I. Epidemiology

  1. Injuries may occur intrapartum prior to delivery: 50%
    1. Unrelated to Shoulder Dystocia or excessive traction
    2. Possibly from fetal Shoulder against symphysis pubis
    3. May be unavoidable
  2. Reference
    1. Gherman (1998) Am J Obstet Gynecol 178:423-7 [PubMed]

II. General

  1. Follows difficult or prolonged delivery

III. Mechanism of injury

  1. Upper plexus Injury
    1. Lateral flexion of neck against fixed head, Shoulder
  2. Lower plexus Injury
    1. Arm forced upward

IV. Types

  1. Duchenne-Erb Paralysis (Waiter's Tip Deformity)
  2. Klumpke's Paralysis (Clawhand Deformity)
  3. Whole Arm Paralysis (uncommon)
    1. Limb completely flaccid
    2. Hands dry and atrophic
    3. All reflexes absent

V. Signs: General

  1. Arm motionless at side with elbow extended
  2. Moro Reflex absent on affected side
  3. Swelling above clavicle due to Hemorrhage
  4. Traumatic neuritis
    1. Tenderness to palpation
  5. Thoracic root injury
    1. Horner's Syndrome

VI. Differential Diagnosis: Pseudoparalysis

VII. Associated Conditions

  1. Phrenic Nerve palsy from Birth Trauma
  2. Horner's Syndrome

VIII. Radiology: XRay Shoulder and XRay arm

  1. Assess for concurrent Fracture

IX. Management

  1. Prevent fixed soft tissue contractures
    1. Gentle repetitive range of motion Shoulder and elbow
    2. Supportive splints for wrist and fingers
  2. Reconstructive surgery for late deformities

X. Prognosis

  1. Improvement in first week suggests full recovery
  2. No improvement by 6 months suggests permanent deficit
  3. No improvement expected after 2 years
  4. Older patients
    1. Underdevelopment of Upper extremity
    2. Humerus shortened
    3. Contractures and disuse atrophy

XI. Resources

  1. The National Brachial Plexus, Erb's Palsy Association
    1. http://www.nbpepa.org

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