Neonatal brachial plexus palsy
- Barry Russman, MD
Barry Russman, MD
- Professor of Pediatrics and Neurology
- Oregon Health and Science University
- Section Editors
- Marc C Patterson, MD, FRACP
Marc C Patterson, MD, FRACP
- Section Editor — Pediatric Neurology
- Professor of Neurology, Pediatrics, and Medical Genetics
- Chair, Division of Child and Adolescent Neurology
- Mayo Clinic College of Medicine
- Jeremy M Shefner, MD, PhD
Jeremy M Shefner, MD, PhD
- Section Editor — Neuromuscular Disease
- Professor and Chair of Neurology, Barrow Neurological Institute
- Professor of Neurology, University of Arizona, Phoenix
- Clinical Professor of Neurology, Creighton University
The brachial plexus (figure 1) is a network of nerve fusions and divisions that originate from cervical and upper thoracic nerve roots and terminate as named nerves that innervate muscles and skin of the shoulder and arm. The first clinical description of neonatal brachial plexus palsy (NBPP) was reported in the 1760s . In the late 1800s, the different types of NBPP were defined; Duchenne and Erb in separate reports described upper trunk nerve injury to the C5 and C6 nerve roots, now called Erb palsy or Duchenne-Erb palsy [2,3], and Klumpke described lower trunk injury involving the C8 and T1 nerve roots . Subsequently, palsy of all the nerve roots from C5 to T1 was reported.
The major controversies about NBPP revolve around the etiologies and the management. Once the diagnosis is established, what studies should be performed? How often does shoulder dystocia or obstetrical intervention contribute to the etiology? What is the role of rehabilitation therapies? When should nerve surgery be considered? When is orthopedic intervention needed? What is the prognosis for complete or partial recovery? Unfortunately, the literature provides a variety of different answers to the questions posed and controversy remains. In addition, the quality of the published evidence about NBPP is suboptimal; high-quality population-based studies with prospective analysis, sufficient follow-up, and clear assessment are scarce .
This topic will review the etiology, epidemiology, clinical features, diagnosis, management, and prognosis of NBPP, which is also known as obstetric brachial plexus palsy and birth-related brachial plexus palsy. Other brachial plexopathies are discussed separately. (See "Brachial plexus syndromes".)
Potential mechanisms of neonatal brachial plexus palsy (NBPP) include stretching/traction, compression, infiltration, and oxygen deprivation . Of these, stretching is considered the most common mechanism. In addition, stretching may contribute to brachial plexus injury in cases where the principal cause is one of the other mechanisms. The etiology of NBPP traditionally has been attributed to iatrogenic lateral traction on the fetal head, typically when shoulder dystocia impedes delivery [7-9]. Downward lateral traction (ie, bending the neck away from the anterior shoulder and toward the posterior shoulder) causes increased stretching of the brachial plexus compared with downward axial traction (ie, applying force parallel to the fetal spine) .
However, NBPP can occur even when axial traction is properly applied; the occurrence of NBPP following birth does not automatically indicate that the practitioner applied forces or maneuvers that caused the nerve injury . The forces of uterine contraction and maternal pushing alone are probably sufficient to cause excessive traction on the brachial plexus [10,11]. In addition, antepartum factors may predispose to NBPP, including uterine abnormalities such as Müllerian anomalies and fibroids that can result in fetal malpositioning and compression .
- McGillicuddy JE. Neonatal brachial plexus palsy - historical perspective. J Pediatr Rehabil Med 2011; 4:99.
- Duchenne GBA. De l'électrisation localisée et de son application à la pathologie et à la thérapeutique, Troisième édition, J.B. Baillière, Paris 1872. p.357.
- Erb WH. Ueber eine eigenthümliche Localisation von Lähmungen im Plexus brachialis, Carl Winter's Universitätbuchhandlung, Heidelberg 1874.
- Klumpke A. Contribution a l'Étude des paralyses radiculaires du plexus brachial: Paralyses radiculaires totales, paralyses radiculaires inferieurs, de la participation du fillets sympathetique oculo-papillaires dans ces paralyses. Rev Med 1885; 5:591. 5:738.
- Pondaag W, Gert van Dijk J, Malessy MJ. Obstetric brachial plexus palsy. Dev Med Child Neurol 2010; 52:502.
- Alfonso DT. Causes of neonatal brachial plexus palsy. Bull NYU Hosp Jt Dis 2011; 69:11.
- Ferrante MA. Brachial plexopathies: classification, causes, and consequences. Muscle Nerve 2004; 30:547.
