What Is a Brachial Plexus Birth Injury?
A brachial plexus injury manifests as neurological symptoms including numbness, tingling, weakness, or complete paralysis affecting various regions of the upper extremity due to nerve trauma. This condition can occur in newborns as a result of complications during the labor and delivery process. The specific presentation and affected areas depend on the precise location and extent of nerve damage within the brachial plexus network.
The brachial plexus comprises a complex network of nerves originating from the spinal cord and extending through the neck into the arm. When these nerves sustain injury during birth, it can impact motor function and sensation in the shoulder, arm, hand, or fingers. The severity ranges from mild, temporary symptoms to permanent impairment. Medical professionals must conduct thorough neurological examinations to determine which nerve roots are affected and develop appropriate treatment protocols. Early identification and intervention are essential for optimizing outcomes in affected infants.
How is brachial plexus birth injury diagnosed?
The diagnosis of BPBI relies on clinical assessment, as no definitive tests exist to determine injury type or severity. Although some medical facilities utilize electrodiagnostic nerve tests such as electromyograph (EMG) to evaluate muscle and nerve condition, these assessments have proven unreliable in infants and frequently overestimate recovery potential. Such tests inflict pain, potentially require anesthesia, incur significant costs, and provide no benefits beyond thorough physical examination. If a physician recommends EMG testing for an infant, seeking an additional medical opinion would be advisable.
Some medical experts suggest magnetic resonance imaging (MRI) for specific cases. However, imaging is not essential for diagnosis and proves unreliable in infants for determining prognosis or surgical necessity. MRI procedures also necessitate general anesthesia. Medical professionals reserve MRI as a pre-surgical tool specifically for patients with global injuries to evaluate potential root avulsions and facilitate surgical planning. When surgery is not indicated, MRI becomes unnecessary. If a physician insists on brachial plexus MRI before two months of age without surgical plans, obtaining a second medical opinion is recommended.
For diagnosing shoulder complications in children with BPBI, current medical guidelines advocate ultrasound usage until one year of age. Beyond this point, ultrasound reliability diminishes, making MRI the more appropriate diagnostic tool.
What causes a brachial plexus birth injury?
The majority of brachial plexus birth injuries occur during delivery when an infant’s shoulder becomes lodged behind the maternal pelvis, a complication known as shoulder dystocia. The most significant predictor of shoulder dystocia is a previous delivery that involved the same complication. Medical guidelines now recommend cesarean section for mothers who experienced shoulder dystocia in prior births. Additional major risk factors include macrosomia (infants weighing over nine pounds) and diabetes in the mother. Although physicians monitor fetal size through prenatal ultrasounds, these measurements can have up to 20% margin of error. Maternal blood glucose levels require consistent monitoring throughout pregnancy.
When shoulder dystocia presents during delivery, medical professionals can employ various techniques to release the shoulders, including the “McRoberts maneuver,” the “Woods corkscrew,” suprapubic pressure, extraction of the posterior arm, and in certain cases, deliberate fracture of the infant’s clavicle. If these interventions prove unsuccessful, the infant faces increased risk of oxygen deprivation, or ischemia, to the brain. Brain ischemia can result in cerebral palsy or mortality. In situations of severe fetal distress, delivering an infant with a brachial plexus injury might represent a better outcome than alternatives, requiring critical judgment from the attending obstetrician, midwife, or healthcare provider.
Research indicates that brachial plexus injuries may also result from uterine muscular contractions or rapid deliveries without shoulder dystocia, though these scenarios occur less frequently. Studies suggest that administering oxytocin (Pitocin) to initiate labor or enhance uterine contractions might elevate the risk of plexus injury.
Several conditions can mimic brachial plexus injuries. Arm bone fractures can cause pseudopalsy, where an infant cannot move the affected arm. Movement typically resumes after fracture healing, approximately 2 to 3 weeks later. Additionally, spinal cord tumors or infections may cause temporary or permanent paralysis.
How is brachial plexus birth injury diagnosed?
The diagnosis of BPBI relies on clinical assessment, as no definitive tests exist to determine injury type or severity. Although some medical facilities utilize electrodiagnostic nerve tests such as electromyograph (EMG) to evaluate muscle and nerve condition, these assessments have proven unreliable in infants and frequently overestimate recovery potential. Such tests inflict pain, may necessitate anesthesia, incur significant costs, and provide no benefits beyond thorough physical examination. If a physician recommends EMG testing for an infant, seeking an additional medical opinion would be advisable.
