“Brachial Plexus Birth Injuries and Surgical Management as Part of Interdisciplinary Care: An Updated Review”

“Brachial Plexus Birth Injuries and Surgical Management as Part of Interdisciplinary Care: An Updated Review” | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 26 April 2025 V1 Latest version Share on “Brachial Plexus Birth Injuries and Surgical Management as Part of Interdisciplinary Care: An Updated Review” Authors : Morgan Lentz , Robert E. George , Stephanie Shen , Samantha Younglove , Bermans J. Iskandar , Brett F. Michelotti , Michael L. Bentz , and Jacqueline S. Israel 0000-0002-8924-0603 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174565447.76699148/v1 293 views 206 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Obstetricians counsel pregnant patients and partners on the risks of childbirth, including brachial plexus birth injury (BPBI), at which time there is an opportunity to mention early referral to a center that offers multidisciplinary care to patients with BPBIs. Early referral for BPBI significantly improves patient outcomes. In certain cases of BPBI, surgical intervention is indicated and improves function for the patient and quality of life for them and their family. This article is a collaboration between obstetricians, plastic surgeons, and neurosurgeons with the aim to provide a review of BPBI with focus on indications and options for surgical management. Title Page: “Brachial Plexus Birth Injuries and Surgical Management as Part of Interdisciplinary Care: An Updated Review” Author list: Morgan Lentz , BS 1 ; Robert E. George , MD 1 ; Stephanie Shen , BA 1 ; Samantha Younglove , DO 2 ; Bermans J. Iskandar , MD 3 ; Brett F. Michelotti , MD 1 ; Michael L. Bentz , MD 1 ; Jacqueline S. Israel , MD 1 1. 600 Highland Ave, Madison, WI 53792, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin - Madison, Madison, WI 2. 9000 N Main St #328, Dayton, OH 45415, Department of Obstetrics and Gynecology, Wright State University, Dayton, OH 3. 600 Highland Ave, Madison, WI 53792, Department of Neurological Surgery, University of Wisconsin - Madison, Madison, WI Corresponding author: Jacqueline S. Israel Assistant Professor [email protected] 600 Highland Avenue Madison, WI 53792 (715)210-9959 Financial Disclosure Statement: The authors have no disclosures. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. This study was not funded. Contributions to Authorship: Each author was involved in the conception, planning, carrying out, analyzing and writing up of this work. Continuation Page: Short Title: Brachial Plexus Birth Injuries: Interdisciplinary and Surgical Care Abstract: Obstetricians counsel pregnant patients and partners on the risks of childbirth, including brachial plexus birth injury (BPBI), at which time there is an opportunity to mention early referral to a center that offers multidisciplinary care to patients with BPBIs. Early referral for BPBI significantly improves patient outcomes. In certain cases of BPBI, surgical intervention is indicated and improves function for the patient and quality of life for them and their family. This article is a collaboration between obstetricians, plastic surgeons, and neurosurgeons with the aim to provide a review of BPBI with focus on indications and options for surgical management. Tweetable Statement: Obstetricians can counsel new parents about the importance of early multidisciplinary care for infants with brachial plexus birth injuries who with early assessment, multidisciplinary care, and surgery when indicated, have improved function and quality of life. Introduction Brachial Plexus Birth Injuries (BPBIs) may occur during childbirth and can be serious and life-altering, potentially leading to long-term hand, elbow, and shoulder dysfunction. While in many cases these injuries may spontaneously recover and/or be appropriately managed nonoperatively, operative intervention may be indicated for some BPBIs. The lack of consistent guidance for differentiating which patients require operative versus nonoperative care can make it challenging for primary care providers to identify patients who need prompt referral to a multidisciplinary team. 1,2 Obstetricians counsel pregnant patients and partners on the risks of childbirth, including BPBI, at which time there is an opportunity to mention early referral to a center that sees patients with BPBIs. Neonatologists, perinatologists, and pediatricians additionally have an opportunity to provide early recognition of BPBI in children and facilitate prompt referral to a multidisciplinary center for comprehensive assessment, and if indicated, surgery. Early referral for BPBI significantly improves patient outcomes. 3–6 The majority of litigation regarding BPBI is due to suboptimal physician-patient communication, rather than severity of injury. 