Pediatric Brachial Plexus

Paediatric Brachial Plexus Palsies
CLINICAL PRESENTATION AND CONSIDERATIONS OF NEONATAL BRACHIAL PLEXUS PALSY
INTRODUCTION
- Neonatal brachial plexus palsy (NBPP) is characterized by flaccid paresis of an upper extremity due
to traumatic stretching of the brachial plexus.
- The first recorded instance of NBPP dates back to the 18th century.
- The incidence of NBPP has increased due to improved care, recognition, and research.
INCIDENCE
- The incidence varies based on geography and baby size, ranging from 0.10 to 5.1 cases per 1000
live births.
- Bilateral brachial plexus palsies occur in 8.3-23% of cases, primarily with breech presentation.
- Advances in neonatal and obstetric care have not significantly reduced the incidence.
RISK FACTORS
- Maternal risk factors include advanced age, high BMI, diabetes, and primiparity.
- High birth weight (>4 kg) is the most significant baby-related risk factor.
- Approximately 14% of affected babies have low Apgar scores.
- Labor and delivery factors such as breech position, shoulder dystocia, and delivery methods are
linked to NBPP.
CLASSIFICATION OF CLINICAL PRESENTATION
- The Gilbert and Tassin/Narakas classification system categorizes NBPP into four groups based on
the extent of nerve injury.
- Group I: Nerve injury of C5 and C6, deltoid and biceps paresis, active limb function in extensors,
wrist, and hand.
- Group II: Nerve injury of C5, C6, and C7, additional triceps and wrist extensor paresis.
- Group III: Paresis of the entire arm (C5 to T1 nerve roots).
- Group IV: Paralyzed limb with Horner's syndrome, severe injury to all nerve roots.
- Other classification schemes include physiologic and anatomical categorizations:

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- Sunderland's physiologic scheme comprises four types of injuries in increasing severity.
- An anatomical scheme categorizes based on anatomical location: upper, intermediate, lower, and
total plexus palsy.
- Erb's palsy is the most common type of NBPP, characterized by a specific arm posture.
- Intermediate palsy affects C7, C8, and T1 roots, with distinct arm positioning.
- Lower plexus palsy involves a flaccid hand in an otherwise active arm.
- Total plexus palsy is the most severe, resulting in total loss of arm function.
Certainly, here are concise bullet points for the "Natural History" section:
NATURAL HISTORY OF NEONATAL BRACHIAL PLEXUS PALSY
- The natural history of NBPP remains speculative and debated due to variations in brachial plexus
lesions and recovery interpretations.
- Recovery definitions are challenging, and referral patterns can introduce bias in reported
outcomes.
VIEWS ON NATURAL HISTORY
- Some authors report over 80% of favorable outcomes or complete recovery.
- Others present a contrasting view with less than 50% achieving good recovery or experiencing
persistent disabilities.
- Functional recovery may still be compromised by musculoskeletal defects like contractures and
joint subluxation, even with appropriate therapy management.
SEVERITY AND RECOVERY
- Generally, as the extent and severity of NBPP increase, the potential for recovery decreases.
- Prospective studies suggest that early recovery, with signs of improvement before 2 months of age,
is associated with better outcomes.
- Recovery rates differ by the severity of NBPP groups (e.g., Group I, II, III, IV), with Group IV having
little to no chance of full spontaneous recovery.
- The Gilbert and Tassin/Narakas classification system remains a popular tool for predicting
outcomes and describing pathology severity.
EARLY RECOVERY
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- The Collaborative Perinatal Study found that 93% of patients who fully recovered did so by 4
months of age.
- Patients who showed no clinical improvement by 3 months had reduced chances of adequate
functional recovery.
- Some authors suggest that patients who recover satisfactorily achieve biceps and deltoid function
by 3 months of age.
- Early elbow flexion alone may not be sufficient to recommend or discourage nerve repair
reconstruction.
PREDICTORS OF RECOVERY
- Simple clinical muscle assessments are used as predictors of recovery.
- More complex statistical models based on multiple independent clinical variables show only
modest improvement in predicting recovery.
Here are concise bullet points for the "Assessment of the NBPP Patient" section:
ASSESSMENT OF THE NBPP PATIENT
PHYSICAL EXAMINATION
- Basic premises of the brachial plexus examination apply but require adaptations for neonates who
can't voluntarily cooperate.
- Parents/caretakers must be counseled once the diagnosis is made.
- A thorough maternal, obstetric, and perinatal history is essential before the physical examination.
- Skeletal injuries/fractures should be detected and treated, and spontaneous movements and
normal reflexes observed.
- Chest expansion and oxygenation issues may indicate phrenic nerve palsy, confirmed by
radiographs or ultrasound.
- Ptosis, meiosis, and classic postures (e.g., waiter's tip) can suggest specific NBPP lesions.
- Passive range of motion should be assessed, with early limitations potentially indicating
musculoskeletal abnormalities.
- Active range of motion and muscle power can be challenging to assess but can be evaluated
through interaction with the baby.
- Measurements of arm circumference and length can help track musculoskeletal dysfunction.
- Sensory function assessment is challenging but can be gestalt-determined through responses to

stimuli and the presence of skin rashes.
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- Radiographic and electrodiagnostic findings can supplement the examination to determine the
potential benefits of nerve repair reconstruction (covered in later chapters).
Here are concise bullet points for the "Peri-operative/Anesthetic Assessment" section:
PERI-OPERATIVE/ANESTHETIC ASSESSMENT
For Short Procedures (e.g., CT-myelogram):
- Assess the neonate's tolerance for anesthesia.
- Ensure intravenous access and control of oxygenation during prone positioning.
- Use standard American Society of Anesthesiologists (ASA) monitors.
- Induce anesthesia with oxygen, nitrous oxide, and sevoflurane.
- Acquire intravenous access, reserving vessels in the unaffected upper extremity.
- Secure the airway with an appropriately sized cuffed endotracheal tube.
- Ensure pressure points are padded.
- Extubate the patient awake and discharge from the post-anesthesia care unit upon meeting
discharge criteria.
For Longer Procedures (e.g., Surgical Nerve Repair/Reconstruction):
- Anesthetic complications are a leading cause of intraoperative morbidity.
- Assess considerations like procedure length (over 6 hours), limited intravenous access, and the use
of neurophysiological studies during surgery.
- Consider using midazolam (0.5 mg/kg orally) if separation anxiety is evident.
- Induce anesthesia with oxygen, nitrous oxide, and sevoflurane.
- Place a peripheral intravenous catheter carefully in the unaffected upper extremity.
- Avoid muscle relaxants due to the need for neurophysiologic assessment.
- Properly secure the endotracheal tube to prevent inadvertent extubation.
- Place a radial arterial line for hemodynamic monitoring.
- Use a combination of remifentanil and isoflurane for maintenance of anesthesia.
- Supplement with dexmedetomidine for minimal effect on monitoring.
- Use temporary muscle paralysis with cisatracurium for neurophysiologic assessment.
- Minimize perioperative fluid overload by restricting intraoperative fluids.

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- Monitor oxygen saturation to prevent pulmonary edema.
- Monitor blood glucose and hematocrit hourly during surgery.
- Maintain postoperative vigilance for oxygen saturation and fluid status, especially if the baby is
immobilized in a restrictive brace.
Here are concise bullet points for the "Assessment Scales" section:
ASSESSMENT SCALES FOR NBPP
Muscle Power Assessment:
- UK Medical Research Council Scale for muscle movement (MRC scale) provides structured grading
of individual muscle groups.
- Difficult to apply in newborns as it requires voluntary cooperation.
Active Movement Assessment for Newborns:
- Active Movement Scale (AMS) proposed by Curtis et al. assesses motor function in newborns.
- Reliable tool for evaluating infants with upper-extremity paresis, independent of rater experience.
Shoulder Function Assessment:
- The Mallet scale quantifiably assesses shoulder function.
- Addresses upper plexus function in children over 3 years old, primarily after cooperation is
possible.
Elbow Function Assessment:
- Gilbert and Raimondi's elbow recovery scale evaluates elbow function.
Hand Function Assessment:
- Raimondi's hand evaluation scale assesses hand function.
- Correlates with the preoperative Gilbert and Tassin/Narakas grade.
Functional Assessment and Quality of Life:
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- Pediatric Outcomes Data Collection Instrument (PODCI) provides semiquantitative, patient- and
parent-reported measures in various domains.
- Validated for assessing children with NBPP.
- Can differentiate potential surgery candidates from those without musculoskeletal disorders.
- Used for evaluating the results of tendon transfers in NBPP.
- Correlates with other measures of active movement.
- Reveals lower PODCI scores in NBPP but shows that children safely participate in sports similar to
their peers.
Self-Care Assessment:
- Pediatric Evaluation of Disability Inventory (PEDI) assesses self-care ability and distinguishes
between different levels of NBPP severity.
- Effective in differentiating between NBPP severity levels.
- Important tools for functional assessments, optimal treatment decisions, and evaluating treatment
efficacy in NBPP patients.
MRC Scale for Muscle Power Description
M1 Palpable muscle contraction without movement
M2 Movement in a horizontal plane
M3 Movement overcoming the pull of gravity
M4 Movement overcoming resistance beyond the pull of gravity
M5 Normal strength
Here's the "Active Movement Scale (AMS)" for assessing motor function in newborns presented in a
concise table format:
Observation Muscle Grade
Gravity Eliminated
No contraction 0
Contraction, no motion 1
Motion ≤ 1/2 range 2
Motion > 1/2 range 3
Full motion 4
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Observation Muscle Grade
Against Gravity
Motion ≤ 1/2 range 5
Motion > 1/2 range 6
Full motion 7
Here's the "Gilbert Scale for Staging Shoulder Function" in a concise table format:
Shoulder Function Stage Description
Flail shoulder 0
Abduction or flexion to 45°; no active external I
Abduction < 90°; external rotation to neutral II
Abduction = 90°; weak external rotation III
Abduction < 120°; incomplete external rotation IV
Abduction > 120°; active external rotation V
Normal VI
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Here's the "Gilbert and Raimondi Scale for Evaluating Elbow Recovery" in a concise table format:
Elbow Function Score Description
Flexion:
Nil or some contraction 1
Incomplete flexion 2
Complete flexion 3
Extension:
No extension 0
Weak extension 1
Good extension 2
Extension Deficit:
0–30° 0
30–50° -1
>50° -2
Here's the "Raimondi Scale for Evaluating Hand Function" in a concise table format:
Description Grade
Complete paralysis or slight finger flexion of no use; useless thumb – no pinch; some or no sensation 0
Limited active flexion of fingers; no extension of wrist or fingers; possibility of thumb lateral pinch I
Active flexion of wrist, with passive flexion of fingers (tenodesis); passive lateral pinch of thumb II
Active complete flexion of wrist and fingers; mobile thumb with partial abduction – opposition.
Intrinsic balance; no active supination; good possibilities for palliative surgery III
Active complete flexion of wrist and fingers; active wrist extension; weak or absent finger extension.
Good thumb opposition, with active ulnaris intrinsics; partial pronation/supination IV
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Description Grade
Hand IV, with finger extension and almost complete pronation/supination V
This scale is used to evaluate hand function, with each grade indicating different levels of hand and
finger functionality.
Here are concise points on the topic of "Neonatal Brachial Plexus Palsy: Antecedent Obstetrical
Factors" with headings in bold:
Introduction:
- Neonatal Brachial Plexus Palsy (NBPP) results from trauma to the fetal brachial plexus during
delivery.
- The timing of this event remains unclear, with arguments for in utero, intrapartum, and during
disimpaction.
- The incidence is around 1.5/1000 live births, with most injuries being transient (70-92%).
Common Obstetric Conditions:
- Chauhan and colleagues identified obstetric conditions associated with NBPP, including shoulder
dystocia, maternal diabetes, and breech presentation (Table 5.1).
Clinical Presentations:
- NBPP can manifest in various ways, with the most common presentations being Duchenne-Erb and
Klumpke palsies.
- Duchenne-Erb palsy involves fifth and sixth cervical nerve roots, resulting in specific weakness
patterns.
- Klumpke palsy involves the eighth cervical and first thoracic nerve roots, leading to a claw-like
deformity of the hand.
Prognosis:
- The prognosis for upper nerve trunk injuries (e.g., Duchenne-Erb) is more favorable than those
involving lower components of the brachial plexus.
- Palsies involving both upper and lower trunks have a higher likelihood of being permanent.
These points provide a concise overview of the topic.
Here are key points related to risk factors for Neonatal Brachial Plexus Palsy (NBPP):
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Difficulty in Identifying Specific Risk Factors:
- Identifying individual risk factors for NBPP can be challenging since many factors often overlap.
- Some historical factors, such as vaginal breech delivery with hyperabduction, are now rare.
- It is difficult to predict NBPP based on epidemiological risk factors reported in the literature.
Obstetrical Factors and Risk:
- Obstetrical factors that may be associated with NBPP include shoulder dystocia, maternal diabetes,
and breech presentation.
- Shoulder dystocia is a significant factor in NBPP and is characterized by the initial failure to deliver
the fetal shoulder after the head.
- Shoulder dystocia can be vaginal or cesarean and is often subjectively determined by clinicians.
Shoulder Dystocia:
- Incidence of shoulder dystocia deliveries is reported to be around 0.2-2.1% of live births.
- Although shoulder dystocia has the highest odds ratio for NBPP, nearly half of all NBPP cases occur
without identifiable shoulder dystocia.
- Neonatal weight plays a role, with the likelihood of shoulder dystocia increasing with higher birth
weights.
- Some cases of NBPP without shoulder dystocia may result from different mechanistic processes
during labor.
There is some controversy regarding the prognosis of NBPP cases with and without shoulder
dystocia in terms of full recovery.
The pathophysiologic mechanisms of Neonatal Brachial Plexus Palsy (NBPP) include various factors:
1. Compression:
- Intrauterine compressive brachial palsy can occur due to compression from uterine anomalies or
pelvic masses during gestation.
- It may also result from brachial plexus compression under the symphysis pubis during vaginal
delivery, either due to external force applied by the delivering clinician or maternal forces to expel
the obstructed fetus.
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2. Inflammation:
- Inflammation-induced disruption of the brachial plexus can result from in utero viral or bacterial
infections.
- Associated findings may include muscular atrophy of the affected arm or conditions like humeral
osteomyelitis.
- Less common causes of in utero NBPP can include hemangiomas, exostosis of the first rib, or
neoplasms near the brachial plexus.
3. Traction/Stretching:
- Traction or stretching of the brachial plexus has been closely associated with the occurrence of
shoulder dystocia during delivery.
- The term "excessive force" is often used in legal discussions regarding NBPP cases related to
shoulder dystocia.
- It is challenging to define what constitutes excessive force, and this threshold may vary
depending on factors like fetal acid/base status, muscle tone, fetal positioning, and the direction of
applied force.
- Delivering clinicians may have difficulty accurately perceiving the force they are applying.
It's important to note that the pathophysiology of NBPP can involve complex interactions among
these factors and may vary from case to case. Understanding these mechanisms is critical for
medical professionals dealing with NBPP cases.
The effect of delivery forces on the brachial plexus, especially in cases of shoulder dystocia, is a
complex and crucial aspect of understanding neonatal brachial plexus palsy (NBPP). Various
bioengineering models have been developed to simulate vaginal delivery scenarios with obstructed
fetal shoulders, shedding light on the forces at play. Here are some key findings:
1. Clinical Perception and Applied Forces: Allen and colleagues examined shoulder extraction forces
using force-sensing devices in clinician's gloved hands. The results showed a wide range of applied
forces (25–100 Newtons) during shoulder extraction. This study emphasized the challenge of
accurately perceiving the force being applied by clinicians during delivery.
2. Biomechanical Models: Several bioengineering models have been developed to study the forces
involved in shoulder dystocia. These models have demonstrated that the direction of force, fetal
positioning, and maternal maneuvers significantly affect brachial plexus strain.
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3. Role of Maternal Positioning and Maneuvers: Studies have shown that maternal positioning,
maneuvers, and fetal rotation can influence the forces applied to the brachial plexus. For example,
the McRoberts maneuver and suprapubic pressure have been found to reduce brachial plexus strain.
4. Threshold Forces: Defining specific threshold forces for brachial plexus nerve injury is challenging.
While some studies suggest 100 Newtons as an injury-defining force, others demonstrate a wide
range of forces associated with brachial plexus palsy. Variables such as axis of traction, joint laxity,
tissue thickness, infant weight, and collarbone fracture can influence the threshold for injury.
5. Injury Patterns: Experimental models and cadaveric studies have reported different injury
patterns. These patterns can vary based on the levels of nerve involvement, with upper levels (C5
and C6) being affected initially, followed by lower levels (C7 and C8).
In summary, the forces involved in brachial plexus injury during delivery, particularly in cases of
shoulder dystocia, are multifactorial and complex. While biomechanical models provide insights into
the mechanics of injury, the clinical environment is influenced by various factors that make it
challenging to define specific threshold forces for injury. Understanding these forces is essential for
improving clinical management and outcomes in cases of NBPP.
The timing of a brachial plexus injury in a neonate can be challenging to establish with precision. It is
less important for clinical management but may have implications from a medicolegal perspective.
The timing of the injury can affect the presence of associated physical findings. Here are some key
points regarding the timing of brachial plexus insults:
1. In Utero Events: Injuries that occur early as an in utero event may lead to additional physical
findings in the affected extremity, such as muscle atrophy or bone demineralization. However, the
exact timing of these in utero injuries is difficult to pinpoint accurately.
2. Labor-Related Injuries: Injuries to the brachial plexus that occur during the labor process are
challenging to time accurately. They cannot be definitively correlated with the clinician's
interventions during delivery. Attempts to correlate neonatal sites of bruising with the timing of the
injury may not provide a precise timeline.
3. Electromyography (EMG): EMG is a diagnostic tool used to assess nerve and muscle function. It
has been used in some cases to determine the timing of a brachial plexus injury. However, using
EMG to establish an in utero occurrence of the injury may not be reliable. EMG studies conducted on
newborn piglet models suggest that denervation can be detected within 24 hours after injury,
contrary to the previously reported timeline based on adult-derived data.
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4. Clinical Observations: Clinical observations that previously relied on EMG findings to time in utero
injuries may need re-evaluation. Early diagnostic studies, including EMG and MRI, may have a role in
therapeutic interventions, particularly when immediate nerve repair or reconstruction is being
considered.
In summary, accurately establishing the timing of a brachial plexus injury in a neonate is challenging.
It is essential to rely on a combination of clinical assessments and diagnostic studies, such as EMG
and MRI, to evaluate and manage these injuries effectively. The timing of the injury may have
medicolegal implications but is less critical for clinical management.
The management of shoulder dystocia, a major obstetrical complication that may lead to brachial
plexus injuries in newborns, is a critical aspect of obstetric practice. Here are some key points
regarding the obstetrical management of shoulder dystocia:
1. Risk Factors and Counseling: Identifying risk factors for shoulder dystocia is essential. Women with
fetuses estimated to be large (usually >5000 grams or >4500 grams in diabetic patients) are often
counseled regarding the option of elective cesarean delivery. However, this approach remains
empiric, and its effectiveness has not been conclusively demonstrated.
2. Anticipate and Prepare: Obstetricians should be prepared for a shoulder dystocia event, especially
when risk factors are present. Preemptive patient counseling and awareness are encouraged.
Institutions and individuals should periodically review the topic, develop training programs, and
establish guidelines or protocols for managing shoulder dystocia.
3. Early Identification: When a shoulder dystocia event is suspected, it is essential to identify the
obstruction early. Diagnostic force is inherent in identifying shoulder dystocia, and clinicians should
avoid excessive pulling and pushing until the obstruction is thought to be cleared.
4. Call for Assistance: Early involvement of additional healthcare providers for assistance is crucial in
managing shoulder dystocia effectively.
5. Minimize Traction: Clinicians should be mindful of the amount of traction being applied during
delivery and should use the least amount necessary to accomplish delivery. Slow and steady
traction, as well as axial positioning of the fetal head when traction is applied, are recommended.
6. Utilize Established Maneuvers: The use of established shoulder dystocia maneuvers, as per the
clinician's training and experience, is crucial. These maneuvers should be employed as needed to
resolve the obstruction.
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7. Avoid Uterine Fundal Pressure: While the use of fundal pressure has been associated with an
increased risk of brachial plexus palsy in limited studies, it is important to justify its use. Its
association may be linked to the severity of the obstruction encountered during the delivery.
8. Documentation: Careful documentation of the delivery event is essential for future reference and
potential medicolegal considerations.
9. Training and Simulation: Given the infrequent occurrence of shoulder dystocia, training models
and simulations have been developed to enhance clinician preparedness. High-fidelity mannequins
and training programs have been shown to improve performance, increase successful deliveries, and
reduce total applied extraction forces. Mandatory shoulder dystocia simulation training has led to a
significant reduction in neonatal injury during shoulder dystocia events.
In summary, effective obstetrical management of shoulder dystocia includes early identification,