Certain specialists advocate for magnetic resonance imaging (MRI) in specific cases. However, imaging is not essential for diagnosis and proves unreliable in infants for determining prognosis or surgical necessity. MRI procedures also require general anesthesia. Medical professionals reserve MRI as a preoperative tool for patients with comprehensive injuries to evaluate potential root avulsions and facilitate surgical planning. When surgery is not indicated, MRI remains unnecessary. If a physician insists on brachial plexus MRI before two months of age without surgical plans, obtaining a second medical opinion is recommended.
For diagnosing shoulder complications in children with BPBI, current medical guidelines recommend ultrasound examination until one year of age. Beyond this point, ultrasound reliability diminishes, and MRI becomes the more appropriate diagnostic tool.
What are the different types of brachial plexus birth injuries?
The three fundamental categories of brachial plexus birth injuries, arranged by increasing severity, are:
- Upper (or Erb’s palsy/C5-6)
- Extended upper (C5-C7)
- Global (or complete/C5-T1)
The majority of upper and extended upper injuries heal independently over time. Global injuries, wherein the entire limb presents as flaccid at birth, typically necessitate surgical intervention.
The magnitude of force (stress) applied to each nerve root during the injury results in stretching (strain) of the nerve root. In cases of minimal strain, the nerve root becomes temporarily inactive for a duration ranging from several hours to approximately two months before achieving complete recovery. When the strain is more significant, the majority of nerve fibers within the nerve root rupture, although the primary nerve structure remains predominantly intact. These injuries possess recovery potential; however, since nerve fibers (axons) must regenerate from the injury site at approximately one inch monthly, restoration of functions such as elbow flexion and shoulder abduction requires 5 to 6 months, while hand function recovery extends to 18 months. In instances where the majority or entirety of the nerve structure sustains damage, recovery might require up to three years merely to regain elbow flexion capabilities, with outcomes being less predictable.
The upper cervical roots, positioned higher on the neck, typically sustain initial injury when downward force affects the shoulder during delivery. This mechanism resembles a zipper’s operation, with upper roots positioned at the top and lower roots at the bottom. Consequently, upper roots experience maximum strain in global injuries affecting all roots. However, upper cervical roots possess specialized ligaments that prevent their detachment from the spinal cord, an injury termed avulsion. The lower roots, C7-T1, lacking these protective ligaments, face increased vulnerability to spinal cord avulsion compared to C5 and C6 nerve roots. Avulsion injuries remain irreparable and unrecoverable. Thus, despite upper trunk experiencing greater stress during global injury, lower roots might sustain more permanent damage.
Upper trunk avulsions correlate with compromised diaphragm function, impeding the infant’s ability to generate sufficient suction for breastfeeding. Lower trunk injuries typically manifest with Horner’s syndrome (ptosis, myosis, anhidrosis). Infants exhibiting Horner’s syndrome display a drooping eyelid and reduced pupil size on the affected side.
What are the consequences of untreated brachial plexus birth injury on the shoulder?
When the shoulder remains untreated, it develops deformities during growth, a condition referred to as glenohumeral dysplasia (Figure 3a). Glenohumeral dysplasia progresses with age, though it might manifest severely in infants as young as three months. In certain cases, patients experience complete dislocation of the shoulder joint.
- Severe glenohumeral dysplasia on ultrasound
- Normal shoulder ultrasound
When patients present late for treatment, making teapot splint implementation unfeasible, shoulder stiffness with internal rotation becomes established. For infants under one year, physicians can employ botulinum toxin to temporarily weaken the muscles rotating the shoulder inward, followed by external rotation casting under general anesthesia. Ultrasound imaging confirms proper joint positioning post-stretching and monitors shoulder development after cast removal. Following cast removal, physicians might recommend nighttime use of a teapot splint for up to two years to maintain proper shoulder positioning.
Should glenohumeral dysplasia persist despite conservative treatment, surgical intervention through shoulder release with or without tendon transfers becomes necessary. Although various shoulder release techniques exist, including arthroscopic approaches, experience demonstrates superior outcomes with open anterior release with coracoidectomy, leading to its preferred implementation over arthroscopic procedures.
For surgical candidates over one year old, magnetic resonance imaging (MRI) provides detailed shoulder assessment. MRI reveals muscle condition, indicating nerve supply recovery, and offers comprehensive joint visualization. X-rays and Computed Tomography (CT) scans prove unsuitable because these modalities cannot effectively image cartilage, which comprises most of the shoulder joint before age four.
Beyond age four, shoulder joint morphology becomes relatively fixed. Surgical interventions in older children focus on cases with normal or near-normal joint configuration. Treatment options include tendon transfers and releases. For patients with deformed joints, physicians might recommend glenoid osteotomy to enhance shoulder shape and function, or humeral rotational osteotomy to achieve improved external rotation positioning.
What is Brachial Plexus Neuroma?
