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Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy)

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Topic updated on 06/10/16 2:11pm
Introduction
  • Injury to the brachial plexus during birth
    • usually a stretching injury from a difficult vaginal delivery
    • some rare reported in C-sections
  • Subtypes includes
    • Erb's Palsy (upper trunk C5-6)
      • Most common type 
    • Klumpke's Palsy (lower trunk C8-T1)
    • Total plexus injury
  • Epidemiology
    • incidence
      • approximately 1 to 4 per 1,000 live births
      • decreasing in frequency due to improved obstetric care
  • Pathophysiology
    • mechanism 
      • condition associated with
        • large for gestational age
        • multiparous pregnancy
        • difficult presentation
        • shoulder dystocia
        • forceps delivery
        • breech position
        • prolonged labor
  • Associated conditions
    • glenohumeral dysplasia 
      • increased glenoid retroversion, humeral head flattening, posterior humeral head subluxation
        • develops in 70% of infants with obstetric brachial plexopathy
        • caused by Internal rotation contracture (loss of external rotation)
    • elbow flexion contracture 
      • etiology is unclear, likely due to persistent relative triceps weakness (C7) compared with biceps (C5-6)
  • Prognosis 
    • 90% of cases will resolve without intervention 
      • spontaneous recovery may occur for up to 2 years
    • prognostic variables for spontaneous recovery
      • favorable 
        • Erb's Palsy
        • complete recovery possible if biceps and deltoid are M1 by 2 months
        • early twitch biceps activity suggests a favorable outcome 
      • poor
        • lack of biceps function by 3 months
        • preganglionic injuries (worst prognosis)
          • avulsions from the cord, which will not spontaneously recover motor function
            • loss of rhomboid function (dorsal scapular nerve)
            • elevated hemidiaphragm (phrenic nerve)
        • Horner's syndrome (ptosis, miosis, anhydrosis)
          • less than 10% recover spontaneous motor function 
        • C5-C7 involvement
        • Klumpke's Palsy
Anatomy
  • Brachial plexus diagram 
Classification
 
 Narakas Classification
Group  Roots 
Characteristics
Group I (Duchenne-Erb's Palsy) C5-C6 Paralysis of deltoid and biceps. Intact wrist and digital flexion/extension.
Group II (Intermediate Paralysis)
 C5-C7
Paralysis of deltoid, biceps, and wrist and digital extension. Intact wrist and digital flexion. 
Group III (Total Brachial Plexus Palsy)
 C5-T1 Flail extremity without Horner's syndrome
Group IV (Total Brachial Plexus Palsy with Horner's syndrome)
 C5-T1 Flail extremity with Horner's syndrome
 
