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Obstetric Brachial Plexopathy

  • Injury to the brachial plexus during birth

Epidemiology

  • Less common in areas with good obstetric care
  • In 1/1000 live births

Etiology

  • Macrosomia
  • Multiparous pregnancy
  • Difficult presentation
  • Shoulder dystocia
  • Forceps delivery
  • Prolonged labour
  • Associated conditions – glenohumeral dysplasia, torticollis, clavicle fracture

Anatomy

Classification – Narakas Classification

Types

Erb’s Palsy (most common)

  • Affects C5, 6
  • Mechanism
    • Traction on plexus is caused by lateral flexion of the head towards the contralateral shoulder with depression of the ipsilateral shoulder
    • Occurs during difficult delivery in infants
  • Clinical features
    • Adducted, internally rotated shoulder; pronated forearm, extended elbow  (‘waiter’s tip’)
    • C5 deficiency
      • Axillary n. deficiency – deltoid and teres minor weakness
      • Suprascapular n. deficiency – supraspinatus and infraspinatus weakness
      • Musculocutaneous n. deficiency – biceps and brachialis weakness
    • C6 deficiency
      • Radial n. deficiency – brachioradialis and supinator weakness
  • Best prognosis

Klumpke’s Palsy (rare)

  • Affects C8, T1
  • Mechanism
    • Occurs in infant born with arm presentation, results in traction/abduction from trunk
  • Clinical features
    • Deficit of all of the intrinsic muscles in the hand – normally flex MCP joints and extend DIP and PIP joints
    •  ‘Claw hand’ – due to loss of opposing action of intrinsics
      • Hyperextension of MCP
      • Flexion of DIP and PIP
  • Poor prognosis for spontaneous recovery
  • Associated with Horner’s syndrome

Total Plexus Palsy

  • Affects C5-T1
  • Mechanism – due to stretch, rupture and avulsion injury
  • Clinical features – flaccid arm; motor and sensory deficits
  • Worst prognosis

Diagnosis

  • XR – to evaluate clavicle/humerus fracture (may be unclear due to incomplete ossification in infants)
  • CT/MRI
  • USS – to assess joint subluxation or dislocation

Treatment

General

  • Non-operative – daily passive exercises
  • Operative
    • Microsurgical nerve grafting
    • Nerve transfer – fascicles from one nerve transferred into another nerve

Shoulder dislocation and contractures

  • Hoffer procedure – latissimus dorsi (LD) and teres major (TM) transfer
    • Transfer of LD and TM tendons to the rotator cuff – improves external rotation and adduction of shoulder
  • Pectoralis major lengthening – to lesson internal rotation forces
  • Arthrodesis –  artificial induction of joint ossification between two bones by surgery

Elbow flexion contracture

  • Non-op – serial elbow extension splinting/casting
  • Op – anterior capsular release

Forearm, wrist, hand

  • Tendon transfer
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