High Yield Overview
Brachial Plexus Birth Palsy
Obstetric Plexopathy | Erb's and Klumpke's | Early Referral
1-2 per 1000Incidence
C5-C6Erb's Palsy (Most Common)
90%Spontaneous Recovery
3-6 MoKey Observation Window
Narakas Classification
Type I (C5-C6)
PatternErb's. Waiter's Tip. Shoulder/Elbow weakness.
TreatmentObservation / Nerve Surgery
Type II (C5-C7)
PatternExtended Erb's. + Wrist/Finger Extension weakness.
TreatmentObservation / Nerve Surgery
Type III (C5-T1)
PatternTotal Plexus. Flail arm.
TreatmentNerve Graft (if no recovery)
Type IV (+ Horner's)
PatternTotal + Horner's (T1 root avulsion likely).
TreatmentNerve Transfer / Graft
Critical Must-Knows
- Definition: Stretch injury to the brachial plexus during delivery. Usually traction on the head-neck angle.
- Erb-Duchenne (C5-C6): 'Waiter's Tip' - Shoulder adducted, Elbow extended, Forearm pronated, Wrist flexed.
- Klumpke (C8-T1): 'Claw Hand' - Intrinsic weakness. Often associated with Horner's syndrome (T1 avulsion).
- Observation Window: Most recover spontaneously by 3-6 months. Surgery considered if no biceps function by 3-6 months.
- Shoulder Sequelae: Posterior dislocation (internal rotation contracture) is the major late complication.
Examiner's Pearls
- "Biceps recovery by 3 months predicts good overall recovery (Gilbert criteria).
- "Horner's syndrome (ptosis, miosis, anhidrosis) indicates T1 root avulsion - poor prognosis.
- "Late sequelae are primarily at the SHOULDER (Medial rotation contracture, posterior dislocation).
- "MRI of plexus is useful to identify root avulsions (pseudomeningoceles).
Clinical Imaging
Imaging Gallery
Click to expand
BPBP Pitfalls
Missed Fracture
Rule out Clavicle/Humerus fracture. Pseudoparalysis from pain mimics BPBP. X-ray essential.
Internal Rotation Contracture
The Silent Dislocator. Progressive internal rotation contracture leads to posterior shoulder subluxation. Monitor and stretch.
Delayed Referral
Window for Nerve Surgery is 3-6 Months. Delayed referral misses the optimal timing for nerve graft/transfer.
The 'Recovered' Child
Hidden Deficits. Even with good recovery, subtle weakness and Glenohumeral Dysplasia can progress. Long-term follow-up.
At a Glance: Erb's vs Klumpke's
| Feature | Erb-Duchenne (C5-C6) | Klumpke (C8-T1) |
|---|---|---|
| Frequency | 80-90% | Less than 5% |
| Posture | Waiter's Tip (Adducted, Pronated) | Claw Hand (Intrinsic minus) |
| Key Losses | Deltoid, Biceps, Supinator | Intrinsics, Finger Flexors |
| Horner's | No | Yes (if T1 avulsed) |
| Prognosis | Good (Majority recover) | Poor (Often permanent) |
Mnemonic
AIPEFWaiter's Tip Posture
A
Adducted
Shoulder Adducted (Weak Deltoid)
I
Internally Rotated
Shoulder Internally Rotated (Weak Infraspinatus)
P
Pronated
Forearm Pronated (Weak Supinator/Biceps)
E
Extended
Elbow Extended (Weak Biceps)
F
Flexed Wrist
Wrist Flexed (Weak Wrist Extensors if C7)
Memory Hook:Erb's Palsy Posture.
Mnemonic
Robert Taylor Drinks Cold BeerBrachial Plexus Roots
R
Roots
C5, C6, C7, C8, T1
T
Trunks
Upper, Middle, Lower
D
Divisions
Anterior, Posterior (each trunk)
C
Cords
Lateral, Posterior, Medial
B
Branches
Terminal Nerves
Memory Hook:Anatomy of the Plexus.
Mnemonic
1, 2, 3, Horner'sNarakas Types
I
C5-C6
Erb's (Shoulder/Elbow)
II
C5-C7
Extended Erb's (+Wrist/Fingers)
III
C5-T1
Total (Flail Arm)
IV
+Horner's
Total + Root Avulsion (Worst)
Memory Hook:Narakas Classification.
Overview and Epidemiology
Definition: Brachial Plexus Birth Palsy (BPBP), also known as Obstetric Brachial Plexus Injury (OBPI), is a stretch injury to the brachial plexus occurring during delivery. It results from lateral flexion of the head away from the shoulder, causing traction on the plexus.
Epidemiology:
- Incidence: 1-2 per 1000 live births.
- Risk Factors: Shoulder dystocia, Macrosomia, Forceps/Vacuum delivery, Breech presentation.
