Obstetrical brachial plexus palsy (OBPP) is a devastating complication associated with difficult or assisted delivery. Newborns may sustain increased forces of distraction on the neck during passage through the birth canal, which in turn put excessive stress on the brachial plexus, causing nerve injury. Although many infants will recover with either no functional deficit or a minor one, others will not regain adequate limb function.
The brachial plexus is a group of nerves that includes the lower four cervical roots (C5–8) and the first thoracic root (T1) (see Figure 1) (Watson, 1991). Because these nerves exit through the anterior vertebral foramen, past the clavicle, and toward the upper extremity, they are easily injured with traction on the extremity or distraction of the head away from the clavicle. The resulting injury is brachial plexus palsy.
Since the beginning of man, there have been reports of infants who were unable to move their arms. In 1764, Smellie first described bilateral arm paralysis in a newborn that resolved a few days after delivery. Duchenne de Boulogne was first to name the paralysis obstetrical brachial plexus palsy. He also localized the injury to the upper plexus. Erb then described his classic case of obstetrical palsy, and the term Erb’s Paralysis was coined. Klumpke followed in 1885 with his description of injury to the lower plexus (Terzis & Papakonstantinou, 1999).
Surgical intervention became popular in the early 1900s. However, reports of the poor functional outcomes of these attempts discouraged physicians from promoting surgical treatment in favor of using conservative measures, such as immobilization, with subsequent physical therapy and occupational therapy. Nonoperative treatment for OBPP remained the norm until the late 1960s. (Terzis & Papakonstantinou, 1999). Improved preoperative imaging techniques (computed tomography [CT] scan, myelography) and the refinement of microsurgery have led to a resurgence of interest in surgical intervention for OBPP.
There is variability in the rate of occurrence of OBPP among studies. The incidence ranges from 0.38 to 3 per thousand live births in industrialized countries (Pollack, Buchman, Yaffe, & Divon, 2000). According to one study, OBPP occurs least frequently in newborns weighing < 4000 g and occurs three times as often in newborns weighing > 4500 g. However, even with the advances in technology, the rate of occurrence has remained stable. This is believed to result from increased mean birth weight secondary to improved prenatal care and the unpredictability of shoulder dystocia, which is an emergency that occurs when the fetus’ anterior shoulder becomes impacted under the mother’s pubic symphysis (Dodds & Wolfe, 2000).
At Texas Children’s Hospital, OBPP incidence is 1 per 1000 births, with 1–2 per 10,000 live births requiring surgery (Shen et al., 1998). Distribution of the different types of OBPP is also similar to that reported by others. Pure upper plexus lesions occur 73% of the time, followed by total plexus injury at 20%, bilateral injury at 4%, and pure lower plexus injury at 2% (Shen et al., 1998).
The risk factors for OBPP are well known. The infants most likely to be born with an injury to the brachial plexus weigh more than 4000 g, are born to mothers who are diabetic, or are breech presentation. In addition, if there is a cephalopelvic disproportion and a subsequent shoulder dystocia, the likelihood of OBPP is increased. Babies who are born breech, even if they are small, may require manipulation of the arms and extension of the neck, resulting in brachial plexus injury. However, breech presentations are generally delivered by cesarean section today, thereby decreasing the risk of OBPP (Terzis & Papakonstantinou, 1999). Delivery assisted by instruments or vacuum may also predispose to injury.
There are other risk factors in the development of a brachial plexus injury. They all have the common denominator of increased possibility of a difficult passage through the birth canal, causing increased traction to the brachial plexus. Some of these additional factors are eclampsia or preeclampsia, prolonged second stage of labor, premature labor, placenta previa, fractures of the clavicle or humerus, facial nerve paralysis, and torticollis (Shen et al., 1998). Any of these factors should alert the neonatologist to the possibility of OBPP.
Traction on nerves can cause a wide range of injuries, which may occur as lateral torsion to the neck or as direct traction to an upper extremity. There has been much legal debate over whether obstetricians are responsible for OBPP because of the lateral traction they must exert during delivery.
