Brachial Plexus Birth Palsy occurs when the brachial plexus nerves are injured during childbirth, often due to shoulder dystocia or breech delivery. While some cases recover spontaneously, surgery within the first 3-9 months can have better outcomes than late or no surgery. The document discusses the anatomy of the brachial plexus, classifications of injuries, physical exam considerations, historical figures who advanced the field, controversies around timing of surgery, and examples of microsurgical procedures used to repair nerve injuries like grafting and nerve transfers. Physicians are advised not to assume excellent recovery and to consider early surgery for severe cases to avoid lifelong limitations.

1. Brachial Plexus Birth Palsy :
Overview and Lessons Learned
So Far
Nezar Hamdi, M. D
King Faisal Specialist Hospital &
Research Center

2. Objectives
- Historic Overview
- Pathophysiology Phase
- Surgical Phase
- Anatomy-
-Clinical Examination

3. What IS IT ?
• The brachial plexus consist of the five nerve roots C5
C6 C7 C8 and T1, that come out of the spinal cord at
the cervical level.
• During difficult birth delivery of the large baby, in
breech delivery of smaller babies, the roots may be
pulled and injured.This traction injury may result in
elongation in continuity of the nerve,extra foraminal
rupture, or avulsion from the spinal cord

8.  1697-1763.
 Born in Lanark, Scotland.
 Greatest figure in British
obstetrics.
 1st to teach obstetrics &
midwifery on a scientific
basis.
 Safe rules for use of forceps.
William Smellie

9. Guillaume-Benjamin
Duchenne de Boulogne
 Born in 1806 at
Boulogne-sur-Mer.
 Pioneer in neurology.

10.  In 1852, described paralysis
of the upper extremity –
particularly after
glenohumeral subluxation.
 In 1872, described a series
of 4 infants with injury to
the upper part of their
plexus.
 He first used the term
“obstetrical palsy”.
The term “Obstetrical Palsy”
(1872)

11.  Site of emergence of C5-C6
from the anterior and
middle scalene muscles.
 By exciting this point able to
cause simultaneous
contraction of deltoid,
biceps, coracobrachialis,
and supinator.
W. Erb (1874)

21. Anatomy:
The beginning and the end

22. Anatomy
• Topographic, brachial plexus is located in the
lower half of the neck.
• The SPP. Nerve, the posterior division of the
upper trunk, is the most lateral branch within
the supraclavicular segment of the brachial
plexus.
• Infraclavicular segment of the brachial plexus
is divided into 2 planes ( Dorsal & Ventral )

23. Direction of the Plexus
• Root C5 has a very oblique direction
downwards and outwards.
• Root T1 has an upward path

24. At the inertervertebral foramen
• C5 and C6 roots incline caudally .
• C7 root the direction coinciding with the
plexus axis.
• C8 and T1 roots have an upward direction

25. • The trunks have an oblique path downwards
and outwards.
• Infraclavicular, the trunks have an parallel
direction .
• In Adduction, inclined vertically while in 90
degree Abduction inclined horizontally

26. Cervical supply to the brachial plexus
• Kerr (1918) suggested a three-group
classification
• C4C5 63%
• C5C6 30%
• C5 alone 7%
• Prefixed & postfixed

27. Anatomy of the Foraminate region
• C4-C7 there are transverse-radicular ligament
• C8T1 No transverse-radicular liagment

28. Scalenus region
• Anterior
C3-C7 anterior tubercles-1st rib
Middle
C3-C6 posterior tubercles-1st rib
Posterior
C4-C6 posterior tubercles-2nd rib

29. Extra-Scalenus region
• Posterior cervical triangle boundary .
• Omohyoid Muscle
• Accessory nerve
• Transverse cervical artery
• Suprascapular artery
• Dorsal artery

30. Infraclavicular region
• The fascicles and terminal branches of the
plexus are organized and strutured
• Lateral cord, medial cord, and posterior cord

31. Collateral branches of the brachial
plexus
• These are topographically classified into
supraclavicular and infraclavicular and they
innervate the muscles of the tronco-scapular
apparatus
• Supraclavicular branches :
- Nerve for the deep muscle of the neck
- Dorsal nerve of the scapula
- Long thoracic nerve
- Suprascapular nerve

