SPECIAL COMMUNICATION
Medical and Legal Issues Related to Brachial Plexus Injuries in Neonates
Gary N. McAbee, DO, JD
Carman Ciervo, DO
Injuries to the brachial plexus in neonates present a mal-
practice dilemma not only for physicians who provide
obstetric care, but also for those who administer immediate
postnatal treatment for newborns who have these injuries
and comorbid medical conditions. Although trauma
remains the probable etiology for many brachial plexus
injuries, other, nontraumatic etiologies need to be con-
sidered. The authors review current medical and legal
principles related to brachial plexus injuries—principles
that are of concern to all practitioners who provide obstetric
and newborn care. They also make a number of recom-
mendations for practitioners to reduce the risk of mal-
practice lawsuits related to these injuries. Among these
recommendations are increasing one’s awareness of non-
traumatic origins; making sure that appropriate testing
(eg, electromyography) is performed for infants whose
conditions fail to improve within several months after
birth; and taking a proactive role in discussing brachial
plexus injuries with patients’ families.
J Am Osteopath Assoc. 2006;106:209–212
T he ongoing medical malpractice crisis, including contin-
uing increases in malpractice awards, underscores the
need to update research on clinical conditions that pose the
greatest malpractice risks to practitioners. Injuries to the
brachial plexus in neonates are relatively common, with an
incidence of clinically significant lesions that is estimated to
be 0.5 to 2.6 births per 1000.1 From a legal perspective, these
plexopathies are a growing concern, mainly because they
are an increasing cause of action in medical malpractice
cases.2 Obstetricians, orthopedists, pediatricians, family prac-
titioners, and physical therapists, any of whom can be
involved in the care of infants with this condition, all
have been named as defendants in malpractice lawsuits.2
From the University of Medicine and Dentistry of New Jersey, Department
of Pediatrics in Camden (McAbee) and the Department of Family Medicine
at the University of Medicine and Dentistry of New Jersey–School of Osteo-
pathic Medicine in Stratford (Ciervo). Dr McAbee is also a member of the
Division of Child Neurology at Children’s Regional Hospital in Camden.
Address correspondence to Gary N. McAbee, DO, JD, Division of Child
Neurology, Children’s Regional Hospital at Cooper University Hospital, Robert
Wood Johnson School of Medicine, 3 Cooper Plaza, Suite 309, Camden, NJ
08103-1438.
E-mail: mcabee-gary@cooperhealth.edu
McAbee and Ciervo • Special Communication
The present article addresses several recent medical and legal
issues of concern to practitioners involved in the care of
neonates with brachial plexus injuries.
Classification of Brachial Plexus Lesions
Injuries to the peripheral nerves that make up the brachial
plexus are classified according to the nerve roots involved.1 For
example, Erb’s palsy involves injury to the fifth and sixth cer-
vical roots at the point where they meet the plexus. This injury
causes weakness of the proximal muscles of the upper
extremity. Another example, Klumpke’s palsy, which rarely
occurs in isolation, involves injury to the eighth cervical and
first thoracic roots at the point where they meet the plexus. This
injury causes weakness of the muscles of the hand. The most
severe injuries to the brachial plexus involve multiple root
levels, with resulting weakness of most of the upper extremity.
Prognosis and Recovery
Prognosis for neonates with brachial plexus injuries is gener-
ally associated with the severity of motor deficit. The less
severe the motor dysfunction at presentation, the less likely
there will be a sequela of permanent significant weakness.1,3
Infants with total plexus palsy often have residual permanent
weakness.
Recovery from congenital brachial plexus injuries may
continue for as long as 1 year after birth. However, infants
who are less severely affected usually recover within a matter
of days or weeks. In 1982, Rossi et al4 reported a case in which
the patient’s recovery lasted until school age.
Therapeutic Options
Therapy for neonates with brachial plexus injuries typically
focuses on appropriate splinting and careful, passive range-of-
motion exercises to prevent contracture and diminish the need
for future orthopedic interventions.3 For infants who fail to
show meaningful improvement after 3 to 6 months, elec-
tromyography (EMG) may be performed to establish prog-
nosis.5 However, there is conflicting evidence regarding the
prognostic value of routine EMG for neonates with brachial
plexus injuries.6,7
For infants with poor recovery during their first few
months of life, especially if there is extensive weakness in their
conditions, surgery may be a viable option. Although the type
and success of various surgical interventions remains contro-
JAOA • Vol 106 • No 4 • April 2006 • 209
SPECIAL COMMUNICATION
versial,8 some infants have demonstrated improvement in
motor function after certain interventions.3,6,9 For example,
one surgical option for infants more than 3 months old who
do not appear to be recovering is reanastomosis (grafting) of
the affected nerves to promote nerve regeneration.6,9 Other
surgical options, if improvement in function is followed by a
plateau, include nerve transfers and neurolysis (scar tissue
removal).6,9 In older children, surgical options include joint
capsule release, tendon transfer, and osteotomy to promote
improved functional capacity.6,9 These types of surgical inter-
ventions are best managed by physicians who specialize in
treating patients with brachial plexus injuries.
