Brachial plexus injury->stretch during birth that is

caused by downward or upward traction on the arm

Secondarily, the muscles and bones of the upper
extremity become contracted or deformed over time
because of the resultant muscle imbalance
may not be detected until the baby tries to use the
extremity
Classification :
Type I (Erb palsy): Injury to roots 4-6 of the cervical
spine
Type II (whole-brachial plexus palsy): C4-T1 involved;
also known as Erb-Duchenne-Klumpkepalsy
Type III (Klumpke palsy): C8-T1 involved

General Prevention
Sometimes obstetricians will advise a caesarean
section if a baby seems extremely large or
cephalopelvic disproportion is present.
Not all cases can be anticipated or prevented

Epidemiology
Incidence
Currently, the incidence is 0.8 per 1,000 live births (2).
This figure is a decline from the rate in 1900, when it was
reported twice as often.
The change most likely results from improved obstetric
care.
Erb palsy is ~4 times as common as Klumpke palsy.
No recognized difference exists in incidence between
boys and girls.

Risk Factors
Fetal malposition
Shoulder dystocia
Cephalopelvic disproportion
High birth weight:
Maternal diabetes
Use of forceps in delivery

Pathophysiology
Pathologic findings vary from stretch to disruption of
the nerves of the brachial plexus (3).
The injury may occur at the cervical foramen as the
nerves exit the spinal canal (poorer prognosis), or
farther down in the neck and shoulder.
Secondary muscle atrophy and contracture ensues.

Etiology
Erb palsy results from downward traction on the
shoulder or arm or lateral traction against the neck.
Klumpke palsy is secondary to upward traction on the
arm.
Both occur because of the force needed in a difficult
extraction.

Associated Conditions
High birth weight
Gestational diabetes

Diagnosis

Signs and Symptoms
Decreased active use of the extremity
Arm held in internal rotation (2)
Loss of full active or passive external rotation
Inability to abduct (raise) the shoulder
Atrophy of the involved muscles (late) (Fig. 1)
Elbow flexion contracture
Possible Horner syndrome in Klumpke palsy
The condition is not painful.
A loss of sensation may be noted with complete plexus
injuries.

History
Decreased infant arm movements sometimes are noted from birth.
In other cases, more subtle decreases in shoulder movement or
presence of arm contracture may not be noted until later.
Physical Exam
Physical examination is the primary means of diagnosis.
Palpate for tenderness over the clavicle, proximal humerus, and ribs.
Test sensation by responses to light touch or pinch.
Test the function of all muscles in the shoulder, elbow, and hand by
stimulation and observation.
In patients with Erb palsy, the shoulder is internally rotated and lacks
external rotation and abduction.
In Klumpke palsy, loss of finger and interosseous function occurs.

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Tests
Imaging
Plain radiographs often are indicated at birth to rule
out other injuries that may cause decreased movement
of the infant's arm (clavicle fracture, proximal
humerus fracture); such injuries may coexist with
brachial plexus birth palsy.
At the time of late reconstruction in a child >4 years
old who has residual shoulder imbalance, plain
radiographs and CT scans are indicated to assess the
shape of the glenohumeral joint.

Diagnostic Procedures/Surgery
An electromyogram should be obtained if no clinical
return of deltoid or biceps function occurs by 36
months of age.
Lack of reinnervation may be a relative indication for surgery.
Cervical myelography may be helpful for diagnosing the
level of injury.
Meningoceles seen at the root levels in the cervical spinal
cord indicate that roots were avulsed from the cord, and the
prognosis is poor.
A finding of meningoceles indicates that different strategies
may be needed at surgery.

Differential Diagnosis
Clavicle fracture:
Usually painful to palpation
Some shoulder motion may be elicited.
Proximal humeral physeal fracture:
Same findings as clavicle fracture, with tenderness over the
proximal humerus; the abnormality may not show on radiographs
because the proximal humerus is not ossified at birth.
Ultrasound or MRI studies may be diagnostic, as are plain films
710 days later.
Septic arthritis of the shoulder:
May cause pseudoparalysis
Fever in the newborn may not be pronounced.

Treatment
General Measures
Parents should stretch the infant's arm several times a day as
directed by the occupational therapist (13).
The patient should be referred to a specialized pediatric
orthopaedic surgeon for monitoring and decision-making.
Observation and passive ROM are indicated for the newborn;
80% of patients recover spontaneously by 1 year of age (4).
Splinting is not necessary, but continued follow-up is needed.
Surgery is indicated for the remaining 20% of patients, with
grafting of the injured nerves (if no meningoceles are present
and the elapsed time is not >2 years) or with tendon transfers to
improve muscle balance .

Activity
No restrictions
Encourage passive ROM.

Special Therapy
Physical Therapy
An occupational therapist is helpful in teaching the parents
how to stretch and what contractures to watch for.
Splinting is not needed, but stretching and passive ROM
are encouraged.

Surgery
Nerve repair/reconstruction:
May be performed with an operative microscope with direct repair or
grafting of the injured nerves if the patient's function does not return
in ~6 months.
The exact timing is controversial.
Tendon transfers may be performed later to restore external rotation to
the shoulder.
Release of the tight internal rotators also may be indicated.
Humeral osteotomy is another way to restore an externally rotated
position.
Several muscle transfers are available to restore elbow flexion, most
notably the latissimus transfer.
Transfers for finger and wrist function are least commonly needed.

Follow-up

Issues for Referral
It is important to refer the baby with brachial birth palsy to an orthopaedic
surgeon with an interest in this condition because it is a specialized field.
Prognosis
80% of patients with brachial plexus birth palsy recover spontaneously.
Surgery may help many of the remainder.
Complications
Contracture of shoulder, elbow, or wrist
Affected extremity smaller in length and girth
Sensory loss
Shoulder dislocation
Patient Monitoring
The patient should be seen approximately every 23 months to look for
return of function and to plan for appropriate diagnostic testing.