minimization of traction forces, use of established maneuvers, and the early involvement of
additional healthcare providers for assistance. Training and simulations play a crucial role in ensuring
that clinicians are well-prepared to manage these challenging situations.
In conclusion, neonatal brachial plexus palsy (NBPP) is a condition identified in the immediate
neonatal period due to trauma to the fetal brachial plexus. The exact timing and cause of this injury
are often challenging to determine. The reported incidence of NBPP is approximately 1.5 per 1000
live births. Fortunately, the majority of NBPP cases are transient, with most infants eventually
regaining full function.
Several pathologic mechanisms have been identified as potential causes of NBPP, including
compression, traction, vascular disruption, and inflammation. Common obstetrical conditions, such
as shoulder dystocia, have been associated with the occurrence of NBPP, leading to significant
discussions and research on the role of both endogenous and exogenous delivery forces in brachial
plexus injuries.
It is important to note that specific threshold limits for brachial plexus disruption have not been
definitively defined, and these limits likely vary based on various factors, including fetal acid/base
status, muscle tone, and the anatomical relationship between the fetal head and the aftercoming
shoulders.
Recent efforts have focused on the need for high-fidelity simulation training models to enhance
clinician preparedness for managing shoulder dystocia and preventing brachial plexus injuries. These
training models aim to improve clinician perception and skills in dealing with this acute obstetric
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emergency, as the infrequent nature of shoulder dystocia makes it challenging for clinicians to gain
expertise based solely on personal clinical experience.
The role of electrodiagnosis (EDX) in infants with brachial plexus palsies is crucial for characterizing
the brachial plexus lesion accurately. Neonatal brachial plexus palsy (NBPP) is relatively uncommon
but can have a significant impact on a child's development. Most NBPP lesions are neurapraxic and
resolve spontaneously, but some children may not regain full arm function. EDX studies play an
essential role in determining the extent and location of the brachial plexus lesion, which is vital for
medical and surgical decision-making.
Here are the key points regarding the role of EDX in infants with brachial plexus palsies:
1. Influencing Surgical Decisions: EDX data help in making critical decisions about the timing and type
of operative intervention. Primary nerve repair is most successful when performed within the first 6
months after the injury. EDX studies can guide the timing and strategy of nerve repair or
reconstruction.
2. Prognosis Estimation: A comprehensive EDX evaluation provides valuable data for estimating the
prognosis of a child's neurological and functional recovery. It helps in understanding the severity and
type of nerve injury, which is essential for setting realistic expectations for recovery.
3. Classifying Nerve Injuries: Traumatic nerve injuries are typically classified into three types:
neurapraxia, axonotmesis, and neurotmesis. EDX studies can identify neurapraxic lesions, where the
nerve conduction is preserved distally without denervation in the relevant muscles. However, they
cannot distinguish between axonotmesis and neurotmesis.
4. Complex Nature of Brachial Plexus Injuries: Brachial plexus injuries are complex, often involving
multiple nerve root and trunk combinations. The presence of nerve root avulsions, which are
preganglionic lesions, can be identified through EDX studies. This distinction is crucial, as
preganglionic lesions are typically not amenable to surgical repair, whereas postganglionic lesions
may be treatable.
5. Understanding the Predominant Lesion: For determining the best course of treatment, it is
essential to understand whether the predominant lesion is axonotmesis (with potential axonal re-
growth) or neurotmesis (complete neural disruption). EDX studies contribute to identifying the type,
extent, and location of the lesion, allowing for more informed treatment decisions.
However, the specific EDX tests used and their sensitivity and specificity remain subjects of ongoing
research and debate, making the diagnostic process complex and challenging. Clinicians must
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consider a combination of clinical, imaging, and EDX findings to provide comprehensive assessments
and treatment plans for infants with brachial plexus palsies.
Nerve conduction studies (NCS) play a significant role in diagnosing and characterizing nerve injuries
in infants with brachial plexus palsies (NBPP). The principles of performing NCS in infants are similar
to those in adult patients, with some necessary modifications due to the infant's age and size.
Here are key points regarding NCS in infants with brachial plexus palsies:
1. Normal Values Vary with Age: It is widely accepted that normal NCS values vary with age. Motor
conduction velocities in newborns are approximately half that of adults. Understanding age-specific
norms is essential for accurate diagnosis and evaluation.
2. Challenges of NCS in Infants: NCS in infants present some unique challenges. Quantifying axonal
loss can be challenging, and correlating the extent of axonal loss with future recovery is not always
straightforward.
3. Diagnosing Preganglionic Lesions: EDX studies can be used to diagnose preganglionic lesions in
NBPP. Preserved sensory nerve action potential (SNAP), loss of compound motor action potential
(CMAP), denervation potentials, and loss of voluntary motor unit action potential (MUAP)
recruitment are consistent with the diagnosis of nerve root avulsion.
4. Distinguishing Preganglionic and Postganglionic Lesions: EDX studies can help distinguish between
preganglionic and postganglionic lesions. Presence or absence of SNAPs in the context of an absent
CMAP helps differentiate the postganglionic from the preganglionic plexus injury.
5. Serial Motor NCS for Axonal Loss: Serial motor NCS can determine the percentage of axonal loss
by comparing the normal amplitude of the response to the nadir (lowest point) observed after
injury. The time frame for this nadir varies from adults and can occur as early as 24 to 48 hours post-
injury.
6. Specific Parameters for Severe Weakness: Some studies have defined specific parameters for
severe weakness resulting from injury to certain nerve roots. For example, CMAP measurements
below 10% of the unaffected limb may predict poor outcomes for C5/C6 injuries.
7. H-Reflex for Outcome Prediction: The H-reflex, particularly in the brachioradialis muscle, has been
used to predict outcomes for infants with NBPP. Complete absence of the H-reflex has been
correlated with limited or no improvement in function.
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In summary, NCS provides valuable data for diagnosing brachial plexus injuries in infants,
differentiating preganglionic and postganglionic lesions, and predicting potential outcomes.
Understanding age-specific norms and the specific parameters for severe weakness can aid in
assessing the severity and prognosis of NBPP in infants.
Electromyography (EMG) plays a crucial role in assessing and diagnosing nerve injuries, including
those in infants with brachial plexus palsies (NBPP). When conducting EMG in infants, several
considerations are essential:
1. Pediatric EMG Needle: It is recommended to use a pediatric EMG needle electrode for muscle
sampling in infants.
2. Two Assessments: The EMG assessment in infants is divided into two main parts: evaluation of the
muscle at rest and during voluntary movement.
3. At Rest Assessment: During the assessment at rest, the electromyographer looks for signs of
abnormal spontaneous activity in the muscle, which is indicative of denervation. This includes
observing fibrillation potentials and positive sharp waves, which help define the anatomical
distribution and severity of the lesion.
4. MUAP Evaluation: Motor unit action potentials (MUAPs) are assessed for their amplitude, phases,
duration, and firing rate related to force. MUAPs in infants have different characteristics compared
to adults, such as often being biphasic with smaller amplitude and shorter duration. These
parameters change as children mature.
5. Motor Unit Recruitment Patterns: The recruitment patterns of motor units can be challenging to
assess in infants, primarily due to the difficulty in controlling voluntary activity. Maximal motor unit
recruitment often occurs when the electrode is first inserted. Flexor muscles are typically more
straightforward to evaluate due to their dominance in infant movement.
6. Denervation Potentials: Denervation potentials, which indicate axonal degeneration, may appear
earlier in infants compared to adults. It is suggested that denervation potentials can be visible within
1 to 2 days after injury in infants. This is likely due to the shorter nerve length in infants and the
faster loss of trophic factors.
7. Voluntary Muscle Activation Assessment: During the assessment of voluntary muscle activation,
the electromyographer focuses on the presence and number of voluntary motor units, as well as
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their morphology and recruitment patterns. Signs of re-innervation, such as collateral sprouting from
surviving axons, can also be assessed.
8. Controversy and Challenges: The use of EDX testing in infants with NBPP is a topic of debate.
Some argue that needle EMG results may not always align with the clinical presentation and
recovery course of the patient. This may be due to factors such as the small size of infant muscle
fibers and the concept of "luxury innervation," where multiple nerves continue to innervate muscles
even after injury.
9. Overestimation of Recovery: EMG interference patterns may consistently overestimate future