Preoperative magnetic resonance imaging can also be
important in management of brachial plexus injuries. It is of
particular value in assessing patients for such complications as
pseudomeningocele, traumatic arachnoid cyst, and syrinx.6
Associated Conditions
Physicians who care for newborns place themselves at high
risk of malpractice lawsuits if they are unaware of the
medical conditions that can be associated with brachial
plexus injuries, including diaphragmatic paralysis (the
most serious condition associated with brachial plexus
injuries) and various traumatic lesions.
Although only a small percentage of brachial plexus
injuries are associated with diaphragmatic paralysis, most
cases of diaphragmatic paralysis have associated brachial
plexus injuries.1 Mortality of neonates with diaphragmatic
paralysis, resulting from respiratory compromise, is approx-
imately 15% in infants with unilateral lesions of the brachial
plexus, but mortality approaches 50% in infants with bilat-
eral lesions.1
When a brachial plexus injury is presumed to be trau-
matic, the infant needs to be assessed for various other trau-
matic lesions. Such lesions include cervical spine injury with
or without subluxation, facial paralysis, slippage of the capital
head of the radius, shoulder subluxation, and unilateral
fracture of the clavicle and humerus.1,10
Etiologic Uncertainties
The etiology of brachial plexus injuries is complex and subject
to debate. The prevailing etiologic theory relates to stretching
of the nerves in an infant who is large for gestational age and
who has sustained a “difficult” vaginal delivery.
Many injuries to the brachial plexus in neonates are
presumed to have a traumatic origin resulting from a difficult
delivery. Signs and symptoms of such injuries include
abnormal presentation, fetal depression, high incidences
of macrosomia and shoulder dystocia, and prolonged
or augmented labor. 11 A connection between injuries
and difficult deliveries is consistent with the presumed
pathogenesis of some brachial plexus lesions, which
involves stretching of the nerve roots from traction or, in
more severe lesions, severing of the nerve sheath. Other
210 • JAOA • Vol 106 • No 4 • April 2006
brachial plexus injuries may be related to compression of
the nerve.
The possibility that some injuries of the brachial plexus are
caused by intrauterine malpositioning rather than traumatic
delivery or compression has been proposed by some
authors.12,13 This possibility is supported by the high per-
centage of abnormal presentations at birth (eg, breech, occiput
posterior, occiput transverse) among neonates with brachial
plexus injuries.13,14 The possibility is also supported by the
occurrence of brachial plexus injuries in infants who were
born prematurely or delivered by cesarean section—in cases
in which there was no shoulder dystocia and in cases in which
there was shoulder dystocia but the posterior arm was the
affected extremity.11,13,14 One study15 described Erb’s palsy in
several infants of normal weight who did not experience trau-
matic delivery. The presence of either abnormal dermato-
glyphics, muscle atrophy, undersized extremities, or defor-
mation of the ribs or neck are useful in indicating prenatal
onset caused by intrauterine malpositioning.16,17 In addition,
compression of the plexus against the walls of a malformed
uterus or uterine fibroma, exostosis of the first rib, an amniotic
band, and the umbilical cord have been implicated as
etiologic factors.13
Electrophysiologic studies have demonstrated evidence of
denervation (ie, nerve injury) within days after birth—notwith-
standing the fact that it usually takes at least 10 to 14 days
after injury for denervation to be detected with EMG.12,13 Thus,
an EMG result that indicates denervation within the first sev-
eral days of life suggests that an injury is likely to be prenatal
in onset—though recent data collected from animal subjects
have raised questions about the use of EMG to time the onset
of brachial plexus injuries in infants.7 Other studies have noted
that EMG changes consistent with denervation may be found
in the normal infant and, therefore, cannot be relied upon to
determine etiology unless the findings are present only in the
affected extremity.16
Nontraumatic, hereditary origins, though rare, should
also be considered. An inherited autosomal-dominant brachial
plexopathy (often referred to as hereditary neuralgic amy-
otrophy) has been identified.18 Although this disorder typically
affects individuals in the second or third decade of life, it has
been rarely reported in neonates.18,19 Both adult and infant
patients may have mild dysmorphisms (eg, cleft palate, epi-
canthal folds, hypotelorism, short stature, syndactyly). The
cranial nerves and the nerves of the lower extremities may
also be affected. Episodes of weakness are recurring, and,
during an episode, symptoms progress over a period of hours
or days. Recovery usually occurs within 30 days, but some
weakness and atrophy may persist.
