1. CASE CONFERENCE
Suying Lam, MD
PGY1

2. Presentation: FT male with L upper extremity weakness Born via NSVD
Nuchal cord x 1 not tight
Apgar: 9 at 1 minute; 9 at 5 minutes

3. Physical Exam VS: Weight: 4kg Length: 53 cm Head circumference: 36 cm
T: F
HR: x’
RR: x’
BP: UE: LE:
Weight: 4kg
Length: 53 cm
Head circumference: 36 cm
Chest circumference: 35 cm
Abdominal circumference: 33.5

4. Physical Exam General: alert, NAD, macrosomic Skin: pink
HEENT: AFOF, + molding, + swelling
Patent nares, no cleft, no pits
Thorax: symmetric expansion
Lungs: clear, equal breath sounds
Heart: RRR, no murmurs
Abdomen: soft, NT, ND, BS+
Extremities: FROM R UE and both LE
L UE: (+)abduction, (+)flexion but not against gravity.
Position: adducted, internally rotated, elbow extended, forearm pronated, wrist and fingers flexed.
Reflexes: asymmetric moro reflex, sucking +, grasp +

5. Neonatal Brachial Plexus Palsies
Smellie 1779
Duchenne and Erb 1870’s
Klumpke 1885

6. Brachial Plexus Anatomy

7. Risk Factors Average vertex: 3.8-5 Kg Average breech: 1.8-3.7 Kg
Large birth weight
Average vertex: Kg
Average breech: Kg
Breech presentation
Maternal diabetes
Multiparity
Second stage of labor that lasts more than 60 minutes
Assisted delivery (mid/low forceps, vacuum extraction)
Forceful downward traction on the head during delivery
Previous child with OBPP
Intrauterine torticollis
Shoulder dystocia

8. Causes Obstetric trauma:
Clavicular fracture
Humeral fracture
Shoulder dislocation or subluxation
Intrauterine compressive brachial plexus palsy
Humeral osteomyelitis
Neonatal Hemangiomatosis
Exostosis of the first rib
Neoplasm's (neuromas, rhabdoid tumors)

9. Differential Diagnosis
Pyramidal Tract Lesions
Pre-brachial plexus lesions
Cervical Spinal Cord Injury
Amyoplasia Congenita (arthrogryposis)
Pseudoparalysis secondary to pain (humeral fracture)
Anterior horn cell injury (congenital varicella or congenital cervical spinal atrophy

10. Diagnosis Laboratory: generally not necessary Imaging studies:
Chest X-ray
CT myelography
High-resolution MRI
Other tests:
Electrodiagnostic studies (2-3 weeks after injury)
Nerve conduction Studies
Glucose levels: macrosomic baby

11. Complete Brachial Plexus Palsy

12. Duchenne-Erb Palsy C5-C6
Position: internally rotated, adducted, elbow extended, forearm is pronated, wrist is flexed and adducted, and fingers are flexed.

13. Upper middle trunk brachial plexus palsy
C5-C6-C7
Difference with Erb’s palsy: wrist is in neutral position (wrist flexor and extensors are equally weak)

14. Klumpke Palsy
C8-T1
Floppy hand: wrist is flexed, fingers extended following the forces of gravity
Horner’s syndrome

15. Fascicular brachial plexus palsy
One muscle or a group of muscles in the arm
Due to injury of a small group of motor fibers

16. Management
Rest period of 7 days  pin the sleeve of neonate’s shirt to hold the elbow in a flexed position
Physical Therapy Goals: minimizing bony deformities and joint contractures, while optimizing functional outcomes
Passive and Active ROM exercise
Bimanual activities
Strengthening
Promotion of sensory awareness
Weight-bearing activities: propioceptive input + skeletal growth
Static and dynamic splints
Instructing parents and family: home exercise program

17. Surgical Intervention
Other treatments:
Neuromuscular electrical stimulation
Botulinum toxin A therapy
Surgical Intervention

18. Prognosis 4-5 months in Erb’s palsy
Degree of future improvement cannot be determined during a single evaluation, especially if performed immediately after birth.
Improvement during the first few weeks is a relatively good indicator of final outcome.
Incidence of permanent sequelae: 3-25%
Findings consistent with severe initial injury (Horner’s syndrome) portend a less favorable prognosis
Peripheral nerves re-myelinate at a rate of 1mm/day. If nerve is not transected, recovery can be expected by:
4-5 months in Erb’s palsy
6-7 months in upper-middle trunk palsy
14 months for a total BPP.