32. • Infraclavicular branches :
- Lateral & Medial pectoral nerve
- Subscapular nerve
- Thoraco-dorsal nerve

33. Terminal branches of the brachial
plexus
• Axillary
• Radial
• Musculocutaneous
• Median
• Ulna

34. Developmental Stages of Anatomic
Learning
• Text and classroom
learning
• Anatomic Dissection
• Intraoperative
visualization and feel
• Variances, Repitition

35. Anatomy

36. Anatomy

37. Anatomy

38. Physical Exam
• Secure with all
developmental stages:
infants, children,
adolescents
• Utilize neonatal reflexes,
keen observation,
simulated play, patience,
age appropriate
instruction
• Consistency: reliable and
valid in repeated exams

39. Physical Exam
• Accuracy of exam,
recording critical
• It truly is “the practice
of medicine”
• Visualization with keen
concentration is key
• Honesty of recording
within “conflicts of
interest”

40. You can not read, see, feel too much….

41. Incidence & Etiology
 0.3-2.5 per 1000 live births.
 Recognized risk factors :
# Large B.W
# Breech position
# Shoulder dystocia
# Prolonged 2nd stage
# Prior delivery of a child with
a brachial plexopathy

42. Upper Plexus
C56 C567
(Hand normal)
Erb’s
Complete
All plexus
C5678T1
Klumpke
Lower plexus
C8T1
(Hand flail)
Classification

43. Two Main Controversies
 Should the Obstetrical Plexus be operated ?
 When should the decision taken ?

44. The significant studies confirm
that the results after operation
are better than with spontaneous
recovery ( Pondaag 2004 )
 “ Therefore, the often cited excellent
prognosis for this type of birth injury cannot
be considered to be based on scientifically
sound evidence”.
 “ The few studies that met two of the four
inclusion criteria suggest that spontaneous
recovery is notably worse than is generally
suggested in most reviews”.

45. Literature based evidence
No class I scientific evidence regarding
optimal timing of microsurgical
repair in patients with BPBP
Recent MEDLINE literature review
195 papers on “brachial plexus
birth palsy” from 1965-present
no randomized control trials
few prospective study designs
Emotionally charged environment of
opinions among patients, families,
surgeons, and care providers

46. Some do very badly
 We now know that
10-20% have a bad
prognosis because of
severe injury.

47. What are the possible lesions?
• Mild stretch
• severe stretch with
scarring
• complete rupture
• root avulsion
• root avulsion, intra-
foraminal

52. Microsurgical Procedures
• Bypass neuroma
• Sural nerve grafts C5, C6 to most proximal
viable nerve to regain biceps, rotator cuff,
wrist extension, digital extension function
• Nerve transfers for avulsions. Prioritize above
and hand function by median and ulnar
nerves.

53. Microsurgery
• UPPER TRUNK
RUPTURE
• Sural grafts C5-C6 to
posterior and anterior
divisions upper trunk,
suprscapular nerve

54. Microsurgery
• AVULSION
• intercostal nerve
transfers to
musculocutaneous,
spinal accessory to
suprascapular

56. Association between internal rotation
contracture and Glenoid dysplasia
• Mintzer et al. studied 111 normal shoulders
in the pediatric age group and found that the
glenoid is maximally retroverted at 6.3 degree
by age 2 years and becomes less retroverted
at 1 .7 degree by age 8 years.

57. • Glenohumeral
deformity so common
as to be expected
• muscle imbalance in a
growing child leads to
bone and joint
deformity
• age is a factor, degree of
muscle imbalance may
be most important
factor

59. Derotational humeral osteotomy
• osteotomy proximal to
deltoid insertion
• internal fixation

62. Conclusions
 Physicians should exercise
caution in predicting excellent
recovery shortly after birth , and
seek an active treatment attitude
to avoid life-long limitations for
the individual patient
 Consider severe cases for nerve
surgery in the 1st 3 months.
 Best results with early surgery, ie
between 3-9 months.
 Reconstructive surgery later often
necessary.