clinical recovery in infants with NBPP. While EMG provides valuable information, it may not always
correlate with the clinical strength recovery assessed using tools like the Medical Research Council
(MRC) strength score.
In summary, EMG is a valuable tool for diagnosing and assessing nerve injuries in infants with
brachial plexus palsies. It provides insights into the extent and location of the nerve injury, as well as
the potential for recovery. However, clinicians should be aware of the challenges and potential
discrepancies in interpreting EMG results in this specific patient population.
In conclusion, electrodiagnostic (EDX) studies are valuable tools for diagnosing and assessing nerve
injuries, including those in infants with brachial plexus palsies (NBPP). These studies provide
essential clinical information and help answer critical questions about the nature and extent of the
nerve injury. Key points to consider include:
1. Identification of Location and Extent: EDX studies can pinpoint the location of the injury, identify
the specific segments of the brachial plexus involved, and determine whether the injury extends
beyond the plexus.
2. Preganglionic Lesions: EDX studies can reveal evidence of preganglionic involvement of the lesion,
which is important for treatment decisions.
3. Assessing Severity: The extent and severity of denervation (axonotmesis or neurotmesis) can be
assessed using EDX, helping guide treatment strategies.
4. Active Denervation: These studies can also indicate whether denervation is still actively occurring
in the affected muscles.
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However, it's important to note that the interpretation of motor unit action potentials (MUAP) can
be challenging, particularly for less experienced electromyographers. Needle EMG in infants with
NBPP remains a controversial topic, as the results may not always align with the clinical presentation
and recovery course of the patient. EMG findings may sometimes appear more optimistic than the
clinical outcome.
Clinicians and electromyographers should exercise caution when interpreting the results of needle
EMG examinations in infants with brachial plexus palsies, considering the specific challenges and
complexities of this patient population. While EDX studies provide valuable insights, a
comprehensive understanding of the clinical context and the nuances of interpretation is essential
for effective diagnosis and management.
The selection of patients with neonatal brachial plexus palsy (NBPP) for surgical intervention can be
a complex and controversial process. Different medical centers may have varying criteria for
determining which patients are suitable candidates for surgery. Here is an overview of the patient
selection process and criteria at the Leiden University Medical Center:
1. Absence of Hand Function: Infants with NBPP who have an absent or significantly impaired hand
function in the context of a flail arm at birth are considered strong candidates for nerve surgery.
2. Timing of Surgery: Surgery is typically recommended for these patients once they reach the age of
3 months. However, it is rarely performed before 3 months of age and almost always done before
the age of 7 months.
3. Assessment of Shoulder and Elbow Function: Patients who do not show spontaneous recovery of
shoulder external rotation, elbow flexion, and forearm supination by 3 to 4 months of age are also
considered for surgical intervention.
4. Early Assessment Paradigm: The medical center has developed a paradigm for identifying severe
nerve lesions at 1 month of age. This assessment includes clinical evaluation of elbow extension and
flexion and needle electromyography (EMG) of the biceps muscle. Severe lesions of C5 and C6 or
upper trunk can be predicted in most infants based on the absence of these functions. Additional
radiographic assessments, such as ultrasound of the diaphragm and CT-myelography, can also
provide evidence of severe NBPP lesions amenable to surgical repair or reconstruction.
The goal of this patient selection process is to assess the severity of the brachial plexus lesions as
early as possible, both for treatment planning and to allow parents and caregivers time to consider
the recommended treatment options.
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It's important to note that patient selection criteria and timing for surgery may vary among medical
centers and individual cases. The decision to pursue surgery should be made in consultation with
healthcare professionals and tailored to the specific needs and circumstances of each patient.
The surgical procedure for neonatal brachial plexus palsy (NBPP) typically involves exploring and
repairing the damaged nerves. The following are key steps in the surgical process:
1. Supraclavicular Exposure: The surgery begins with a supraclavicular approach to explore and
assess the brachial plexus lesion. The surgical site is exposed in the posterior triangle of the neck.
2. Patient Positioning: Proper positioning of the patient is crucial for the success of the operation.
The patient is placed in a supine position, and the head is turned toward the opposite direction with
the neck in gentle extension. Care is taken to avoid compressing the cervical vascular structures. The
affected arm is positioned in the sterile field, supported at 45 degrees of abduction.
3. Incision: A curvilinear incision is made, extending from the sternocleidomastoid muscle to the
coracoclavicular joint. The exact location and length of the incision depend on the level of the
brachial plexus lesion, with a shorter incision for lower plexus and a longer one for upper plexus
lesions.
4. Tissue Dissection: The platysma muscle is incised perpendicularly to its fibers, and subplatysmal
dissection is performed to access the underlying structures. The external jugular vein may be
encountered and should be retracted or ligated when necessary.
5. Identification of Key Nerves: The spinal accessory nerve (SAN), which courses from the posterior
aspect of the sternocleidomastoid muscle, is identified along its course. This is important for
preserving trapezius function and for potential nerve transfers. An intraoperative nerve stimulator
may be used to confirm the identification.
6. Release of Clavicular Head: The lateral margin of the sternocleidomastoid muscle is identified, and
the lateral aspect of the clavicular head is released to facilitate exposure.
7. Identification of Supraclavicular Nerves: Sensory nerve branches of the ansa cervicalis (C2-C4) are
identified along their cranial-caudal course and are preserved for anatomical landmarks, potential
intraplexal transfers, or nerve graft donors.
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8. Release of Cervical Fascia/Scalene Fat Pad: The cervical fascia and scalene fat pad are released
along the parallel path of the sternocleidomastoid muscle, starting at the C4 level in a cranial to
caudal direction and then turning 90 degrees parallel to the clavicle.
9. Transverse Cervical Vessels: The transverse cervical artery and vein, which run parallel to the
clavicle in front of the brachial plexus elements, are retracted or ligated as necessary.
10. Identification of Omohyoid Muscle: The omohyoid muscle is identified between the superficial
and deep cervical fascia. It can be tagged and retracted, which is especially helpful for identifying the
suprascapular nerve in patients with distorted anatomy.
11. Intraoperative Retractors: The placement of appropriate intraoperative retractors helps facilitate
the surgical exposure of the supraclavicular brachial plexus.
This approach provides access to the brachial plexus and other critical structures, allowing the
surgeon to assess the extent of nerve damage and proceed with necessary repairs or
reconstructions. The choice of specific surgical techniques and interventions will depend on the
individual patient's condition and the findings during the exploration.
The surgical procedure for addressing neonatal brachial plexus palsy (NBPP) involves careful
identification of key nerves and structures in the supraclavicular region. Here are the steps and
considerations for this part of the procedure:
1. Identification of Phrenic Nerve: The phrenic nerve, which plays a vital role in diaphragm function
(important for respiration), is identified starting from the C4 spinal nerve root. It is dissected along
its length on the ventral aspect of the anterior scalene muscle.
2. Key Pointers for Safe Identification: To safely identify the phrenic nerve:
- Use nerve stimulation to locate its course, as it may be covered by deep transverse cervical fascia,
and the transparency of this fascia can vary.
- Recognize that the phrenic nerve usually originates from C3 and C4 and occasionally includes a
thin C5 contribution.
- Be careful not to mistake adjacent artery and vein as the nerve.
- Occasionally, there may be an auxiliary phrenic nerve at higher cervical levels.
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3. Course of Phrenic Nerve: The phrenic nerve travels from lateral to medial toward the diaphragm,
in contrast to other plexus contents and surrounding nerves that course from medial to lateral.
4. Identification of C5 Spinal Nerve Root: As the phrenic nerve approaches the lateral edge of the
anterior scalene muscle, the C5 spinal nerve root emerges, making it a reliable site for identification.
5. Freeing Up Phrenic Nerve: The phrenic nerve is completely freed in its trajectory, ventral to the
anterior scalene muscle, allowing gentle medial retraction without significant traction. This is crucial
to preserve diaphragmatic function.
6. Dissection of Scalene Muscle: Resection or partial resection of the anterior scalene muscle is
performed to optimize exposure of the proximal, intraforaminal part of the spinal nerve roots. This
may reveal a pseudomeningocele, which should be identified.
7. Identification of Spinal Nerve Roots: Following the C5 root distally leads to the upper trunk, and
following the upper trunk proximally will lead to the C6 spinal nerve root. The C6 root is located
caudal and dorsal to the C5 root. Subsequent roots (C7, C8, T1) are sequentially more caudal and
dorsal, forming the lower trunk.
8. Care around First Rib and Pleura: The roots of the lower trunk surround the first rib, so care must
be taken to avoid injury to the pleura (lining of the lung).
9. Identification of Suprascapular Nerve (SSN): The SSN and the divisions of the upper trunk are then
identified. The upper trunk "splits" into three structures: the SSN, the posterior division, and the
anterior division. The SSN originates from the lateral aspect of the upper trunk and normally travels
toward the suprascapular notch.
10. Retroclavicular Exposure: In cases where the NBPP lesion extends to the retroclavicular region,
the surgeon may expand the retroclavicular space for adequate exposure using retraction
techniques, which can involve lace passed beneath the clavicle. For more extensive exposure,
clavicle osteotomy may be considered, although it's rarely done.
This step-by-step approach allows for a thorough examination of the brachial plexus and
surrounding structures, facilitating the identification of nerve lesions and guiding potential surgical
repairs or reconstructions.
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Infraclavicular exposure is a surgical technique that is used in cases of neonatal brachial plexus palsy
(NBPP) when the lesion extends to the infraclavicular region, although this is relatively rare. The
following are the key steps for infraclavicular exposure:
1. Patient Position: The patient is placed in a supine position.
2. Incision: A linear incision is made from the clavicle toward the axilla, following the deltopectoral
groove.
3. Management of Cephalic Vein: The cephalic vein, which is located within the groove, is identified.
It can either be retracted laterally or ligated, depending on the surgical needs.
4. Detachment of Pectoralis Major Muscle: If necessary, a portion of the pectoralis major muscle is
detached from the inferior surface of the clavicle and the humerus. The tendon cuff from the
humerus is tagged for later repair.
5. Retraction of Pectoralis Major Muscle: The pectoralis major muscle is retracted caudally, and the
deltoid muscle is retracted laterally to expose the underlying structures.
6. Separation of Pectoralis Minor: Blunt dissection is used to separate the pectoralis minor from the
coracobrachialis and the surrounding tissues. The pectoralis minor tendon can be divided and later
reapproximated, or the muscle may be retracted as needed.
7. Identification of Brachial Plexus Elements: The infraclavicular brachial plexus elements are found
immediately dorsal and caudal to the pectoralis minor. The exact location of these elements
depends on the position of the arm.
- Lateral Cord: When the arm is at or lower than the plane of the shoulder, the most superficial
structures include the lateral cord, which gives rise to the musculocutaneous nerve (MCN), and its
medial branch leading to the median nerve.
- Medial Cord: The medial cord can be identified medial and slightly posterior to the axillary artery.
The lateral branch of the medial cord leads to the median nerve, while the medial branch continues
down the arm as the ulnar nerve.
- Posterior Cord: Exposure of the posterior cord and its axillary and radial nerve branches is best
accomplished in the region lateral and posterior to the axillary artery.
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8. Identification of Axillary Nerve: The axillary nerve branches from the posterior cord and runs
through the quadrilateral space above the latissimus dorsi and teres major tendons. It can be
identified more easily by externally rotating the humerus.
This surgical approach allows for thorough exposure of the brachial plexus elements in the
infraclavicular region, enabling the surgeon to identify and assess the extent of the nerve lesions for
potential repair or reconstruction.
The surgical exposure of donor nerves for nerve transfer procedures in neonatal brachial plexus
palsy (NBPP) is crucial to enable the restoration of lost functions. Here are some details on the
exposure of these donor nerves:
1. Spinal Accessory Nerve (SAN): The SAN is commonly used as a donor nerve for neurotization to
the suprascapular nerve (SSN) to restore shoulder function. To access the SAN:
- Locate the SAN as it approaches and enters the anterior surface of the trapezius muscle.
- Mobilize the SAN as distally as possible and then transect it.
- Pass the proximal stump through the cervical fascia/scalene fat pad for direct coaptation with the
SSN.
2. Medial Pectoral Nerve (MPN): The MPN is another commonly used donor nerve for nerve transfer
to the musculocutaneous nerve (MCN) to restore elbow flexion. To access the MPN:
- Identify the MCN in its course dorsal to the pectoralis major and minor muscles.
- Retract the pectoralis major muscle cranially through a low incision in the deltopectoral groove.
- Use intraoperative nerve stimulation to identify the MPNs, as their appearance and course can be
similar to small vessels.
- Usually, two individual MPN branches exist, which should be cut as distally as possible and coapted
to the MCN. If the total cross-sectional area of the MPN branches is smaller than that of the MCN,
coaptation to a fascicle of the MCN is undertaken.
3. Intercostal Nerves (ICNs): ICNs can also be used as donors for nerve transfer to the MCN for
restoring elbow flexion. The technique is similar to that used in adults. To access the ICNs:
- Make an undulating skin incision over the ipsilateral chest, starting at the anterior axillary line at
the inferior border of the pectoralis major muscle.
- Shift the inferior part of the pectoralis major muscle upward and partially detach its sternal
insertion, if necessary.
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- Identify the main branch of the ICN halfway in its ventral course between the external and internal
intercostal muscles.
- Assess ICN motor responses using electrical nerve stimulation.
- If feasible, identify sensory branches by their course toward the skin and leave them intact after
interfascicularly dissecting from the main nerve.
- Transect the ICNs as close as possible to the sternum to obtain sufficient length for direct
coaptation to the MCN, and tunnel them to the axilla.
- Female infants may have sensory innervation to the nipple, which should be preserved if
anatomically localized. The third ICN is left untouched to preserve at least partial sensation to the
breast.
- Cut the MCN proximally after freeing it from the lateral cord until fascicular intermingling is
encountered. No attempt is made to identify the motor branches within the MCN.
- Coapt the ICNs to the centrally located MCN fascicles using fibrin glue. The infant's arm should be
abducted 90 degrees before coaptation.
This surgical approach allows for the transfer of healthy nerves to restore function in cases of NBPP
where the patient has lost specific motor or sensory functions due to brachial plexus injuries.
The intraoperative assessment of lesion severity in the brachial plexus is a critical step in
determining the appropriate surgical approach for neonatal brachial plexus palsy (NBPP) and
whether to perform nerve repair/reconstruction. Lesions are classified based on clinical findings and
intraoperative observations:
1. Nerve Root Avulsion: Nerve root avulsion is a severe form of injury where the nerve root is
detached from the spinal cord. It is characterized by the following features:
- Visual evidence of nerve continuity at the intraforaminal level combined with preoperative
knowledge of the presence or absence of root filaments on CT-myelography.
- Lack of nerve root filaments visible near the neural foramen.
- Proximal injury is often indicated by scarring and fibrosis in the scalene muscles.
- Intraoperative nerve stimulation generally does not yield distal muscle contraction.
- Confirmation is often based on CT-myelography demonstrating the absence of nerve rootlets.
- Nerve root avulsion usually indicates a poor prognosis for spontaneous recovery.
2. Neurotmetic Lesion: Neurotmetic lesions are less severe than avulsions but still represent
significant nerve damage. Features of neurotmetic lesions include:
- Normal appearance of the nerve root at the intraforaminal level.

