Untitled Quiz

Brachial Plexus Injury

• Brachial plexus is a network of nerves supplying the arms and hands.
• Injury results in weakness or paralysis of the upper extremities (UE).
• Injuries are often temporary, with full function returning in 70-92% of cases.
• Incidence ranges from 0.19-2.5/1000 to 0.38-3/1000 births.
• This is related to advancements in obstetrics.

Anatomy of Brachial Plexus

• Network of nerves extending from the cervical spinal cord to the arm and hand.
• Nerve roots include C5, C6, C7, C8, and T1.
• Branches form the musculocutaneous, ulnar, radial, and median nerves.

Causes of Brachial Plexus Injury

• Fetal:
  • Macrosomia (birth weight ≥ 4 kg)
  • Breech presentation
• Maternal:
  • Diabetes during pregnancy
  • Shoulder dystocia (shoulder impacted behind pubic bone)
  • Small stature/cephalopelvic disproportion
  • Prolonged labour
  • Precipitous labour
  • Use of assisted delivery such as forceps or vacuum

Shoulder Dystocia

• Difficult birth, one shoulder gets stuck behind the pubic bone.
• A rare condition, with occurrence between 0.6% to 1.4% of births with babies weighing 5 lb 8 oz to 8 lb 13 oz
• Rate increases to 5% to 9% for infants weighing more than 8 lb 13 oz at birth.

Classification of Brachial Plexus Injury - Severity

• Avulsion: Complete tear of nerve root
• Rupture: Partial tear of nerve root
• Neuroma: Scar tissue formation around the nerve
• Neuropraxia: Temporary nerve dysfunction

Classification of Brachial Plexus Injury - Grades

• Grade I: Paralysis of shoulder and elbow flexors (Erb-Duchenne) - Waiter's tip position. Spontaneous recovery 90%.
• Grade II: Paralysis of shoulder, elbow flexion, pronation/supination, wrist drop, and altered hand sensation. Spontaneous recovery 60%.
• Grade III: Total paralysis (C5, C6, C7, C8, T1), 40% spontaneous recovery. Surgery for extensive nerve repair and muscle transplantation may be required.
• Grade IV: Severe damage and sympathetic injury (Klumpke's, claw hand). Full spontaneous recovery is rare, surgery may be needed

Erb's Palsy

• Results from stretching of the 5th and 6th cervical nerves.
• Infant's arm held in the "waiter's tip" position (arm extended, internally rotated, and wrist flexed).
• Moro reflex and R hand grasp intact, but the affected arm is absent.
• Spontaneous resolution in 90% by 4 months of age. Nerve grafting might help for persistent deficits.

Klumpke's Palsy

• Injury to the inferior part of the brachial plexus (C8 and T1).
• Due to excessive abduction of the arm (hyper-abduction traction) during delivery.
• Less common than Erb's palsy.
• Motor loss in the small muscles of the hand (C8, T1). Sensory loss in the medial aspect of the upper limb.

Signs and Symptoms

• Weakness and loss of movement in the forearm and hand.
• Horner syndrome (unilateral ptosis, miosis, anhidrosis) may be present; drooping eyelid, constricted pupil, reduced sweating.
• Infant holds the arm in supination, elbow bent, and wrist extended.
• Decreased grip strength on the affected side.
• Sensory loss difficult to assess in newborns.
• Reflexes in the affected roots are absent.
• Claw hand (Older children) - Wrist extension, metacarpophalangeal joint hyperextension, and interphalangeal joint flexion.

Towel Test

• Developed to assess nerve function, particularly in infants.
• Child is supine with face covered with the towel.
• Shoulder, elbow, and hand motion needed to remove the towel.
• Important test to assess recovery and identify potential need for surgery for persistent deficits by 3 months of age if not successful.

Treatment

• Surgery: Tendon transfer, nerve transfer/neurotization, nerve anastomosis, nerve reconstruction.
• Therapy: Occupational therapy, hydrotherapy (water-based therapy), physical therapy, muscle strengthening exercises, and flexibility