- Wilbourn AJ. Plexopathies. Neurol Clin 2007; 25:139.
- Foad SL, Mehlman CT, Ying J. The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Joint Surg Am 2008; 90:1258.
- Executive summary: Neonatal brachial plexus palsy. Report of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Brachial Plexus Palsy. Obstet Gynecol 2014; 123:902.
- Gherman RB, Ouzounian JG, Goodwin TM. Brachial plexus palsy: an in utero injury? Am J Obstet Gynecol 1999; 180:1303.
- Ouzounian JG. Risk factors for neonatal brachial plexus palsy. Semin Perinatol 2014; 38:219.
- Allen RH, Gurewitsch ED. Temporary Erb-Duchenne palsy without shoulder dystocia or traction to the fetal head. Obstet Gynecol 2005; 105:1210.
- Gilbert WM, Nesbitt TS, Danielsen B. Associated factors in 1611 cases of brachial plexus injury. Obstet Gynecol 1999; 93:536.
- Paradiso G, Grañana N, Maza E. Prenatal brachial plexus paralysis. Neurology 1997; 49:261.
- Dunn DW, Engle WA. Brachial plexus palsy: intrauterine onset. Pediatr Neurol 1985; 1:367.
- Malessy MJ, Pondaag W, van Dijk JG. Electromyography, nerve action potential, and compound motor action potentials in obstetric brachial plexus lesions: validation in the absence of a "gold standard". Neurosurgery 2009; 65:A153.
- Kay SP. Obstetrical brachial palsy. Br J Plast Surg 1998; 51:43.
- van Dijk JG, Pondaag W, Malessy MJ. Obstetric lesions of the brachial plexus. Muscle Nerve 2001; 24:1451.
- Dawodu A, Sankaran-Kutty M, Rajan TV. Risk factors and prognosis for brachial plexus injury and clavicular fracture in neonates: a prospective analysis from the United Arab Emirates. Ann Trop Paediatr 1997; 17:195.
- Evans-Jones G, Kay SP, Weindling AM, et al. Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and Republic of Ireland. Arch Dis Child Fetal Neonatal Ed 2003; 88:F185.
- Lagerkvist AL, Johansson U, Johansson A, et al. Obstetric brachial plexus palsy: a prospective, population-based study of incidence, recovery, and residual impairment at 18 months of age. Dev Med Child Neurol 2010; 52:529.
- The American College of Obstetricians and Gynecologists Task Force on Neonatal Brachial Plexus Palsy. Incidence of neonatal brachial plexus palsy. In: Neonatal Brachial Plexus Palsy, Washington, D.C. 2014. p.1.
- The American College of Obstetricians and Gynecologists Task Force on Neonatal Brachial Plexus Palsy. Neonatal brachial plexus palsy and shoulder dystocia. In: Neonatal Brachial Plexus Palsy, Washington, D.C. 2014. p.41.
- Gurewitsch ED, Johnson E, Hamzehzadeh S, Allen RH. Risk factors for brachial plexus injury with and without shoulder dystocia. Am J Obstet Gynecol 2006; 194:486.
- Levine MG, Holroyde J, Woods JR Jr, et al. Birth trauma: incidence and predisposing factors. Obstet Gynecol 1984; 63:792.
- Eng GD, Binder H, Getson P, O'Donnell R. Obstetrical brachial plexus palsy (OBPP) outcome with conservative management. Muscle Nerve 1996; 19:884.
- Wolf H, Hoeksma AF, Oei SL, Bleker OP. Obstetric brachial plexus injury: risk factors related to recovery. Eur J Obstet Gynecol Reprod Biol 2000; 88:133.
- Ouzounian JG, Korst LM, Miller DA, Lee RH. Brachial plexus palsy and shoulder dystocia: obstetric risk factors remain elusive. Am J Perinatol 2013; 30:303.
- The American College of Obstetricians and Gynecologists Task Force on Neonatal Brachial Plexus Palsy. Risk and predictive factors. In: Neonatal Brachial Plexus Palsy, Washington, D.C. 2014. p.15.
- Zuarez-Easton S, Zafran N, Garmi G, et al. Are there modifiable risk factors that may predict the occurrence of brachial plexus injury? J Perinatol 2015; 35:349.
- Volpe JJ. Injuries of extracranial, cranial, intracranial, spinal cord, and peripheral nervous system structures. In: Neurology of the Newborn, 5th edition, Saunders, Philadelphia 2008. p.959.
