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A Review of Brachial Plexus Birth Palsy: Injury and Rehabilitation

Article  in  Rhode Island medical journal · November 2017

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A Review of Brachial Plexus Birth Palsy: Injury and Rehabilitation

JEREMY E. RADUCHA, MD; BRIAN COHEN, MD; TRAVIS BLOOD, MD; JULIA KATARINCIC, MD

A BST RA C T A NATOMY
Brachial plexus injuries during the birthing process can The brachial plexus is derived from the fifth cervical (C5) to
leave infants with upper extremity deficits corresponding the first thoracic (T1) nerve roots. It undergoes a complex
to the location of the lesion within the complex plexus pattern of branching and convergence before terminating as
anatomy. Manifestations can range from mild injuries with peripheral nerves that provide motor and sensory innervation
complete resolution to severe and permanent disability. to the upper extremity. (Figure 1, Table 1) The plexus can be
Overall, patients have a high rate of spontaneous recovery divided into supraclavicular (roots and trunks) and sub-cla-
(66–92%).1,2 Initially, all lesions are managed with passive vicular (cords and terminal branches) for prognostic pur-
range motion and observation. Prevention and/or correc- poses, with supraclavicular injuries having worse outcomes.9
tion of contractures with occupational
therapy and serial splinting/casting along Figure 1. Brachial Plexus Anatomy
with encouraging normal development
are the main goals of non-operative treat-
ment. Surgical intervention may be war-
ranted, depending on functional recovery.
K E YWORD S: Brachial plexus, Erb’s palsy,
Klumpke’s palsy, serial splinting

INTRO D U C T I O N
Brachial plexus birth palsy (BPBP) involves
injury to any nerve of the brachial plexus
during birth. It occurs in 0.42 to 4.6 cases
per 1,000 births, which translates to approxi-
mately 5 to 50 cases per year in Rhode Island,
with varying degrees of severity.1–3 The most
common presentation is Erb’s Palsy (50-
60%), followed by the more severe upper
plexus and pan-plexus variants.1,4 Klumpke’s
lower plexus palsy is rare, and occurs in 0.6%
of all patients.5 Maternal risk factors include gestational dia- Pathophysiology
betes, multi-parity and having a previous child with a brachial The majority of BPBPs are traction injuries, as with shoul-
plexus injury. Maternal factors can cause fetal macrosomia der dystocia when traction on the infant’s neck leads to an
and/or shoulder dystocia, increasing the risk of forceps or increased neck shoulder angle.1 Very rarely, compression
suction-assisted deliveries and traction nerve injury.6 Since injuries from fractured clavicles, hematomas, and pseudo-
the majority of fetuses present in the left occiput anterior aneurysm can occur.7 Lesions can be divided into symptom-
position, with the right shoulder under the maternal pel- atic categories using multiple systems. The simplest approach
vis, the right upper extremity is most commonly involved.7 is to classify lesions as pre-ganglionic or post-ganglionic,
However, only about half of patients have these risk fac- distal to the dorsal root ganglion. Pre-ganglionic lesions,
tors, demonstrating our lack of true understanding of the with the nerve injured proximally, e.g., root avulsions, are
etiology.8 This article will review the pathology, diagnosis, more difficult to heal/repair and have worse outcomes than
treatment, rehabilitation and outcomes of BPBP. post-ganglionic lesions. It is only possible to determine this

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Table 1. Brachial Plexus Functions

Branching Location Nerve Root Innvervation Muscle action
Roots Dorsal Scapular n. C5 M: Rhomboid mm. and Levator Scapulae m. Rhom: scapular retraction, Levator=scapular elevation

Long Thoracic n. C5,C6 & C7 M: Serratus anterior m. Scapular protraction

First intercostal n. T1 M: intercostal m. n/a

Trunks Suprascapular n. C5, C6 M: Supraspinatus m, Infraspinatus m. S: Supra= Arm abduction. Infra= Arm external rotation
Shoulder joint capsule
Nerve to Subclavius C5, C6 M: Subclavius m. n/a

Divisions none

Cords
Posterior Upper Subscapular n C5-T1 Motor : Upper subscapularis m. Arm internal rotation
Lower Subscapular n C5-T1 Motor : Lower Subscapularis m., Teres LS= Arm internal rotation
Major m.
Thoracodorsal n. C5-T1 Motor : Latissimus dorsi m. Arm adduction
Lateral Lateral Pectoral n. C5-C7 Motor : Pectoralis Major m. Arm Adduction
Medial Medial Pectoral n. C8-T1 Motor : Pectoralis Major m., Pectoralis Arm Addution
Minor m.
Medial Brachial cutaneous n. C8-T1 Sensory : medial arm n/a
Medial Antebrachial cutaneous n. C8-T1 Sensory: medial forearm n/a

