Infantile Brachial Plexus Injury: Difference between revisions
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== Introduction == | == Introduction == | ||
Neonatal brachial plexus palsy (NBPP) is a closed nerve traction injury of the [[brachial plexus]] (C5-T1). It predominately occurs during labour and it can limit arm function.<ref name=":0">Shah V, Coroneos CJ, Ng E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8711584/ The evaluation and management of neonatal brachial plexus palsy]. Paediatrics & Child Health. 2021 Dec;26(8):493-7.</ref> <ref name=":1">Van der Looven R, Le Roy L, Tanghe E, Samijn B, Roets E, Pauwels N, Deschepper E, De Muynck M, Vingerhoets G, Van den Broeck C. [https://onlinelibrary.wiley.com/doi/epdf/10.1111/dmcn.14381 Risk factors for neonatal brachial plexus palsy: a systematic review and meta‐analysis.] Developmental Medicine & Child Neurology. 2020 Jun;62(6):673-83.</ref> <ref name=":2">Frade F, Gómez-Salgado J, Jacobsohn L, Florindo-Silva F. [https://www.mdpi.com/2077-0383/8/7/980 Rehabilitation of neonatal brachial plexus palsy: integrative literature review]. Journal of clinical medicine. 2019 Jul 5;8(7):980.</ref> NBPP | Neonatal brachial plexus palsy (NBPP) is a closed nerve traction injury of the [[brachial plexus]] (C5-T1). It predominately occurs during labour and it can limit arm function.<ref name=":0">Shah V, Coroneos CJ, Ng E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8711584/ The evaluation and management of neonatal brachial plexus palsy]. Paediatrics & Child Health. 2021 Dec;26(8):493-7.</ref> <ref name=":1">Van der Looven R, Le Roy L, Tanghe E, Samijn B, Roets E, Pauwels N, Deschepper E, De Muynck M, Vingerhoets G, Van den Broeck C. [https://onlinelibrary.wiley.com/doi/epdf/10.1111/dmcn.14381 Risk factors for neonatal brachial plexus palsy: a systematic review and meta‐analysis.] Developmental Medicine & Child Neurology. 2020 Jun;62(6):673-83.</ref> <ref name=":2">Frade F, Gómez-Salgado J, Jacobsohn L, Florindo-Silva F. [https://www.mdpi.com/2077-0383/8/7/980 Rehabilitation of neonatal brachial plexus palsy: integrative literature review]. Journal of clinical medicine. 2019 Jul 5;8(7):980.</ref> NBPP causes flaccid paralysis or weakness in the upper extremity and is diagnosed soon after birth. The global incidence of NBPP is reported to be between 1-4 cases per 1000 live births with rates varying depending on study setting and availability of foetal and maternal care.<ref name=":4">Heyworth BE, Fabricant PD. [https://books.google.com/books?hl=en&lr=&id=3g8zEAAAQBAJ&oi=fnd&pg=RA2-PA39&dq=infantile+brachial+plexus+injury+scholarly+article&ots=yWB8xitlLV&sig=4JNMV-07gMbabVNU3LumBsBrS50#v=onepage&q&f=false BRACHIAL PLEXUS BIRTH PALSY]. Rockwood and Matsen's The Shoulder E-Book. 2021 Jun 12:39.</ref> The overall incidence of NBPP is decreasing.<ref name=":1" /> | ||
[[File:Brachial Plexus - Shutterstock - ID 2111953730.jpg|none|thumb|500x500px|Brachial plexus]] | [[File:Brachial Plexus - Shutterstock - ID 2111953730.jpg|none|thumb|500x500px|Brachial plexus]] | ||
== Mechanism of Injury == | == Mechanism of Injury == | ||
[[File:Erb's Palsy Mechanism of Action - Adapted Shutterstock - ID 628024163.jpg|thumb]] | [[File:Erb's Palsy Mechanism of Action - Adapted Shutterstock - ID 628024163.jpg|thumb]] | ||
In neonatal [[Brachial Plexus Injury|brachial plexus injury]], obstetric, maternal and infant factors | In neonatal [[Brachial Plexus Injury|brachial plexus injury]], obstetric, maternal and infant factors cause traction to be applied to the brachial plexus.<ref name=":1" /> The most common cause of NBPP is shoulder dystocia - i.e. the "delivery of the anterior shoulder of the baby is hampered by mother’s pubic symphysis".<ref name=":3" /> This traction force widens the angle between the baby's shoulder and neck, resulting in an overstretched ipsilateral brachial plexus.<ref name=":3">Meena R, Doddamani RS, Sawarkar DP, Agrawal D. [https://www.thieme.in/thieme-e-Journals/jpnspdf/JPNS-21-2-0030-First-article.pdf Current Management Strategies in Neonatal Brachial Plexus Palsy]. Journal of Peripheral Nerve Surgery Vol. 2021;5(1).</ref> | ||
Many infants spontaneously recover or gain close to normal upper extremity function. For those whose motor recovery is incomplete, close monitoring and expert interventions are | Many infants spontaneously recover or gain close to normal upper extremity function. For those whose motor recovery is incomplete, close monitoring and expert interventions are essential to optimising outcomes.<ref name=":4" /> Prognosis depends on the level of nerve root involvement and the severity of injury.<ref name=":2" /> Within the first year of life, 80-96% of individuals with NBPP will recover completely.<ref name=":3" /> | ||
== Risk factors == | == Risk factors == | ||
The risk factors for NBPP include neonatal, | The risk factors for NBPP include neonatal, maternal and labour-related issues. | ||
1. Neonatal | 1. Neonatal | ||
| Line 26: | Line 26: | ||
3. Labour-related factors | 3. Labour-related factors | ||
* Shoulder dystocia | * Shoulder dystocia | ||