When nerve tissue experiences trauma, such as surgical incisions, scar tissue may develop during the natural healing process. This scar tissue formation, known as a neuroma, potentially creates a painful nodule along one of the brachial plexus nerve pathways.
The surgical management of brachial plexus neuromas involves excision of the affected nerve tissue. Following removal, the surgeon either applies a protective cap to the nerve ending or performs a nerve transfer procedure to prevent neuroma recurrence.
What are the common causes of Brachial Plexus Birth Injuries?
These injuries often result from excessive pulling during delivery, shoulder dystocia, or the use of forceps. Understanding the cause is crucial as it can impact your legal rights.
What are Brachial Plexus Injury Symptoms?
Symptoms depend on where along the length of the brachial plexus the injuries occur and how severe they are. Injuries to nerves that root higher up on the spinal cord, in the neck, affect the shoulder. If nerves that originate lower in the brachial plexus are injured, the arm, wrist and hand are affected.
- Common symptoms of brachial plexus injuries are:
- Numbness or loss of feeling in the hand or arm.
- Inability to control or move the shoulder, arm, wrist or hand.
- An arm that hangs limply.
- Burning, stinging or severe and sudden pain in the shoulder or arm.
Brachial plexus injury pain can be mild to severe, and temporary to chronic, depending on the type and extent of the injury. For instance, a simple stretched nerve may hurt for a week or so, but a ruptured nerve can cause serious, long-term pain that might require physical therapy and potentially surgery.
What treatment options are available for Brachial Plexus Birth Injuries?
Treatment options vary based on the severity of the injury. They may include physical therapy, occupational therapy, or in some cases, surgical intervention to improve function and mobility.
For additional resources and support, contact Brachial plexus birth injury lawyer Timothy L. Miles.
What are the different types of brachial plexus birth injuries?
The three basic types of brachial plexus birth injuries, in order of severity, are:
- Upper (or Erb’s palsy/C5-6)
- Extended upper (C5-C7)
- Global (or complete/C5-T1)
Most upper and extended upper injuries recover on their own with time. Global injuries, where the entire limb is limp at birth, usually require some form of surgical treatment.
The amount of force (stress) that each nerve root is subjected to at the time of injury leads to a stretch (strain) of the nerve root. If the strain is minimal, the nerve root will shut down for anywhere from a few hours to a couple of months and fully recover. If the strain is more severe, a majority of the nerve fibers within the nerve root will tear, while most of the structure of the nerve itself remains intact. These injuries have the potential for recovery, but because the nerve fibers (axons) have to regrow from the site of injury at about an inch a month, it takes about 5 to 6 months for recovery of functions like elbow bending and shoulder abduction, and about 18 months to reach the hand. If most or all of the structure of the nerve is torn, recovery can take up to three years to gain even elbow bending and is less certain.
Because the upper cervical roots are higher up on the neck, they tend to be injured first when the shoulder is forced downward during delivery. Think of opening a zipper with the upper roots at the top and the lower roots at the bottom. The upper roots therefore experience the most strain in global injuries where all of the roots are injured. However, the upper cervical roots have specialized ligaments that resist them from being pulled out of the spinal cord, an injury known as an avulsion. The lower roots, from C7-T1, do not have these ligaments and are therefore more at risk for avulsion from the spinal cord than the C5 and C6 nerve roots. Avulsion injuries are not recoverable, and they cannot be repaired. Therefore, even though the upper trunk sees more stress during a global injury, the lower roots may be more permanently injured.
Avulsions of the upper trunk are associated with loss of diaphragm function, leading to difficulty for the child to generate enough suction to breastfeed. Injuries of the lower trunk are usually associated with a Horner’s syndrome (ptosis, myosis, anhidrosis). Children with a Horner’s syndrome will have a droopy eyelid and a small pupil on the injured side.
How can I seek compensation for a Brachial Plexus Birth Injury?
To pursue compensation, gather medical records, document the injury, and consult with a qualified lawyer experienced in birth injury cases such as Brachial plexus birth injury lawyer Timothy L. Miles who can guide you through the legal process.
Call Brachial Plexus Birth Injury Lawyer Timothy L. Miles Today for a Free Case Evaluation
If you your child suffered a brachial plexus birth injury, call Brachial plexus birth injury lawyer Timothy L. Miles for a free case evaluation day. (855) 846-6529 or [email protected]. The call is free and so is the fee unless we win or settle your case, so call today and see what a Brachial plexus birth injury lawyer do for you.
Timothy L. Miles, Esq.
Law Offices of Timothy L. Miles
Tapestry at Brentwood Town Center
300 Centerview Dr. #247
Mailbox #1091
Brentwood,TN 37027
Phone: (855) Tim-MLaw (855-846-6529)
Email: [email protected]
Website: www.classactionlawyertn.com
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