However, obstetric literature has demonstrated the existence of injury to the brachial plexus before the obstetrician has touched the infant (Dodds & Wolfe, 2000). The posterior shoulder may be injured as it passes over the sacral promontory. In utero injury has been shown to occur when the fetus is lying in an abnormal uterus. Even in cases of cesarean delivery, brachial plexus injury has occurred (al-Quattan, el-Sayed, al-Kharfy, & al-Jurayyan, 1996).
In addition, one study reported two cases of OBPP caused by neoplasm, and another identified the Pavlik harness as a cause from the downward pull of the harness straps on the shoulders (Alfonso, Papazian, Prieto, Alfonso, & Melnick, 2000;Mooney & Kasser, 1994).
OBPP injuries are commonly divided into three groups: upper, lower, and total. The upper plexus injury (C5–C6 nerve roots, with or without involvement of C7) is also called Erb’s palsy and presents with an adducted arm, which is internally rotated at the shoulder. The elbow is extended, the wrist is flexed, and occasionally the fingers are also flexed. If C7 is injured, the elbow may be slightly flexed and the characteristic “waiter’s tip” posture may be present (see Figure 2). This is the most common type of plexus injury (Terzis & Papakonstantinou, 1999).
Lower plexus injuries (C8–T1) are rare and account for only 0.6% of all reported brachial plexus injuries. The etiology is believed to be breech delivery of the infant whose hyperextended arm is delivered with the head rather than before it. Also called Klumpke palsy, the clinical picture is demonstrated in poor hand grasp while more proximal muscles are intact (Dodds & Wolfe, 2000).
Total plexus injuries are the second most common type of injury and involve C5–T1. They are the most devastating plexus injury because the infant is left with a clawed hand and a flail and insensate arm. There is a strong positive correlation between deliveries assisted by forceps or vacuum extraction and total brachial plexus palsy, which indicates that a more severe injury has occurred to the plexus (Michelow et al., 1994).
The types of injuries that occur to the nerve roots are illustrated in Figure 3. An avulsion is a tearing of the nerve roots away from the spinal cord before they form the ganglion and is similar to a postganglionic rupture. A neuroma is a disorganized collection of fibrous tissue and nerve endings and is the attempt of nerves to grow over the sight of a rupture. Neuropraxia is a temporary conduction defect from which the infant recovers quickly because it is associated with no permanent structural damage (Shen et al., 1998).
It is important for the examining physician to obtain a history, including obstetric history, mode of delivery, and postnatal health of the infant. In addition, a thorough physical examination can determine the diagnosis of brachial plexus injury and its type and severity and aid in predicting prognosis.
All limbs should be examined for fractures and potential neurologic deficit, and a comprehensive examination of the entire body should identify any other injuries incurred during delivery. Swelling in the neck and shoulder region may cause a pseudoparalysis that can mimic brachial plexus palsy. Abdominal asymmetry is a finding that can indicate phrenic nerve involvement and paralysis of the hemidiaphragm, which could affect prognosis. Ocular asymmetry may be associated with Horner’s syndrome (ptosis, myosis, enophthalmosis, and anhydrosis), which would most likely be caused by total plexus palsy (Shen et al., 1998).
The affected limb should be examined for active and passive motion, and range of motion should be assessed for future comparison. Assessment of motor and sensory function is a crucial part of the physical examination. Reaction from light touch to pinprick can be elicited in a neonate. Infants may ignore one side of the body, indicating lack of sensation in that arm. Cool dry skin may indicate the loss of sympathetic tone.
There are several motor function grading systems in use for brachial plexus palsy. A comprehensive assessment protocol was published by the Hospital for Sick Children, which requires that full range of motion without gravity be achieved before scoring antigravity muscle strength. Three commonly used grading systems are compared in Table 1 (Dodds & Wolfe, 2000, p. 43). It is important to remember that consistency of assessment is the most important factor in determining improvement. The specific grading system is less significant.