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- A clear increase in the cross-sectional diameter at the juxta-foraminal level.
- Abundant epineurial fibrosis.
- Loss of fascicular continuity, increased density, and increased length of the nerve elements with
concomitant displacement of the trunks and divisions distally.
- Electrical stimulation of the spinal nerve proximal to the neuroma may cause weak muscle
contractions that are detectable with palpation, but they are not strong enough to move the limb.
- Resection of neurotmetic tissue is performed, and the proximal and distal stumps are prepared for
nerve repair/reconstruction.
3. Axonotmetic Lesion: Axonotmetic lesions are less severe and typically indicate that the nerve's
structural integrity is maintained, but there is damage to the nerve fibers. Features include:
- No substantial increase in the cross-sectional diameter of the brachial plexus elements.
- Limited epineurial fibrosis.
- Good continuity of fascicular structure.
- Direct stimulation of the spinal nerve results in limb movement.
- For example, C5 stimulation causes abduction and external rotation, and C6 stimulation leads to
elbow flexion against gravity with supination.
- These lesions are generally left in situ as spontaneous nerve regeneration can occur.
The assessment of lesion severity is crucial for determining the appropriate surgical intervention.
Severe cases of nerve root avulsion may require more extensive reconstruction, while less severe
neurotmetic or axonotmetic lesions might benefit from nerve grafting and repair techniques to
restore function. The decision should be made based on the specific findings during surgery and the
potential for nerve regeneration and recovery.
The principles underlying surgical reconstruction strategies for neonatal brachial plexus palsy (NBPP)
depend on several factors, including the specific nerve lesions observed during surgery and the
ultimate goal of restoring functional limb movement. These principles involve prioritizing the
restoration of specific functions and selecting appropriate surgical approaches based on the clinical
findings. Here is a summary of these principles for various types of NBPP lesions:
1. Prioritizing Functional Restoration:
- The primary goal is the restoration of hand grasp function.
- Second priority is given to restoration of elbow flexion.
- Third priority is restoring shoulder movements.
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- The fourth priority is extension of the elbow, wrist, and fingers.
2. Surgical Strategies Based on Lesion Types:
- The surgical approach depends on the type of lesion observed during surgery.
Group 1: C5, C6/Upper Trunk Lesions:
- This group includes the majority of NBPP patients.
- Type 1: C5, C6 neurotmetic lesions, where hand grasp function is essentially normal. The primary
goal is to restore elbow flexion and shoulder movements. Neuromas-in-continuity are typically
observed and should be resected.
- Sural nerve grafts are harvested endoscopically to bridge the gap between the proximal and distal
stumps, typically requiring grafts from both legs.
- Coaptation strategies include grafts from C5 to the SSN, the posterior division of the upper trunk,
and the anterior division of the upper trunk.
- An alternate strategy may involve SAN (spinal accessory nerve) to SSN transfer.
- Type 1 lesions can become more extensive if wrist and finger extension is decreased, indicating a
partial neurotmetic/axonotmetic lesion at C7.
- Type 2: C5, C6 lesions involving a neurotmetic C5 lesion and a nerve root avulsion of C6. Graft
repair from C5 to the posterior division of the upper trunk, SAN to SSN transfer, and transfer of
anterior root filaments of the avulsed C6 root to C5 are performed.
- Intraplexal transfer of the anterior root filaments of C6 to C5 contributes to brachioradialis

muscle reinnervation.
- Decision factors include the quality of C6 root filaments, the coaptation site, and the cross-
sectional area of the posterior division of the superior trunk.
- Type 3: Both C5 and C6 roots are avulsed, typically resulting from a breech presentation. In this
case, neither root is useful for repair, and nerve transfers are performed.
- Patients undergo SAN to SSN transfer coupled with MPN to MCN transfer, avoiding other
transfers that may carry potential risks for the growing hand.
These surgical strategies are adapted to the specific needs of the patient based on the observed
lesions and the availability of donor nerves for repair or neurotization. The goal is to maximize
functional recovery and minimize complications. Surgical planning and execution are highly
individualized for each patient with NBPP.
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Group 2 of neonatal brachial plexus palsy (NBPP) patients typically have intact preoperative finger
grasp function but experience impairments in elbow, wrist, and finger extension, as well as limited or
absent elbow flexion and shoulder movements. Group 2 lesions can be further divided into five
types based on specific clinical findings. Here is a summary of the surgical approaches for each type:
Type 1:
- Features a neurotmetic lesion of C5, C6, and C7.
- Surgical repair is conducted in several steps:
1. Resection of the C5, C6/upper trunk neuroma.
2. Harvesting of sural nerves from both legs to assess graft quantity and quality.
3. The decision regarding the C7 neuroma is made based on graft availability. Extensive neurolysis is
chosen when grafts can be harvested from other sites (e.g., superficial radial) or when some
fascicular continuity is observed within the neuroma.
4. The nerve repair strategy is similar to that for patients in Group 1, with the additional repair of
the C7/middle trunk.
Type 2:
- Involves a C5, C6/upper trunk neuroma-in-continuity coupled with a C7 nerve root avulsion.
- Resection of the upper trunk neuroma is performed.
- The avulsed C7 root is transected as proximally as possible. If the dorsal root ganglion can be
identified, it is resected.
- Nerve transfer is conducted from the caudal aspect of the C6 proximal stump to the C7 ventral root
filaments. Alternatively, nerve grafting from the caudal aspect of the proximal C6 nerve stump to the
C7 ventral root can be considered.
- Sensory restoration can be achieved through direct coaptation of the medial supraclavicular nerve
(C4) to the postganglionic sensory part of the C7 root, innervating the C7 dermatome in the hand.
Types 3, 4, and 5:
- These types are rare and usually involve C8 nerve root avulsion.
- For Type 3 and 4 injuries, the repair strategy may include graft repair from C5 to the posterior
division of the superior trunk, direct coaptation of the ventral root filaments of C6 to the caudal
aspect of the proximal C5 nerve stump, and SAN to SSN transfer.
- The C7 and C8 roots may be left in situ.
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- For Type 3 lesions, if the C5 proximal nerve stump can only accommodate the posterior division of
the upper trunk, C6 and C7 remain untouched, and MPN to MCN transfer is performed to restore
elbow flexion.
- Type 4 lesions may use C5 only for graft repair to the anterior division of the upper trunk, which is
augmented.
- Type 5 lesions are typically reconstructed similarly to Type 2 lesions, with C8 roots being left in situ.
The surgical strategies in Group 2 focus on specific lesions and their impact on different aspects of
limb function, aiming to restore extension and mobility while preserving finger grasp function. Each
surgical approach is tailored to the individual patient's needs and clinical findings.
Group 3 of neonatal brachial plexus palsy (NBPP) patients typically presents with a flail arm. In these
cases, the highest priority for surgical intervention is the restoration of hand function, followed by
elbow flexion and shoulder movements. Group 3 lesions usually involve neurotmetic lesions of C5
and C6 with avulsions of C7, C8, and T1. Here is an overview of the surgical strategies for these
patients:
1. Hand Function Restoration:
- C5 and C6 proximal stumps are typically available as donors for graft repair to restore function to
C8, T1, or the lower or middle trunk.
- C8 and T1 roots are divided into their motor and sensory components at the neural foramen
without violating the vertebral artery.
- Direct coaptation is performed between the C6 proximal stump and the motor portions of C8
and, if possible, T1 to restore hand function.
- For sensory function, the supraclavicular nerves can be directly coapted to the postganglionic
sensory portions of C8 and/or T1.
2. Upper Trunk Repair:
- Graft repair is carried out from the remaining part of C6 to the anterior division of the upper
trunk.
- Graft repair is also performed from the C5 proximal stump to the posterior division of the upper
trunk.
3. Elbow Flexion Restoration:
- The intercostal nerves (ICNs) are used to restore elbow flexion by transferring them to the
musculocutaneous nerve (MCN).
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4. Shoulder Movement Restoration:
- The spinal accessory nerve (SAN) can be transferred to the suprascapular nerve (SSN) to restore
shoulder movements.
5. C7 Root Management:
- The C7 root can either remain in situ, or the supraclavicular nerves can be coapted to C7 to
augment sensory function in the hand.
The surgical approach for Group 3 patients involves a combination of nerve grafts, nerve transfers,
and coaptations to restore hand, elbow, and shoulder functions. The selection of distal targets for
hand function reinnervation is a crucial aspect of the strategy to achieve the best functional
outcomes.
The postoperative care for infants who have undergone nerve repair or reconstruction for neonatal
brachial plexus palsy involves several important steps and follow-up examinations. Here is an
overview of the postoperative care protocol:
1. Immediate Postoperative Phase (Weeks 1-2):
- The infant's upper body is placed in a prefabricated cast to limit the movement of the head and
the affected arm for the first 2 weeks.
2. Early Immobilization (Weeks 3-5):
- In postoperative weeks three to five, the arm is immobilized under the shirt to protect and
support the surgical site.
3. Range of Motion Exercises (Week 6 Onwards):
- Starting from week six onwards, parents are instructed to begin daily and frequent exercises to
achieve and maintain an optimal passive range of motion in the affected arm.
4. Follow-up Examinations:
- Patients undergo clinical examinations at the outpatient clinic at six-month intervals.
- During these follow-up visits, various assessments are conducted, including:
- Recording of active and passive ranges of motion in degrees.
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- Evaluation of motor function using the Medical Research Council grading system.
- Assessment of shoulder function using the Mallet score.
- Evaluation of hand function using the Raimondi hand score.
The goal of postoperative care is to monitor the progress of the infant's recovery, promote healing,
and optimize functional outcomes. Rehabilitation exercises and regular follow-up assessments are
essential components of the postoperative care plan to achieve the best possible results.
Brachial plexus palsy is a condition that affects a small percentage of infants at birth, with an
estimated prevalence ranging from 0.1% to 0.4% of live births. While the majority of children with
brachial plexus palsy experience spontaneous recovery, there are cases where children have
persistent deficits. These deficits can lead to functional limitations due to muscle weakness and soft
tissue contractures. The extent and severity of deformities can vary, influenced by the type of lesion
and the degree of recovery.
Persistent muscle weakness and muscle imbalance can have significant effects on bone growth and
joint development. Over time, these factors can contribute to progressive glenohumeral (shoulder)
deformities in affected children. The impact of brachial plexus palsy on shoulder function and
structure is an important consideration in the care and management of these patients.
Clinical examination is a crucial aspect of evaluating and managing children with brachial plexus
palsy (BPP). The examination typically includes the following components:
1. Observation: Observe the child's spontaneous and stimulated (with and without gravity
assistance) shoulder and upper limb movements.
2. Passive Range of Motion (ROM): Assess the passive range of motion of the shoulder and elbow.
This includes internal and external rotation in both adduction and abduction positions.
3. Scapular Assessment: Note the degree of scapular winging (posteriorly with internal rotation,
superiorly with adduction, and into the axilla with full abduction and forward flexion).
4. Active Abduction: Evaluate the child's ability to actively abduct the shoulder. Pay attention to any
hyperlordosis of the back and lateral trunk motion.
5. Muscle Strength: Assess muscle strength using standardized grading scales such as the Mallet
Classification or the Hospital for Sick Children scores.
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6. Posterior Humeral Head Dislocation: Palpate for posterior humeral head dislocation. If the
shoulder appears dislocated, check for improved external rotation after reducing the humeral head
into the glenoid.
7. Joint Contractures: Evaluate for joint contractures, such as internal rotation contractures and
glenohumeral deformity. Contractures can develop early in children with BPP.
8. Modified Mallet Scale: The modified Mallet scale is commonly used to assess shoulder function. It
includes subscales to evaluate shoulder abduction, global external rotation, and various hand
positions. An aggregate score is calculated based on these assessments.
9. Active Movement Scale (AMS): The AMS may be used as an alternative to muscle grading for
assessing muscle strength in children. It is particularly useful when children may have difficulty
cooperating with muscle strength testing.
10. Midline Function: In addition to assessing external and internal rotation, midline function should
be evaluated to determine the child's ability to perform tasks at the midline, such as buttoning and
zippering.
These assessments aid in understanding the child's functional limitations, muscle strength, and joint
mobility. They are essential for treatment decision-making and tracking the child's progress over
time. It's important to use a combination of tools and assessments to provide a comprehensive
evaluation.
Imaging plays a crucial role in assessing the morphology of the glenohumeral joint in children with
brachial plexus palsy (BPP). Since the humeral head and glenoid are primarily cartilage in the first
few years of life, it is challenging to identify glenohumeral pathology using plain radiographs. Various
imaging modalities have been utilized to provide a more detailed understanding of the glenohumeral
joint in children with BPP:
1. Ultrasonography: Ultrasonography is used to identify the relationships between the humeral head
and glenoid, helping to distinguish between congruous and incongruous shoulders. It offers real-time
imaging but may have limitations due to operator dependency and the ability to evaluate soft
tissues.
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2. Shoulder Arthrography: This imaging technique involves the use of a contrast agent injected into
the shoulder joint. It is particularly useful when imaging the shoulder in the abducted position. An
axillary view can provide valuable information.
3. Computed Tomography (CT): CT scans are used to evaluate the morphology of the glenohumeral
joint. They offer detailed images, allowing for the quantification of shoulder joint deformities. CT
scans can provide information about the position of the humeral head relative to the glenoid and the
shape of the glenoid.
4. Magnetic Resonance Imaging (MRI): MRI is known for providing excellent detail of the
glenohumeral joint. It is particularly valuable for assessing soft tissues and joint morphology.
However, the need for general anesthesia in young children and the cost may limit its routine use.
There have been classification systems proposed to grade the severity of glenohumeral deformity
based on the relationships between the humeral head and the glenoid. These classifications help in
understanding the degree of deformity, with increasing deformity corresponding to increasing
posterior displacement of the humeral head from its normal concentric position and alterations in
the shape of the glenoid.
Preoperative imaging is important for documenting the preoperative morphology of the

glenohumeral joint. It provides essential information for creating a surgical plan for the patient and
should be used in conjunction with the results of the physical examination. Longitudinal follow-up
imaging postoperatively helps in tracking the progress of these patients and assessing the outcomes
of surgical interventions.
The management of residual deformities of the shoulder in children with brachial plexus palsy (BPP)
depends on several factors, including the nature of the deformity and the child's unique
circumstances. The primary goal is to improve the functionality of the shoulder and enhance the
child's quality of life. The classification of residual deformities proposed by Zancolli has helped guide
treatment decisions. Here are some key considerations for managing these deformities:
1. Internal Rotation Contracture: Internal rotation contracture is a common issue in children with
incomplete recovery from BPP. It results from an imbalance between the internal rotator muscles
(latissimus dorsi, subscapularis, teres major, and teres minor) and the paralyzed external rotators
(infraspinatus). The initial goal is to maintain range of motion (ROM) and keep the shoulder
congruous during the period of reinnervation.
2. Soft Tissue Procedures: If the glenohumeral joint remains congruous, soft tissue procedures aimed
at rebalancing and reducing the joint contracture are indicated. These procedures may include the
release of the tight subscapularis and pectoralis, along with an anterior capsule release.
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3. Muscle Transfers: To augment external rotation, muscle transfers may be performed. Common
transfers include moving the teres major to an external rotation position and transferring the
latissimus dorsi to the external rotator position.
4. Extraarticular Procedures: Extraarticular procedures, such as subscapularis and pectoralis

lengthening in combination with tendon transfers, have been shown to significantly improve global
shoulder function, especially in the presence of an internal rotation contracture.
5. Glenohumeral Joint Reduction: If the glenohumeral joint is incongruous due to glenoid deformity,
procedures to achieve glenohumeral joint reduction may be necessary. Open reduction of the
glenohumeral joint with tendon lengthening and transfer can improve glenohumeral retroversion
and may promote glenohumeral remodeling. Arthroscopic techniques have also been employed,
allowing for direct visualization of the joint and anterior release of ligaments and subscapularis to
restore joint congruity.
6. Imaging and Monitoring: Imaging modalities like arthrography, CT scans, and MRI play a vital role
in assessing shoulder deformities. They help in the preoperative evaluation of glenohumeral
morphology and can be used for longitudinal follow-up postoperatively.
The choice of procedure depends on individual patient factors, including age, the degree of
deformity, muscle strength, and the goals of the child and their family. The selection of the most
appropriate management strategy should be made through a collaborative effort between the
medical team, including orthopedic surgeons and physical therapists, and the patient's family.
Arthroscopic procedures have shown promise in the management of shoulder deformities in

children with brachial plexus palsy. Several studies have reported improved outcomes in terms of
glenohumeral deformity and shoulder function when arthroscopic techniques are applied. Key
findings from these studies include:
1. Arthroscopic Release and Tendon Transfers: In some cases, arthroscopic release of the
subscapularis and/or anterior glenohumeral capsule is performed in combination with tendon
transfers, such as the latissimus dorsi and teres major tendon transfers to the rotator cuff. These
procedures are aimed at addressing internal rotation contractures and improving shoulder function.
2. Improvement in Passive External Rotation: Patients undergoing arthroscopic procedures have

