Evaluation and Management of Brachial Plexus Birth Palsy

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Key points

  • Brachial plexus birth palsies occur in varying degrees and can have lifelong physical and psychological impact for patients as well as their families.

  • The best method for diagnosing and following infants with brachial plexus birth palsy is serial physical examinations.

  • 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.

  • Assessment of midline function is

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

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    • Brachial Plexus Birth Injury: A Review of Neurology Literature Assessing Variability and Current Recommendations

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      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.

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      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.

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      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

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      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.

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