Early days – congenital deformity. Smillie  – Obstetric origin Danyau  – Autopsy – lesion Duchenne - traction injury, OBPI ERB - pointed lesion at upper trunk Kennedy - early surgical repair Narakas - microsurgical results.
Incidence: 4/1000 in poor OBG care, 0.1-0.3% in good centers. 1% of OBPP, injury is bilateral More on one side. [exclusive in breach]
Formed by anterior primary rami of C5-T1. Roots – between scalene muscles Trunks – posterior triangle Divisions- behind clavicle. Cords in axilla. Roots & trunk- supraclavicular part [OBPP] Cords & branches – infraclavicular part
Stretching Overweight babies with cephalicpresentations Underweight babies with breech Forceful widening of angle between the neck& shoulder. Force is more at C5 root Always supraclavicular Not associated with vascular damage.
Large birth weight Breech presentation Maternal diabetes Multiparity II stage of labour - > 60 min Assisted delivery [forceps, vacuum ext] previous child with OBPP Intrauterine torticollis Shoulder dystocia
Lesions range from degree I[neuropraxia] – V[neurotmesis or root avulsions]. Upper trunk –1staffected, most vulnerablepart. Upper trunk – mostly stretched Lower trunks – mostly ruptured
U.E is flail & dangling Look for other extremities U.R: arm held in IR,add, active abd notpossible, elbow extended forearm pronated,thumb flexed. Complete paralysis- vasomotor impairment,pale & marble like color Horner’s sign Associated # [clavicle,humerus,]
Complete Recovery Extent of paralysis regress, total paralysis limitedto U.R No improvement.
C5-6: the arm is adducted and internallyrotated at the shoulder, elbow extended,forearm pronated, wrist and (sometimes)fingers flexed. (Classic waiter tip/Erb’spalsy/upper roots). C5-7 : as above, although the elbow may beslightly flexed. Intermediate root palsy C7. C5-T1 : the arm is totally flail with a clawhand. marbled appearance, Horner’ssyndrome.
Done at 2 months of age Not anatomic, Grading overall severity of lesion based onclinical course. Prognosis.
X - RAY epiphyseal # of humerus, # clavicle, Later changes, retardation of growth,deformity of shoulder jt & dislocation of radialhead.
EMG Performed at 3-4 wks- confirm neuropraxia oraxonotmesis At 2 months, signs of re-innervation.EVOKED SENSORY POTENTIAL Useful to ascertain root avulsions Can be used preop to test the availability ofproximal stumps.
Fluoroscopy- phrenic nerve injury. Lumbar puncture- xanthochromic CSF- in rootavulsions. C.T myelogram Fast spin Echo MRI: preganglionic nerve rootinjuries. Large diverticulae and meningoceles areindicative of root avulsions
Nature of injury [rupture better] Lower plexus paralysis, global involvement, persistence of pupillary signs of phrenic nervepalsy Ass. #.
Physiotheraphy- cornerstone Rest for first 2 wks, Arm fixed across the chest by pinning ROM ex, facilitation of active movt, promotionof sensory awareness. Avoid abduction & posterior projection ofshoulder. Limb to be supported when holdingbaby Goals: minimizing bony deformities, Jtcontractues. Weight bearing activity-skeletal growth
Early nerve repair Indications:1. Failure of recovery of biceps or deltoid at 3months2. Group III& IV lesions3. Presence of Horners sign.
Diminishing potential for axon regeneration withage Cross innervation & muscle imbalance aborted Provide better condition for tendon transfer Nerve repair is superior to spontaneous recovery.
Total palsy: 3 months Upper trunk palsy: 5 monthsTYPE OF SURGERY1. neurolysis,2. resection and anastomosis in ruptures3. nerve grafting using sural nerves asinterposition grafts.
Repair using the proximal roots of the plexus itselfif the injury is post ganglionic as in a rupture Extra plexal neurotisation using other donormotor nerves to selectively aim at reinnervatingthe important muscle groups.
Spinal accessory (XIth) nerve. Intercostal nerves (commonly 3rd to 6th) C4 motor root Ansa hypoglossi Opposite C7.
Suprascapular Musculocutaneous, Axillary Median.Order of priority of restoration of function Elbow flexion Shoulder stability (rotator cuff viasuprascapular nerve) Shoulder abduction Hand prehension
To predict poor outcomes if microsurgicalrepair or grafting is not done. scale consists of grading elbow flexion,elbow extension, wrist extension, fingerextension, and thumb extension. [max -12] score of < 3.5 predicted a poor long-termoutcome without microsurgery.
Fracture of clavicle or humerus shaft or physealseparation septic arthritis / osteomyelitis Congenital malformation of plexus Postinfectious [varicella] plexopathy of muscles
Nerve regeneration: some muscles recoverearlier, others paretic muscle imbalance Recovery results from misdirection of regeneratedaxons cross innervation
Sequelae depends on three factors whichare additive1. Paralysis of muscle groups [ext.rot, elbowflexors]2. Contracture of healthy antagonist muscles3. Impaired growth osseous deformities Sequale – seen in spontaneous recovery ingr III & IV lesion.
Putti sign; with shoulder abduction, medialedge of scapula, often seen protruding aboveshoulder jt line Reduction of shou abd – deltoid weakness orlack of ER. Trumpet sign Mild shortening & atrophy of limb Posterior sublux of shoulder – IR overpowerER. Bitting of nail & hand (47%) –total obp.
UPPER ARM: mainly in shoulder & occ elbow &forearm LOWER ARM: hand more affected WHOLE ARM; flaccid paralysis
Group I: joint contracture due to nerve lesions& simultaneous trauma to shoulder Jt Group II Flaccid; flaccid paralysis- upper trunkinjury. Group I: subdivided in to 4 groups
I –internal rotation & adduction contracturewith preservation of Jt II – with Jt deformity – posterior subluxation &dilocation III – external rotation & abd contracture-anterior & inferior disloc IV –pure abduction contracture.
Grade I ,II, mild grade III (slight posteriorsubluxation) glenohumeral deformities havean anterior musculotendinous lengthening ofthe pectoralis major and posterior latissimusdorsi and teres major transfer to the rotatorcuff Advanced grade III, IV, or V glenohumeraldeformities should have a humeral derotationosteotomy.
Fairbank: release of subscapularis & capsule. L’ Episcopco procedure improves externalrotation of the shoulder by releasing theinternal rotation contracture and transferringthe latissimus dorsi and teres majorposteriorly to provide active external rotation Wickstrom recommendes external rotationosteotomy of the humerus for severe fixedrotation contracture.
In flaccid paralysis of complete lesion Difficult to manage & difficult to rehabilitation If no active wrist extension & no possible transfers– W. fusion with comb inter-metacarpalarthrodesis.
Elbow flexion and forearm supinationdeformities weak or absent triceps, pronator teres, andpronator quadratus muscles with an intactbiceps muscle Radial head dislocation wrist & hand usually in extreme dorsiflexion –unopposed DF biceps tendon, Z-lengthened and reroutedaround the radius to convert it from asupinator to a pronator
Prevention is better than cure Effort made to improve obstetric practice Group I & II- conservative Group III & IV –early surgery Late sequale: proper evalu & manage withtendon transfer or osseous surgry Conservative Rx – fruitless.