Early days – congenital deformity. Smillie [1768] – Obstetric origin Danyau [1851] – Autopsy – lesion Duchenne [1861]- traction injury, OBPI ERB [1875]- pointed lesion at upper

trunk Kennedy [1903]- early surgical repair Narakas [1981]- microsurgical results.

Incidence: 4/1000 in poor OBG care, 0.1-0.3 % in good centers.

1% of OBPP, injury is bilateral More on one side. [exclusive in breach]

Formed by anterior primary rami of C5-T1.

Roots – between scalene muscles Trunks – posterior triangle Divisions- behind clavicle. Cords in axilla. Roots & trunk- supraclavicular part

[OBPP] Cords & branches – infraclavicular part

Stretching Overweight babies with cephalic

presentations Underweight babies with breech Forceful widening of angle between the

neck & shoulder. Force is more at C5 root Always supraclavicular Not associated with vascular damage.

Large birth weight Breech presentation Maternal diabetes Multiparity II stage of labour - > 60 min Assisted delivery [forceps, vacuum ext] previous child with OBPP Intrauterine torticollis Shoulder dystocia

Lesions range from degree I[neuropraxia] – V [neurotmesis or root avulsions].

Upper trunk –1st affected, most vulnerable part.

Upper trunk – mostly stretched Lower trunks – mostly ruptured

U.E is flail & dangling Look for other extremities U.R: arm held in IR,add, active abd not

possible, elbow extended forearm pronated, thumb flexed.

Complete paralysis- vasomotor impairment, pale & marble like color

Horner’s sign Associated # [clavicle,humerus,]

Complete Recovery Extent of paralysis regress, total paralysis

limited to U.R No improvement.

C5-6: the arm is adducted and internally rotated at the shoulder, elbow extended, forearm pronated, wrist and (sometimes) fingers flexed. (Classic waiter tip/Erb’s palsy/upper roots).

C5-7 : as above, although the elbow may be slightly flexed.

Intermediate root palsy C7. C5-T1 : the arm is totally flail with a claw

hand. marbled appearance, Horner’s syndrome.

Done at 2 months of age Not anatomic, Grading overall severity of lesion based

on clinical course. Prognosis.

X - RAY epiphyseal # of humerus, # clavicle, Later changes, retardation of growth,

deformity of shoulder jt & dislocation of radial head.

EMG Performed at 3-4 wks- confirm

neuropraxia or axonotmesis At 2 months, signs of re-innervation. EVOKED SENSORY POTENTIAL Useful to ascertain root avulsions Can be used preop to test the

availability of proximal stumps.

Fluoroscopy- phrenic nerve injury. Lumbar puncture- xanthochromic CSF-

in root avulsions. C.T myelogram Fast spin Echo MRI: preganglionic nerve

root injuries. Large diverticulae and meningoceles

are indicative of root avulsions

Nature of injury [rupture better] Lower plexus paralysis, global involvement, persistence of pupillary signs of phrenic

nerve palsy Ass. #.

Physiotheraphy- cornerstone Rest for first 2 wks, Arm fixed across the chest by pinning ROM ex, facilitation of active movt,

promotion of sensory awareness. Avoid abduction & posterior projection

of shoulder. Limb to be supported when holding baby

Goals: minimizing bony deformities, Jt contractues.

Weight bearing activity-skeletal growth

Early nerve repair Indications:1. Failure of recovery of biceps or deltoid

at 3 months2. Group III& IV lesions3. Presence of Horners sign.

Diminishing potential for axon regeneration with age

Cross innervation & muscle imbalance aborted

Provide better condition for tendon transfer Nerve repair is superior to spontaneous

recovery.

Total palsy: 3 months Upper trunk palsy: 5 months TYPE OF SURGERY1. neurolysis, 2. resection and anastomosis in ruptures 3. nerve grafting using sural nerves as

interposition grafts.