7 As a result, a strengthened understanding of BPBIs can not only help obstetric care providers enhance patient care but also can potentially provide protection from malpractice lawsuits. A nuanced comprehension of BPBIs can also augment the prenatal conversation regarding risks of delivery. This article is a collaboration between obstetricians, plastic surgeons, and neurosurgeons with the aim to provide a review of BPBI with focus on indications and options for surgical management. Anatomy The brachial plexus is a highly intricate nervous network formed by the anterior rami of the C5 through T1 nerves to provide sensory and motor function to the upper limbs. The brachial plexus is illustrated in Figure 1 (Figure 1). Each anatomic level of the brachial plexus is responsible for distinct motor and sensory functions. The most commonly involved structures in BPBIs are the C5-C6 nerve roots. 8 Other structures involved in BPBI, although less common, include the C8-T1 nerve roots and on some occasions, the C5-T1 nerve roots. Pan-plexus injury is possible but rare. 9 Pathophysiology The Seddon and Sunderland classification systems are widely used to characterize, prognosticate, and guide treatment decisions based on what components of the nerve are damaged. The anatomy of a peripheral nerve is seen in Figure 2 (Figure 2). The Seddon Classification characterizes peripheral nerve injuries into three categories: neurapraxia, axonotmesis, neurotmesis. 10 Neurapraxia is focal demyelination of a nerve with otherwise preserved architecture of the axon and its surrounding connective tissue. Axonotmesis involves damage to both the myelin and the axon. Neurotmesis occurs when there is complete nerve transection. The Sunderland Classification expands on the degree of injury with a grading system of one through five corresponding with increasing severity. 11 A Sunderland first degree injury is neurapraxia. Sunderland second-, third-, and fourth-degree injuries are axonotmesis. More specifically, a second degree is when the surrounding connective tissue, namely the endoneurium, perineurium, and epineurium, remain intact, whereas a third degree includes damage to the endoneurium, and a fourth degree includes damage to both the endoneurium and perineurium. 11 Sunderland fourth degree injuries are especially important as this is the point where surgical intervention is likely necessary for recovery. A Sunderland fifth degree injury corresponds with neurotmesis (e.g. transection) and necessitates surgical repair; this includes nerve root avulsion which very rarely has spontaneous recovery without repair. 11 BPBI can occur by various mechanisms and some newborns are at a higher risk of BPBI due to certain maternal and fetal characteristics, as well as the method of vaginal delivery. BPBI-associated risk factors in maternal medical history include preeclampsia and diabetes while risk factors during delivery include mechanical extraction techniques such as the use of forceps, shoulder dystocia, fetal-maternal disproportion, prolonged labor, or breech delivery. 12–14 Newborn factors that may contribute to risk include macrosomia (birthweight ≥ 4000g), gestational age, shoulder subluxation, and torticollis. 12–14 The mechanism of injury for BPBI usually involves an increase in the neck-shoulder angle that produces longitudinal stretching forces which exceed the tensile stress tolerance of a nerve. 1 During the birthing process, expulsive forces generated by the uterus, external forces required to deliver the baby, or a combination of the two, are often responsible for production of such stretching forces. 1 Compression forces may also contribute to BPBI and can be produced by hematoma, humerus or clavicle fractures, or instrumentation utilized during delivery. The classic mechanism of injury for BPBI is when birth is complicated by shoulder dystocia with the newborn’s shoulder impinging on the mother’s sacral promontory and manual traction of the newborn’s neck is required to deliver the child from the birthing canal. 15 More recent literature suggests that shoulder dystocia is not the only cause of BPBI; intrauterine injury due to uterine maladaptation, for example high intrauterine pressures, are additional contributors, resulting in brachial plexopathies in utero. 16,17 Intrauterine brachial plexus injury may also result from uterine malformation such as uterine constraint from a bicornate uterus. 18 Incidence of Obstetrical Plexus Injuries It is estimated that BPBI occurs in up to 0.4% of births. 14 BPBI has been most commonly associated with vaginal delivery while caesarean section has been considered to be protective, especially in pregnancies with high risk factors such as fetal macrosomia; however, the incidence of BPBI has continued to rise despite increasing rates of caesarean sections. 