- Recovery: Approximately 80-90% recover spontaneously, often fully or with minimal residual deficit.
Neuroanatomical Pattern:
- Upper Plexus (Erb's - C5, C6 +/- C7): Most common (80-90%). Best prognosis.
- Lower Plexus (Klumpke's - C8, T1): Rare in isolation (less than 5%). Associated with Horner's.
- Total Plexus (C5-T1): Flail arm. Worst prognosis.
Pathophysiology and Mechanisms
Plexus Anatomy: The brachial plexus is formed by the ventral rami of C5-T1. It has 5 components (Roots, Trunks, Divisions, Cords, Branches).
- Upper Trunk: C5, C6.
- Middle Trunk: C7.
- Lower Trunk: C8, T1.
- Key Nerve Outputs: Musculocutaneous (Biceps), Axillary (Deltoid), Radial (Triceps/Wrist Extensors), Median (Forearm Flexors/Thenar), Ulnar (Intrinsics/Hypothenar).
Injury Mechanisms:
- Stretch/Neurapraxia: Temporary conduction block. Full recovery expected.
- Rupture: Nerve disrupted distal to DRG. Scar formation. May need grafting.
- Avulsion: Root torn from spinal cord. No spontaneous recovery. Requires nerve transfer.
Pathophysiology of Late Shoulder Deformity: Muscle imbalance (Strong internal rotators vs Weak external rotators) leads to:
- Internal rotation contracture.
- Posterior subluxation of glenohumeral joint.
- Glenoid retroversion, posterior humeral head flattening.
- Ultimately, Glenohumeral Dysplasia (GHD).
Classification
Narakas Classification
Based on clinical pattern and root involvement.
| Type | Roots | Presentation | Prognosis |
|---|---|---|---|
| I | C5-C6 | Erb's. Shoulder/Elbow weak. | Good (greater than 90% recover) |
| II | C5-C7 | Extended Erb's. +Wrist/Finger Ext weak | Good (70-80% recover) |
| III | C5-T1 | Total. Flail arm. | Guarded (20-30% recover) |
| IV | C5-T1 + Horner's | Total + Root Avulsion | Poor (No spontaneous recovery if avulsion) |
Horner's Syndrome (Ptosis, Miosis, Anhidrosis) indicates T1 root avulsion.
Clinical Assessment
Initial Exam (Newborn):
- Posture: Waiter's Tip? Flail? Claw?
- Passive ROM: Full in newborn (to exclude contracture or fracture).
- Reflexes: Moro (abducted arm doesn't follow), Grasp (if lower plexus involved).
- Horner's Syndrome: Ptosis, Miosis, Anhidrosis.
- Rule Out Fracture: Clavicle, Humerus (Pseudoparalysis). Order X-ray.
Serial Assessment:
- Active Movement: Use Active Movement Scale (AMS). 0-7 per muscle.
- Key Milestone: Biceps recovery. If antigravity biceps by 3-6 months, expect good recovery (Gilbert).
- Shoulder ROM: Monitor for internal rotation contracture (External Rotation deficit).
- Later: Mallet Classification for shoulder function.
Mallet Classification (Shoulder Function): Grades shoulder function (Abduction, External Rotation, Hand to Mouth, etc.).
- Grade I: Flail shoulder.
- Grade V: Normal.
- Grade II-IV: Intermediate.
Investigations
Imaging:
- X-ray (Clavicle, Humerus): Initial. Rule out fracture.
- MRI Brachial Plexus: If no recovery by 3 months. Look for pseudomeningoceles (root avulsion), neuroma.
- Ultrasound Shoulder: Assess glenohumeral joint if internal rotation contracture. Look for posterior subluxation, glenoid retroversion.
- CT Shoulder (3D): For surgical planning in older children with GHD.
Electrodiagnostics:
- EMG/NCS: Can differentiate neurapraxia from axonotmesis/avulsion. Often used to supplement clinical exam.
- Timing: 3-4 weeks after injury (for fibrillation potentials).
Management Algorithm
📊 Management Algorithm
Click to expand
Early Management (0-3 Months)
- Parental Reassurance: Majority recover spontaneously.
- Gentle ROM Exercises: Prevent contracture. Physio referral.
- Positioning: Avoid adduction contracture. Full ROM.
- Serial Exam: AMS at each visit. Document biceps recovery.
- Referral: If no biceps recovery by 3 months, refer to a BPBP specialist center.
Splinting is generally NOT indicated in BPBP.
Surgical Technique
Release and Transfer (Shoulder)
For Internal Rotation Contracture.
Anterior Subscapularis Release (Modified Carlioz):
- Indication: Internal Rotation Contracture greater than 20 degrees, Mallet III or less.
- Approach: Anterior axillary incision.