A gene for hereditary neuralgic amyotrophy has been
localized to chromosome 17q24-q25.18 The key to diagnosis
is a family history that shows a similar clinical syndrome.
There is a single report of a patient with an apparent bilateral
brachial plexopathy associated with agenesis of the biceps
McAbee and Ciervo • Special Communication

muscle.15 It is likely that other nontraumatic hereditary origins
of brachial plexus injuries will be reported in newborns.
Malpractice Monetary Judgments
As would be expected, permanent weakness in a newborn
can result in a high malpractice monetary judgment, espe-
cially when the weakness is severe. According to the Data
Sharing Project,2 which is a database of medical malpractice
claims started in 1985 by the Physician Insurers Association of
America, nearly 60% of lawsuits related to brachial plexus
injuries between January 1985 and December 2001 resulted
in payouts of monetary damages. These payments had a
median indemnity of $301,000 (nearly four times the median
payout for all malpractice claims during this period) and a
total payout of $54 million.2 The total monetary judgment for
brachial plexus injuries was greater for physicians working in
teaching hospitals than for those in nonteaching hospitals
(teaching, $31 million; nonteaching, $22 million), as was the
median payout (teaching, $403,000; nonteaching, $221,000).2
The potential for monetary payout far in excess of the
median is possible. In one case involving a child who had
Erb’s palsy with severe residual weakness, the verdict for the
plaintiff was more than $3 million: $20,000 was awarded for
past pain and suffering, $2 million for future pain and suf-
fering, and $1 million for loss of future earnings.20
Recommendations
To avoid creating evidence that might be misconstrued in
later malpractice actions, it has been recommended that physi-
cians adopt policies limiting how much of an infant’s delivery
can be videotaped by family members.21 For example, a
delivery involving the use of forceps or vacuum extraction
might be interpreted by a plaintiff’s attorneys as a “difficult”
one that should have been handled via cesarean section. The
risks of permitting videotaping of a birth must be weighed
against the possibility of its use as adverse, legal evidence.21
Practitioners caring for infants with brachial plexus injuries
need to take a proactive approach in discussing this medical
condition with the infants’ parents. Communication between
caregivers and parents can be an effective risk-management tool
in reducing malpractice lawsuits. Studies have demonstrated
that parents who later sue for malpractice involving neonates
often note a lack of communication between themselves and
their child’s physician.22 In one study, 89 (70%) of 127 mothers
who subsequently sued for their newborn’s perinatal injury
complained that their caregivers did not adequately inform
them about the potential for long-term neurodevelopment
problems.22
Relevant to this discussion is a recent report23 suggesting
a less promising outcome for patients with brachial plexopathy
than had been previously reported. Pondaag et al23 reported
that an estimated 20% to 30% of infants with brachial plexus
palsy may have residual neurologic deficits—percentages that
are much higher than the previously estimated 10%.1 In light
McAbee and Ciervo • Special Communication
SPECIAL COMMUNICATION
of this revelation, it is imperative for physicians who care for
infants and children to recognize the causes, associated med-
ical conditions, appropriate treatments, and prognoses of
brachial plexus injuries.
Based on our review of the medical and legal principles
related to brachial plexus injuries, we conclude with the fol-
lowing recommendations:
䡲 Physicians who practice obstetrics should be aware of the
limits of their malpractice coverage. There is potential for a
high payout for brachial plexopathy, especially if the patient
has severe residual weakness and if the legal case is heard
in a geographic area where such payouts are common.
䡲 Practitioners should not assume that brachial plexus injuries
are necessarily the result of traumatic deliveries. Such injuries
can also result from intrauterine malpositioning.
䡲 When appropriate, rare etiologic origins—including
those of a hereditary, nontraumatic nature—should be
considered. Obtaining a patient’s family medical history
is important in determining etiologic origins.
䡲 Newborns with brachial plexus injuries need to be care-
fully assessed for comorbid conditions.
䡲 To ascertain the degree and extent of injury and to eval-
uate other treatment options in infants who do not recover
within several months, appropriate testing and consulta-
tion (eg, EMG, neurosurgery) must be considered.
