history of obstetrical brachial plexus palsy
Plast Reconstr Surg
Identification of the lesion in brachial plexus injuries with root avulsion: a comprehensive assessment by means of preoperative findings, myelography, surgical exploration and intraoperative diagnosis
Neuro-Orthop
An approach to obstetrical brachial plexus injuries
Hand Clin
Cited by (51)
Brachial Plexus Birth Injury: A Review of Neurology Literature Assessing Variability and Current Recommendations
2022, Pediatric NeurologyCitation Excerpt :Fewer than 20% of articles recommended early referral to a multidisciplinary BPBI care center, despite nearly a third of articles recognizing the need for surgical intervention in children with minimal recovery by three to nine months. Current literature in BPBI suggests that early microsurgical intervention by three months for infants presenting with global injuries and/or Horner syndrome leads to more favorable outcomes, whereas infants with upper brachial plexus lesions can undergo surgical intervention at five to six months while still demonstrating good outcomes.67-69 Centers at Boston Children's Hospital, Cincinnati Children's Hospital, Toronto Sick Kids, and Shriners Hospital all reached consensus on timing for plexus exploration at three months for global and five to six months for uppers/extended uppers.
Clavicle lengthening, a novel operation technique to reduce pain in brachial plexus birth injury patients
2022, Journal of Shoulder and Elbow SurgeryCitation Excerpt :Two subjects underwent uncomplicated hardware removal 1 year postoperatively, due to symptomatic hardware. Brachial plexus birth palsy can lead to glenohumeral joint and osseous deformities of the scapula, clavicle, and humerus due to shoulder muscle imbalance and glenohumeral contractures.1,9,10,23 This can lead to tension in the musculature of the shoulder and neck and pain of the periscapular muscles due to overloading.
Brachial Plexus Birth Injuries
2022, Orthopedic Clinics of North AmericaCitation Excerpt :For instance, relative hypotonia—due to fetal distress—is a more recently recognized risk factor as it leads to less protection of the brachial plexus during delivery, making it more susceptible to stretch injury.2,8 In addition, oxytocin use and uterine tachysystole (defined as greater than 5 contractions in a 10 minute period) have been recently identified factors that contribute to BPBI.7,11 Understanding the types of nerve injury is helpful to determine the management and prognosis for BPBI.
Reachable workspace with real-time motion capture feedback to quantify upper extremity function: A study on children with brachial plexus birth injury
2022, Journal of BiomechanicsCitation Excerpt :Neuromuscular injuries – such as brachial plexus birth injuries (BPBI) – frequently result in lifelong deficits in upper extremity (UE) function (Abzug et al., 2019; Wall et al., 2014). Clinical interventions are often employed early in life to improve UE function (Abzug and Kozin, 2014; Gart and Adkinson, 2018). Pre/post-treatment assessment is essential for understanding how interventions alter a patient’s function.
The authors have nothing to disclose.