demonstrated improvements in passive external rotation of the shoulder. This is an essential aspect
of shoulder function in these patients.
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3. Glenohumeral Joint Realignment: Arthroscopic techniques have been shown to assist in realigning
the humeral head within the glenoid, thus addressing glenohumeral deformity. This can be critical
for ensuring better joint congruity.
4. Postoperative MRI Findings: Postoperative MRI scans have confirmed improvements in

glenohumeral deformity after arthroscopic procedures. These scans have provided valuable insights
into the effectiveness of the techniques.
5. Age and Surgical Intervention: The choice of surgical intervention may be influenced by the child's
age and the severity of deformity. Some studies have suggested that arthroscopic release and joint
reduction are suitable for younger children (under 3 years of age) without the need for simultaneous
tendon transfers. In contrast, older children may benefit from concomitant tendon transfers.
Despite these promising findings, there is currently no consensus in the medical community
regarding the optimal secondary procedures for the child's shoulder deformity. Different studies
have employed varying approaches, and there is heterogeneity in the assessment of outcomes,
making direct comparisons challenging. Additionally, no clear guidelines exist for determining the
age and deformity criteria for surgical intervention.
It is essential to recognize that the long-term consequences of glenohumeral dysplasia, whether it

contributes to shoulder pain or arthritis in adulthood, remain uncertain. Long-term studies are
needed to better understand the natural history of treated and untreated glenohumeral joint
dysplasia and to provide guidance for future treatment strategies. Management decisions should be
tailored to each patient's unique circumstances, and a collaborative effort involving orthopedic
surgeons and physical therapists is crucial in optimizing outcomes.
In cases where patients have advanced glenohumeral deformities, such as humeral head flattening,
increased glenoid retroversion, and posterior humeral head subluxation, the choice of surgical
procedures may differ. For these patients, tendon transfers and extraarticular procedures may not
yield successful outcomes due to the underlying glenohumeral deformities undermining their
effectiveness. Instead, alternative surgical approaches may be considered, and one such option is
derotational osteotomy of the humerus.
Derotational osteotomy is a surgical procedure that aims to improve shoulder function in patients
with advanced glenohumeral deformities. This procedure reorients the humerus into a more
functional position, enhancing the arc of shoulder rotation and improving overall shoulder function.
The key steps in derotational osteotomy include:
1. Humerus Exposure: The humerus is exposed through a deltopectoral approach or a medial

incision, depending on the surgeon's preference. The deltopectoral approach involves an incision
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along the anterior aspect of the shoulder, while the medial approach uses an incision along the
medial aspect of the arm.
2. Osteotomy: The osteotomy is performed proximal to the deltoid insertion. This osteotomy helps
to rotate the deltoid more laterally, facilitating lateral abduction of the arm. In cases of internal
rotation and abduction contractures, a varus-producing osteotomy can be added to promote arm
adduction.
3. Fixation: The osteotomy is stabilized with a plate to maintain the corrected position of the
humerus. Rigid fixation is important to prevent angular deformity. Following the procedure,
postoperative immobilization may be used as needed.
The choice between the deltopectoral and medial approach for osteotomy can depend on factors
like incision placement, ease of surgical access, and cosmetic considerations. Both approaches have
been reported to yield comparable outcomes.
Derotational osteotomy is a valuable surgical option for patients with advanced glenohumeral
deformities, as it can significantly improve the functional positioning of the arm and enhance
shoulder function. This procedure is particularly beneficial for patients with internal rotation and
abduction contractures. Ultimately, the selection of the most suitable surgical approach should be
based on individual patient characteristics and the surgeon's expertise.
Patients with residual abduction/external rotation contractures following brachial plexus palsy (BPP)
present a unique subset of individuals. They typically have better passive range of motion (ROM)
than active ROM and often complain of scapular winging, which can affect the appearance and
function of the shoulder. Glenohumeral deformity is less common in these cases.
The primary issues with abduction/external rotation contractures are:
1. Winging of the Scapula: Patients exhibit winging of the scapula when attempting internal rotation,
and this can be a source of concern, especially if it affects the shoulder's appearance.
2. Preserved Overhead Function: Despite the contracture, overhead function is usually preserved.
Treatment options for abduction contractures include:
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- Anterior Capsular Release and Muscle Transfer: Some reports suggest modest improvements in
active elevation with procedures involving anterior capsular release and muscle transfer.
- Upper Trapezius Transfer: In some cases, an upper trapezius transfer has been used to improve
active elevation. The procedure involves detaching the upper trapezius from the acromion and
transferring it distally on the humerus. The latissimus and pectoralis muscles are used to replace the
deltoid. However, the success of this procedure may vary, and recent clinical series demonstrating
its effectiveness are limited.
- Internal Rotation Osteotomy of the Humerus: In some instances, internal rotation osteotomy of the
humerus has been effective in helping children reach the midline. This can be particularly helpful
when there is limited shoulder elevation.
It's essential to approach these cases with caution because weakening the muscles that control
external rotation and overhead motion can have functional consequences. The choice of surgical
intervention should be individualized based on the patient's specific needs and the degree of
contracture and deformity present.
Scapular dyskinesia, characterized by abnormal scapular movement, is another common concern in

children with BPP. It often occurs in conjunction with stiffness or limited glenohumeral joint motion.
The specific type of scapular dyskinesia, whether associated with internal or external rotation
contractures, may be addressed through various surgical procedures or interventions. The
assessment and management of scapular dyskinesia should be tailored to each patient's unique
situation, and no universal surgical protocol has been established for addressing this issue. Further
studies and research are needed to better understand the underlying causes of scapular dyskinesia
and to develop effective treatment strategies.
In conclusion, patients with brachial plexus palsy (BPP) are at risk for long-term functional
limitations, particularly in the shoulder. The treatment of infantile shoulder issues primarily focuses
on maintaining full passive range of motion (ROM). This involves a gentle home program initiated
during the first week of life, with ongoing monitoring and assistance from therapists to ensure the
preservation of passive ROM. Passive external rotation and abduction are crucial indicators of the
degree of glenohumeral deformity and the need for additional interventions.
External rotation strength and motion are essential for achieving above-horizontal shoulder
activities. Scapulothoracic winging can compensate for limited glenohumeral motion in various
planes, except in external rotation, where the scapula encounters the posterior thorax.
Indications for surgical intervention around the shoulder include infantile dislocation, persistent
internal rotation contracture that does not resolve with nonoperative measures, and progressive
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glenohumeral deformity. The preoperative evaluation should establish the status of glenohumeral
joint congruity. If internal rotation contractures persist and nonoperative measures prove
ineffective, an MRI is recommended to assess the glenohumeral joint. Surgical approaches, such as
anterior shoulder structure release and tendon transfers, may be indicated.
Clinical studies support the reduction of the glenohumeral joint either through open or arthroscopic
procedures when glenohumeral joint deformities are present. Tendon transfers should be
considered in addition to joint reduction, particularly for patients over the age of 3. Adequate
deltoid strength and internal rotation strength must be confirmed preoperatively to achieve
successful outcomes with tendon transfers.
Patients with severe glenohumeral deformities, including flattening of the humeral head and
complete posterior humeral head dislocation with pseudoglenoid formation, may benefit most from
a humerus derotational osteotomy. This procedure can reorient the shoulder's rotation arc into a
more functional position and improve global shoulder function.
In summary, addressing the shoulder issues associated with BPP involves a combination of
nonoperative and surgical approaches, with the goal of preserving or restoring functional shoulder
motion and minimizing long-term functional limitations. Treatment decisions should be tailored to
each patient's unique needs and the specific nature of their shoulder involvement.
Neonatal brachial plexus palsy (NBPP) is a condition that affects infants and results from an injury to
the brachial plexus, a network of nerves in the shoulder and arm. The incidence of NBPP has
remained relatively stable over the years, despite advancements in obstetric techniques. Several risk
factors may predispose infants to NBPP, including macrosomia, prolonged labor, breech delivery,
shoulder dystocia, and other factors.
The severity of NBPP can vary, ranging from minor nerve injuries that resolve within a few weeks to
severe avulsion injuries that may not recover spontaneously. The classification of NBPP typically
divides cases into four groups, with each group representing a more severe injury. These groups
include Erb palsy (C5, C6 involvement), Erb-Klumpke palsy (C5, C6, and C7 involvement), total palsy
(C5-T1 involvement), and Horner syndrome (involvement of all roots, along with injury to the
sympathetic fibers).
The clinical presentation of NBPP varies according to the group, with each group experiencing
different patterns of muscle weakness and paralysis in the shoulder, arm, and hand. Management
strategies depend on the specific pattern of involvement.
In contrast to adult brachial plexus injuries, children with NBPP do not typically experience
neuropathic pain. This difference is attributed to the maturation of peripheral nerves and the
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plasticity of the central nervous system in infants. Long-term follow-up of children with NBPP shows
that while motor function may be affected, sensory function often recovers well.
This chapter focuses on the secondary procedures available to restore hand, wrist, and forearm
function in cases of late NBPP. Late NBPP occurs when children present later in life with sequelae of
the condition, which may include deformities in the hand and wrist. The chapter outlines various
surgical options, including soft tissue releases, corrective osteotomies, tendon transfers, joint
fusions, and free muscle transfers. Rehabilitation and physical therapy play crucial roles in the
recovery process following these secondary procedures.
The goal of this chapter is to provide an overview of reconstructive strategies for managing late
NBPP and improving hand and upper limb function in affected children. It emphasizes the
importance of early intervention for infants and outlines the available options for secondary
procedures in cases where reconstruction may no longer be feasible.
Neonatal brachial plexus palsy (NBPP) is not a static condition and can lead to various secondary
deformities as the child grows. The severity of these secondary deformities is influenced by several
factors, including the initial brachial plexus lesion's severity, the child's age at presentation, and the
degree of muscle function recovery. Several factors can contribute to these deformities:
1. Lesions of the osteoarticular system: These can result from injuries such as epiphyseolysis of the
proximal humerus or anterior subcoracoid dislocation of the shoulder.
2. Lesions of the muscular system: Muscular fibrosis in the shoulder girdle muscles or the biceps can
occur following birth trauma.
3. Incorrect initial treatment: Forced manipulation to correct contractures, the use of plaster casts or
splints in an exaggerated position of abduction and external rotation, and delayed surgical correction
of muscular contractures can all worsen secondary deformities.
The recovery of muscle function also plays a role in the development of secondary deformities.
Three types of muscle impairments may be observed following recovery:
1. Paresis: Incomplete recovery with weakened motor strength.
2. Paralysis: No recovery with muscle atrophy.
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3. Co-contraction: Simultaneous contraction of different muscles due to aberrant reinnervation.
Co-contraction is often a problem unique to late NBPP and can lead to functional impairment.
Aberrant reinnervation, or cross-innervation, is believed to be the cause of co-contractions. This
occurs when regenerating axons misdirect and innervate muscles other than their intended targets.
As a result, abnormal multiple muscle contractions (co-contractions) occur, antagonizing the desired
action. This phenomenon is particularly problematic in shoulder and elbow function.
Co-contractions can lead to muscle imbalance, hypertrophy, joint contractures, bony deformities,
and joint displacement, which affect the child's growing body. The risk of co-contractions is
associated with ruptures of the upper roots (C5, C6, and/or C7). Co-contractions are less common in
the forearm and hand because deformities in these areas are typically associated with injury to the
lower roots (C8 and T1) and are more likely to result from avulsions than ruptures.
Co-contractions in NBPP have been categorized into different types, including co-contractions
between shoulder abductors and adductors, elbow flexors and extensors, and elbow flexors and
shoulder abductors, as well as more widespread co-contractions affecting the shoulder, elbow,
forearm, and hand. Understanding and addressing these co-contractions is crucial in the
management of late NBPP to optimize functional outcomes.
Co-contractions in neonatal brachial plexus palsy (NBPP) are sometimes considered a learned
response that can be unlearned. One example of a typical co-contraction is the simultaneous
contraction of the deltoid and biceps when a child tries to bring their hand to their mouth, known as
the "trumpet sign." This co-contraction occurs because a child with limited external rotation "learns"
that they need to move their arm away from the body before flexing the elbow to reach the mouth.
Without good external rotation, the chest can block the hand's ability to reach the mouth.
There are various theories regarding the underlying causes of co-contractions in NBPP:
1. Cortical Co-Activation: Some researchers suggest that cortical co-activation, which involves
neighboring motor cortex areas, is responsible for co-contraction.
2. Aberrant Re-Innervation: Others believe that the aberrant reinnervation of muscles leads to
incorrect sensory feedback that affects central motor programming. This feedback loop can be
interrupted by treatments such as botulinum toxin injections, which allow the muscles to recover,
and the child's neuronal plasticity helps maintain the improvement in range of motion once the
effects of botulinum toxin wear off.
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While the shoulder is the most frequently affected joint in NBPP, other joints in the limb may also
display disabling deformities. The common sequelae in late NBPP cases may include:
- Internal rotation contracture of the shoulder (72%)
- Flexion contracture of the elbow (62%)
- Supination contracture of the forearm (69%)
- Pronation contracture of the forearm (29%)
- Ulnar deviation of the wrist (27%)
- Various types of finger paralysis
These deformities can lead to functional limitations and may require specific interventions and
surgeries to address them and optimize limb function.
Elbow joint deformities in neonatal brachial plexus palsy (NBPP) are often less severe than those
around the shoulder but can still present significant challenges. The most common issues around the
elbow joint include:
1. Flexion Contracture (62%): This occurs when the elbow is locked in a flexed position, making it
difficult to fully extend the arm (Figure 11.8).
2. Weakness of Extension (46%): Weakness in the muscles responsible for extending the elbow can
affect the ability to straighten the arm fully.
3. Weakness of Flexion (18%): Weakness in the muscles responsible for bending the elbow can limit
the ability to bend the arm.
The pathophysiology of elbow flexion contracture, in particular, is not entirely understood. Several
factors may contribute to its development:
- Muscle Imbalance: It can result from a combination of muscle imbalance, where certain muscle
groups may become hypertrophic while others remain weak or paralyzed. In the case of a weak or
absent triceps muscle, the biceps may recover, leading to an unopposed action that causes
progressive elbow flexion and supination contracture.
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- Rigid Splinting: A study by Aitken suggested that the development of this deformity might result
from a combination of muscle imbalance and rigid splinting. This could lead to proximal ulnar
curvature, radial neck clubbing, posterior subluxation of the radial head, radial head dislocation, and
even dislocation of both the ulna and radius.
- Shoulder Deformity: Elbow flexion contracture may also be associated with a shoulder internal
rotation contracture. Some children stand with the shoulder slightly abducted, which, in turn, places
the elbow in slight flexion. This constant flexed posture of the elbow can contribute to the
development of the contracture.
It's important to note that elbow flexion contracture can develop even in children with triceps
function, possibly due to insidious fibrosis of the biceps following trauma during delivery. Therefore,
a comprehensive understanding of the factors contributing to these deformities is crucial in
developing effective treatment strategies for children with NBPP.
Forearm deformities in neonatal brachial plexus palsy (NBPP) typically manifest as either supination
contractures or pronation contractures. These deformities can have a significant impact on the
child's functional abilities and may require intervention. Here's an overview of these forearm
deformities:
Supination Contracture (69%): In this type of deformity, the forearm remains in a supinated (palm-
facing-up) position due to the unopposed action of the supinator muscles (primarily the biceps and
supinator) in the presence of paralyzed or weak pronator muscles (pronator teres and pronator
quadratus). This deformity is most common in children with NBPP Groups 2, 3, and 4 who have had
recovery of their C5 and C6 roots. Initially, passive correction may be possible, but as the child
grows, the deformity can become fixed due to the contracture of the interosseous membrane,
leading to structural changes in the forearm, including bowing of the radius and ulna and possible
dislocation of the distal ulna or head of the radius (Figure 11.10). This deformity affects daily
activities that require elbow flexion and pronation, such as eating, writing, and bimanual tasks.
Pronation Contracture (28%): In this type of deformity, the forearm remains in a pronated (palm-
facing-down) position due to the unopposed action of the pronator muscles in the presence of
paralyzed or weak supinator muscles. Pronation contractures are seen in children with NBPP Group
1 (Erb's palsy) who have had little or no recovery of their C5 and C6 roots. These contractures can
progress to become fixed deformities over time and may result in deformities of the radius and ulna,
including dislocation of the distal ulna and radial head (Figure 11.11). This deformity affects tasks
that require forearm supination, such as carrying objects and performing activities that involve
supination of the hand.
Both supination and pronation contractures can have a significant impact on a child's quality of life
and functional abilities, making them important considerations for treatment and rehabilitation in
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children with NBPP. Early intervention and management are crucial to address these deformities and
improve the child's ability to use their affected limb effectively.
Late neonatal brachial plexus palsy (NBPP) can result in various wrist and hand problems, which can
have a significant impact on a child's hand function. Some common issues affecting the wrist and
hand include:
1. Extension Deficit at the Metacarpophalangeal Joint (MCPJ) (60%): This problem is characterized by
a limitation in extending the fingers at the MCPJ, the joint connecting the fingers to the hand. It can
significantly affect a child's ability to straighten their fingers.
2. Thumb Instability (37%): Children with NBPP may experience instability in the thumb due to the
lack of control and support provided by certain hand muscles. This instability can affect the precision
and strength of thumb movements.
3. Ulnar Deviation of the Wrist (19%): Ulnar deviation refers to the wrist bending towards the ulnar
(pinky) side of the hand. This deformity results from muscle imbalance caused by the paralysis of
specific muscles (ECRB, ECRL, FCR) relative to the activity of other muscles (ECU, FCU). Ulnar
deviation can affect wrist alignment and hand function.
4. Extension Deficit at the Wrist (15%): An extension deficit at the wrist means that the child may
have difficulty extending their hand at the wrist joint. This limitation can affect hand positioning and
function.
5. Digital Flexion Deficit (15%): Some children with NBPP may experience difficulty in flexing their
fingers, particularly in the digital joints. This can affect fine motor skills and finger control.
6. Interphalangeal Joint (IPJ) Extension Deficit (13%): Children with NBPP may have limitations in
extending the interphalangeal joints, the joints between the finger segments. This can affect finger
movement and dexterity.
The pathogenesis of these wrist and hand deformities is usually related to muscle imbalances caused
by paralysis or weakness in certain muscle groups. For example, ulnar deviation of the wrist results
from the paralysis of specific muscles in relation to the unopposed activity of other muscles.
Similarly, thumb instability can be attributed to the absence of certain hand muscles required for
thumb control and stability.
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It's important to note that the clinical presentation of hand deformities can vary from one child to
another, depending on the extent of spontaneous recovery and the specific nerves affected. These
deformities can significantly impact a child's hand function and overall quality of life, making early
intervention and appropriate reconstructive procedures crucial for improving hand function in late
NBPP cases.
Assessing elbow and hand function in cases of neonatal brachial plexus palsy (NBPP) is crucial for
determining the need for surgical intervention and tracking outcomes. Various systems and scoring
methods have been proposed to evaluate motor power, range of motion, and overall hand function.
Below are some of the commonly used assessment methods:
Motor Power Assessment:
1. Medical Research Council (MRC) Grading: The MRC grading system is a standard method for
assessing motor power. It grades muscle strength on a scale from 0 (no contraction) to 5 (normal
strength). This grading system is typically used for children older than 3 years. However, it does not
assess the range of motion or overall hand function.
2. Modified MRC Grading: Modifications have been introduced for use in younger children and for
assessing muscle groups that are not adequately covered by the standard MRC grading.
3. Bhardwaj's Modification: Bhardwaj et al. introduced a modification that includes three subgroups
(A, B, and C) for grades 2, 3, and 4. Subgroup A indicates limited range of motion (ROM), subgroup B
indicates more than 50% of normal ROM, and subgroup C indicates full ROM.
4. Revised MRC Grading: A revised version was proposed, removing subgroup C and using ROM
subgroups for grade 4.
Functional Assessment:
1. Mallet Score: The Mallet score is used to assess shoulder function, particularly in cooperative
children. It evaluates a child's ability to perform specific shoulder movements.
2. Toronto Test Score and Active Movement Scale: These scoring systems do not require testing
against resistance and can be carried out in young children. They assess function by quantifying
specific movements.
3. Score of 10: Chuang et al. developed a "score of 10" that combines an Erb score (upper plexus
assessment) and a Klumpke score (lower plexus assessment). This system helps evaluate functional
ability and reconstructive options.
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Hand Function Assessment:
Several methods for assessing overall hand function exist, including the Dubousset classification,
Raimondi classification, modified Raimondi classification, and the King Saud University hand function
grading. These methods evaluate sensibility and intrinsic hand function. The choice of assessment
method may depend on clinical preferences and the individual presentation of each child's hand
function.
It's important to note that no single assessment method is universally accepted, and there may be
variations in how these methods are used in clinical practice. The selection of a specific method may
depend on the child's age, clinical presentation, and the focus of the evaluation (motor power,
functional ability, or hand function).
Pre-operative considerations in the treatment of neonatal brachial plexus palsy (NBPP) are essential
for achieving optimal results in improving upper extremity function. Here are some important
factors to consider:
1. Understanding Natural History: Surgeons must have a comprehensive understanding of the