䡲 Communication between the physician and the patient’s
family is crucial. Parents should be informed of the possibility
of long-term sequelae related to brachial plexus injuries.
References
1. Volpe JJ. Injuries of extracranial, cranial, intracranial, spinal cord, periph-
eral nervous system. In: Volpe JJ. Neurology of the Newborn. 4th ed. Philadel-
phia, Pa: WB Saunders; 2001:825–829.
2. Physicians Insurers Association of America. Data Sharing Project 1985–2001.
Rockville, Md: Physicians Insurers Association of America; 2002.
3. Grossman JA. Early operative intervention for birth injuries to the brachial
plexus [review]. Semin Pediatr Neurol. 2000;7:36–43.
4. Rossi LN, Vassella F, Mumenthaler M. Obstetrical lesions of the brachial
plexus. Natural history in 34 personal cases. Eur Neurol. 1982;21:1–7.
5. Brown T, Cupido C, Scarfone H, Pape K, Galea V, McComas A. Develop-
mental apraxia arising from neonatal brachial plexus palsy. Neurology.
2000;55:24–30.
6. Piatt JH Jr. Birth injuries of the brachial plexus [review]. Pediatr Clin North
Am. 2004;51:421–440.
7. Gonik B, McCormick EM, Verweij BH, Rossman KM, Nigro MA. The timing
of congenital brachial plexus injury: a study of electromyography findings in
the newborn piglet. Am J Obstet Gynecol. 1998;178:688–695.
8. Bodensteiner JB, Rich KM, Landau WM. Early infantile surgery for birth-
related brachial plexus injuries: justification requires a prospective controlled
study. J Child Neurol. 1994;9:109–110.
9. Laurent JP, Lee RT. Birth-related upper brachial plexus injuries in infants:
operative and nonoperative approaches. J Child Neurol. 1994;9:111–117; dis-
cussion 118.
JAOA • Vol 106 • No 4 • April 2006 • 211
SPECIAL COMMUNICATION
10. Eng GD. Brachial plexus palsy in newborn infants. Pediatrics. 1971;48:18–28.
11. Gherman RB, Ouzounian JG, Goodwin TM. Brachial plexus palsy: an in
utero injury [review]? Am J Obstet Gynecol. 1999;180:1303–1307.
12. Jennett RJ, Tarby TJ. Brachial plexus palsy: an old problem revisited
again. Am J Ob Gyn. 1997;176:1354–1356.
13. Alfonso I, Papazian O, Shuhaiber H, Yaylali I, Grossman JA. Intrauterine
shoulder weakness and obstetric brachial plexus palsy. Pediatr Neurol.
2004;31:225–227.
14. al-Qattan MM, el-Sayed AA, al-Kharfy TM, al-Jurayyan NA. Obstetrical
brachial plexus injury in newborn babies delivered by cesarean section. J Hand
Surg [Br]. 1996;21:263–265.
15. Graham EM, Forouzan I, Morgan MA. A retrospective analysis of Erb’s palsy
cases and their relation to birth weight and trauma at delivery. J Matern
Fetal Med. 1997;6:1–5.
16. Menkes JH, Sarnat HB. Perinatal asphyxia and trauma. In: Menkes JH,
Sarnat HB, eds. Child Neurology. 6th ed. Philadelphia, Pa: Lippincott Williams
& Wilkins; 2000:451–454.
17. Dunn DW, Engle WA. Brachial plexus palsy: intrauterine onset. Pediatr
Neurol. 1985;1:367–369.
18. Jeannet PY, Watts GD, Bird TD, Chance PF. Craniofacial and cutaneous
findings expand the phenotype of hereditary neuralgic amyotrophy. Neu-
rology. 2001;57:1963–1968.
19. Menkes JH. Heredodegenerative disease. In: Menkes JH, Sarnat HB, eds.
Child Neurology. 6th ed. Philadelphia, Pa: Lippincott Williams & Wilkins;
2000:205.
20. Reid v Nassau County, 600 NYS2d 604 (NY 1993).
21. Eitel DR, Yankowitz J, Ely JW. Legal implications of birth videos. J Fam
Pract. 1998;46:251–256.
22. Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted fam-
ilies to file medical malpractice claims following perinatal injuries. JAMA.
1992;267:1359–1363.
23. Pondaag W, Malessy MJ, van Dijk JG, Thomeer RT. Natural history of
obstetric brachial plexus palsy: a systematic review [review]. Dev Med Child
Neurol. 2004;46:138–144.