- Procedure: Release Subscapularis from humerus (lengthen or slide).
- Post-op: Immobilize in External Rotation (Spica or Shoulder Immobilizer) for 6 weeks.
L'Episcopo / Mod Sever-L'Episcopo:
- Indication: Weak External Rotation (Mallet II-III).
- Procedure: Transfer Latissimus Dorsi and Teres Major to the posterior humerus (act as External Rotators).
- Post-op: Similar. External Rotation immobilization.
Often combined: Release + Transfer.
Complications
Key Complications
| Complication | Cause | Management |
|---|---|---|
| Glenohumeral Dysplasia | Muscle imbalance, Internal Rotation Contracture | Early release, Osteotomy |
| Posterior Dislocation | Progressive dysplasia | Reduction + Bony Reconstruction |
| Internal Rotation Contracture | Weak ER, Strong IR | Stretching, Subscap Release |
| Elbow Flexion Weakness | Poor biceps recovery | Nerve transfer / Steindler |
| Co-Contraction | Abnormal re-innervation | Botox, Selective Transfer |
Glenohumeral Dysplasia (GHD): The major late complication. Characterized by:
- Glenoid retroversion.
- Posterior subluxation of humeral head.
- Flattening of humeral head.
- Eventual osteoarthritis.
Postoperative Care
- Nerve Surgery: Sling/Shoulder Immobilizer. Gentle ROM at 4-6 weeks. Expect recovery over 12-18 months.
- Tendon Transfer/Release: External Rotation Immobilization (Spica or Brace) for 6 weeks. Intensive physio after.
- Osteotomy: Sling. ROM as tolerated. Bone healing in 6-8 weeks.
Outcomes
Click to expand
- Erb's (Type I): Greater than 90% recover good function (Mallet IV-V).
- Total Palsy (Type III/IV): Poor prognosis. Permanent deficits common.
- Nerve Surgery: Improves function significantly but rarely restores normal.
- Long-term: Shoulder problems (GHD, OA) are the main late issues.
Evidence Base
Gilbert Criteria
Key Findings:
- Described biceps recovery by 3 months as key predictor.
- If no biceps by 3 months, consider surgical exploration.
- Established the modern framework for BPBP management.
Clinical Implication: Biceps recovery is the gold standard milestone.
Limitation: Expert opinion / Retrospective
Toronto Test Score
Key Findings:
- Developed a scoring system (AMS) to predict outcome.
- Score less than 3.5 at 3 months suggests need for exploration.
- More nuanced than Gilbert alone.
Clinical Implication: Use AMS to quantify recovery.
Limitation: Observational
Nerve Transfer Outcomes
Key Findings:
- Described ulnar fascicle transfer to biceps (Oberlin transfer).
- Rapid elbow flexion recovery (motor neurons already matured).
- Now a workhorse for elbow flexion restoration.
Clinical Implication: Nerve transfer can offer better results than graft in specific situations.
Limitation: Case series
Shoulder Surgery Outcomes
Key Findings:
- Showed release and transfer (L'Episcopo) improves shoulder function.
- Greater than 1 Mallet grade improvement expected.
- Timing important (before GHD progresses).
Clinical Implication: Secondary shoulder surgery is effective.
Limitation: Retrospective
Narakas Score Prediction
Key Findings:
- Described the classification system.
- Correlated injury pattern with prognosis.
- Type IV (Horner's) has worst prognosis.
Clinical Implication: Use Narakas for initial prognostication.
Limitation: Descriptive
Viva Scenarios
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
VIVA SCENARIOStandard
The Newborn with Arm Weakness
EXAMINER
"What is your assessment and initial management?"
EXCEPTIONAL ANSWER
**Likely Erb's Palsy (C5-C6).**
1. **Examination**: Confirm posture (Adducted, IR, Pronated, Extended). Check for Horner's (Ptosis/Miosis).
2. **Rule Out Fracture**: X-ray Clavicle and Humerus.
3. **Reassure Parents**: 90% of Erb's palsies recover spontaneously.
4. **Management**:
- Gentle ROM by parents (avoid contracture).
- Physiotherapy referral.
- Serial follow-up (every 2-4 weeks initially).
5. **Key Milestone**: Biceps recovery by 3 months.
6. **Referral**: If no biceps by 3 months, refer to BPBP specialist for nerve surgery consideration.
KEY POINTS TO SCORE
Rule out fracture
Reassure (90% recover)
Track biceps recovery
Refer if no biceps by 3mo
COMMON TRAPS
✗Missing clavicle fracture
✗Splinting (not needed)
✗Delaying referral past 6 months
LIKELY FOLLOW-UPS
"What is Horner's syndrome?"
"What is the Oberlin transfer?"
VIVA SCENARIOStandard
The Stiff Shoulder
EXAMINER
"What is your assessment and management plan?"