* Increased duration of second stage of | * Increased duration of second stage of labour (>60 minutes) | ||
* Operative vaginal deliveries | * Operative vaginal deliveries | ||
* Vacuum extraction | * Vacuum extraction | ||
| Line 32: | Line 32: | ||
== Classification == | == Classification == | ||
There are several ways to classify NBPP. One classification system is based on which portion of the [[brachial plexus]] is injured. The "upper trunk" refers to nerves C5-C6 and is referred to as Duchenne-Erb syndrome. The lower trunk affects nerves C7-T1 and know as Dejerine-Klumpke syndrome. If there is a complete severing of the brachial plexus, then all nerve roots between C5-T1 would be disturbed | There are several ways to classify NBPP. One classification system is based on which portion of the [[brachial plexus]] is injured. The "upper trunk" refers to nerves C5-C6 and is referred to as Duchenne-Erb syndrome. The lower trunk affects nerves C7-T1 and know as Dejerine-Klumpke syndrome. If there is a complete severing of the brachial plexus, then all nerve roots between C5-T1 would be disturbed.<ref name=":2" />[[File:Seddon's - Classification of Nerve Injuries - Wikimedia Commons.jpg|thumb|450x450px|Classification of Nerve Injuries]]Another classification system is based on the degree of lesion of the nerve. For example: | ||
* neurotmesis: complete tear of the [[Axons|axon]] and connective tissue with no chance of recovery | * neurotmesis: complete tear of the [[Axons|axon]] and connective tissue with no chance of recovery | ||
| Line 45: | Line 45: | ||
Infantile [[Brachial Plexus Injury|brachial plexus injury]] is generally detected by parents or healthcare workers in the immediate neonatal period - they generally observe an absence of motor function in the arm or hand.<ref name=":2" /> These motor deficits should be painless. If there is pain during passive range of motion, a [[fracture]] should be suspected.<ref name=":4" /> | Infantile [[Brachial Plexus Injury|brachial plexus injury]] is generally detected by parents or healthcare workers in the immediate neonatal period - they generally observe an absence of motor function in the arm or hand.<ref name=":2" /> These motor deficits should be painless. If there is pain during passive range of motion, a [[fracture]] should be suspected.<ref name=":4" /> | ||
The table below highlights common presentations based on which nerve root is injured | The table below highlights common presentations based on which nerve root is injured. | ||
{| class="wikitable" | {| class="wikitable" | ||
|+<ref name=":3" /> | |+<ref name=":3" /> | ||
| Line 77: | Line 77: | ||
|} | |} | ||
NBPP may occur with other conditions including: | NBPP may occur with other conditions, including: | ||
* humeral and clavicular fractures | * humeral and clavicular fractures | ||
| Line 85: | Line 85: | ||
== Assessment == | == Assessment == | ||
The assessment of an individual with infantile brachial plexus injury should include the following:<ref name=":0" /><ref name=":6" /> | |||
* detailed maternal and delivery history | |||
* musculoskeletal examination | |||
** check posture | |||
** muscle activation / strength | |||
** active and passive range of motion | |||
** check for age-appropriate activities of daily living (e.g. holding a toy / bottle, reaching for feet) | |||
* neurological examination | |||
** reflex testing and righting reactions: (if the entire brachial plexus is impacted, the [[Moro Reflex|Moro reflex]], [[asymmetrical tonic neck reflex]] and grasp reflex will not be present<ref name=":6">Eskay K. Infantile Brachial Plexus Injury Course. Plus, 2023.</ref>) | |||
** sensory examination | |||
** serial EMGs may be performed (usually started at 2 weeks, and repeated in 6-8 week intervals) | |||
* functional assessment | |||
* respiratory status | |||
* symmetry of chest movements | |||
* determine if there is a need for an x-ray to rule out bony injury | |||
* check for secondary impairments (e.g. soft tissue contractures, scapula winging) | |||
== Rehabilitation == | == Rehabilitation == | ||
Conservative treatment is always initiated as early as possible. Treatment will depend on each child's presentation and their specific impairments. Conservative treatment for infantile brachial plexus injury could include the following interventions:<ref name=":2" /><ref name=":6" /> | |||
* | * active movement of the upper extremity | ||
* stretches and passive range of motion | * stretches and passive range of motion | ||
* support of upper limb for activities in sitting, prone, or when reaching, grasping (e.g. kinesiotaping, table for support); provide proximal support to help ensure success during activities (e.g. use a semi-reclined, supported chair) | |||
* sensory stimulation | * sensory stimulation | ||
* tactile stimulation with varying textures | * tactile stimulation with varying textures | ||
* brushing and vibration techniques | * brushing and vibration techniques | ||
* bimanual activities | * bimanual activities | ||