natural history of NBPP, which includes the progression of the condition over time and the potential
for spontaneous recovery. This knowledge guides decision-making regarding the timing and
necessity of surgical interventions.
2. Assessment of Growth: The growth of the child is a critical factor in planning and executing
reconstructive procedures. As children grow, the anatomy of the affected limb changes, and this can
impact the choice of surgical techniques and their timing.
3. Functional Deficits: Each child with NBPP may present with specific functional deficits. It is crucial
to assess and document these deficits to tailor the surgical approach to the individual needs of the
child.
4. Available Active Muscles: The number and condition of available active muscles in the affected
limb play a crucial role in determining the feasibility of various reconstructive procedures. Surgeons
must carefully assess muscle function before planning surgery.
5. Multidisciplinary Approach: The treatment of NBPP often involves collaboration between various
medical specialties, including pediatric neurosurgery, orthopedics, and physical therapy, among
others. A multidisciplinary team can provide a more comprehensive and effective approach to
treatment.
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6. Integrated Treatment Plan: An integrated approach to treatment involves considering

conservative, primary (microsurgical reconstruction), and secondary (muscle and tendon transfers,
tenodeses, osteotomies, arthrodesis) treatment modalities. It is essential to plan not only for the
initial microsurgical reconstruction but also for potential secondary procedures to enhance overall
functional outcomes.
7. Timing of Surgery: The timing of surgical interventions, both primary and secondary, should be
carefully considered based on the child's age, the extent of recovery, and the specific functional
deficits. Some procedures may be more effective if performed at a certain stage of growth and
development.
8. Optimal Results: The primary goal of surgical intervention in NBPP is to maximize upper extremity
function. Surgeons should work toward achieving the best possible outcomes for the child, with an
emphasis on functional improvement and quality of life.
In summary, pre-operative considerations in NBPP involve a thorough understanding of the

condition's natural history, the child's growth, functional deficits, and the availability of active
muscles. A multidisciplinary approach and careful timing of primary and secondary surgical
procedures are key to achieving the best functional outcomes for children with NBPP.
The optimum age for secondary reconstruction in cases of late neonatal brachial plexus palsy (NBPP)
is typically considered to be around age 4 or older. This age range offers several advantages:
1. Easier Evaluation: Children at this age are more cooperative and can be assessed more
comprehensively. They can actively participate in their own rehabilitation, making the evaluation
and treatment process smoother.
2. Less Severe Contractures: Children in this age group often have fewer and less severe
contractures, which can make the surgical and rehabilitative process more manageable.
3. Better Co-operation in Rehabilitation: The willingness and ability of children to cooperate in the
rehabilitation process improve with age. This is important for achieving the best post-operative
outcomes.
Chuang et al. suggest that the optimal age for reconstructing shoulder and elbow function is during
the preschool years (4-6 years), while the best age for forearm and hand reconstruction is during the
school-going years (6-13 years). This approach takes into account the differing recovery patterns of
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proximal and distal muscles and aims to address deformities and contractures in a manner that
aligns with the natural progression of muscle recovery. Specifically, proximal musculature (shoulder
and elbow) tends to recover earlier and more completely than distal musculature (forearm and
hand).
The priority for secondary reconstruction in NBPP is individualized based on the specific functional
deficits and contractures of each child. In many cases, addressing shoulder and elbow deformities is
prioritized, as these deformities are more common and tend to recover earlier. Once shoulder and
elbow function is improved, attention can be turned to forearm and hand reconstruction, which may
require more time due to the delayed recovery of distal muscles. However, the ultimate goal
remains the comprehensive restoration of upper extremity function to enable bimanual activities.
The choice of reconstruction timing and priorities should be based on a thorough evaluation of the
child's condition, their age, the severity of contractures, and the specific functional deficits they are
experiencing. By taking a multidisciplinary and individualized approach, surgeons can work toward
achieving the best functional outcomes for children with NBPP.
Sensory reconstruction in the context of neonatal brachial plexus palsy (NBPP) is a subject of
discussion and consideration among experts. Several points and observations have been made
regarding sensory function in children with NBPP:
1. Limited Sensory Impairment: Sensory function is often less severely affected than motor function
in children with NBPP. This means that, irrespective of the severity of the brachial plexus lesion,
many children with NBPP retain some degree of sensibility in their hands.
2. Contact Burns Risk: While sensory impairment is generally less severe, there can be challenges
related to sensibility, especially in cases of total palsy and Erb's palsy. Al-Quattan reported a 4%
incidence of accidental contact burns in children with NBPP. This risk is attributed to the
combination of poor motor control and insensibility in the affected hand.
3. Accommodation to Insensibility: Many children with NBPP tend to adapt to the paralyzed hand
and may not frequently experience injury due to decreased hand sensibility. Over time, they develop
strategies to compensate for their sensory limitations.
Considering these factors, some experts, like Chuang, argue that sensory reconstruction for the
forearm and hand is often unnecessary in cases of late NBPP. They suggest that the sensory
disturbance in these areas is a minor problem, and most children become accustomed to their
paralyzed hand. Instead, the focus is primarily on motor function and overall hand function.
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It's essential to individualize the approach to sensory reconstruction and assess the specific needs
and challenges faced by each child with NBPP. Factors such as the degree of sensory impairment, the
child's adaptability, and the risk of injury should be considered when making decisions about sensory
reconstruction procedures. Ultimately, the goal is to provide the best possible care and functional
outcomes for each child with NBPP.
Pre-operative preparation for tendon transfers in cases of neonatal brachial plexus palsy (NBPP) is a
crucial aspect of achieving successful outcomes. Several key considerations and principles are
involved in the pre-operative phase:
1. Cooperative Child and Informed Parents: Successful tendon transfer procedures in NBPP require
the cooperation of the child and the active involvement of the parents. Parents should have a clear
understanding of the objectives of the surgery and be committed to working diligently with their
child to attain the best possible results.
2. Principles of Tendon Transfer: Tendon transfer procedures in NBPP should adhere to established
principles as outlined by experts in the field, such as Mayer, Bunnell, Boyes, Burkhalter, and Brand.
These principles include ensuring mobile joints and adequate skin cover at the surgical site.
3. Donor Muscle Evaluation: A thorough evaluation of potential donor muscles is critical for the
success of tendon transfer procedures. The selected donor muscle should ideally have an MRC grade
of 4 or higher. It's important to consider that there may be a loss of one grade of muscle strength
after the transfer, making an initially strong donor muscle essential for a successful outcome.
4. Pre-operative Exercise Program: Children should undergo a pre-operative exercise program aimed
at improving available passive range of motion. The success of tendon/muscle transfer procedures is
closely related to the passive range of motion achievable before surgery. A willingness to participate
in this program serves as an indicator of the child's and parents' likely involvement in post-operative
therapy.
5. Sensory Considerations: The impact of sensory deprivation should be taken into account when
planning tendon transfer procedures. Children with significant sensory loss in the hand may face
challenges in integrating the transfer into functional hand use, affecting their ability to perform tasks
requiring tactile sensation.
The success of tendon transfer procedures depends on careful pre-operative planning, a supportive
environment involving both the child and the parents, and adherence to established surgical
principles. It's crucial to address both motor and sensory considerations to achieve the best possible
functional outcomes for children with NBPP.
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If the child is unable or unwilling to cooperate in the pre-operative phase, or if these criteria cannot
be met, it may be more appropriate not to proceed with the procedure to ensure a satisfactory
outcome. Successful pre-operative preparation sets the stage for effective surgical interventions in
the treatment of NBPP.
The management of forearm deformities in cases of neonatal brachial plexus palsy (NBPP) involves
addressing both supination and pronation deformities. The approach to surgery depends on the
condition of the interosseous membrane, the function of the triceps, and the congruity of the
proximal and distal radio-ulnar joints.
1. Supination Deformity:
- Flexible Deformity: If the child has a flexible supination deformity, which allows passive pronation
and functional triceps, the biceps tendon can be addressed. The biceps tendon is lengthened via a z-
plasty and re-routed around the radius, converting it from a supinator to a pronator. This procedure
is performed in the presence of a functional triceps and is done to improve forearm pronation.
- Fixed Deformity: For children with a fixed supination deformity (contracted interosseous
membrane and no passive pronation) but a functional triceps, the procedure involves releasing the
interosseous membrane in addition to z-lengthening and re-routing of the biceps tendon. Extensive
release of the interosseous membrane and release of the distal radio-ulnar joint may be necessary
to achieve maximum benefit.
2. Pronation Deformity:
- In cases of mild pronation deformity, no surgical intervention may be required, as the posture
often positions the hand functionally.
- Surgical procedures to address more severe pronation deformities might involve detaching the
pronator teres over the radius and re-routing it under the radius, converting it into a supinator.
Fractional lengthening of the pronator teres and release of the lacertus fibrosis may be effective for
greater degrees of pronation deformities.
3. Dislocated Joints: Tendon transfers should not be considered if the joints are dislocated. In cases
of a dislocated radial head with a supination deformity, surgical options include excising the radial
head, releasing the interosseous membrane, and performing a proximal radioulnar fusion. For
dislocation of the distal radio-ulnar joint, a Sauve-Kapandji procedure (DRUJ arthrodesis and ulnar
resection) is recommended.
It's essential to assess the child's specific deformities, joint conditions, and functional needs before
planning and performing surgical procedures to correct forearm deformities in NBPP. The choice of
procedure should be tailored to the individual case to optimize functional outcomes.
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In children with neonatal brachial plexus palsy (NBPP) in Group 2 (C7–T1 involvement) who do not
recover function of the C5-7 roots, they may present with deficits in MCPJ (metacarpophalangeal
joint) extension and, occasionally, weak wrist extension. They might also have an ulnar deviation
deformity of the wrist, which is often associated with a supination contracture of the elbow. These
children typically have good strength in the forearm flexor-pronator group.
The following surgical procedures can be considered for late reconstruction of wrist and hand
function in children with C7–T1 involvement:
1. Flexor to Extensor Transfer: This procedure, similar to what is used in radial nerve palsy, involves
transferring a functioning flexor tendon to an extensor tendon to restore extension in the affected
joint(s). The choice of tendon for transfer depends on the pre-operative wrist deviation and the
strength of wrist extensors.
2. Ulnar Deviation Correction: If the child has an ulnar deviation deformity along with wrist extension
deficits, a suitable flexor tendon (like FCU or ECU) can be used for correction of the deformity and
restoration of wrist extension. The choice between FCU and ECU depends on the underlying cause of
the ulnar deviation deformity.
- If the ulnar deviation deformity is due to the ECU, the ECU can be divided at its insertion, passed
through the interosseous membrane (which has been released for correcting the supination
contracture), routed around the volar aspect of the radius, and sutured to the distal end of the ECRL
with appropriate tension to achieve 20 degrees of wrist extension.
- If the ulnar deviation deformity is due to the FCU, the FCU can be divided at its insertion, routed
from volar to dorsal around the radius, and sutured to the distal end of the ECRL with tension,
thereby correcting both the ulnar deviation and wrist drop.
3. Finger and Thumb Extension: To restore finger and thumb extension, the following tendon
transfers can be considered:
- Transfer of the palmaris longus to EPL (extensor pollicis longus).
- Transfer of the middle finger FDS (flexor digitorum superficialis) to EDC (extensor digitorum
communis) of the index finger.
- Transfer of the ring finger FDS to EDC of the long, ring, and small fingers.
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Before performing these tendon transfers, it is crucial to assess the strength of the involved muscles
and ensure that the FDP (flexor digitorum profundus) is functional.
The goal of these surgical procedures is to correct wrist and hand deformities and restore functional
movements and positioning of the hand to enhance the child's overall hand function. The specific
procedure chosen will depend on the individual child's condition and the underlying causes of their
wrist and hand deficits.
In children with neonatal brachial plexus palsy (NBPP) in Group 2 (C7–T1 involvement) who do not
recover function of the C5-7 roots and do not have an ulnar deviation deformity, several surgical
options are available to address wrist and hand deficits. The choice of procedure depends on the
specific muscle availability and function in the affected limb. Here are some of the surgical options:
1. Traditional Radial Nerve Palsy Transfer: In cases where the child does not have an ulnar deviation
deformity, one can consider using traditional radial nerve palsy transfers. This might involve
transferring a muscle like pronator teres (PT) to restore wrist extension. Alternatively, the flexor
carpi radialis (FCR) can be used if the PT muscle is weak.
2. Brachialis Muscle Transfer: Another option, suggested by Bertelli, is the use of the brachialis
muscle transfer to restore wrist extension. However, this transfer requires a functional triceps
muscle, as the brachialis contraction requires counterbalance by triceps co-contraction.
3. Muscle Selection: Chuang and others have noted that muscles on the radial side, such as FCR/ECRL
(extensor carpi radialis longus), innervated more by the upper plexus, are stronger than the ulnar
side muscles in late NBPP. Therefore, these radial-sided muscles are considered more reliable for
transfer. Wrist and finger flexors are often considered more reliable donor muscles compared to
extensors in these cases.
The choice of muscle transfer depends on the individual child's condition and the degree of recovery
of the C5-7 roots. The priority in these cases is to restore wrist extension, followed by addressing
thumb flexion, finger flexion, and finger and thumb extension. While wrist fusion may seem like an
option to make all wrist motors available for transfer, it is generally preferable to preserve wrist
mobility because it allows for passive wrist motion, which, in turn, affects finger excursion and the
range of finger motion.
The specific procedure chosen will be determined through a careful pre-operative examination and
consideration of the available muscles and their functional recovery in the affected limb. The goal is
to improve wrist and hand function, taking into account the unique characteristics and needs of each
child.
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In cases of neonatal brachial plexus palsy (NBPP) in Group 3 and 4, where there is no significant
recovery of the C5-7 roots and a high level of function needs to be restored, reconstructive
procedures often involve more complex surgical interventions. The options available include
plication, tenodesis, chondrodesis, free functioning muscle transfers (FFMT), and arthrodesis. Each
of these procedures has specific considerations and may be chosen based on the child's age, growth
status, and the functional goals of the surgery:
1. Plication and Tenodesis: Plication and tenodesis procedures, which involve modifying the existing
structures or tendons to improve function, are generally not considered reliable options for children
with ongoing growth. These procedures can result in issues such as bowstringing, wrist, and finger
extension contractures.
2. Wrist Chondrodesis: Wrist chondrodesis, a procedure that involves shaving the cartilage off
certain wrist bones and stabilizing the wrist with pins, has been described but is typically indicated
only in older children (typically >15 years old) once their growth is complete. It is a more invasive
procedure and usually considered a last resort.
3. Arthrodesis: Arthrodesis is a formal fusion of joints and is also considered in older children when
their growth is complete. While it may provide stability, it can limit mobility, so it is chosen
selectively.
4. Free Functioning Muscle Transfers (FFMT): FFMT is often the core reconstructive procedure for
these cases. In this procedure, a muscle is transferred to restore lost function. Commonly used
muscles for FFMT include the gracilis, latissimus dorsi, and rectus femoris. The choice of muscle
depends on the specific deficits that need to be addressed, such as digital flexion or extension.
5. Reinnervation: After the FFMT, the transferred muscle needs to be reinnervated to provide motor
control. Reinnervation can be achieved by various methods, including the use of intercostal nerves
(2-6), the distal spinal accessory nerve, or the contralateral C7 root extended with nerve grafts (such
as sural or vascularized ulnar nerve grafts). The goal is to establish effective neural control of the
transferred muscle.
6. Two-Stage Technique: Some surgeons employ a two-stage technique, as popularized by Doi,