Controversy still exists surrounding the use of imaging techniques for diagnosing OBPP. There is considerable support for using magnetic resonance imaging (MRI) for direct visualization of the spinal cord and brachial plexus. However, CT myelography is more sensitive in locating nerve root avulsion from the spinal cord, which, if present, alters the treatment of brachial plexus injuries significantly (Dodds & Wolfe, 2000). The initial surgical approach that includes brachial plexus exploration followed by physical therapy additionally includes internal neurolysis (removal of constricting scar tissue around the nerve), excision of the neuroma, nerve grafting, and/or nerve transfers (Shen et al, 1998).
Electromyograms and nerve conduction studies have a limited role for diagnosis of OBPP in the neonate since they have not been shown to be consistently predictive of specific root damage. EMG’s depend heavily on the presence or absence of spontaneous activity which requires the complete relaxation of the muscle being tested. This is difficult to achieve in neonates (Pollack et al., 2000).
The timing of electrodiagnostic testing must be considered since reinnervation may take weeks to months to develop. Therefore, studies that are performed within three weeks following the injury may underestimate the degree of nerve damage (Pollack et al., 2000).
Early recognition of OBPP and referral to an appropriate treatment facility remains the best option for a positive functional outcome. The Collaborative Perinatal Study (U.S. Department of Health Education and Welfare, 1972) found that 95% of infants born with OBPP recovered complete function with physical therapy only. A small percentage required further physical therapy to achieve a better level of recovery. The remaining 5% with persistent symptoms developed considerable handicaps over time if treatment was not instituted early. Significant improvement has occurred in 90% of these children, as opposed to a 50–70% improvement rate in those whose treatment was delayed. These results are also contingent on the specific pathology of the injury (Shen et al., 1998).
A multidisciplinary team (composed of the pediatrician, pediatric neurologist, neurosurgeon, and physiatrist), pediatric orthopaedic surgeon, pediatric plastic surgeon, electrophysiologist, occupational therapist, physical therapist, social worker, and educational resource person optimally determines the treatment path (Michelow et al., 1994). The initial goal of therapy is to maintain passive range of motion, supple joints, and muscle strength. More specific therapy involves stretching muscle groups to prevent contracture. All exercises should be performed carefully to minimize stress on the elbow joint.
Orthopaedically, the shoulder and elbow of the child should be checked periodically for subluxation or dislocation, and radiographs should be taken twice yearly for persistent upper plexus palsy (Dodds & Wolfe, 2000). If there is phrenic nerve involvement, plain radiographs can diagnose hemidiaphragmatic paralysis and fractures of the clavicle or humerus. In addition, axillary radiographs can diagnose posterior shoulder dislocation in children who continue to lose external rotation (Semel-Concepcion & Conway, 2001).
Primary Surgical Reconstruction
Although there is debate about whether to perform surgery for brachial plexus palsy, most authors agree that if normal function of the deltoid and biceps muscles has not returned by 3 months of age, there is little expectation of a good outcome. At this time, surgical options and interventions should be considered. The timing of surgery remains controversial.
Rationale for reconstructive surgery ranges from surgery before 3 months of age for global paralysis to surgical intervention between 12 and 24 months of age to prevent the development of contractures, hypoplasia of the arm, and humeral head dislocations. Most surgeons prefer to consider the results of electrodiagnostic studies and indications of spontaneous return of function before making the decision to operate (Terzis & Papakonstantinou, 1999).
The initial surgical intervention is most often exploration, evaluation, and repair of the brachial plexus injury (Shen et al., 1998). This approach includes a supraclavicular incision and exposure of the nerves. Scar tissue is then removed and nerve conduction is evaluated with electrophysiologic studies. If muscle action potential is decreased by more than 50% across a neuroma, the neuroma is excised and a graft with autologous sural nerve is placed. In patients older than 9 months of age, a cervical and infraclavicular approach is used and neurolysis (scar removal) is performed, combined with decompression, nerve grafting, and nerve transfer (Shen et al., 1998). When the gap between nerve ends is large and undue tension would be placed on the anastomosis, a nerve graft is used. Some common harvesting sites are the sural nerve, the lateral and medial antebrachial cutaneous nerves, and the terminal sensory branch of the posterior interosseus nerve (Dagum, 1998).