* electrical stimulation to increase muscle strength and inhibit atrophy | * electrical stimulation to increase muscle strength and inhibit atrophy (may be better to wait until at least 18 months of age when much of the nerve regeneration has already occurred<ref name=":6" />) | ||
* botulinum toxin injections into healthy antagonist muscles | * botulinum toxin injections into healthy antagonist muscles | ||
* splints for infants with impaired wrist function to facilitate increased hand function | * splints for infants with impaired wrist function to facilitate increased hand function - other adaptive equipment like kinesiotaping, de-rotation straps may also be used | ||
* [https://www.physio-pedia.com/Constraint_Induced_Movement_Therapy?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal constraint induced movement therapy] | * [https://www.physio-pedia.com/Constraint_Induced_Movement_Therapy?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal constraint induced movement therapy] | ||
Ideally, therapy would occur several times a week, and a home programme should be prescribed to achieve the best outcome.<ref name=":2" /> | |||
== Surgery == | == Surgery == | ||
Children are considered suitable candidates for surgery if | Children are considered suitable candidates for surgery if conservative management has failed.<ref name=":6" /> Surgery for children aged less than 12 months is controversial - an infant must be significantly impacted to consider early surgery (e.g. they should have had no anti-gravity muscle control for at least three to nine months).<ref name=":6" /> | ||
There are two types of surgery for NBPP: primary and secondary. | There are two types of surgery for NBPP: primary and secondary.<ref name=":3" /> | ||
* Primary reconstruction: for children who do not have spontaneous recovery | * '''Primary reconstruction''': for children who do not have spontaneous recovery. This type of surgical management may include nerve grafting, nerve transfers, direct repair and/or soft tissue procedures. | ||
* Secondary reconstruction: recommended for children who have had some spontaneous recovery but continue to have significant functional deficit or children who have undergone a primary surgery but continue to have | * '''Secondary reconstruction''': recommended for children who have had some spontaneous recovery but continue to have significant functional deficit or children who have undergone a primary surgery but continue to have limitations in limb function. Secondary surgery may include osseous procedures and soft tissue reconstructions.<ref name=":3" /> | ||
Post | Post-surgical management: the infant is placed in a prefabricated cast to limit movement of the neck and affected arm for 1-2 weeks. After 2-3 weeks, gentle range of motion can be initiated. Regular follow-up by a rehabilitation team for a minimum of 5 years is recommended for assessment of recovery and to identify if any secondary reconstructions may be needed to improve function.<ref name=":3" /> | ||
<nowiki>**</nowiki> Due to the rate of nerve regeneration (i.e. 1 mm/day or 1 inch/month), clinical changes may not be evident until 1-2 years after surgery. Regular physiotherapy should be provided while waiting for reinnervation to prevent contractures.<ref name=":3" /> | <nowiki>**</nowiki> Due to the rate of nerve regeneration (i.e. 1 mm/day or 1 inch/month), clinical changes may not be evident until 1-2 years after surgery. Regular physiotherapy should be provided while waiting for reinnervation to prevent contractures.<ref name=":3" /> | ||
Revision as of 00:19, 9 May 2023
Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Robin Tacchetti, Jess Bell and Kim Jackson
Top Contributors - Robin Tacchetti, Jess Bell and Kim Jackson
Introduction[edit | edit source]
Neonatal brachial plexus palsy (NBPP) is a closed nerve traction injury of the brachial plexus (C5-T1). It predominately occurs during labour and it can limit arm function.[1] [2] [3] NBPP causes flaccid paralysis or weakness in the upper extremity and is diagnosed soon after birth. The global incidence of NBPP is reported to be between 1-4 cases per 1000 live births with rates varying depending on study setting and availability of foetal and maternal care.[4] The overall incidence of NBPP is decreasing.[2]
Mechanism of Injury[edit | edit source]
In neonatal brachial plexus injury, obstetric, maternal and infant factors cause traction to be applied to the brachial plexus.[2] The most common cause of NBPP is shoulder dystocia - i.e. the "delivery of the anterior shoulder of the baby is hampered by mother’s pubic symphysis".[5] This traction force widens the angle between the baby's shoulder and neck, resulting in an overstretched ipsilateral brachial plexus.[5]
Many infants spontaneously recover or gain close to normal upper extremity function. For those whose motor recovery is incomplete, close monitoring and expert interventions are essential to optimising outcomes.[4] Prognosis depends on the level of nerve root involvement and the severity of injury.[3] Within the first year of life, 80-96% of individuals with NBPP will recover completely.[5]
Risk factors[edit | edit source]
The risk factors for NBPP include neonatal, maternal and labour-related issues.
