Perinatal Brachial Plexus Palsy
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- The brachial plexus contains sensory and motor nerves to the upper extremities, stemming from the cervical and thoracic spine (commonly C5–T1 roots).
- The brachial plexus contains a consistent pattern of nerves that innervate predictable muscles and skin regions.
- Brachial birth palsy is a proximal stretch, avulsion, or rupture type injury and may involve
- C5–C6 (Erb palsy), most common, best prognosis
- C5–C7, less common, worse prognosis
- C5–T1, least common, flail extremity and worst prognosis
- There is no predominance of gender, but variations in clinical care, preventive measures, and birth weight may explain estimates of incidence to range from 0.4 to 4 per 1,000 live births.
- Incidence drops from 0.2% with vaginal delivery to 0.02% after cesarean section as there is a probable mechanical basis for the plexopathy.
- Erb palsy is the most commonly encountered plexus injury.
- Large size for gestational age, multiparity, prolonged labor, breech position, difficult delivery—especially when forceps- or vacuum-assisted
- Diabetic mothers and/or neonatal birth weight >4.5 kg
- Although there is no genetic basis per se, previous delivery leading to obstetric palsy is a risk factor.
- Careful positioning of the upper extremity during childbirth and conversion to cesarean section when necessary
- Prevention of long-term disability and contracture can be minimized with exercise of the child’s joints and functioning muscles every day beginning at 3 weeks of age.
- Seddon and Sunderland have described classification systems to describe degree of injury.
- Mildest form, interruption of conduction, axons continuous
- Good recovery
- Axonal degeneration with loss of axonal continuity
- Nerve intact. Epineurium and perineurium intact.
- Most severe, nerve is completely contused. Axonal discontinuity
- Nerve may be grossly intact, but epineurium, perineurium, and axons disrupted. Recovery difficult to predict.
- Downward mechanical force on the shoulder during difficult delivery can lead to stepwise stretch injury leading to transient or permanent damage or total avulsion of nerve roots.
- Upward mechanical force, that is, after face delivery, leads to C8–T1 injury (Klumpke).
- Avulsion injury carries the worst prognosis, particularly if proximal to the cell body of the motor nerve (preganglionic), as these injuries cannot spontaneously recover.
- Horner syndrome, phrenic nerve injury, and long thoracic nerve injury (winged scapula) may be observed and are associated with preganglionic injury and a poor prognosis.