19–21 Although less common than in vaginal births, infants delivered by caesarean section can also have BPBI. 22 While 85-90% of BPBI cases recover spontaneously, antigravity function may not be demonstrated until the first or second year of life and this recovery, while functional, may be incomplete, requiring occupational therapy and surgical interventions such as muscle or tendon transfers in the future. 23,24 Careful assessment of newborns with BPBIs must be completed to help clinicians guide families on the timing and types of intervention necessary for optimized recovery. Impact of Brachial Plexus Birth Injuries BPBIs can have great impact on patients, families, and the healthcare system. Most parents describe learning of the newborn’s disability as a traumatic and distressing experience and are significantly impacted by stress regarding their child’s injury for up to 12 years after diagnosis. 25 Both adults with longstanding deficits related to BPBI and the parent(s) of children with BPBI report a lower quality of life when compared to the general population, with negative impact on employment potential, access to disability benefits, and need for caregiver support. 26,27 Patients with BPBI may experience debilitating chronic pain and long-term challenges with upper extremity function. 26 This impairment restricts their ability to perform activities of daily living, participate in leisure activities, and fulfill occupational or parenting responsibilities. 26 The psychosocial impacts of this obstetrical trauma include social isolation, lowered self-esteem, difficulty making and maintaining relationships, and heightened awareness of visible deformities. 28 BPBI also has significant implications for healthcare teams including litigation and cost of care. 7 These injuries are a source of legal disputes for the interdisciplinary team ubiquitously involved in the care of this patient population. 7 Few studies have identified clinical peripartum factors specific to obstetric care that are associated with birth complications resulting in litigation; discussions have highlighted factors unrelated to the delivery, such as family dynamics and caregiver perceptions. 7 A 2016 study found that the most significant factor associated with legal pursuit by patient families was whether the infant required surgical reconstruction. 7 Management of BPBI can also be extremely costly. Neonates with BPBI have 1.48 times longer hospital stay and 2.21 times greater hospital costs than neonates without BPBI as they require more therapies, greater time for work-up, and more subspecialty consulting. 29 In addition, families report high cost of travel and lost wages due to time away from work for medical appointments as the greatest financial burdens associated with the child’s BPBI. 30 Assessment Infants with BPBI commonly present with flaccid paresis of the affected limb (Table 1). 31 Passive range of motion can be assessed by the child’s pediatrician for shoulder subluxation, dislocation, or contractures, with caution exercised if there is a fracture. Clavicle and upper extremity fractures may also be present as they can suggest concomitant trauma to the brachial plexus. 32,33 Torticollis, or abnormal neck muscle contraction limiting movement, is associated but not pathognomonic for a BPBI. 6 While the incidence of phrenic nerve injury is low (1 in 15,000-30,000 live births), infants with such injuries should especially be evaluated for BPBI as approximately two thirds of infants with phrenic nerve injury have a concurrent BPBI. 34 A newborn’s motor function can help localize the level of the injury, as seen in Table 1 (Table 1), and parents should be educated on more common signs to look for. When the C5-C6, and sometimes C7, nerve roots are injured, there is lack of active shoulder abduction and elbow flexion while hand flexion is commonly preserved. The elbow may be extended, forearm pronated, with the wrist and digits held in flexion, commonly known as the “waiter’s tip” position or Erb-Duchenne (or Erb’s) palsy. 6 When the C8-T1 nerve roots are injured, complete hand and wrist involvement occurs often, and exam may demonstrate a flaccid hand in an otherwise active arm known as Dejerine-Klumpke (Klumpke’s) palsy. 35 A positive Horner’s sign, with ipsilateral eyelid ptosis, miosis, and anhidrosis, indicates injury to the lower trunk, specifically at the T1 root proximal to the level at which the sympathetic fibers separate from the somatic motor fibers. 6 Winging of the scapula indicates injury to the long thoracic nerve which arises from the C5-C7 nerve roots. Horner’s and scapular winging both indicate a very proximal, and likely avulsion, injury. Injury to C5-T1, or a total plexus palsy, causes a flail limb, in which no spontaneous motor activity is present. 6 Interventions Reconstruction for BPBI is most commonly done between 3 and 9 months of age. 36–38 However, initial surgical intervention with nerve procedures has been reported as early as 1 month to as late as 24 months of age and the most effective timing of surgical intervention for BPBIs remains controversial. 