Birth trauma and brachial plexus injury

Overview & Definition

Birth trauma is the physical injury a newborn sustains during the mechanical forces of labour and delivery. It spans the gamut from trivial soft-tissue bruising and clavicular fracture to the devastating neurological injuries that shape a child's lifetime function — and the most important of these, because of its frequency and its treatability, is brachial plexus birth injury (BPBI). A newborn who holds one arm adducted, internally rotated, and pronate at the side with the wrist flexed — the so-called waiter's-tip posture — has an upper-trunk (Erb-Duchenne) palsy until proven otherwise. [1] [2]

Brachial plexus birth injury is the traction injury of the C5–T1 nerve roots sustained when the head and neck are forced laterally away from the shoulder during delivery. It is not a single disease but a spectrum, graded by the Narakas system from a mild conduction-block neurapraxia (grade I, near-complete recovery) to a total-plexus injury with preganglionic root avulsion and Horner syndrome (grade IV, the poorest outcome). The decisive clinical task is not the diagnosis at birth — the posture makes it obvious — but the disciplined monthly tracking of recovery, because the absence of biceps recovery by three months is the threshold that separates the infants who will recover spontaneously from those who need microsurgical nerve reconstruction. [2] [3]

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1. [1]Foad SL; Mehlman CT; Ying J The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Joint Surg Am, 2008.PMID 18519319
2. [2]Hale HB; Bae DS; Waters PM Current concepts in the management of brachial plexus birth palsy. J Hand Surg Am, 2010.PMID 20141905
3. [3]Hoeksma AF; ter Steeg AM; Nelissen RG; van Ouwerkerk WJ; de Jong BA; Lankhorst GJ Neurological recovery in obstetric brachial plexus injuries: an historical cohort study. Dev Med Child Neurol, 2004.PMID 14974631
4. [4]Waters PM Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg Am, 1999.PMID 10360693
5. [5]Hoeksma AF; Ter Steeg AM; Dijkstra P; Nelissen RG; van Ouwerkerk WJ; Lankhorst GJ; de Jong BA Shoulder contracture and osseous deformity in obstetrical brachial plexus injuries. J Bone Joint Surg Am, 2003.PMID 12571311
6. [6]Parker LA Part 1: early recognition and treatment of birth trauma: injuries to the head and face. Adv Neonatal Care, 2005.PMID 16338668
7. [7]Chauhan SP; Gherman R; Hendrix NW; Magann EF; Morrison JC Shoulder dystocia: comparison of the ACOG practice bulletin with another national guideline. Am J Perinatol, 2010.PMID 19565435
8. [8]Lewis SP; Sweeney JK Comorbidities in infants and children with neonatal brachial plexus palsy: a scoping review to inform multisystem screening. Phys Occup Ther Pediatr, 2023.PMID 36659827
9. [9]Gilbert A; Pivato G; Kheiralla T Long-term results of primary repair of brachial plexus lesions in children. Microsurgery, 2006.PMID 16634084
10. [10]Malik S; Bhandekar HS; Korday CS Traumatic peripheral neuropraxias in neonates: a case series. J Clin Diagn Res, 2014.PMID 25478423