Obstetric Brachial Plexus Palsy

1. Obstretic brachial plexus palsy
Dr. Gajanan Pandit
Mumbai Port Trust Hospital

2. Anatomy

3. Anatomy Variations
 Pre Fixed
run from C4-C8
stretching injury
-Erb’s palsy
 Post fixed
run from C6-T2
abduction injury
-Kumpke’s palsy

4. Definition
 An injury to all or to a portion of a
child’s brachial plexus nerve network
occurring at the time of delivery.

5. Classification
 Pre/Postganglionic
 Supra/Infraclavicular
 Nature of injury
 Level of injury

6. Risk factors
 Cephalopelvic disproportion
 A large or a macrosomic baby
 Delivery-Premature/Breech/Instrumental
 Shoulder dystocia
 Primigravida
 Prolonged labour
 Congenital anomalies

7. Shoulder dystocia

8. Types
 Erb-Duchenne Palsy (60%)
 Klumpke’s Palsy (5%)
+ Horner syndrome (1%)
 Mixed (35%)

9. Erb-Duchenne Palsy
 William Smellie, a British obstetrician is credited
with the first medical description of obstetric
brachial plexus palsy.
 1861- Benjamin Amand Duchenne coined term
‘obstetric palsy of the brachial plexus’
 1874 - Wilhelm Heinrich Erb concluded his thesis
on adult brachial plexus injuries

10. Risk Factors
 Maternal
 Foetal
 Intrapartum events
 Neonatal

11. Mechanism of injury
 Bending or
stretching of the
neck in a direction
away from the side
of injury

12. Clinical presentation
 waiter’s /porter's/policeman’s tip position

13. Affected nerves
 Dorsal scapular, suprascapular, lateral
pectoral, long thoracic,
musculocutaneous, radial, median and
phrenic nerves.

14. Sensory deficits
 Radial side of the
deltoid, forearm
and hand

15. Muscle weakness
 External rotators and abductors of
the shoulder/arm.
 Flexors of the forearm.
 Extensors of the fingers (C7).
 Diaphragm descent (C4).

16. Muscle weakness
• Moro, biceps and radial reflexes
are absent on the affected
extremity however,
• grasp reflex remains intact.

17. Klumpke’s Palsy
 1885 -Augusta Dejerine-Klumpke
neurologist and neuroanatomist
diagnosed total brachial plexus
radicular paralysis with
oculopupillary involvement in a
patient

18. Risk Factors
 Maternal
 Foetal
 Intrapartum events
 Neonatal

19. Mechanism of injury
 Pulling up of the
arm above the
head, so that
stretch on the C8
and T1 roots

20. Affected nerves
 Inferior trunk ( C8,T1)
 Radial nerve, ulna nerve, the
thoracodorsal nerve, median nerve
and the medial pectoral nerve.

21. Sensory deficits
 Ulnar side of the
forearm and hand

22. Muscle weakness
 Pronators of the forearm
 Flexors of the wrist joint.

23. Horner syndrome
 Bernard-Horner syndrome and oculo-
sympathetic palsy
 Injury to cervical sympathetic ganglions.
 Enophthalmos, partial ptosis, swelling of
the lower eyelid, miosis , unhydrosis and
heterochromia.
 Loss of ciliospinal reflex.

24. Complications
Fracture of the clavicle
Fracture of the humerus
Subluxation of the cervical spine
Cervical cord injury
Facial nerve palsy
Phrenic nerve palsy

25. Nerve Injury
 Avulsion :-
 Rupture :-
 Stretching :-
 Scarring :-
Neuropraxia
Axonotmesis
Nerotonmesis

26. Management
X-rays to exclude fractures and examination
for phrenic nerve paresis are important.
Other investigations -
Electromyography,
NAP, SEP,
Nerve conduction studies,
CT myography and
MRI.

27. Management
Most cases of OBPI resolve spontaneously
in ~ 4 months to 2 year after delivery.
To prevent contractures, physiotherapy
using wrist splits after 7days
immobilization.
Surgery if movement doesn’t return after 3
months and electrophysiology indicate a
poor prognosis.

28. Opponens Pollicis
Flexor Pollicis Longus
Adductor Pollicis
Pectoralis Major (lower)
Biceps
Flexor Pollicis
Brevis
Extensor Digitorum Superficialis
Extensor Digitorum Profundus
Pronator Quadratus
Extensor Carpi Radialis
Longus & Brevis
Frexor Carpi Radialis
Triceps
Extensor indices
Extensor Digitorum
Flexor Carpi Ulnaris
Extensor Digiti Minini
Extensor Carpi Ulnaris
Extensor Pollicis Longus
Abductor Pollicis Longus
Extensor Pollicis Longus
Brachialis
Pronator Teres
Pectoralis Minor
Deltoid
Serratus Anterior
Rhomboid Major & Minor
Supinator
C5
Supraspinatus
Infraspinatus
Pectoralis Major (upper)
T1 C8 C7 C6
Lumbricals
Brevis
Abductor Pollicis
Interossei

29. Neurrorhaphy

30. Neurolysis

31. Neuroma

32. Neurotization

33. Botox Injection

34. Nerve Conduit

35. Tendon Transfer

36. Modified ‘Quad’

37. Tendon Transfer

38. Nerve Decompression

39. Bony Procedures

40. Triangle Tilt

41. Post op.

42. Thank you…..