Plexus University Curriculum
Families who experience a difficult delivery followed by a child with limited arm motion are often in the dark about what has happened to their baby, what to do about it, who to see, and what they can expect in the long term. A weak or limp arm at birth does not mean that your child has had a brachial plexus injury or Erb’s palsy. Sometimes children with fractures of the arm may not move the arm just to protect themselves. Movement recovers when the fracture heals. Erb’s palsy and other brachial plexus birth injuries are a serious and time-sensitive problems. Delays in evaluation and treatment have been shown to lead to worse outcomes. It is therefore important to know that there are consensus guidelines of what to do if your child is diagnosed with an Erb’s palsy, also known as an obstetrical brachial plexus injury, neonatal brachial plexus injury, or brachial plexus birth palsy/injury. We at Plexus Nexus have partnered with the United Brachial Plexus Network (UBPN) to develop the guidelines listed below:
The first 30 days
The standard newborn physical examination done at birth by a pediatrician or neonatologist should include assessment and documentation in the medial record of active upper extremity limb movement. A diagnosis of BPBI shoulder be considered if:
Caregivers express concern about asymmetric upper limb movement or lack of upper limb movement
Lack of active upper limb movement in one or both arms
Asymmetry in upper limb active movement
Asymmetric Moro reflex
Radiographs to evaluate for clavicle and/or humerus fractures are recommended when:
Upper limb movement abnormality/asymmetry
Physical examination shows crepitus, deformity, and/or pain response with movement
A clavicle or humerus fracture DOES NOT rule out a BPBI.
As long as there is no fracture, the affected limb should be allowed unrestricted active movement. Routine newborn care can include:
Normal feeding with the injured limb supported
No change in recommendations for use of car seats or sleeping positions
Touching and gentle passive range of motion of the injured limb is recommended
Routine care will not hurt or harm the baby, including dressing/undressing
Any child with suspected BPBI (Erb’s palsy) should be referred to a center specializing in the surgical and non-surgical treatment of BPBI within 4 weeks of life.
The family should be informed that:
There may have been a birth injury.
The evaluation and diagnosis should be performed within 4 weeks
The severity of injury and degree of recovery cannot be determined at birth.
Not all BPBIs resolve. Only 1 out of 3 completely improve.
As long as there is no fracture, routine care of the newborn is safe and appropriate.
Patient/Family Educational Videos
brachial plexus birth injuries 101:
Delivery
Brachial Plexus Birth Injuries occur in 1 to 3 per 1000 live births. The most common cause is the baby's shoulder getting stuck during delivery after the head is out, an event known as shoulder dystocia. Risk factors for shoulder dystocia include large babies greater than 9 pounds (macrosomia) and gestational diabetes. However, it is impossible to predict based on risk factors alone whether shoulder dystocia will occur. Mom's who encountered a shoulder dystocia in a previous delivery are at the highest risk, however, and we recommend delivery by Cesarian section for all subsequent pregnancies. Once shoulder dystocia occurs, there are a limited number of techniques that can be used to deliver the baby, including suprapubic pressure, McRoberts Maneuver, and the Wood Screw Maneuver. If the child is not delivered in a timely fashion, the consequences can be brain injury and death of the child.
brachial plexus birth injuries 102:
Nerve injury
Any stretch of the brachial plexus during delivery can result in a Brachial Plexus Birth Palsy. There have also been sporadic reports of brachial plexus injuries occurring without an identified stretch event.
Brachial plexus birth injuries 201: principles of nerve surgery
If nerve function does not recover by 3 months in complete (global) injuries, or by 5-6 months in incomplete injuries, surgery to reconnect the torn nerves may be indicated. The most commonly performed technique is nerve grafting, where nerve cables are taken from the leg (sural nerve) and spliced into the gap between the torn nerve ends. Other reconstruction techniques include transferring a working nerve that is expendable to a nonworking nerve. Examples of nerve transfers include Spinal Accessory to Suprascapular Nerve Transfer, Intercostal to biceps nerve transfer, ulnar fascicle to biceps nerve transfer, partial triceps to axillary nerve transfer, and contralateral C7 nerve transfer. Nerve transfers can be performed at an older age than nerve grafting, typically between 6 and 12 months of age.
Brachial plexus birth injuries 201:
the shoulder
The most common long term consequence of a brachial plexus birth injury is limited shoulder motion and scapular winging.
Surgical Techniques
Spinal Accessory to Suprascapular nerve transfer
The Spinal Accessory Nerve can be transferred to the Suprascapular Nerve to reanimate the supraspinatus and infraspinatus muscles of the rotator cuff. The procedure can be performed from the front or, as depicted here, from the back. The goal of the surgery is to improve shoulder movement. The success rate of the surgery has been reported at between 40 and 60%.
ulnar motor to triceps nerve transfer
This video demonstrates the ulnar nerve to triceps nerve transfer, a variant of the standard Oberlin transfer.
intercostal nerve transfers
Intercostal nerves (up to 6) can be transferred to power the biceps, the triceps, the deltoid, and/or the supra scapular nerve. A minimum of 2 intercostals is required to provide sufficient axons to power each muscle, with 3 intercostals being better than 2. When transferring intercostal nerves to 2 muscles, it is important to make sure that the muscles are operating at the same time (synergistically), such as the deltoid and rotator cuff, or the deltoid and triceps. Innervating both the triceps and the biceps usually yields recovery of only one muscle, with co-contraction of the biceps and the triceps at the same time limiting function.
Practicioner Education
basic Overview
Brachial Plexus Birth Injuries occur in 1 to 3 per 1000 live births. The most common cause is the baby's shoulder getting stuck during delivery after the head is out, an event known as shoulder dystocia. Risk factors for shoulder dystocia include large babies greater than 9 pounds (macrosomia) and gestational diabetes. However, it is impossible to predict based on risk factors alone whether shoulder dystocia will occur. Mom's who encountered a shoulder dystocia in a previous delivery are at the highest risk, however, and we recommend delivery by Cesarian section for all subsequent pregnancies. Once shoulder dystocia occurs, there are a limited number of techniques that can be used to deliver the baby, including suprapubic pressure, McRoberts Maneuver, and the Wood Screw Maneuver. If the child is not delivered in a timely fashion, the consequences can be brain injury and death of the child.
humeral osteotomy
An osteotomy of the humerus can help to realign the shoulder in a better rotational position.
glenoid osteotomy
Glenoid osteomies are used to correct the retroversion of a dysplastic shoulder. Because of the technical challenges and unclear indications, glenoid osteotomies are rarely performed.
Glenohumeral Dysplasia and Shoulder kinematics
Glenohumeral dysplasia alters the kinematics of the shoulder, changing the line of pull of the supraspinatus to make it an internal rotator, and the infraspinatus to an abductor of the shoulder.