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Clinical features of neonatal brachial plexus injuries

Clinical features of neonatal brachial plexus injuries
Associated spinal level C5 C6 C7 C8 T1
Common pattern of injury Erb palsy      
Erb palsy plus    
      Klumpke palsy
Total brachial plexus palsy
Common neurologic signs on observation
  • Winged scapula
  • Upper arm adducted and internally rotated
  • Respiratory impairment*
  • Forearm extended
  • Wrist flexed ("waiter's tip" posture)
  • Hand flexed
  • Fingers extended
  • Horner syndrome (ipsilateral ptosis and miosis)
  • Fingers extended
  • Horner syndrome (ipsilateral ptosis and miosis)
Common neurologic findings on examination
  • Impaired shoulder abduction (supraspinatus and deltoid muscles)
  • Impaired elbow flexion (biceps muscle)
  • Impaired wrist extension (forearm extensor muscles)
  • Impaired elbow extension (triceps muscle)
  • Impaired wrist flexion (forearm flexor muscles)
  • Impaired finger flexion (flexor muscles)
  • Impaired finger extension (lumbrical and interossei muscles)
Neonatal brachial plexus injuries cause ipsilateral arm weakness that vary according to the severity and location of the injury. Common patterns of injury may be identified by clinical observation and neurologic examination. These nerve injuries can be associated with other clinical findings in some cases including clavicle and humerus fractures, shoulder and cervical spine subluxation/dislocation, cervical spinal cord injury, and facial palsy.

* Ipsilateral diaphragmatic paralysis from phrenic nerve dysfunction may cause weak cry, poor feeding, asymmetric chest expansion, respiratory distress, vomiting.

¶ Horner syndrome may occur in the setting of brachial plexus injuries due to disruption of the sympathetic nerve pathway as it courses over the lung apex and adjacent to the C8 to T2 spinal nerve roots.
References:
  1. Volpe JJ. Injuries of extracranial, cranial, intracranial, spinal cord, and peripheral nervous system structures. In: Neurology of the Newborn, 6th ed, Volpe JJ, Inder TE, Darras BT, et al (Eds), Elsevier 2018.
  2. Bowerson M, Nelson VS, Yang LJ. Diaphragmatic paralysis associated with neonatal brachial plexus palsy. Pediatr Neurol 2010; 42:234.
  3. Executive summary: Neonatal brachial plexus palsy. Report of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Brachial Plexus Palsy. Obstet Gynecol 2014; 123:902.
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