Perinatal Brachial Plexus Palsy

A Birth Injury?
Or an Injury
Detected at
Birth
 INCIDENCE
In Less than 4000 gm 0.9 in 1000
Live Births.
In Birth Weight 4000 to 4500 gm
1.8 in 1000 Live Births
In Birth Weight More than 4500 2.6
in 1000 Live Births
Bilateral in 8.3 to 23%
cases(Breach)
 NORMAL MOBILITY AT THE
CERVICAL ROOTS
There is definite movement noted at
the spinal roots
Problem arises when the stretch
imparted is beyond the physiological
limits
Effectively causing Avulsion of the
roots or the peripheral nerve injury
equivalent to
Neurapraxia/Axonetmesis/Neurotmes
is
 MECHANISM
Cadaver Work By Clarke-Sever
They Produced Fraying of the radicals
by Graduated Rostra Caudal Traction
This Concept Was Endorsed by
Gilbert Who Did first Operative
Repairs ,in Erbs Palsy
 PARADIAGM
Shoulder Dystocea in the Setting of
Maternal Gestational Diabetes
Causing Delayed 2nd Stage Needing
Manipulative Delivery of the Fetus
Can It Occur Before Manipulation?
It Can Occur in Early Second Stage
Due to Abdominal and Uterine
Contraction Force Acting On Posterior
Shoulder Impacted Against Sacral
Promontory.
 Risk Factors
Macrosomia
Shoulder Dystocea
Breach Presentation
Assisted Delivery
Weight Gain Maternal-Fetal
Erbs Palsy in previous labour
Pox Infection/cord around neck
Ut abnormality/flat pelvis
 Observations
50% Palsies are Noted in Vertex
Gonic Series of 26033 Live Birth
162 Dystocea 84 Injuries
1)Dystocea with Injuries
2)Dystocea Without Injuries
3)Injuries Without Dystocea
Dystocea Inadequately Documented
Injury Without-Dystocea is Severe
 OBSERVATIONS
Jennette Identified Birth
Weight/Maternal Weight Gain/Parity
as Important Pointers
Gherman in His series of 40
Identified Those Without Dystocea
Qualitatively Different in Recovery
and of Higher Severity
 ASSOCIATED
INJURIES
Ipsilateral Phrenic Nerve Injury**
Ipsilateral Horner's Syndrome*****
Ipsilateral Fracture Clavicle****
Ipsilateral Fracture Humerus*
Ipsilateral Shoulder Injury***
Facial Palsy
 CLINICAL PICTURE
Painful/Cold
Clammy
Deformed/Flail
Limb.
Absent Biceps and
Moro Reflex
 DIAGNOSIS
CLINICAL
ELECTRICAL EMG/Nerve
Conduction/Evoked Potentials
RADIO DIAGNOSIS
Myelogram/Contrast CT/MRI
X-rays Shoulder/Spine/Humerus
 Prognostic Factors
Diaphragmatic palsy
Flaccid whole limb
Absence of Dystocea
C7 Root involvement
Horner’s
Flail Limb with Horner's in a
Multiparous Mother and Birth Weight
of 4500 gms has Grave Prognosis
 TYPES OF LESIONS

Upper Plexus Type Roots C5/6?7

73 to 80 % Incidence
Lower Plexus Type Roots Incidence
0.6%
Total Plexus Type 20% incidence
Transient Palsy
Pre Ganglionic Post Ganglionic
Possible Horner’s Absence of
due to sympathetic Horner’s sign
loss Absence of sensory
Positive sensory action potentials
action potentials Absent
Meningocoele in Meningocoele
Myelogram Absence of pain
May Produce Pain Positive Tinel’s sign
at rest
 Important Anatomical Facts
C5/6/7 secured in Trough in The
Transverse Process Hence Rupture
Than Avulse Causing Post-Ganglionic
injury
C5/6 Innervated Muscles are in
Upper Arm Hence Recover Quicker
due to The Distance to The
Destination.
C7 Has a Receding Presence Hence
Confuses The Electrical/Clinical
Picture
 RECOVERY PATTERN
95.7% Recover Completely
92% of These Recover in First 6
Months
Upper Plexus Lesions Carry Better
Prognosis
Post-Ganglionic Lesions Carry Better
Operative Prognosis
 MANAGEMENT
CONSERVATIVE
Counseling
Physiotherapy
Institutional/Group Therapy
Regular Assessment at 2 Weekly Interval
Objective Documentation Biceps/Deltoid
In Not more than 6 Months
 PROBLEMS FACED
Non Compliance
Communication
Delayed Diagnosis
Associated Congenital Problems
Litigation
EARLY OPERATIVE OPTIONS
Micro vascular Techniques
Repair/Neurolysis/Nerve
Graft/Neurotization
Timing
 Micro-Surgical Facts