EXCEPTIONAL ANSWER
**Internal Rotation Contracture with Glenohumeral Involvement.**
1. **History**: Confirmed BPBP. What was Narakas? Nerve surgery done?
2. **Examination**:
- *Mallet Score*: Likely II-III.
- *Shoulder ROM*: Internal Rotation Contracture (can't ER past 0).
- *Active ER*: Is there any active ER power? (Key for surgery choice).
3. **Imaging**: Ultrasound or MRI Shoulder. Assess glenoid/humeral head (GHD?).
4. **Management**:
- *If no GHD*: Subscapularis Release +/- L'Episcopo Transfer.
- *If GHD*: May need bony osteotomy later.
5. **Goal**: Get hand to mouth. Improve function.
KEY POINTS TO SCORE
Assess passive and active ER
Image the GH joint
Release +/- Transfer
Goal: Functional Hand Position
COMMON TRAPS
✗Waiting too long (GHD worsens)
✗Ignoring GHD (release alone won't fix it)
LIKELY FOLLOW-UPS
"What is L'Episcopo?"
"When would you do a humeral osteotomy?"
VIVA SCENARIOStandard
The Infant with No Recovery
EXAMINER
"Discuss prognosis and management."
EXCEPTIONAL ANSWER
**Narakas Type IV. Poor Prognosis.**
1. **Significance of Horner's**: Indicates T1 root avulsion. No spontaneous recovery of that root.
2. **MRI**: Essential. Will likely show pseudomeningocele (avulsion) at T1, possibly C8.
3. **Prognosis**: For avulsed roots, NO spontaneous recovery. Nerve graft cannot reconnect avulsion.
4. **Management**:
- **Nerve Surgery (Urgent)**: Exploration, Nerve Graft for ruptured roots (C5-C7 if not avulsed). Nerve Transfers for avulsed roots (e.g., SAN to Suprascapular, Intercostal to Musculocutaneous).
- **Goals**: Elbow flexion (priority), Shoulder stability/abduction.
5. **Long-term**: Will likely need secondary shoulder surgery. Hand function will remain poor.
KEY POINTS TO SCORE
Horner's = T1 Avulsion
No spontaneous recovery from avulsion
Nerve transfer is key for avulsed roots
Prioritize elbow flexion
COMMON TRAPS
✗Expecting spontaneous recovery (Horner's = No)
✗Not doing MRI
✗Delaying surgery past 6 months
LIKELY FOLLOW-UPS
"What is the difference between transfer and graft?"
"Name a nerve transfer for elbow flexion."
MCQ Practice Points
Erb's Posture
Q: What is the classic posture in Erb-Duchenne palsy? A: Waiter's Tip - Shoulder Adducted and Internally Rotated, Elbow Extended, Forearm Pronated, Wrist Flexed.
Key Recovery Predictor
Q: What is the most important clinical predictor of good outcome in BPBP? A: Biceps recovery (antigravity elbow flexion) by 3-6 months.
Horner's Syndrome
Q: What does the presence of Horner's Syndrome indicate in BPBP? A: T1 root avulsion. Indicates poor prognosis (no spontaneous recovery of avulsed root). Nerve transfer required.
Major Late Complication
Q: What is the major late orthopedic complication of BPBP? A: Glenohumeral Dysplasia (GHD) - posterior subluxation and glenoid retroversion due to internal rotation contracture.
Oberlin Transfer
Q: What is the Oberlin procedure? A: A nerve transfer where a fascicle of the Ulnar nerve is transferred to the Musculocutaneous nerve (Biceps branch) to restore elbow flexion.
Australian Context
- Tertiary Referral: BPBP should be managed at specialized centers (e.g., Children's Hospitals with Hand/Peripheral Nerve Surgery expertise).
- Early Referral: If no biceps by 3 months, urgent referral for nerve surgery consideration.
- NDIS: Supports therapy, equipment, and long-term management.
High-Yield Exam Summary
Patterns
- •Erb's: C5-C6 (Waiter's Tip)
- •Extended Erb's: C5-C7
- •Klumpke: C8-T1 (Claw Hand)
- •Total: C5-T1 (Flail)
- •Horner's: T1 Avulsion
Key Milestones
- •Biceps by 3 months: Good
- •No Biceps by 6mo: Surgery
- •90% Erb's Recover
- •Horner's = Poor Prognosis
Surgery
- •Nerve Graft (Rupture)
- •Nerve Transfer (Avulsion)
- •Subscap Release (Contracture)
- •L'Episcopo (Weak ER)
- •Osteotomy (Fixed Posture)
Red Flags
- •Rule out Clavicle Fracture
- •Horner's = T1 Avulsion
- •Refer early (by 3mo)
- •Monitor for GHD