Definition
Birth injury of brachial plexus
Epidemiology
R > L
1 / 1000 live births
1 in 10 of these develop significant impairment
Recent increase due to bigger babies / DM
Aetiology
Usually secondary to traction
1. Big baby / maternal DM / > 4000 gm
2. Breech
3. Prolonged / difficult labour
4. Shoulder dystocia
- inability to deliver the shoulders after delivery of the head
- indirect traction injury on limb with excessive lateral neck flexion
5. Forceps delivery
- direct forcep crush injury
Pathology
Spectrum of injury
- supraclavicular traction injury
- upper roots ruptured
- lower roots avulsed
Classification
Erb Palsy
Klumpke Palsy
Total Plexus
ERB Palsy
A. C5,6 lesion
Weak
- deltoid / rotator cuff
- biceps - elbow flexion and supination
- wrist extension
Waiter's Tip Deformity
- shoulder adducted & internally rotation (P major / Lat dorsi)
- elbow extended
- forearm pronated
- wrist flexed 2° FCR
May have winging of scapula as compensation
Best prognosis
- 90% recover 6/12
B. C5,6,7
Additional weakness
- triceps / loss of elbow extension
Prognosis
- 50% recover 6/12
Klumpke Palsy
C8,T1 lesion
- rare
- Horner's Syndrome if preganglionic
Weakness of
- finger flexion
- intrinsics
Numb forearm & hand
Poor prognosis
Total Plexus Injury
C5 - T1
- flaccid numb arm
- Horner's if preganglionic
Worst prognosis
- 40% recover 6/12
NHx
90% recover overall
Biceps best indicator of recovery
- if biceps recovers in 3/12 90% will make full recovery
- also is easiest to assess in young child
- see if child will use that hand to bring something to the mouth
Poor prognosis
- no recovery 3/12
- Total plexus
- Klumpke
- preganglionic (Horner's, DSN, LTN, SSN)
DDx
Pseudoparalysis
- clavicle fracture (from delivery)
- humeral fracture
Arthrogryposis
- nil elbow crease
- hasn't flexed in utero
Monoplegic CP
Other
- OM / Septic arthritis
- Congenital shoulder dislocation
- sprengel shoulder
- myelodysplasia
Management
Non operative
Initial
Physiotherapy
- maintain FROM / passive ranging
- no splinting
3/12
- assess biceps recovery
- EMG at 3months if no recovery
Long term
Maintain shoulder ER
- prevent posterior shoulder dislocation
- reassess child in clinic every six months
Operative Management
Indications
No elbow flexion / biceps recovery at 3 - 6/12
- biscuit test (hold other arm, see if can eat biscuit)
- very difficult to assess shoulder or wrist extension
If children don't have full recovery of biceps at 3/12 will often be left with residual deficit
MRI
Valuable if see pseudomeningocoeles
- low chance of recovery of those nerve roots
Timing
6/12 to 1 year
Options
Preganglionic avulsion
- nerve transfer
Postganglionic
- nerve grafting
Preganglionic Avulsion
Nerve transfer
A. Accessory nerve to suprascapular
B. Intercostal nerve to MCN
Postganglionic injury
Neuroma resection & sural nerve grafting
Erbs / C5/6
- resection Erb's point
- nerve grafting
Aims
- lateral cord / MCN
- SS nerve
- posterior division of upper trunk to posterior cord
Results
Late Shoulder Management
Issue
- residual internal rotation / adduction contracture
- tight SSC / P major / T Major / short head biceps
- humeral neck retroverted
- develop dysplasia head and glenoid
- GHJ tends to dislocates posteriorly
Incidence
10%
- more common in C5/6
- due to strong P Major and LD
Management Summary
< 6/12 Observe
6/12 Nerve transfer / graft
<2 years Release contracture Subscapularis / T major / P major
2-5 years Lat Dorsi Transfer
>5 years Derotation Humeral osteotomy
Initial
Monitor and maintain ER shoulder
- physio / botox
Investigations
Indication
- limited ER
- anterior shoulder crease
Ultrasound
- very sensitive at 6/12 age
Shoulder releases
Timing
- < 2 years
- important to do releases early
- avoids IR contracture
- avoids consequent need for osteotomy or reduction of dislocation
Release
- P major
- T major
- Subscapularis
Tendon Transfers
Timing
- 2-5 years
Options
Lat Dorsi transfer to posterolateral rotator cuff
- act as shoulder ER
- often combine with releases
Steindler's flexorplasty
Humeral derotation osteotomy
Assessment
- CT to assess bony anatomy
- may need posterior glenoid bone block
- shoulder may be dislocated
Timing
- > 6-8 years