Obstetric brachial plexus injury

• Erb’s palsy
• Klumpke’s palsy
• Brachial plexus injury
• Birth brachial plexus injury

• 767.6 Injury to brachial plexus due to birth trauma

• P14.0 Erb’s paralysis due to birth injury
• P14.1 Klumpke’s paralysis due to birth injury
• P14.3 Other brachial plexus birth injuries

• Pattern 5F: Impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury

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

General Considerations

• Classifications
  • Upper or Erb’s 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’s palsy (C8, T1) is rare: hand is flaccid
  • Total palsy (C5-T1): arm and hand involved

Demographics

• About 1.5 per 1,000 infants4

Signs and Symptoms

• Weakness of deltoid, biceps, brachioradialis, brachialis (Erb’s palsy)
• Weakness of wrist flexors and finger intrinsics (Klumpke’s 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 position or creep on hands and knees
• Asymmetrical use of arms
• Neglect of involved side

Possible Contributing Causes

• Compression
• Traction on the shoulder with or without cervical rotation
• Avulsion
• Large birth weight
• Breech presentation5
• Shoulder dystocia5

Differential Diagnosis

• Spinal cord injury
• Stroke
• Cerebral palsy

Imaging

• Standard radiograph of arm and chest
• CT scan
• MRI

Diagnostic Procedures

• EMG

Medical Procedures

• Surgery for nerve, tendon, or muscle transfers
• Botox injections to antagonist muscles

• Neurologist
• Orthopedist
• Occupational therapist

• Decreased strength
• Decreased ROM
• Asymmetrical in and/or delay of gross motor skills

• Test of infant motor performance
• Goniometry
• Sensory testing

• No ROM for 7 to 10-day-old infant5
• Avoid lying on affected side
• Avoid picking infant up under axilla
• Splinting
• Gentle, pain free passive range of motion
• Parent/caregiver education
• Serial casting
• Stabilize scapula during ROM and activities
• Facilitate developmental activities

• Increase strength in right biceps to at least 3/5 to allow for holding bottle with two hands within 6 months
• Achieve prone position on elbows with weight bearing equally on both arms, to increase shoulder and scapular stability within 2 months
• Reach up ...