Presentation General
  • Symptoms
    • lack of active hand and arm motion  
  • Physical exam
    • upper extremity exam
      • arm hangs limp at side in an adducted and internally rotated position
      • decreased shoulder external rotation 
      • affected shoulder subluxates posteriorly
    • provocative testing
      • stimulate neonatal reflexes including Moro, asymmetric tonic neck and Votja reflexes
    • muscle strength grading system
      • M0 - no contraction
      • M1 - contraction without movement
      • M2 - contraction with slight movement
      • M3 - complete movement
Erb's Palsy (C5,6) - Upper Lesion
  • Mechanism
    • results from excessive abduction of head away from shoulder, producing traction on plexus
      • occurs during difficult delivery in infants
  • Physical exam
    • adducted, internally rotated shoulder; pronated forearm, extended elbow (“waiter’s tip”)
    • C5 deficiency
      • axilllary nerve deficiency
        • deltoid, teres minor weakness
      • suprascapular nerve deficiency
        • supraspinatus, infraspinatus weakness 
      • musculocutaneous nerve deficiency
        • biceps weakness 
    • C6 deficiency
      • radial nerve deficiency
        • brachioradialis, supinator weakness 
  • Prognosis
    • best prognosis for spontaneous recovery
Klumpke's Palsy (C8,T1) - Lower lesion
  • Mechanism
    • rare in obstetric palsy
    • usually arm presentation with subsequent traction/abduction from trunk 
  • Physical exam
    • deficit of all of the small muscles of the hand (ulnar and median nerves)
    • “claw hand”
      • wrist in extreme extension because of the unopposed wrist extensors
      • hyperextension of MCP due to loss of hand intrinsics
      • flexion of IP joints due to loss of hand intrinsics
  • Prognosis
    • poor prognosis for spontaneous recovery
    • frequently associated with a preganglionic injury and Horner's Syndrome
Total Plexus Palsy
  • Physical exam
    • flaccid arm
    • both motor and sensory deficits
  • Prognosis
    • worst prognosis
Treatment 
  • Nonoperative
    • observation & daily passive exercises by parents 
      • indications
        • first line of treatment for most obstetric brachial plexopathies
      • technique
        • key to treatment is maintaining passive motion while waiting for nerve function to return
  • Operative
    • early surgical attempt at nerve restoration
      • microsurgical nerve repair or nerve grafting 
        • indications
          • complete flail arm at 1 month of age
          • Horner's syndrome at 1 month of age
          • lack of antigravity biceps function between 3-6 months of age
      • neurotization (nerve transfer)   
        • indications
          • root avulsion at 3 months of age
        • donor nerves
          • sural
          • intercostal
          • spinal accessory
          • phrenic
          • cervical plexus
          • contralateral C7
          • hypoglossal
    • posterior glenohumeral dislocation - late surgery
      • open reduction and capsulorrhaphy
        • indications
          • early recognition with minimal glenoid deformity
      • proximal humeral derotation osteotomy 
        • indications
          • late recognition, no glenoid present
    • Internal rotation contractures and glenohumeral joint dysplasia - late surgery
      • latissimus dorsi and teres major transfer to rotator cuff
        • indications 
          • persistent external rotation and abduction weakness, internal rotation contractures, and mild-to-moderate glenohumeral joint dysplasia
      • pectoralis major and +/- subscapularis lengthening
        • indications
          • <5 years of age
      • proximal humeral derotation osteotomy
        • indications
          • > 5 years of age
    • forearm supination contractures - late surgery
      • biceps tendon transfers
        • indications
          • supination contractures with intact forearm passive pronation
      • forearm osteotomy (radius +/- ulna) +/- biceps tendon transfer
        • indications
          • supination contractures with limited forearm passive pronation
    • elbow flexion contractures - late surgery
      • Clarke's pectoral transfer and Steindler's flexoplasty
        • indications
          • lack of elbow flexion

 

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Qbank (11 Questions)

TAG
(OBQ12.160) Which of the following is the most common long term consequence of untreated brachial plexus birth palsy? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(OBQ12.218) A newborn child born via a difficult breech delivery is found to have a brachial plexus birth palsy. While initially born with a flail limb, the child regained elbow flexion at 10 weeks. At age 18 months (1.5 years old), which of the following deficits is most likely to be seen on physical exam? Topic Review Topic

1. Claw hand
2. Fixed adduction and internal rotation at shoulder with elbow extension
3. Hyperextension of the MCP joints and flexion of the IP joints of the hand
4. Weakness in elbow flexion
5. Normal physical exam without deficits

PREFERRED RESPONSE ▶
TAG
(OBQ11.232) A 3-month-old is brought to clinic for evaluation of a right upper extremity abnormaility present since birth. Which of the following physical exam findings is associated with the best functional outcome? Topic Review Topic

1. Loss of hand function with preserved shoulder function
2. Absent shoulder abduction and external rotation with intact wrist and digit flexion and extension
3. Rotator cuff dysfunction, elevated hemidiaphragm, and absence of rhomboid function
4. Loss of shoulder and wrist function
5. Ptosis, myosis and anhydrosis

PREFERRED RESPONSE ▶
TAG
(OBQ10.73) An infant is born with total brachial plexus palsy and Horner’s syndrome after a difficult vaginal delivery. What is the prognosis for spontaneous recovery of motor function in the involved arm by 3 months?
Topic Review Topic

1. >90%
2. 75%
3. 50%
4. 25%
5. <10%

PREFERRED RESPONSE ▶
TAG
(OBQ08.232) Which of the following muscles would be affected if a 6-month-old child sustains a birth-related brachial plexopathy affecting C5 nerve root? Topic Review Topic

1. Trapezius
2. Triceps
3. Biceps
4. Interossei
5. Flexor digitorum profundus

PREFERRED RESPONSE ▶
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