which involves sequential procedures. In the first stage, the contralateral gracilis muscle, innervated
by the spinal accessory nerve, is used to restore elbow flexion and finger extension. In the second
stage, performed three months later, the ipsilateral gracilis muscle, innervated by the third and
fourth intercostal nerves, is used to restore finger flexion.
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The choice of surgical procedure and the specific approach will be based on the individual child's
condition, the functional goals, and the need to restore motor control to the affected limb. Surgical
interventions in these cases are typically more complex and require careful planning and
consideration of the child's age and growth status.
In conclusion, the reconstruction of the hand and wrist in cases of brachial plexus palsy requires a
creative and individualized approach. Several key considerations are vital for achieving successful
outcomes:
1. Understanding the Child's Needs: The focus should be on understanding the specific needs of the
child rather than just considering the technical possibilities. This includes assessing the child's
functional limitations and addressing their unique requirements.
2. Limited Resources: Brachial plexus palsy cases may involve limited donor tendons and other
resources. Careful planning is necessary to make the best use of available options.
3. Cooperation and Rehabilitation: Secondary surgical procedures should only be considered when
the child can actively participate in post-surgery therapy. Joint mobility and muscle strength in the
affected arm should be maintained before surgery to enhance the chances of success.
4. Complexity of Cases: Hand and wrist presentations in children with brachial plexus palsy can vary
widely. There is no one-size-fits-all approach. The treatment plan should be tailored to the specific
condition and needs of the child.
5. Formative Years: Successful surgical interventions can significantly improve the child's prospects
during their formative years. By addressing hand and wrist issues, these procedures provide children
with greater functional possibilities.
Ultimately, a multidisciplinary approach, careful observation, and a deep understanding of the child's
condition are essential to ensure that surgical interventions have a positive impact on their quality of
life. The goal is to provide children with the best chance for improved hand and wrist function and a
better overall quality of life.
Rehabilitation for pediatric brachial plexus palsies (NBPP) involves a multifaceted approach to
address the varying degrees of severity and functional limitations. The key principles of rehabilitation
remain consistent and include:
1. Early Evaluation: Initial assessment and intervention should begin as soon as possible after
delivery, as early evaluation can provide insights into the severity and prognosis of NBPP. A
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comprehensive history of the mother's pregnancy, labor, and delivery, as well as the infant's
neonatal course, should be taken into account. Physical examination should encompass the entire
upper extremity, as well as other aspects of the infant's health.
2. Initial Rehabilitation: Regardless of the potential need for surgical intervention, occupational and
physical therapy should be initiated early to optimize outcomes. Early therapy can help prevent
contractures, which can hinder later recovery. Goals should include maintaining soft tissue and joint
flexibility, addressing core strength, and promoting proximal stability. Exercises for passive range of
motion are crucial, and parents or caregivers should be educated to perform these exercises at
home routinely.
3. Specific Motor Recovery Patterns: Motor recovery patterns in NBPP often follow a distinct course.
Infants with upper trunk (Erb's) palsy may initially present with a limp arm in internal rotation, with
the shoulder adducted, elbow extended, forearm pronated, and fingers and wrist flexed. Over time,
motor function recovery occurs gradually, initially involving shoulder flexion, then extending to
elbow flexion and wrist extension. Therapy should aim to facilitate these movements, particularly
shoulder flexion, and elbow flexion against gravity.
4. Timing of Nerve Repair/Reconstruction: The timing of nerve repair or reconstruction varies among
practitioners but is often considered when clinical progress is insufficient and supported by
electrodiagnostic and radiographic data, particularly in cases of nerve root avulsion injuries. In
general, if a child shows recovery of shoulder and elbow function by <3 months of age, surgical
intervention may not be necessary.
5. Soft Tissue and Joint Flexibility: Maintaining soft tissue and joint flexibility is a primary goal in
therapy to prevent contractures, which can occur due to muscle imbalances and limited range of
motion. Passive range-of-motion exercises should be performed regularly, and parents or caregivers
should be instructed in their execution.
6. Preventing Skeletal Deformities: Children with NBPP are at risk of developing skeletal deformities
in the trunk and affected extremity due to poor bone growth associated with muscle weakness and
imbalance. These deformities can be mitigated by optimizing muscle function and weight-bearing
activities.
Overall, early and comprehensive rehabilitation for pediatric brachial plexus palsies plays a crucial
role in maximizing recovery potential and improving the long-term function and quality of life for
affected children.
In the case of infants with brachial plexus palsy (NBPP), early motor training is essential to stimulate
muscle activity in denervated muscles, promote muscle activation upon nerve regeneration, prevent
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or minimize soft tissue contractures, and reduce ineffective substitution movements. Motor training
should continue as long as signs of recovery are evident.
In the newborn period, the initial evaluation should include an assessment of clavicle or humeral
fractures, respiratory problems, and other complications. Evaluation should also encompass arm
function, oral motor skills, feeding, head control, and head positioning. In some cases, newborns
with clavicle fractures may also have NBPP, so vigilance is crucial.
Parents of healthy newborns with brachial plexus palsy should be educated about the importance of
performing passive range-of-motion exercises for all muscle groups. These exercises should be
integrated into the daily routine, ideally at every diaper change. Additionally, parents should be
advised to incorporate "tummy time" during diaper changes to encourage symmetrical head rotation
and positioning, as torticollis is a common issue in infants with NBPP.
Torticollis is an abnormal head posture characterized by ipsilateral tilt, contralateral rotation, and
translation. Persistent torticollis can lead to plagiocephaly and facial asymmetry, which may be
observed as early as six weeks of age. The primary cause of deformational plagiocephaly is limited
head mobility due to cervical imbalance. Parents of infants with torticollis should be encouraged to
vary the position of their child's head during play, feeding, and sleep, and the use of positioning
wedges can be helpful. Neck stretches may also be prescribed for some infants, and parents should
be trained in these exercises by qualified therapists.
In certain cases, newborns may require a hand or elbow splint before hospital discharge. The
indications for a hand splint include tightness of the finger joints and significant atrophy of the
thenar eminence. If Horner's sign is present, it often indicates significant atrophy of the thenar
eminence and necessitates the use of a resting hand splint. The recommended position for a resting
hand splint is the intrinsic plus position, where the metacarpophalangeal joints are flexed at 60–70
degrees, the interphalangeal joints are fully extended, the thumb is partially abducted and flexed or
opposed to the extended index finger, and the wrist is held in extension at 10 degrees less than
maximal.
Early intervention and parental education play a critical role in addressing the needs of newborns
with NBPP, promoting motor recovery, and preventing complications such as contractures and
torticollis.
In the context of neonatal brachial plexus palsy (NBPP), various interventions and precautions are
essential to promote optimal development and prevent complications:
1. Elbow Flexion Splint: In cases of subluxation (partial dislocation) of the elbow, an elbow flexion
splint may be recommended. Extreme hyperextension of the elbow may occur due to the absence of
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biceps muscle activity while the triceps remain active, resulting in muscle imbalance. Passive range-
of-motion exercises for elbow flexion should be carried out with attention to forearm positioning,
either in supination or pronation, to prevent subluxation.
2. Pain Management: Newborns should not experience pain during range-of-motion exercises. If
pain is present, it's essential to re-evaluate for potential skeletal injuries. Sensory changes and
altered sensation can occur due to the initial nerve injury, which can lead to hyperesthesia and
allodynia. Desensitization techniques, such as firm touch, infant massage, varied texture inputs, or
vibratory stimulation from infant toys, can help alleviate symptoms.
3. Fracture Immobilization: When clavicle or humerus fractures are present, immobilization of the
arm is necessary. A sling should be used to keep the shoulder adducted and internally rotated, with
the elbow flexed at 90 degrees, allowing the arm to rest upon the infant's chest for a period of 3-6
weeks. When lifting the newborn, it's recommended to scoop them under the buttocks with one
hand and under the head with the other to minimize movement of the injured extremity.
4. Order of Dressing: Families should be taught to dress the involved extremity first and undress it
last. This minimizes unnecessary movement of the injured limb during the healing phase of
fractures.
5. Therapy Sessions: The therapy session for infants with NBPP begins with passive range-of-motion
exercises, followed by the elicitation of active range-of-motion exercises through various techniques
like stroking, tapping, or vibrating the muscle belly. These activities stimulate muscle activation.
Vibrations can be used for specific muscle groups like triceps, deltoids, or finger/wrist extensors.
Therapy sessions should also focus on facilitating the infant's current level of developmental
milestones, with an emphasis on achieving symmetry in development.
6. Developmental Milestones: Infants with NBPP often adapt to unilateral development. Progression
toward symmetrical development is essential. This includes activities that encourage rolling from
prone to supine and back, transitioning from supine to sitting, and, eventually, progressing to 4-point
positioning. Some children may not crawl but may transition directly from sitting to walking.
Techniques to facilitate crawling, such as the use of splints, positioning, and neuromuscular electrical
stimulation, can be employed.
7. Protective Reactions: Focus should be placed on developing protective reactions in the affected
extremity. A small therapy ball can be used to promote forward protective reactions in both prone
and sitting positions.
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These interventions are essential in promoting optimal development, minimizing complications, and
helping infants with NBPP adapt to their unique circumstances. Parental involvement and education
play a crucial role in implementing these strategies.
Promoting the optimal development and function of infants with neonatal brachial plexus palsy
(NBPP) involves several strategies, especially in the context of the "back to sleep" campaign and the
need to address the potential issues resulting from a lack of prone positioning:
1. Prone Activities and Neck Rotation: To encourage maximal muscle function recovery and prevent
plagiocephaly (a form of head flattening), it's important to promote prone activities and neck
rotation skills. Prone positioning can be achieved through techniques and exercises that help
strengthen the neck and shoulder muscles and prevent tightness or contractures in the
sternocleidomastoid muscle.
2. Release of Sternocleidomastoid Contracture: Stretching techniques and the use of inhibitory or