Motors Borrowed When Repair is Not

Possible .Motor Branch C4/Distal
Stump Cervical
Accessory/Intercostals/Pectoral
Nerve/Phrenic
Recipients Nerves are
Suprascapular/Axillary/MusculoCutan
eous
 Surgical Facts
Surgery improves Mallet Score by one
Grafts Used Sural/M.C.N. Arm &Forearm
Neurolysis If Stimulation Causes Contract
Agonist/Antagonist Recovery confuses
Exploration is Worthless After 18 Months
 Post –Operative Regime
2 to 6 weeks Sling/Shoulder Spika if
We Use Cervical accessory
6 Weekly Examination for 2 Years
Quarterly Examination for 4/5 Years
 If No Recovery
They Develop Deformity of Internal
Rotation and Adduction at Shoulder
Extension Attitude in Elbow
Pronation Deformity in RadioUlnar
Joints
 DISABILITY
Difficulty in Bimanual and Grooming
Activity Due to Contractures in
Unopposed Action of Non-Paralyzed
Muscles Causing Deformity Like
Trumpeting.
Loss of Hand to Mouth and Hand to
Head Postures
Resulting in Apraxia/Sensory Neglect
 Changes in Shoulder due to
Deformity
Glenoid Hypoplasia Changed Version
Flattening of Humeral Head
Acromian Beaking/Coracoid Hooking
Posterior Instability Shoulder
Importance of Gleno-Scapular Angle
Degree of Posterior Subluxation
 DELAYED OPERATIVE
TREATMENT
Incomplete Recovery :Elbow and
Shoulder Contractures(Waiter
tip/Trumpet/Erbs Ingram)
Available Options
A) Release of Contractures
B)Muscle Enhancement
C)Bony procedures
VARIOUS OPERATIVE OPTIONS
Severs Procedure Release Pectoralis
Maj/Latissimus/Teres Major/Short
Head Biceps and CoracoBrachialis
Al Zahrani Severs Plus Anterior
Closed Wedge 20 Degree Osteotomy
of Humerus
L,episcopo L.D/T.M To Infraspinatus
Kirkos Ext.Rot.Osteotomy Humerus
 Surgical Options Available
Hoffers Procedure for Posterior
Subluxation Shoulder.Severs Release
plus Enhance ment of Infra Spinatus
and Maintain it In Spika for 6 Weeks
Liggio Release of Pronators and
Interrosseous Membrane for
Pronation Contracture
 BURAIMI EXPERIENCE

New Born to The Age of 14 Years Age

Longest Follow Up Was 8 Years
Total Number Seen 24
8 Transient Palsy
3 Total cord Palsy
10 Upper Cord Type
2005 Year We Saw 7
Nerve Repairs nil/Osteotmy1/Transfer and
Contracture Release3.
Incidence Has Dropped to 1 in 2006 That too
Transient
 Message
Dystocea may be predicted
Prevention is better than cure
Meticulous Supervision
Timely action
Options are precise
Aim is to prevent sensory inattention
 Most Popular Procedures
Triangle Tilt

Mod Quad Procedure

Predisposing Maternal Factors
Diabetes Mellitus
Thyroid Hypo function
Elderly Mother
Grand Multiparity
Excessive Maternal Weight gain
Uterine Abnormality
Plexus Injury in Previous Delivery
Short Stature/Flat Pelves/Obesity
Reports in the Literature
History of Documentation of Obstetrical
Brachial Plexus Palsy in the Literature
Smellie (1768): First
DocumentationDuchenne (1872):
Mechanism of Injury Traction during
BirthErb (1874): C5 - 6 nerve root
injury"Erb's Palsy"Klumpke (1885): C8 -
T1 Injury"Klumpke's Palsy"Sever (1925):
"Surgery plays no role"Gilbert & Tassin
(1987): Rejuvenated interest in Surgery
 Predisposing Fetal Factors
Large Baby (Macrosomic)
Breach Presentation
Post Maturity
High Birth Weight
Congenital Fetal Anomalies/diseases
Cord Around Baby's Neck
Amniotic Adhesions
 PATHOPHYSIOLOGY
Shoulder Dystocea in STAGE 1 OR 2
After coming head in Breach
Hastened second Stage ?Forceps?
Vacuum