Postoperatively, the child will wear an arm sling for approximately 6 to 8 weeks, with the arm loosely secured to the chest, and will remain hospitalized for 2 days. Parents will be taught to perform wound care and dressing changes. Physical therapy will start with removal of the brace with passive range of motion and possibly with slow-pulse electrical stimulation (Terzis & Papakonstantinou, 1999). Therapy will progress gradually until full function is achieved or until there is a plateau in progress (Shen et al., 1998). The operating surgeon will periodically examine the child to determine further treatment.
When the child is no longer making progress with physical therapy, it is time to consider secondary reconstruction. These procedures are many and are typically reserved for children who have already had brachial palsy reconstruction. Their goal is to improve overall function (Shen et al., 1998;Terzis & Papakonstantinou, 1999). They are often performed in combination, and each procedure aims to improve a specific functional deficit.
Categories of secondary surgical intervention include muscle or tendon transfers, during which the decision is made to “weaken” one function to enhance another. L’Episcopo described the classic tendon transfer procedure for internal rotation. The latissimus dorsi and teres major muscles are transferred to create external rotators out of internal rotators (Dodds & Wolfe, 2000). Other procedures include nerve transfers, joint fusions, and rotational, wedge, or sliding osteotomies. In instances where a contracture reoccurs after release, a rotational osteotomy may be performed on the proximal humerus to improve function and appearance. Additional surgical options are outlined in Table 2 (Shen et al., 1998).
The postoperative course after secondary reconstruction includes a 2-day hospital stay and application of a shoulder spica and/or custom-fitted body brace for 6 to 8 weeks. The arm is immobilized in an external rotation and abduction for protection of the transferred tendon or muscle units. Patient-controlled analgesia (PCA) with morphine is used for pain control for at least 24 hours, after which oral analgesics, such as acetaminophen with codeine, are prescribed. Physical therapy begins when the splint is removed and continues for 6 months. Parents are taught to actively encourage and praise use of the operative arm by the child to maximize function.
A COMPlan (Clinical Outcomes Management Plan, Shriners Hospitals for Children, Tampa, FL) (see Figure 4) is a multidisciplinary plan of care that contains interventions on a timeline leading to desired outcomes. It helps to focus the patient’s plan of care for a given diagnosis, procedure, or problem. It functions as a cueing mechanism so all staff will be aware of what to expect on any given day. It is used in conjunction with flow sheets or narrative documentation.
COMPlans are patient care plans rather than nursing care plans. Essential components of care are anticipated and are less easily overlooked. Multidisciplinary collaboration is increased as clinicians begin to appreciate others’ viewpoints. The result is working together with the primary focus on patient outcomes.
A variance occurs when an outcome is not achieved or a medical intervention does not occur on the specified day. Accurate variance recording is important to the determination of trends and the management of problems. Variances may also indicate that the plan is not accurate and needs revision. These variances do not mean that the patient is in jeopardy.
Nursing care and interventions are clearly prioritized on the COMPlan. After each intervention is complete or each outcome achieved, the nurse highlights and initials it. If an intervention is not done, it is entered onto the variance form with a brief explanation. Variance forms (see Figure 5) are given to the COMPlan coordinator upon the discharge of a patient. Variance data are entered into a database for tracking. Information is shared with all clinical disciplines and the performance improvement coordinator. If a trend or problem has been identified, it is analyzed and can be solved quickly.
This child is a 5-year 10-month-old male who was the product of a normal vaginal delivery at 8 months’ gestation and weighed 5 pounds, 11 ounces. The mother was noted to have a cephalopelvic disproportion. A brachial plexus injury was noted immediately after birth, as well as a bruised forehead and bridge of the nose. He had slight jaundice but required no treatment. He had a CT scan that showed minor hemorrhage in the brain from which there has been no sequelae. He was discharged from the hospital in 3 weeks with instructions for the parents to perform range-of-motion exercises.