Terminal Nerves Radial n. C5-T1 Motor : Triceps mm, brachioradialis m., Elbow extension, Wrist extension, Finger Extension, Thumb
ECRL, ECRB, ECU, EDC, EIP, EDM, EPL, EPB, extension, thumb abduction, Forearm supination;
APL, Supinator m., Finger extensors Brachioradialis=elbow flexion
Sensory : posterior brachial cutaneous,
inferior lateral brachial cutaneous,
posterior antebrachial cutaneous,
superficial radial (post. radial hand)

Axillary n. C5-T1 Motor: Deltoid m., Teres Minor m., Delt= Arm abduction, Teres= Arm external rotation
Sensory: Lateral proximal arm

Musculocutaneous n. C5-C7 Motor : Biceps brachii m., Brachialis m, Elbow Flexion, Forearm supination S: lateral forearm
corocobrachialis m.
Sensory: Lateral cutaneous n. of the
forearm
Median n. C5-T1 Motor : FCR, Palmaris longus m., FDS, radial Wrist flexion, Forearm pronation, thumb
1/2 FDP, Pronator teres m. FPL, Pronator flexion/abduction/opposition, finger PIP flexion, IF/MF MCP
quadratus m., FPB (superficial head), and DIP flexion
Opponens pollicis, APB, 1st-2nd lumbricals
Sensory : Radial 3 1/2 fingers, palmar
cutaneous branch

Ulnar n. C8-T1 Motor : FCU, ulnar 1/2 FDP, Flexor DM, Wrist flexion, Thumb adduction/flexion, SF
Abductor DM, Opponens DM, Adductor flexion/abduction/opposition, finger adduction/abduction, 4th
pollicis, FPB (deep head), Palmaris brevis and 5th finger DIP/MCP flexion
m. Dorsal interossei mm. Palmar interossei
mm., 3rd-4th Lumbricals
Sensory : Dorsal ulnar cutaneous n., Palmar
ulnar cutaneous n.

classification after advanced imaging. The Sunderland clas- Table 2. Sunderland Classification
sification (Table 2) categorizes nerve injuries based on the Type of Nerve Injury Prognosis
nerve structures damaged, ranging in severity from neuro-
praxia to neurotmesis.10 As expected, patients with less severe Neuropraxia Stretch injury with intact Spontaneous recovery
nerve continuity likely
damage, e.g., neuropraxia, have a better chance at recovery.
The most common way to describe BPBPs is based on Axonotmesis Axonal injury with intact Variable recovery
the nerve roots involved, which can be detected by phys- nerve sheath
ical examination. Upper trunk (Erb-Duchenne) palsies
Neurotmesis Complete nerve rupture; Poor prognosis for
involve only the disruption of input from the C5 and C6 neither axon nor sheath spontaneous recovery
nerve roots. Upper plexus palsies involve roots C5, C6 and intact
C7, with the addition of more distal deficits. Lower plexus
Sunderland SS. The anatomy and physiology of nerve injury. Muscle Nerve.
(Klumpke’s) palsies involve the C8 and T1 nerve roots and 1990;13(9):771-784. doi:10.1002/mus.880130903
can also affect the sympathetic chain with pre-ganglionic
injuries. The most severe is the all-encompassing pan-plexus
injury involving nerve roots C5-T1, with disruption to all
functions of the upper extremity.

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DIAGN O S I S two-week period of immobilization to promote healing and