- Bowerson M, Nelson VS, Yang LJ. Diaphragmatic paralysis associated with neonatal brachial plexus palsy. Pediatr Neurol 2010; 42:234.
- The American College of Obstetricians and Gynecologists Task Force on Neonatal Brachial Plexus Palsy. Anatomy and clinical presentation of neonatal brachial plexus palsy. In: Neonatal Brachial Plexus Palsy, Washington, D.C. 2014. p.51.
- Zafeiriou DI, Psychogiou K. Obstetrical brachial plexus palsy. Pediatr Neurol 2008; 38:235.
- Hoeksma AF, Wolf H, Oei SL. Obstetrical brachial plexus injuries: incidence, natural course and shoulder contracture. Clin Rehabil 2000; 14:523.
- ter Steeg AM, Hoeksma AF, Dijkstra PF, et al. Orthopaedic sequelae in neurologically recovered obstetrical brachial plexus injury. Case study and literature review. Disabil Rehabil 2003; 25:1.
- Alfonso I, Alfonso DT, Price AE, Grossman JA. Cortical dysplasia and obstetrical brachial plexus palsy. J Child Neurol 2008; 23:1477.
- Yang LJ. Neonatal brachial plexus palsy--management and prognostic factors. Semin Perinatol 2014; 38:222.
- Van Dijk JG, Pondaag W, Buitenhuis SM, et al. Needle electromyography at 1 month predicts paralysis of elbow flexion at 3 months in obstetric brachial plexus lesions. Dev Med Child Neurol 2012; 54:753.
- Pitt M, Vredeveld JW. The role of electromyography in the management of the brachial plexus palsy of the newborn. Clin Neurophysiol 2005; 116:1756.
- Pitt M. Why wait 3 months before doing electromyography in obstetric brachial plexus lesions? Challenging the norm. Dev Med Child Neurol 2012; 54:682.
- Medina LS, Yaylali I, Zurakowski D, et al. Diagnostic performance of MRI and MR myelography in infants with a brachial plexus birth injury. Pediatr Radiol 2006; 36:1295.
- Tse R, Nixon JN, Iyer RS, et al. The diagnostic value of CT myelography, MR myelography, and both in neonatal brachial plexus palsy. AJNR Am J Neuroradiol 2014; 35:1425.
- Somashekar D, Yang LJ, Ibrahim M, Parmar HA. High-resolution MRI evaluation of neonatal brachial plexus palsy: A promising alternative to traditional CT myelography. AJNR Am J Neuroradiol 2014; 35:1209.
- Pillen S, Semmekrot B, Meulstee J, et al. Ultrasound of the cervical roots and brachial plexus in neonates. Muscle Nerve 2015; 51:35.
- Zaidman CM, Holland MR, Noetzel MJ, et al. Newborn brachial plexus palsy: evaluation of severity using quantitative ultrasound of muscle. Muscle Nerve 2013; 47:246.
- Joseph JR, DiPietro MA, Somashekar D, et al. Ultrasonography for neonatal brachial plexus palsy. J Neurosurg Pediatr 2014; 14:527.
- Smith EC, Xixis KI, Grant GA, Grant SA. Assessment of obstetric brachial plexus injury with preoperative ultrasound. Muscle Nerve 2016; 53:946.
- Somashekar DK, Di Pietro MA, Joseph JR, et al. Utility of ultrasound in noninvasive preoperative workup of neonatal brachial plexus palsy. Pediatr Radiol 2016; 46:695.
- Spinner RJ, Kline DG. Surgery for peripheral nerve and brachial plexus injuries or other nerve lesions. Muscle Nerve 2000; 23:680.
- Bodensteiner JB, Rich KM, Landau WM. Early infantile surgery for birth-related brachial plexus injuries: justification requires a prospective controlled study. J Child Neurol 1994; 9:109.
- Shenaq SM, Berzin E, Lee R, et al. Brachial plexus birth injuries and current management. Clin Plast Surg 1998; 25:527.
- Grossman JA. Early operative intervention for birth injuries to the brachial plexus. Semin Pediatr Neurol 2000; 7:36.
- Lin H, Hou C, Chen D. Modified C7 neurotization for the treatment of obstetrical brachial plexus palsy. Muscle Nerve 2010; 42:764.
- Louden EJ, Broering CA, Mehlman CT, et al. Meta-analysis of function after secondary shoulder surgery in neonatal brachial plexus palsy. J Pediatr Orthop 2013; 33:656.
- Grossman JA. Early operative intervention for selected cases of brachial plexus birth injury. Arch Neurol 2006; 63:1031.