He underwent a neurolysis and exploration of the left shoulder at 8 months of age. He then received physical and occupational therapy. This procedure improved his nerve conduction velocity studies. He continued to have difficulty using his left upper extremity, which was evidenced as he started to play baseball, basketball, and T-ball at approximately 5 years of age. He had difficulty catching the ball, an inability to externally rotate or abduct his shoulder, and limited active forward elevation of his left upper extremity. He also began riding a bicycle at this time. He also had difficulty with supination of his forearm and full extension at his elbow. It was noted in June 2001 that he also had a hypoplastic glenoid and a posteriorly subluxed humeral head. He was admitted to the hospital in August 2001, with a diagnosis of left brachial plexopathy with internal rotation contracture. He underwent a left proximal humeral external rotation osteotomy and open reduction and internal fixation (ORIF), with Z-lengthening of the left pectoralis major and application of a shoulder spica cast (see Figure 6). Pain management included PCA morphine for 36 hours, followed by oral Tylenol with codeine. His postoperative course was uneventful, and he achieved appropriate outcomes as outlined in the COMPlan “Shoulder/Surgical” (see Figure 4). He was discharged on the second day after surgery.
He remained in his spica cast for 4 weeks, at which time his wound was checked and x-rays were obtained. He then wore an airplane splint for 4 weeks. Three months after his splint was discontinued, his mother stated that the improved external rotation of his arm is obvious and that he is able to lift his arm more easily. He is looking forward to resuming T-ball and riding his bicycle in the spring.
This child was born after an uncomplicated 9-month pregnancy and weighed 8 pounds, 10 ounces. At birth, she was noted to have a shoulder dystocia with bruising and swelling of the right upper extremity and was diagnosed with right upper trunk brachial plexopathy. She went home from the hospital after 3 days. Her arm was described as flail.
She was treated with an aggressive physical therapy regimen from 1 week of age on. She experienced much improvement with physical therapy and presented at clinic at 9 years of age. Her parents were most concerned with the cosmetic appearance of her elbow flexion and internal rotation of her shoulder. She was most concerned with her inability to do cartwheels like her friends, as well as other arm-overhead activities.
On examination, she was noted to have no active external rotation on the right. Internal rotation was fully active. She had an elbow flexion contracture of 30 degrees, with normal biceps and triceps function. She had normal wrist extension and flexion. Her right arm, however, was smaller then her left. Sensation was mildly decreased although present to light touch. At rest, she was noted to hold her right upper extremity internally rotated with the elbow flexed.
It was decided at this time to perform a right external rotation humeral osteotomy with fixation, which would improve the appearance in terms of position, and perhaps put the limb in a more functional position to use.
She did well postoperatively with her right arm in a sling, and her PCA morphine was discontinued on postoperative day 2. She did receive prophylactic antibiotics for 48 hours. She was discharged to her home on the second postoperative day, with limits placed on her recreational activities and instructions for range-of-motion exercises for her wrist and fingers.
One year later she underwent hardware removal. Four years postoperatively, she still complained of limited motion in her right elbow but had strong elbow flexion and good extension. She also had good motion and good strength in her hand. On examination she had full forward shoulder elevation bilaterally, full shoulder abduction, and full internal rotation. She could elevate her left arm functionally to approximately 140 degrees. No active intervention was required at this time. She was able to do most activities, and her biggest concern at this time was the widening of the surgical scar. She requested and was scheduled for a plastic surgery consult. She will return to shoulder clinic in 2 years for evaluation.
It is accepted that OBPP is a traumatic injury that occurs during birth. It is also generally agreed that results of operating on the brachial plexus are superior to spontaneous recovery (Gilbert, 1995). The timing of the surgical intervention remains the only unresolved issue. Most authors agree that if there is no return of biceps function by 3 months of age, surgical intervention is the best way to achieve maximum function. The majority of patients recover spontaneously, with no surgery and with extensive physical therapy. There are others whose prognosis is less favorable unless surgery is performed. It is of great importance to identify the type of brachial plexus injury early, especially if there is no recovery in the first few weeks of life. This allows surgical reconstruction to occur in optimal time for the best functional results (Terzis & Papakonstantinou, 1999). Nurses in the pediatric orthopaedic setting are in an ideal position to support parents in their decision to pursue surgical correction for OBPP. They can reassure parents that the choice they have made is a medically sound one that is based in clinical research.
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