Brachial Plexus Birth Palsy

What it means?

          Brachial plexus birth palsy means injury to group of nerves from neck that supply the upper limb which control the muscle strength and feeling in the arm around the time of birth

What causes it?

          During birth, the nerves in brachial plexus which runs from neck to the upper limb can get stretched or torn. Due to this baby will not be able move the affected upper limb.

• Mild type only upper part gets affected which controls the shoulder and elbow known as ERB’s Palsy
• Worst type affects all of the nerves to the arm which results in inability to use entire arm from shoulder to fingers known as GLOBAL or TOTAL Palsy
• Rare type affects only lower part which results in loss of function of hand and wrist known as KLUMPKE Palsy

The severity of nerve injury depends on the amount of damage

• When the nerve is just stretched a little known as NEUROPRAXIA which will recover on its own within a few months
• When the nerve get stretched more known as AXONTEMESIS which results in formation of scar tissue at the damaged areas of nerve called NEUROMA. This type of injury nerve will recover but not completely
• When the nerve get stretched and breaks it apart known as NERVE RUPTURE which will not be able to recover on its own
• When the nerve get torn from the spinal cord in the neck known as NERVE AVULSION which is the worst type and will not be able to recover on its own

How child will present like?

• Baby will not able to move the affected upper limb partially or completely depends upon the severity of nerve damage
• Baby arm will be weak, not able to move actively like normal side, will lie on the side of the body, elbow extended, forearm turned down and wrist fingers were flexed

What are the tests required?

• Baby will be assessed clinically to check the severity of nerve injury and amount of weakness
• X-ray of the chest to check for any break in the collar bone (Clavicle)
• If baby fails to recover any functions even after 6 months then MRI need to be done to assess the severity of nerve injury and level of injury
• If older children recovered partially, but restriction of shoulder movement will need MRI and CT scan of the shoulder joint to assess whether the joint is slipping, slipped out or deformed which helps in determining the further treatment

What are the treatment options?

• Initially baby will not be able to his/ her upper limb on the affected side in order prevent stiffness, start therapy in the form of passively mother will be taught to move each and every joint of affected upper limb gentle manner. This helps to maintain the joint movement until nerve recover enough function
• If the baby not recover nerve function in the first 3 to 6 months will require surgery on the nerves in order to improve the arm function. Nerve surgery means scar tissue secondary to injury will be removed and working nerves will be connected to the nerves that do not work
• If the baby develops only stiffness of the shoulder joint which will start to come out of place and need to be addressed at the earliest before the shoulder joint get deformed or slip out of its joint space.
• Mild cases of shoulder stiffness can be treated with Botox and casting. If shoulder joint starts to slip out, this need shoulder muscle balancing surgery which means moving the tight muscles to less powerful muscles around the shoulder joint and helps to stabilise and prevent the shoulder from coming out again
• Older children with weakness and limitations of movement may require both bony and muscle surgery to improve function

What will be outcome?

• The outcome of this condition depends upon the severity of nerve injury at the time of the birth
• Early diagnosis and timely management according to the severity of injury helps to achieve better functional outcome