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Obstetric Brachial Plexus Palsy (OBPP) 

Sub-topics

Introduction / Aetiology / Classification / Clinical Features / 

Diagnosis (Electrophysiology)  / Prognosis / Treatment / Surgery / 

Results / Late Effects of OBPP.

Treatment

Physiotherapy

It must be emphasised to patients that the physiotherapy session are merely adjuncts to parents administering exercises to child's limb. It is a tragedy if parents wait for the physiotherapy appointment each few times a week to work on the limb. As a rule parents can be taught the regime and be advised to do them just before each feed. There are three main maneuvers:

1. With the elbows bent and arm by the side of the body, the forearm is rotated outwards (Picture 1).

2. Keeping the scapula steady, the shoulder is abducted passively to increase the inferior glenohumeral angle (Picture 2).

3. Keeping the scapula steady, the upper limb is moved across the  chest (abduction and forward flexion. This reduces the posterior glenohumeral angle (Picture 3).

 Click pictures for larger images.

        (Picture 1)                        (Picture 2)                (Picture 3)

Surgical Treatment

Exploration and Nerve graft

Controversy surrounds the indications for early exploration and repair the Brachial plexus with no definite agreement amongst workers in this field. Gilbert and Tassin proposed exploration if the biceps did not recover at three months. Michelow et al challenged this oversimplification and have proposed a elaborate scoring system that I personally have not seen applied. We feel it might exclude some children who need early repair and some some children who might have recovered on their own, might be subjected to unnecessary surgery.

The absolute indications for surgery are:

1. Group 4 lesions that are recovering well.

2. C 5/6 lesion with phrenic nerve palsy with diaphragm paralysis.

3. Group 1, 2 and 3 lesions that are poorly recovering supported by adequate neurophysiological evidence.

The surgery involves a General Anaesthetic. The position is supine. Recording electrodes are placed on the scalp and neck. The Median and Ulnar nerves are stimulated and SSEP (Somato-Sensory Evoked Potentials) recorded and compared from each side. The effects of the muscle relaxants in the general anaesthetic should be borne in mind.

The incision is transverse above the clavicle but a longitudinal limb can be added for the infraclavicular portion of the Brachial Plexus. The plexus is then dissected and the brachial plexus and injury is identified. There can be 3 types of lesions:

1. Lesion in continuity: At surgery the nerves seem to be intact. The nerve is actually stretched, tortuous or fibrosed but not ruptured. Recovery is useful but never complete.

2. Rupture: After rupture, the nerves end up being pulled apart and a gap is created. An end to end repair of the nerves is not possible as this repair would be under tension and therefore is likely to fail. Thus a nerve graft has to be performed.

3. Avulsion: The nerve root is avulsed from where it takes origin in the spinal cord. The dorsal root ganglion is seen attached to the distal nerve root.

Below is a depiction of the different types of lesions. Click on the picture for a larger image.

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Last modified: July 02, 2002