1. Neonatal
- Large birth weight
- Breech presentation (caesarean section may be a protective factor)[2]
- Congenital anomalies
2. Maternal
- Age > 35 years
- Cephalopelvic disproportion
- Obesity
- Gestational diabetes mellitus (macrosomia - i.e. babies who are large for their gestational age[6])
- Previous child with NBPP
3. Labour-related factors
- Shoulder dystocia
- Increased duration of second stage of labour (>60 minutes)
- Operative vaginal deliveries
- Vacuum extraction
- Direct compression of the foetal neck during delivery by forceps[5][2][4]
Classification[edit | edit source]
There are several ways to classify NBPP. One classification system is based on which portion of the brachial plexus is injured. The "upper trunk" refers to nerves C5-C6 and is referred to as Duchenne-Erb syndrome. The lower trunk affects nerves C7-T1 and know as Dejerine-Klumpke syndrome. If there is a complete severing of the brachial plexus, then all nerve roots between C5-T1 would be disturbed.[3]
Another classification system is based on the degree of lesion of the nerve. For example:
- neurotmesis: complete tear of the axon and connective tissue with no chance of recovery
- axonotmesis: axon interruption with no, or only partial, interruption to myelin and connective tissue with gradual recovery
- neuropraxic: transient physiological blockage with spontaneous recovery; no nerve rupture with full recovery
- neuroma: blocking of nerve impulse to muscle by injured nerve scar tissue[3][5]
Mallet Classification[edit | edit source]
The Mallet classification system is an assessment tool used with children who have brachial plexus birth injuries. The examination assesses the performance of six upper extremity functional movements. Administrators score the test based on observation of the movement on a scale from V (full function) to I (no function). This test is easy to administer in a clinical setting and has been found to have good internal consistency, inter-observer reliability and intra-observer reliability.[7]
Clinical Presentation[edit | edit source]
Infantile brachial plexus injury is generally detected by parents or healthcare workers in the immediate neonatal period - they generally observe an absence of motor function in the arm or hand.[3] These motor deficits should be painless. If there is pain during passive range of motion, a fracture should be suspected.[4]
The table below highlights common presentations based on which nerve root is injured.