facilitative Kinesio-taping can be employed to release contractures in the sternocleidomastoid
muscle. This helps maximize proximal stability in the trunk and shoulder area, allowing for better
arm movement and function.
3. Dynamic Weight-Shifting Activities: Activities that involve dynamic weight-shifting can further aid
in developing proximal stability and encourage symmetrical movement patterns, essential for
optimal shoulder range of motion. These activities can also promote motor planning and proper
development.
4. Motor Pattern Program: Implementing a motor pattern program is crucial to avoid the inadvertent
establishment of compensatory motor patterns. This program should encourage the use of the
affected arm and promote its functional development.
5. Visual and Tactile Stimulation: Neglect of the involved extremity should be prevented by bringing
it into the child's visual field as much as possible. Encourage the child to explore the involved hand at
midline and, when appropriate, encourage mouthing of the affected hand. Be cautious, as some
children may bite the affected hand.
6. Bilateral Integration with Toys: Use various toys and playtime activities to encourage bilateral
integration. Play mats, overhead play gyms, wrist rattles, toys that make noise or vibrate, and
lightweight rattles with small diameter handles can be used at home to promote the exploration and
use of both hands and arms.
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These strategies are designed to help infants with NBPP develop essential motor skills and overcome
limitations in their early development, ensuring they have the best opportunities for functional use
of their affected limbs as they grow. Parents and caregivers play a vital role in implementing these
strategies and creating an enriching environment for the child.
Providing occupational and physical therapy for toddlers with neonatal brachial plexus palsy (NBPP)
can indeed be challenging due to their preference for independent learning and limited attention
spans. To effectively engage toddlers in therapy and promote their motor development, play-based
activities and carefully chosen exercises are essential. Here are some strategies for therapy with
toddlers:
1. Play-Based Activities: Utilize play activities as the primary means of therapy. Toddlers learn best
through play, and incorporating therapeutic exercises into fun, engaging games can help maintain
their interest and motivation.
2. Guided Play: While encouraging independent exploration, provide guidance and supervision to
ensure that play activities target the specific goals of therapy. This can help children develop their
motor skills effectively.
3. Weight-Bearing Activities: Include weight-bearing activities in therapy sessions to promote muscle

strengthening. Crawling through tunnels, rolling over large exercise balls, and practicing side-sitting
are excellent activities for developing strength and coordination.
4. Address Muscle Weakness: Tailor activities to address specific muscle weaknesses commonly
associated with NBPP. For instance, if a child has weak rhomboid or middle/lower trapezius muscles,
exercises like reverse prop sitting can be beneficial. This exercise involves lifting the buttocks from
the floor and can be progressed to achieve "crab-walking."
5. Progressive Challenges: Gradually increase the complexity of activities to challenge the child's
motor skills. For example, you can add forward or backward motion to crab-walking to make it more
engaging and beneficial for muscle development.
6. Positive Reinforcement: Use positive reinforcement, praise, and encouragement to keep the child
motivated and engaged during therapy. Celebrate their achievements, no matter how small, to
boost their confidence and willingness to participate.
7. Short, Frequent Sessions: Given the limited attention span of toddlers, keep therapy sessions
relatively short and frequent. Multiple short sessions throughout the day may be more effective than
one long session.
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8. Variety of Activities: Introduce a variety of activities and exercises to prevent boredom and
maintain the child's interest. Rotate activities regularly to keep therapy sessions engaging.
9. Parent/Caregiver Involvement: Encourage parents and caregivers to participate in therapy

sessions and incorporate therapeutic exercises into daily routines. This promotes consistent practice
and support for the child's development.
10. Observation and Adjustment: Continuously observe the child's progress and adjust therapy
activities based on their evolving needs and abilities. Flexibility in the therapy approach is crucial to
accommodate the child's development.
By tailoring therapy to the specific needs and preferences of toddlers, therapy sessions can be both
effective and enjoyable, helping children with NBPP achieve their developmental milestones and
improve their motor skills. Collaboration with parents and caregivers is also key to ensuring that
therapeutic goals are consistently addressed outside of therapy sessions.
Older children with brachial plexus palsy (BPP) face unique challenges as they become increasingly
aware of their condition and differences compared to their peers. This stage of development,
typically around 5 to 6 years of age, requires special attention, support, and rehabilitation
considerations. Here are some key points to consider for older children with BPP:
1. Awareness of Differences: Children in this age group begin to recognize and become more
conscious of their differences when compared to their peers. It is essential to provide emotional and
psychological support to help them navigate these feelings.
2. Family Support: Family support and encouragement are crucial during this transitional period.
Open communication within the family can help the child understand their condition and build self-
esteem.
3. School Transition: The transition to school can be challenging for children with BPP. Physical
education classes and outdoor recess activities may accentuate differences and lead to avoidance.
School staff should be informed about the child's condition to provide appropriate support and
accommodations.
4. Therapeutic Intervention: Some children may choose to seek therapy or other medical or surgical
interventions during this phase to improve active range of motion and muscle strength in the
affected extremity. These interventions can enhance their ability to participate in various activities.
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5. School-Based Therapy: It is advisable to involve a therapist within the school system to evaluate
the child's specific needs in the school setting. A child with BPP may face challenges related to
playground equipment, lunchroom activities, computer use, and other bimanual tasks that disrupt
their independent routine at school.
6. Functional Independence: Therapy at this stage should focus on promoting independence in age-
appropriate functional skills that are important to the child and their family. This may include
developing strategies for opening containers, carrying trays, using computer keyboards and mice,
using desk tools, and engaging in various school-related activities.
7. Adaptive Strategies: Encourage the child to develop adaptive strategies that allow them to
participate in physical activities and games. Depending on their individual abilities, they may find
alternative ways to climb, jump, throw, catch, and engage in other activities.
8. Emotional Well-Being: Pay attention to the emotional well-being of the child. Discuss their feelings
and concerns, and consider involving a counselor or therapist to address any emotional challenges
associated with their condition.
9. Peer Education: Educating peers about the child's condition can help create a more inclusive and
supportive environment. It can reduce misunderstandings and promote empathy among classmates.
10. Future Planning: Discuss the child's goals and aspirations for the future. Understanding their
desires and expectations can guide therapy and rehabilitation efforts.
Supporting older children with BPP requires a holistic approach that addresses physical, emotional,
and social aspects of their well-being. Collaborative efforts involving healthcare professionals,
educators, and families can help these children build confidence, adapt to their condition, and thrive
in their academic and social environments.
Adolescence is a unique phase for teenagers with brachial plexus palsy (BPP). It's a time when they
start considering activities they deem personally important, such as driving and complex daily living
tasks, and prepare for the transition to college or moving away from home. Here are some key
considerations for therapy and support during the teenage years:
1. Adaptive Driving: Teenagers with poor function of the affected arm may need to explore adaptive
driving options. Therapists and physiatrists should be aware of state driving laws and approved
adaptive driving equipment to help these teenagers achieve greater independence.
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2. Transition to Independence: Adolescence is a critical period for preparing teenagers with BPP to
become more independent in their daily lives. Therapy should focus on activities that are particularly
important to them and that will help them prepare for life beyond high school.
3. Age-Appropriate Goals: Teenagers have often attended therapy sessions for many years and may
be less interested in formal therapy. Therapists should set age-appropriate goals and make therapy
engaging and relevant to the teenagers' interests and concerns.
4. Addressing Contractures: Many teenagers may develop shoulder internal rotation contractures or
elbow contractures that can limit their ability to perform complex daily living activities. Therapists
should work on addressing these contractures and improving range of motion.
5. Compensatory Movements: By adolescence, many teenagers have developed subconscious habits

to compensate for their arm weakness. These habits may limit their awareness of their
compensatory movements, and they may not actively seek therapeutic options. Therapists should
work to identify and address these issues.
6. Stay Informed: Therapists should stay informed about current medical and surgical interventions
that can be offered to teenagers with BPP. Being aware of the latest advancements and treatment
options can provide valuable guidance.
7. Preventing Overuse Syndromes: Overuse syndromes are common in teenagers with BPP. They can
manifest as issues in the unaffected extremity or the affected extremity. Carpal tunnel syndrome,
tennis elbow, shoulder impingements, scoliosis, and back pain are some potential complications.
Therapists should monitor for signs of overuse and develop strategies to prevent and manage these
syndromes.
8. Psychological Support: Adolescence can be a challenging time emotionally. Support from

therapists and counselors can help teenagers cope with the physical and emotional aspects of their
condition. It's important to address any self-esteem or body image issues that may arise.
9. Encourage Independence: Therapists should encourage teenagers to take an active role in

managing their condition, making decisions about their treatment, and advocating for their own
needs and preferences.
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10. Peer Relationships: Adolescents often value their peer relationships. Therapists can work with
teenagers to develop strategies for social interactions and address any concerns related to their
condition in social settings.
Supporting teenagers with BPP during this transitional phase is essential for helping them achieve
their goals, develop independence, and maintain their overall well-being. Collaboration between
healthcare professionals, educators, families, and the teenagers themselves is crucial for a successful
transition to adulthood.
It's essential to individualize treatment techniques for children with brachial plexus palsy (BPP), as
each child's condition and response to therapy can vary. Here are some selected treatment
techniques and considerations for different age groups:
Infants and Toddlers:
- Play-Based Therapy: Therapy for infants and toddlers is integrated into their play activities.
Purposeful movement patterning is encouraged during normal play.
- Hands-On Cuing: Therapists may use hands-on cues to guide the child's movements.
- Home-Based Therapy: Parents are involved in therapy at home, incorporating recommended

exercises and activities into the child's daily routine.
Older Children and Teenagers:
- Hands-On Techniques: For older children and teenagers, therapy may involve more specific hands-
on techniques to improve movement patterns.
- Verbal Cues: Therapists provide verbal cues to guide the child through specific movements.
- Motivation and Engagement: Maintaining motivation and interest can be a challenge, so therapy
should be engaging and relevant to the child's goals and interests.
- Repetition: Repetition of desired movement patterns is encouraged at both formal therapy sessions
and at home.
- Addressing Compensatory Patterns: Children with BPP may develop compensatory patterns, such
as arching the trunk or elevating the scapula during reaching activities. Therapy aims to address and
correct these patterns.
Range of Motion:
- Shoulder External Rotation: Full passive and active range of motion, especially in shoulder external
rotation, is a key focus of therapy. Weakness in external rotation and elbow flexion can lead to a
posture known as "Trumpeter's sign," which may persist as motor memory. Therapy targets the
elimination of this posture through specific activities and exercises.
Page 62 of 63
Feedback Tools:
- Mirrors: Mirrors can be used as visual feedback tools for older patients to help them become aware
of and address compensatory patterns and posture issues.
Individualized Treatment:
- It's important to tailor therapy activities to the individual child's needs, goals, and abilities. No one-
size-fits-all approach works for children with BPP.
Overall, early intervention and consistent therapy are crucial for optimizing the function of the
affected arm. The goal is to help children develop improved movement patterns, range of motion,
and strength while minimizing compensatory behaviors and posture issues. Collaboration between
therapists, parents, and the child is essential for successful outcomes.
Page 63 of 63

Pediatric Brachial Plexus

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Pediatric Brachial Plexus

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Paediatric Brachial Plexus Palsies

CLINICAL PRESENTATION AND CONSIDERATIONS OF NEONATAL BRACHIAL PLEXUS PALSY

- Approximately 14% of affected babies have low Apgar scores.

CLASSIFICATION OF CLINICAL PRESENTATION

- Group III: Paresis of the entire arm (C5 to T1 nerve roots).

- Other classification schemes include physiologic and anatomical categorizations:

- Lower plexus palsy involves a flaccid hand in an otherwise active arm.

NATURAL HISTORY OF NEONATAL BRACHIAL PLEXUS PALSY

VIEWS ON NATURAL HISTORY

- Some authors report over 80% of favorable outcomes or complete recovery.

SEVERITY AND RECOVERY

- Simple clinical muscle assessments are used as predictors of recovery.

ASSESSMENT OF THE NBPP PATIENT

- Parents/caretakers must be counseled once the diagnosis is made.

- Sensory function assessment is challenging but can be gestalt-determined through responses to

For Short Procedures (e.g., CT-myelogram):

- Assess the neonate's tolerance for anesthesia.

- Ensure intravenous access and control of oxygenation during prone positioning.

- Use standard American Society of Anesthesiologists (ASA) monitors.

- Induce anesthesia with oxygen, nitrous oxide, and sevoflurane.

- Acquire intravenous access, reserving vessels in the unaffected upper extremity.

- Secure the airway with an appropriately sized cuffed endotracheal tube.

- Ensure pressure points are padded.

For Longer Procedures (e.g., Surgical Nerve Repair/Reconstruction):

- Anesthetic complications are a leading cause of intraoperative morbidity.

- Consider using midazolam (0.5 mg/kg orally) if separation anxiety is evident.

- Induce anesthesia with oxygen, nitrous oxide, and sevoflurane.

- Place a peripheral intravenous catheter carefully in the unaffected upper extremity.

- Avoid muscle relaxants due to the need for neurophysiologic assessment.

- Properly secure the endotracheal tube to prevent inadvertent extubation.

- Place a radial arterial line for hemodynamic monitoring.

- Use a combination of remifentanil and isoflurane for maintenance of anesthesia.

- Supplement with dexmedetomidine for minimal effect on monitoring.

- Use temporary muscle paralysis with cisatracurium for neurophysiologic assessment.

- Minimize perioperative fluid overload by restricting intraoperative fluids.

- Monitor blood glucose and hematocrit hourly during surgery.

ASSESSMENT SCALES FOR NBPP

Muscle Power Assessment:

- Difficult to apply in newborns as it requires voluntary cooperation.

Active Movement Assessment for Newborns:

Shoulder Function Assessment:

- The Mallet scale quantifiably assesses shoulder function.

Elbow Function Assessment:

- Gilbert and Raimondi's elbow recovery scale evaluates elbow function.

Hand Function Assessment:

- Raimondi's hand evaluation scale assesses hand function.

- Correlates with the preoperative Gilbert and Tassin/Narakas grade.

Functional Assessment and Quality of Life:

- Validated for assessing children with NBPP.

- Used for evaluating the results of tendon transfers in NBPP.

- Correlates with other measures of active movement.

- Effective in differentiating between NBPP severity levels.

MRC Scale for Muscle Power Description

M1 Palpable muscle contraction without movement

M2 Movement in a horizontal plane

M3 Movement overcoming the pull of gravity

M4 Movement overcoming resistance beyond the pull of gravity

Observation Muscle Grade

Motion ≤ 1/2 range 2

Motion > 1/2 range 3

Motion ≤ 1/2 range 5

Motion > 1/2 range 6

Shoulder Function Stage Description