Repair using the proximal roots of the plexus itself if the injury is post ganglionic as in a rupture

Extra plexal neurotisation using other donor motor nerves to selectively aim at reinnervating the important muscle groups.

Spinal accessory (XIth) nerve. Intercostal nerves (commonly 3rd to

6th) C4 motor root Ansa hypoglossi Opposite C7.

Suprascapular Musculocutaneous, Axillary Median. Order of priority of restoration of function Elbow flexion Shoulder stability (rotator cuff via

suprascapular nerve) Shoulder abduction Hand prehension

To predict poor outcomes if microsurgical repair or grafting is not done.

scale consists of grading elbow flexion, elbow extension, wrist extension, finger extension, and thumb extension. [max -12]

score of < 3.5 predicted a poor long-term outcome without microsurgery.

Fracture of clavicle or humerus shaft or physeal separation

septic arthritis / osteomyelitis Congenital malformation of plexus Postinfectious [varicella] plexopathy of

muscles

Nerve regeneration: some muscles recover earlier, others paretic muscle imbalance

Recovery results from misdirection of regenerated axons cross innervation

Co-contraction of synergestic & antagonistic muscles

Diminishing functional recovery Muscle contracture deformity

Sequelae depends on three factors which are additive

1. Paralysis of muscle groups [ext.rot, elbow flexors]

2. Contracture of healthy antagonist muscles

3. Impaired growth osseous deformities

Sequale – seen in spontaneous recovery in gr III & IV lesion.

Between shoulder abductors [S.S, I.S ,del] & adductors [pect maj, ter.m] limitation of shoulder elevation

Elbow flexors [biceps & brachialis] & elbow extensors [triceps]

Elbow flexors & shoulder abductors trumpet sign

Shou abd, elb flex,forearm flex

Putti sign; with shoulder abduction, medial edge of scapula, often seen protruding above shoulder jt line

Reduction of shou abd – deltoid weakness or lack of ER.

Trumpet sign Mild shortening & atrophy of limb Posterior sublux of shoulder – IR

overpower ER. Bitting of nail & hand (47%) –total obp.

UPPER ARM: mainly in shoulder & occ elbow & forearm

LOWER ARM: hand more affected WHOLE ARM; flaccid paralysis

Group I: joint contracture due to nerve lesions & simultaneous trauma to shoulder Jt

Group II Flaccid; flaccid paralysis- upper trunk injury.

Group I: subdivided in to 4 groups

I –internal rotation & adduction contracture with preservation of Jt

II – with Jt deformity – posterior subluxation & dilocation

III – external rotation & abd contracture- anterior & inferior disloc

IV –pure abduction contracture.

Grade I ,II, mild grade III (slight posterior subluxation) glenohumeral deformities have an anterior musculotendinous lengthening of the pectoralis major and posterior latissimus dorsi and teres major transfer to the rotator cuff

Advanced grade III, IV, or V glenohumeral deformities should have a humeral derotation osteotomy.

Fairbank: release of subscapularis & capsule.

L’ Episcopco procedure improves external rotation of the shoulder by releasing the internal rotation contracture and transferring the latissimus dorsi and teres major posteriorly to provide active external rotation

Wickstrom recommendes external rotation osteotomy of the humerus for severe fixed rotation contracture.

In flaccid paralysis of complete lesion Difficult to manage & difficult to

rehabilitation If no active wrist extension & no possible

transfers – W. fusion with comb inter-metacarpal arthrodesis.

Elbow flexion and forearm supination deformities

weak or absent triceps, pronator teres, and pronator quadratus muscles with an intact biceps muscle

Radial head dislocation wrist & hand usually in extreme

dorsiflexion – unopposed DF biceps tendon, Z-lengthened and

rerouted around the radius to convert it from a supinator to a pronator

Prevention is better than cure Effort made to improve obstetric

practice Group I & II- conservative Group III & IV –early surgery Late sequale: proper evalu & manage

with tendon transfer or osseous surgry Conservative Rx – fruitless.