Maternal history, physical examination and diagnostic imag- decrease pain,9 but others find little evidence that immobi-
ing can provide a wealth of information to make the proper lization has any benefit.1 Contractures can begin as early
diagnosis and injury classification. The patient’s mother as 2-3 weeks after birth, with the glenohumeral joint most
should be interviewed for the BPBP risk factors mentioned commonly affected. Without early treatment, the contrac-
previously. Abnormal primitive reflexes, e.g., Moro reflex tures can progress rapidly and cause posterior subluxation/
and tonic neck reflex, are often the first clues in the new- dislocation of the humeral head.1,9,12
born examination. It is also important to palpate the infant’s After an initial observation period, children can be cate-
clavicle and humerus, as fractures can affect upper extremity gorized as having either partial or total paralysis. Patients
movements and be confused with brachial plexus palsy. A with total paralysis should be referred to a tertiary center for
septic shoulder and isolated radial nerve palsy should also be early surgical evaluation, as they have a very low likelihood
in the differential diagnosis, but they are less common and of spontaneous recovery. Patients with partial paralysis have
are associated with different physical and laboratory findings. a higher chance of recovery, and there is complete recovery
Depending where the lesion is located, the patient’s by 3 months of age with as many as 92% of these patients.9,13
affected extremity will present in different positions. With Other evidence suggests complete recovery rates may not
Erb’s palsy (C5-6), the arm is adducted and internally rotated be as high as originally thought, with as many as 20–30%
at the shoulder and extended at the elbow, due to weakness of patients having a long-term defecit.1,2 Patients who do
in the deltoid, supero-posterior rotator cuff and biceps. A not have complete recovery by 1 month of age should be
patient with upper plexus palsy (C5-7) has the above pos- evaluated by a pediatric therapist for continued monitoring
ture as well as wrist and fingers flexion due to radial nerve and rehabilitation. Many physicians use the lack of antigrav-
involvement and wrist/finger extensor weakness. Pan-plexus ity biceps function return by 3 months as an indication for
injuries (C5-T1) typically present with a flaccid extremity. nerve surgery since it is a poor prognostic indicator for com-
Pre-ganglionic injuries, which carry a worse prognosis,, plete spontaneous recovery;1,4 however, this does not pre-
may lead to head tilting to the opposite side (denervation clude good functional recovery. Recovery of wrist extension
of paraspinal musculature), medial winging of the scapula, is also a positive prognostic sign. Other physicians advocate
diaphragm dysfunction, and Horner’s syndrome. continued rehabilitation until at least 6 months of age before
As children age, their disabilities become more apparent. considering surgery. Some evidence has shown that children
Scoring systems such as the Toronto Test Score, Active who recovered antigravity biceps function between the 3rd
Movement Scale, and Modified Mallet system have been and 6th months of life always had an incomplete recovery
developed to grade and track upper extremity function.11 compared to those who regained function prior to 3 months.9
The Modified Mallet score is the most commonly used If children undergo surgery, it is typically performed
when evaluating older children (≥3 years old). It uses five between 3 and 8 months of age; earlier surgery (at 3 months)
categories to assess shoulder function, with a 0–5 grading is indicated in children with pan-plexus palsies and Horner’s
for each category. Higher scores correlate to higher function, syndrome. The main goals of surgery, in order of importance,
but the examination requires patient participation and is are to restore elbow flexion, shoulder abduction, shoulder
heavily weighted toward shoulder external rotation. external rotation, wrist extension and hand function.7 The
Imaging can help clarify the diagnosis and classifica- options for early surgical intervention include direct nerve
tion. Initially, radiographs of the upper extremity should be repair with resection and grafting, or nerve transfers from
obtained to rule out fractures, which could be confused with surrounding motor nerves. In spite of surgery, many patients
or occur concomitantly with brachial plexus palsy. MRI and still suffer some degree of long-term sequalae.2 In patients
CT myelography can be used to detect root avulsions. Elec- who develop contracture or have persistent weakness, later
tromyography has been suggested if there is no nerve recov- surgery can be beneficial. Lysis of contractures, osteotomies
ery by 6 months of age, in order to detect a pre-ganglionic and local tendon transfers can help return functional motion
injury, which is potentially amenable to operative interven- and correct deformities.12,14
tion. Other evidence shows, however, that electromyography Children who recover meaningful biceps function by 6
can be discordant from clinical bicep function at 3 months of months of age are typically treated non-operatively with
age and the test may not be a reliable indicator for surgery.1 rehabilitation and monitoring. There is little high grade
research discussing non-operative management techniques
and protocols for brachial plexus birth palsies. All non-oper-
T REAT M E N T A ND O UT COM E S ative treatment involves a multidisciplinary team approach,
Treatment for a suspected brachial plexus palsy should with occupational therapy and splinting to prevent or correct
begin immediately with frequent, passive range of motion of contractures. The goals of treatment prior to muscle func-
the affected upper extremity. Parents should be instructed to tion recovery are to prevent contracture, strengthen recov-
range both arms at every diaper change to make it a daily rou- ering muscles, stimulate sensory nerves, and encourage the
tine and encourage compliance. Some authors recommend a achievement of normal developmental milestones. As the

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child grows, passive range of motion should be transitioned References

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Authors Correspondence
Jeremy E. Raducha, MD; Department of Orthopaedic Surgery, Jeremy E. Raducha, MD
Warren Alpert Medical School of Brown University, Department of Orthopaedic Surgery
Providence, RI. Rhode Island Hospital
Brian Cohen, MD; Department of Orthopaedic Surgery, Warren 593 Eddy Street
Alpert Medical School of Brown University, Providence, RI. Providence, RI 02903
Travis Blood, MD; Department of Orthopaedic Surgery, Warren 401-444-4030
Alpert Medical School of Brown University, Providence, RI. Fax 401-444-6182
Julia Katarincic, MD; Department of Orthopaedic Surgery, Warren Jeremy.raducha@gmail.com
Alpert Medical School of Brown University, Providence, RI.

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