| Segment Involved | Muscular Deficits | Arm Position |
|---|---|---|
| C5 - deltoid | Abduction of shoulder | Adducted |
| C5 - supra and infraspinatus | External rotation of shoulder | Internally rotated |
| C5 C6 - bracioradialis | Flexion of elbow | Extended |
| C5 C6 - supinators | Supination of forearm | Pronated |
| C6 C7 - extensors of wrist | Wrist extensors | Flexed |
| C6 C7 - extensors of fingers | Finger extensors | Flexed |
NBPP may occur with other conditions, including:
- humeral and clavicular fractures
- flexion contracture of the elbow
- progressive glenohumeral dysplasia
- torticollis[4]
Assessment[edit | edit source]
The assessment of an individual with infantile brachial plexus injury should include the following:[1][8]
- detailed maternal and delivery history
- musculoskeletal examination
- check posture
- muscle activation / strength
- active and passive range of motion
- check for age-appropriate activities of daily living (e.g. holding a toy / bottle, reaching for feet)
- neurological examination
- reflex testing and righting reactions: (if the entire brachial plexus is impacted, the Moro reflex, asymmetrical tonic neck reflex and grasp reflex will not be present[8])
- sensory examination
- serial EMGs may be performed (usually started at 2 weeks, and repeated in 6-8 week intervals)
- functional assessment
- respiratory status
- symmetry of chest movements
- determine if there is a need for an x-ray to rule out bony injury
- check for secondary impairments (e.g. soft tissue contractures, scapula winging)
Rehabilitation[edit | edit source]
Conservative treatment is always initiated as early as possible. Treatment will depend on each child's presentation and their specific impairments. Conservative treatment for infantile brachial plexus injury could include the following interventions:[3][8]
- active movement of the upper extremity
- stretches and passive range of motion
- support of upper limb for activities in sitting, prone, or when reaching, grasping (e.g. kinesiotaping, table for support); provide proximal support to help ensure success during activities (e.g. use a semi-reclined, supported chair)
- sensory stimulation
- tactile stimulation with varying textures
- brushing and vibration techniques
- bimanual activities
- electrical stimulation to increase muscle strength and inhibit atrophy (may be better to wait until at least 18 months of age when much of the nerve regeneration has already occurred[8])
- botulinum toxin injections into healthy antagonist muscles
- splints for infants with impaired wrist function to facilitate increased hand function - other adaptive equipment like kinesiotaping, de-rotation straps may also be used
- constraint induced movement therapy
Ideally, therapy would occur several times a week, and a home programme should be prescribed to achieve the best outcome.[3]
Surgery[edit | edit source]
Children are considered suitable candidates for surgery if conservative management has failed.[8] Surgery for children aged less than 12 months is controversial - an infant must be significantly impacted to consider early surgery (e.g. they should have had no anti-gravity muscle control for at least three to nine months).[8]
There are two types of surgery for NBPP: primary and secondary.[5]
- Primary reconstruction: for children who do not have spontaneous recovery. This type of surgical management may include nerve grafting, nerve transfers, direct repair and/or soft tissue procedures.
- Secondary reconstruction: recommended for children who have had some spontaneous recovery but continue to have significant functional deficit or children who have undergone a primary surgery but continue to have limitations in limb function. Secondary surgery may include osseous procedures and soft tissue reconstructions.[5]
Post-surgical management: the infant is placed in a prefabricated cast to limit movement of the neck and affected arm for 1-2 weeks. After 2-3 weeks, gentle range of motion can be initiated. Regular follow-up by a rehabilitation team for a minimum of 5 years is recommended for assessment of recovery and to identify if any secondary reconstructions may be needed to improve function.[5]
** Due to the rate of nerve regeneration (i.e. 1 mm/day or 1 inch/month), clinical changes may not be evident until 1-2 years after surgery. Regular physiotherapy should be provided while waiting for reinnervation to prevent contractures.[5]
Resources[edit | edit source]
References[edit | edit source]
- ↑ 1.0 1.1 Shah V, Coroneos CJ, Ng E. The evaluation and management of neonatal brachial plexus palsy. Paediatrics & Child Health. 2021 Dec;26(8):493-7.
- ↑ 2.0 2.1 2.2 2.3 2.4 Van der Looven R, Le Roy L, Tanghe E, Samijn B, Roets E, Pauwels N, Deschepper E, De Muynck M, Vingerhoets G, Van den Broeck C. Risk factors for neonatal brachial plexus palsy: a systematic review and meta‐analysis. Developmental Medicine & Child Neurology. 2020 Jun;62(6):673-83.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Frade F, Gómez-Salgado J, Jacobsohn L, Florindo-Silva F. Rehabilitation of neonatal brachial plexus palsy: integrative literature review. Journal of clinical medicine. 2019 Jul 5;8(7):980.
- ↑ 4.0 4.1 4.2 4.3 4.4 Heyworth BE, Fabricant PD. BRACHIAL PLEXUS BIRTH PALSY. Rockwood and Matsen's The Shoulder E-Book. 2021 Jun 12:39.
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Meena R, Doddamani RS, Sawarkar DP, Agrawal D. Current Management Strategies in Neonatal Brachial Plexus Palsy. Journal of Peripheral Nerve Surgery Vol. 2021;5(1).
- ↑ Akanmode AM, Mahdy H. Macrosomia. [Updated 2022 Sep 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557577/
- ↑ Russo SA, Topley MT, Richardson RT, Richards JG, Chafetz RS, van Roden EA, Zlotolow DA, Mulcahey MJ, Kozin SH. Assessment of the relationship between Brachial Plexus Profile activity short form scores and modified Mallet scores. Journal of Hand Therapy. 2022 Jan 1;35(1):51-7.
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Eskay K. Infantile Brachial Plexus Injury Course. Plus, 2023.
