Brachial plexus birth injury (BPBI) or Erb’s palsy is a relatively uncommon injury (1 to 2 in every 1000 babies) that occurs to a newborn baby during the process of vaginal delivery.
What is the Brachial Plexus?
There are 5 main nerves that arise in the spinal cord and provide
sensation and muscle power to the arm. These nerves then branch and
interconnect with each other in a complex way. This network of nerves that
supply the upper limb from the shoulder to the fingers is called the brachial
plexus.
What is the cause of brachial plexus birth injury?
Prolonged and difficult labour along with larger baby size are the
most common risk factors for brachial plexus injury at birth. Twin births, use
of vacuum or forceps during delivery and breech delivery also increase the
chances of developing this condition.
What are the types of brachial plexus birth injury?
The severity of the injury varies according to the pattern of
nerves affected and the type of injury to each nerve. The commonest pattern is
affection of the upper 2 nerves of the brachial plexus (C5 and C6) called Erb’s
Palsy. In around 20% of babies, all the 5 nerves are affected, called Total
Plexus Involvement. Drooping of the eyelid may also be seen in children with
total plexus involvement (Horner’s syndrome). In rare cases, the nerves controlling
the chest muscles can be affected causing breathing difficulties after birth.
Nerves can be stretched, ruptured, or torn away from the spinal
cord. In cases of a mild nerve stretch, complete recovery occurs within 6 to 8
weeks after birth. In case of more severe injuries, spontaneous recovery is
less likely and surgery to reconnect the nerves may be required.
Even in children with good recovery of hand function in the early stages, difficulty in lifting the arm or eating with the hand can occur at an older age (3 – 4 years) due to an imbalance in the shoulder muscles.
How is brachial plexus birth injury diagnosed?
The paediatrician or obstetrician will usually be able to make the
diagnosis by observation. Movements of the affected arm will be reduced or
absent. Moving the arm may be painful if there are associated fractures of the
collar bone. A thorough assessment is usually carried out at 4 weeks after
birth. Specialised scoring systems are used to document the severity of the injury
and the extent of recovery, if any. Specialised tests such as nerve conduction
studies and MRI scans are required only in case of doubt or if surgery is being
considered.
What is the treatment of brachial plexus birth injury?
In the first 6 weeks after birth, observation and simple exercises
are the mainstay of treatment. Electrical stimulation of the nerves can be
performed by physiotherapists with experience in managing babies. If there is
poor recovery by 3 to 6 months of age, surgery to reconnect the affected nerves
may be required. Nerve surgery provides good results only when performed in the
first 12 months after birth. In older children who are unable to use the arm or
shoulder, muscle release and tendon transfer surgery can be performed with good
results. It is advisable for all children with brachial plexus injury to take
up swimming, dancing and sports that strengthen the muscles of the arm and
shoulder.
What is the prognosis following brachial plexus birth injury?
The good news for parents is that the vast majority of brachial plexus injuries in infants recover completely without any disability. A small proportion of children may require nerve surgery in the first 12 months of life, if there is lack of spontaneous recovery. Problems with arm or shoulder function can be corrected even in the older child. Consulting an expert in the management of brachial plexus birth injury soon after birth allows medical professionals to assess the condition properly, counsel the parents and start appropriate management at the earliest.
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