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246: OBSTETRIC BRACHIAL PLEXUS INJURY

Kay Tasso, PhD, PT, PCS

CONDITION/DISORDER SYNONYMS

  • Erb palsy

  • Klumpke palsy

  • Brachial plexus injury

  • Birth brachial plexus injury

ICD-9-CM CODE1

  • 767.6 Injury to brachial plexus due to birth trauma

ICD-10-CM CODES2

  • P13.0 Erb paralysis due to birth injury

  • P14.1 Klumpke paralysis due to birth injury

  • P14.3 Other brachial plexus birth injuries

PREFERRED PRACTICE PATTERN3

  • 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury

PATIENT PRESENTATION

A 3-week-old infant is referred to outpatient physical therapy for right Erb palsy. The mother reports an uneventful pregnancy but prolonged and difficult delivery especially in getting the shoulder out of the birth canal. Upon examination, the infant presents with fisting of the left hand and physiologic flexion of the elbow typical of a newborn but the right arm is postured by the baby’s side. There is full passive range of motion (ROM) for the elbow, wrist, and hand and at least 90 degrees of right shoulder motions with the therapist deferring assessment above 90 degrees to prevent overstretching of the shoulder. There is active motion of the right upper trapezius but no active shoulder abduction, external rotation, or elbow or wrist extension. The therapist instructs the family on gentle passive ROM, dressing, positioning, and handling of the affected side and recommends weekly physical therapy.

KEY FEATURES

Description

  • Traumatic injury to the brachial plexus caused during delivery of an infant

Essentials of Diagnosis

  • Stretch or incomplete rupture of the plexus is the most common injury often resulting from vacuum or forceps delivery4

FIGURE 246-1

Delivery of anterior shoulder. (From DeCherney AH, Nathan L. Current Diagnosis & Treatment Obstetrics & Gynecology. 11th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

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General Considerations

  • Classifications

    • Upper or Erb palsy (C5, C6, and/or C7) is the most common: Arm postured in shoulder adduction, internal rotation, neutral extension; elbow extension; forearm pronation; wrist and finger flexion.

    • Lower or Klumpke palsy (C8, T1) is rare: Hand is flaccid.

    • Total palsy (C5-T1): Arm and hand are involved.

Demographics

  • About 1.5 per 1000 infants4

CLINICAL FINDINGS

SIGNS AND SYMPTOMS

  • Weakness of deltoid, biceps, brachioradialis, brachialis (Erb palsy)

  • Weakness of wrist flexors and finger intrinsics (Klumpke palsy)

  • All of the above plus sensory loss for total brachial plexus injury

Functional Implications

  • Limits ability to use involved arm for reaching, grasping, or participating in ADLs

  • Inability to weight bear on involved arm

  • Inability to attain quadruped ...

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