39–43 The exact timing of surgery is controversial because the potential for spontaneous recovery is variable and depends on the type of injury. For example, a total plexopathy is best repaired within weeks of the injury whereas a partial plexopathy is best addressed with surgery within three to six months of the injury when antigravity function in shoulder abduction and elbow flexion remains absent. 63,64 Following these surgical timelines has demonstrated functional improvement in patients with BPBIs as demonstrated by increased scores on the Active Movement Scale. 65 Antigravity shoulder abduction and elbow flexion strength are the most reliably recovered after surgery as the primary goal of BPBI surgical intervention is to reinnervate these functions. 66 Families should be counseled, however, that full recovery may take a year or more postoperatively as the nerves require time for recovery, and later reconstructive procedures, like nerve or tendon transfers, may be needed to fine tune function. These considerations highlight the challenge of managing BPBIs, but educating patients and their families and continuing to investigate best practices for BPBIs will help optimize patient outcomes. Parents may ask about what to expect in the setting of high risk for BPBI. At 2 weeks of age, the infant’s BPBI can be categorized into one of four groups described by Narakas, where a higher group number corresponds to a lower chance of spontaneous recovery and a greater need for intervention. Group 1 is an upper Erb’s palsy, 2 is an extended Erb’s palsy, 3 is total palsy with no Horner syndrome, and 4 is total palsy with Horner syndrome. 6,44 Group 2 is further broken into Group 2A (extended Erb’s and ’early recovery of wrist extension’) and Group 2B (extended Erb’s and ’no early recovery of wrist extension’) as patients with early recovery of wrist extension have demonstrated significantly higher percentages of spontaneous limb function recovery than those without. 45 Because lesions categorized as Group 4 have no to poor recovery of hand function, surgery is almost universally agreed to be indicated. 44,45 Occupational therapy and rehabilitation are essential components of early and late nonoperative management. These interventions are important in nearly all patients as they demonstrate effectiveness in improving disability. 46 Further intervention with primary microsurgical nerve repair is indicated in the following situations. Patients with injuries causing extended Erb’s palsy and Horner syndrome are best managed with surgical intervention due to very low chance of spontaneous function recovery. 47 BPBIs involving avulsions are also generally agreed to require early repair as recovery is unlikely. 11 Patients with a flaccid arm resting in intrinsic minus position or “claw hand” due to loss of intrinsic hand muscle function, may represent T1 avulsion; if the avulsion is not obvious, referral to a multidisciplinary center is particularly essential so the injury’s potential for recovery can be determined and surgery can be promptly pursued if there is no recovery in the first year of life. 12 One of the most common indications for surgery is the lack of biceps function by age 3 months. 6,12,48,49 However, because biceps function or lack thereof is not perfectly predictive of the probability for spontaneous function recovery in BPBIs, assessing elbow flexion and elbow, wrist, thumb, and finger extension may have higher utility as it has been shown to have better prognostication as it reduces the rate of incorrect recovery prediction to 5.2%. 50 Nonetheless, operative management for lack of biceps function at 6 months produced better outcomes than those managed nonoperatively. 5 Further evaluation utilizing the Test Score of Clarke and Curtis at age three months has been shown to be a validated instrument for use as an indication for operative intervention. 6,38 Pre-operatively, patients may require a diaphragmatic ultrasound to assess phrenic nerve function and a CT myelography to assess which roots are avulsed. 6 There are several techniques that can be used in BPBI, including neurolysis, neuroma resection and nerve grafting, and nerve transfers. Direct repair, when feasible, for example in a single nerve injury, is preferred and superior to grafting. However, if the plexus is significantly damaged, direct repair is undesirable as achieving a tensionless repair is difficult and hence, poor outcomes ensue. 51 Similarly neurolysis, surgical release of scar tissue or fibrosis, of a single injured nerve works well if the nerve action potentials identified by neuromonitoring confirm the presence of sufficient axons. However, neurolysis of a vastly damaged plexus is not useful. 