2.  Early days – congenital deformity.
 Smillie [1768] – Obstetric origin
 Danyau [1851] – Autopsy – lesion
 Duchenne [1861]- traction injury, OBPI
 ERB [1875]- pointed lesion at upper trunk
 Kennedy [1903]- early surgical repair
 Narakas [1981]- microsurgical results.

3.  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]

4.  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

6.  Stretching
 Overweight babies with cephalic
presentations
 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.

7.  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

8.  Lesions range from degree I[neuropraxia] – V
[neurotmesis or root avulsions].
 Upper trunk –1st
affected, most vulnerable
part.
 Upper trunk – mostly stretched
 Lower trunks – mostly ruptured

9.  U.E is flail & dangling
 Look for other extremities
 U.R: arm held in IR,add, active abd not
possible, elbow extended forearm pronated,
thumb flexed.
 Complete paralysis- vasomotor impairment,
pale & marble like color
 Horner’s sign
 Associated # [clavicle,humerus,]

11.  Complete Recovery
 Extent of paralysis regress, total paralysis limited
to U.R
 No improvement.

12.  C5-6: the arm is adducted and internally
rotated at the shoulder, elbow extended,
forearm pronated, wrist and (sometimes)
fingers flexed. (Classic waiter tip/Erb’s
palsy/upper roots).
 C5-7 : as above, although the elbow may be
slightly flexed.
 Intermediate root palsy C7.
 C5-T1 : the arm is totally flail with a claw
hand. marbled appearance, Horner’s
syndrome.

13.  Done at 2 months of age
 Not anatomic,
 Grading overall severity of lesion based on
clinical course.
 Prognosis.

16. X - RAY
 epiphyseal # of humerus, # clavicle,
 Later changes, retardation of growth,
deformity of shoulder jt & dislocation of radial
head.

17. EMG
 Performed at 3-4 wks- confirm neuropraxia or
axonotmesis
 At 2 months, signs of re-innervation.
EVOKED SENSORY POTENTIAL
 Useful to ascertain root avulsions
 Can be used preop to test the availability of
proximal stumps.

18.  Fluoroscopy- phrenic nerve injury.
 Lumbar puncture- xanthochromic CSF- in root
avulsions.
 C.T myelogram
 Fast spin Echo MRI: preganglionic nerve root
injuries.
 Large diverticulae and meningoceles are
indicative of root avulsions

19.  Nature of injury [rupture better]
 Lower plexus paralysis,
 global involvement,
 persistence of pupillary signs of phrenic nerve
palsy
 Ass. #.

20.  Physiotheraphy- cornerstone
 Rest for first 2 wks,
 Arm fixed across the chest by pinning
 ROM ex, facilitation of active movt, promotion
of sensory awareness.
 Avoid abduction & posterior projection of
shoulder. Limb to be supported when holding
baby
 Goals: minimizing bony deformities, Jt
contractues.
 Weight bearing activity-skeletal growth

21. Early nerve repair
 Indications:
1. Failure of recovery of biceps or deltoid at 3
months
2. Group III& IV lesions
3. Presence of Horners sign.

22.  Diminishing potential for axon regeneration with
age
 Cross innervation & muscle imbalance aborted
 Provide better condition for tendon transfer
 Nerve repair is superior to spontaneous recovery.

23.  Total palsy: 3 months
 Upper trunk palsy: 5 months
TYPE OF SURGERY
1. neurolysis,
2. resection and anastomosis in ruptures
3. nerve grafting using sural nerves as
interposition grafts.

24.  Repair using the proximal roots of the plexus itself
if the injury is post ganglionic as in a rupture
 Extra plexal neurotisation using other donor
motor nerves to selectively aim at reinnervating
the important muscle groups.

25.  Spinal accessory (XIth) nerve.
 Intercostal nerves (commonly 3rd to 6th)
 C4 motor root
 Ansa hypoglossi
 Opposite C7.

26.  Suprascapular
 Musculocutaneous,
 Axillary
 Median.
Order of priority of restoration of function
 Elbow flexion
 Shoulder stability (rotator cuff via
suprascapular nerve)
 Shoulder abduction
 Hand prehension

27.  To predict poor outcomes if microsurgical
repair or grafting is not done.
 scale consists of grading elbow flexion,
elbow extension, wrist extension, finger
extension, and thumb extension. [max -12]
 score of < 3.5 predicted a poor long-term
outcome without microsurgery.

28.  Fracture of clavicle or humerus shaft or physeal
separation
 septic arthritis / osteomyelitis
 Congenital malformation of plexus
 Postinfectious [varicella] plexopathy of muscles

29.  Nerve regeneration: some muscles recover
earlier, others paretic  muscle imbalance
 Recovery results from misdirection of regenerated
axons  cross innervation

30.  Co-contraction of synergestic & antagonistic
muscles
 Diminishing functional recovery
 Muscle contracture  deformity

31.  Sequelae depends on three factors which
are additive
1. Paralysis of muscle groups [ext.rot, elbow
flexors]
2. Contracture of healthy antagonist muscles
3. Impaired growth  osseous deformities
 Sequale – seen in spontaneous recovery in
gr III & IV lesion.

32.  Between shoulder abductors [S.S, I.S ,del] &
adductors [pect maj, ter.m]  limitation of
shoulder elevation
 Elbow flexors [biceps & brachialis] & elbow
extensors [triceps]
 Elbow flexors & shoulder abductors  trumpet
sign
 Shou abd, elb flex,forearm flex

33.  Putti sign; with shoulder abduction, medial
edge of scapula, often seen protruding above
shoulder jt line
 Reduction of shou abd – deltoid weakness or
lack of ER.
 Trumpet sign
 Mild shortening & atrophy of limb
 Posterior sublux of shoulder – IR overpower
ER.
 Bitting of nail & hand (47%) –total obp.

34.  UPPER ARM: mainly in shoulder & occ elbow &
forearm
 LOWER ARM: hand more affected
 WHOLE ARM; flaccid paralysis

35.  Group I: joint contracture due to nerve lesions
& simultaneous trauma to shoulder Jt
 Group II Flaccid; flaccid paralysis- upper trunk
injury.
 Group I: subdivided in to 4 groups

36.  I –internal rotation & adduction contracture
with preservation of Jt
 II – with Jt deformity – posterior subluxation &
dilocation
 III – external rotation & abd contracture-
anterior & inferior disloc
 IV –pure abduction contracture.

38.  Grade I ,II, mild grade III (slight posterior
subluxation) glenohumeral deformities have
an anterior musculotendinous lengthening of
the pectoralis major and posterior latissimus
dorsi and teres major transfer to the rotator
cuff
 Advanced grade III, IV, or V glenohumeral
deformities should have a humeral derotation
osteotomy.

39.  Fairbank: release of subscapularis & capsule.
 L’ Episcopco procedure improves external
rotation of the shoulder by releasing the
internal rotation contracture and transferring
the latissimus dorsi and teres major
posteriorly to provide active external rotation
 Wickstrom recommendes external rotation
osteotomy of the humerus for severe fixed
rotation contracture.

41.  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-metacarpal
arthrodesis.

42.  Elbow flexion and forearm supination
deformities
 weak or absent triceps, pronator teres, and
pronator quadratus muscles with an intact
biceps muscle
 Radial head dislocation
 wrist & hand usually in extreme dorsiflexion –
unopposed DF
 biceps tendon, Z-lengthened and rerouted
around the radius to convert it from a
supinator to a pronator

43.  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 with
tendon transfer or osseous surgry
 Conservative Rx – fruitless.