- Sparagana SP, Ezaki M. Microneurosurgery for neonatal brachial plexus palsy: The need for more information. Arch Neurol 2006; 63:1033.
- Gilbert A, Tassin JL. [Surgical repair of the brachial plexus in obstetric paralysis]. Chirurgie 1984; 110:70.
- The American College of Obstetricians and Gynecologists Task Force on Neonatal Brachial Plexus Palsy. Patterns of neonatal brachial plexus palsy and outcomes. In: Neonatal Brachial Plexus Palsy, Washington, D.C. 2014. p.65.
- Noetzel MJ, Park TS, Robinson S, Kaufman B. Prospective study of recovery following neonatal brachial plexus injury. J Child Neurol 2001; 16:488.
- Gilbert A. Long-term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin 1995; 11:583.
- Pondaag W, Malessy MJ. Recovery of hand function following nerve grafting and transfer in obstetric brachial plexus lesions. J Neurosurg 2006; 105:33.
- Marcus JR, Clarke HM. Management of obstetrical brachial plexus palsy evaluation, prognosis, and primary surgical treatment. Clin Plast Surg 2003; 30:289.
- Curtis C, Stephens D, Clarke HM, Andrews D. The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy. J Hand Surg Am 2002; 27:470.
- Bertelli JA, Ghizoni MF. The towel test: a useful technique for the clinical and electromyographic evaluation of obstetric brachial plexus palsy. J Hand Surg Br 2004; 29:155.
- Shenaq SM, Bullocks JM, Dhillon G, et al. Management of infant brachial plexus injuries. Clin Plast Surg 2005; 32:79.
- Gilbert A, Pivato G, Kheiralla T. Long-term results of primary repair of brachial plexus lesions in children. Microsurgery 2006; 26:334.
- Birch R, Ahad N, Kono H, Smith S. Repair of obstetric brachial plexus palsy: results in 100 children. J Bone Joint Surg Br 2005; 87:1089.
- Haerle M, Gilbert A. Management of complete obstetric brachial plexus lesions. J Pediatr Orthop 2004; 24:194.
- Kawabata H, Shibata T, Matsui Y, Yasui N. Use of intercostal nerves for neurotization of the musculocutaneous nerve in infants with birth-related brachial plexus palsy. J Neurosurg 2001; 94:386.
- El-Gammal TA, Abdel-Latif MM, Kotb MM, et al. Intercostal nerve transfer in infants with obstetric brachial plexus palsy. Microsurgery 2008; 28:499.
- Al-Qattan MM, Thallaj A, Abdelhamid MM. Ulnar nerve to musculocutaneous nerve transfer in an ulnar ray-deficient infant with brachial plexus birth palsy: case report. J Hand Surg Am 2010; 35:1432.
- Noaman HH, Shiha AE, Bahm J. Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results. Microsurgery 2004; 24:182.
- Arad E, Stephens D, Curtis CG, Clarke HM. Botulinum toxin for the treatment of motor imbalance in obstetrical brachial plexus palsy. Plast Reconstr Surg 2013; 131:1307.
- Ezaki M, Malungpaishrope K, Harrison RJ, et al. Onabotulinum toxinA injection as an adjunct in the treatment of posterior shoulder subluxation in neonatal brachial plexus palsy. J Bone Joint Surg Am 2010; 92:2171.
- Michaud LJ, Louden EJ, Lippert WC, et al. Use of botulinum toxin type A in the management of neonatal brachial plexus palsy. PM R 2014; 6:1107.
- Sarac C, Bastiaansen E, Van der Holst M, et al. Concepts of functioning and health important to children with an obstetric brachial plexus injury: a qualitative study using focus groups. Dev Med Child Neurol 2013; 55:1136.
- Alyanak B, Kılınçaslan A, Kutlu L, et al. Psychological adjustment, maternal distress, and family functioning in children with obstetrical brachial plexus palsy. J Hand Surg Am 2013; 38:137.
- Akel BS, Öksüz Ç, Oskay D, et al. Health-related quality of life in children with obstetrical brachial plexus palsy. Qual Life Res 2013; 22:2617.
- Pondaag W, Malessy MJ, van Dijk JG, Thomeer RT. Natural history of obstetric brachial plexus palsy: a systematic review. Dev Med Child Neurol 2004; 46:138.
- Michelow BJ, Clarke HM, Curtis CG, et al. The natural history of obstetrical brachial plexus palsy. Plast Reconstr Surg 1994; 93:675.