41 Previously, excision of conducting and nonconducting neuromas with nerve grafting was advocated for broadly with the use of the sural nerve as an autologous graft. 51,52 Now, the most commonly performed surgical treatment for BPBI is distal nerve transfers. 53–55 Nerves grow at approximately 1 mm per day and unlike adults due to their longer limbs, infants with BPBI are able to more reliably regain hand function after nerve transfers. 51 In general, nerve transfers utilize a donor nerve with redundant or less critical function that is transected and surgically approximated to a deinnervated recipient nerve to restore function. Distal nerve transfer techniques utilized in complete plexopathy include the spinal accessory nerve to the suprascapular nerve to correct shoulder abduction and intercostal nerves to the musculocutaneous nerve and the phrenic nerve to the distal musculocutaneous nerve to correct elbow flexion. 53–56 In addition to the aforementioned nerve transfers, upper plexopathies can be addressed by transferring the medial head of the triceps branch of the radial nerve to the axillary nerve to correction shoulder abduction and the medial pectoral nerve to the musculocutaneous nerve and the ulnar and/or median nerve fascicle to the musculocutaneous nerve to correct elbow flexion. 55,56 As children age, tendon transfers may also be utilized to augment upper extremity function. 57–61 This is most commonly needed when a patient with a BPBI has shoulder contracture from imbalanced internal and external rotators; the tendon transfer restores this balance by reinforcing external rotation and abduction of the shoulder. 57 Transfer of the latissimus dorsi and teres major tendons are most commonly performed. 57,59,60 Prolonged rotator imbalance can cause a glenohumeral joint deformity leading to glenohumeral joint dysplasia which can be addressed via derotational osteotomies. 57,62 Conclusions Obstetricians, in addition to neonatologists, perinatologists, and pediatricians, can play a vital role in management during pre-birth counseling with new parents which may help direct an affected infant to a multidisciplinary plexus center as early as possible. The healthcare team can provide comprehensive intervention on BPBIs and early multidisciplinary team assessment and surgery, if indicated, improves function and quality of life. References 1. Coroneos CJ, Voineskos SH, Christakis MK, et al. Obstetrical brachial plexus injury (OBPI): Canada’s national clinical practice guideline. BMJ Open . 2017;7(1):e014141. doi:10.1136/bmjopen-2016-0141412. Nayak A, D’Souza A, Bhat AK, et al. Role of Early Referral and Surgical Intervention in Brachial Plexus Birth Palsy: Awareness Among Obstetricians and Pediatricians in a Teaching Hospital. Int Q Community Health Educ . 2020;40(4):363-366. doi:10.1177/0272684X198835233. Malessy MJA, Pondaag W, Yang LJS, et al. Severe Obstetric Brachial Plexus Palsies Can Be Identified at One Month of Age. PLOS ONE . 2011;6(10):e26193. doi:10.1371/journal.pone.00261934. BELLEW M, KAY SP. Early Parental Experiences of Obstetric Brachial Plexus Palsy. 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Plast Reconstr Surg . 2019;143(5):1017e-1026e. doi:10.1097/PRS.0000000000005557 Supplementary Material File (table 1 bpbi paper.docx) Download 14.70 KB Information & Authors Information Version history V1 Version 1 26 April 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords antenatal care clinical guidelines fetal medicine fetal medicine: fetal physiology paediatrics: general paediatrics: neonatal paediatrics: surgical Authors Affiliations Morgan Lentz University of Wisconsin-Madison Department of Surgery View all articles by this author Robert E. George University of Wisconsin-Madison Department of Surgery View all articles by this author Stephanie Shen University of Wisconsin-Madison Department of Surgery View all articles by this author Samantha Younglove Wright State University College of Health Education and Human Services View all articles by this author Bermans J. Iskandar University of Wisconsin-Madison Department of Neurological Surgery View all articles by this author Brett F. Michelotti University of Wisconsin-Madison Department of Surgery View all articles by this author Michael L. Bentz University of Wisconsin-Madison Department of Surgery View all articles by this author Jacqueline S. Israel 0000-0002-8924-0603 [email protected] University of Wisconsin-Madison Department of Surgery View all articles by this author Metrics & Citations Metrics Article Usage 293 views 206 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Morgan Lentz, Robert E. George, Stephanie Shen, et al. “Brachial Plexus Birth Injuries and Surgical Management as Part of Interdisciplinary Care: An Updated Review”. Authorea . 26 April 2025. DOI: https://doi.org/10.22541/au.174565447.76699148/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. 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