Brachial Plexus Injury

Risk factors High birth weight Type of delivery Breech; caesarean section; forceps; ventouse; precipitate

Signs of OBPP
Upper limb lying in a classical waiters tip position (Erbs palsy). Loss of active shoulder elevation and elbow flexion +/- hand movements. Horners sign Differential diagnosis: Pseudo-paralysis due to infection or fractures of the clavicle or humerus. Cerebral palsy. Arthrogryposis

Natural history
Substantial spontaneous recovery in the majority of cases. Incomplete recovery - usually the shoulder that fails to recover fully. Predictors of the degree of recovery: The age at which biceps function recovers: < 2 months - full recovery. > 4 months - full recovery will not occur.

Symptoms
oedema, Decreased sensibility Ioss of motor control and normal joint Mobility Alterations in muscular extensibility pain Impaired functional use of the arm Extent of the lesion Narakas classification. More extensive lesions have a lower chance of full recovery.

Shoulder Deformity
Weakness of shoulder external rotation and elevation. May result in: - Internal rotation contracture. - Posterior subluxation or dislocation of the shoulder (signs subtle, prognosis adversely affected).

Motor assessment
Shoulder (C5): - Assess with child sitting/standing. - Amount of active elevation. Elbow (C5,C6): - Flexion against gravity. - Hand to mouth. Wrist (C7): - Extension against gravity and when grasping. Fingers (C8,T1): - Flexion (grasp); Extension. Position of the limb at rest

 Passive range of movement at shoulder: - Elevation - External rotation (with elbow against trunk)

Sensory assessment
Not possible to assess sensation in this age group.

Mallet scale

Joint Movement Grading

Observation Central Grade No joint movement 0 Flicker of movement 0+ Less than half range 1Half range of 1 movement More than half range 1+ Good but not full range 2Full range of 2+ movement Numerical Score 0 0.3 0.6 1.0 1.3 1.6 2.0

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Investigations
Not usually necessary before referral. Radiographs MRI Neurophysiology

 Injury to the roots of c5 & c6 Erbs paralysis Injury to the roots of c8 & T1 klumpke paralysis Combined upper and lower root injury Erb Duchenne Klumpke paralysis

Erbs Paralysis
Paralysis involving
Deltoid Biceps brachialis Supinator Supraspinatus infraspinatus

Klumpke pralysis
Paresis of
Wrist flexion Finger flexion Small muscle of hand

Fingers become extended, elbow flexed. Sensory impairment over the inner aspect of the forearm and hand Horner syndrome ????????

Traumatic injury to brachial plexus

Causes
Fall onto the apex of shoulder and side of the head Blow to the angle between shoulder and the neck Fall on front of the shoulder Blow to the anterior axilla Force of an injury is directed upwards into the axilla with the arm abducted Dislocation of shoulder Gun shot injury Traction injuries