Obstetric Brachial Plexus Injury (OBPI), also known as Birth Brachial Plexus Injury (BBPI), refers to the paralysis of one arm from the neck down in an infant shortly after birth. This condition occurs due to an injury to the Brachial Plexus while the baby passes through the birth canal.
Unfortunately, OBPI is relatively common among newborn children, with an incidence rate of 0.38 to 1.56 cases per 1000 live births.
Following birth, newborns are routinely examined by pediatricians in hospitals. Any loss of movement in the arm or hand is identified and monitored. If arm palsy is detected, parents are advised to consult a Plastic surgeon for confirmation of the diagnosis and potential early intervention.
In rural areas where immediate post-birth evaluations are not feasible, arm paralysis in children with BBPI often goes unnoticed initially by parents. As the child grows and experiences difficulty performing normal hand functions, they are taken to a physician. Due to a lack of awareness, even healthcare professionals may fail to refer the child to the appropriate specialist promptly, leading to delayed intervention and suboptimal outcomes.
Several risk factors increase the likelihood of a child developing BBPI, including:
Yes, spontaneous recovery is possible in cases of BBPI. Although some children experience natural improvement, there remains a subset of children who do not recover and require primary or secondary surgical intervention.
Obstetrical brachial plexus palsies are categorized into two major types based on the extent and severity of the injury:
Upper Brachial Plexus Palsy (“Erb’s Palsy”) – Involving the C5 and C6 nerve roots and sometimes C7 as well. This condition results in no movement at the shoulder and elbow joints but normal hand grip function.
Complete Brachial Plexus Palsy – Involving all nerve roots from C5 to T1, leading to a complete lack of movement at the shoulder, elbow, and hand, along with complete sensory loss.
In most cases, babies with a brachial plexus injury regain some or full movement in the affected arm. Mild cases may improve without treatment. However, the concept of “wait and watch” has been replaced with early intervention to achieve better outcomes. Early intervention has proven to be more effective, aligning with results observed in adult patients after injury.
Nerve repair outcomes in children differ from those in adults. Paralysis in children due to obstetric causes is usually not complete, with some fibers undergoing reinnervation due to neuromas crossing and resulting in minimal muscle activity. This innervation keeps the muscles viable and suitable for later nerve surgery.
Nerve surgery in children with BBPI typically involves two main approaches:
Nerve Repair with Nerve Grafts: Using a nerve from another part of the body (usually the back of the foot and leg) to patch an injured nerve in the brachial plexus.
Nerve Transfer: Connecting a healthy nerve outside the brachial plexus or an intra-plexus functioning nerve to the nerve whose function needs to be restored. Nerve transfer has the advantage of facilitating faster muscle reinnervation.
Brachial plexus birth palsy injuries are usually low-velocity injuries. Injuries are either nerve rupture or in-continuity injuries but nerve avulsions from the spine are rare. The distance between the injured nerve ends is small in children after an injury during birth and hence reinnervation occurs leading to misdirected cross-innervation of fibres. This results in inadequate recovery of muscles and co-contractions.
Some muscle groups recover earlier than their antagonists and the unopposed action of these muscles combined with co-contractions could result in no action at the joints and contractures.
The result is-
a) inadequate functional range of moments and
b) deformities at various joints which are initially correctable but can lead to fixed
contractures if not corrected.
How are various deformities arising from BPBP corrected in a child?
A) Shoulder Deformities –
B) Elbow Flexion Deformity – This can be corrected by the serial casting of the joint.
C) Forearm Deformities – These can be either supination deformity or pronation deformity.
These deformities can be corrected by rerouting specific muscles and osteotomies.
D) Hand Deformities – Loss of wrist extension
These hand deformities can be corrected by tendon transfers.
E) Other Deformities – There could be other deformities as well in a child which can be corrected as per the requirement.
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OBPI or BBPI refers to a condition in which an infant’s brachial plexus nerves are injured during the process of childbirth. This can occur due to various factors, including shoulder dystocia or difficult deliveries.
Newborns with OBPI/BBPI may exhibit weakness, limited movement, or paralysis in one arm. They might also display signs of discomfort when the affected arm is touched or moved.
OBPI/BBPI can result from the excessive pulling or stretching of the baby’s shoulder during a difficult delivery. Risk factors may include macrosomia (large baby), maternal diabetes, or a breech presentation.
Diagnosis typically involves a physical examination by a pediatrician or neonatologist who assesses the baby’s arm movements and reflexes. Further evaluation may include imaging studies such as ultrasound or MRI.
Treatment options vary depending on the severity of the injury. Mild cases may resolve with physical therapy, while more severe cases may require surgery to repair damaged nerves or muscles. Early intervention is crucial for the best outcomes.
The prognosis varies based on the extent of the injury and the effectiveness of treatment. With early diagnosis and appropriate intervention, many infants with OBPI/BBPI can achieve near-normal function in their affected arm, although some residual weakness or limitations may persist.
Dr. Amit uses a combination of physical examinations and diagnostic tools like ultrasound or MRI to assess and diagnose OBPI/BBPI in newborns accurately.
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