Obstetrical Brachial Plexus Palsy and The Benefit of Physiotherapy
Obstetrical Brachial Plexus Palsy is a disorder of the peripheral nervous system occurring in infants.
The brachial plexus is a network of nerves that originates at the spinal cord near the neck and passes down your upper arm from under your collar bone. This network can be injured during the birthing process and is referred to as Obstetrical brachial plexus injury.
The brachial plexus consists of 5 nerve roots. These include nerve roots from the lower cervical segment of the spinal cord known as C5, C6, C7 and C8, and a nerve root from the first thoracic spinal cord segment known as T1. These nerves join to form the upper, middle and lower trunks of the brachial plexus which split into nerves that supply your upper limbs, controlling your shoulder, elbow, wrist and hand. An injury to any part of these nerves can stop signals to and from the brain and may partially or completely paralyze your arms.
Types of brachial plexus injuries that may occur in infants include:
- Neurapraxia: the nerves are stretched, but their internal architecture is maintained. With time they are likely to recover more or less completely.
- Axonotemesis: the nerves are stretched and their internal structure is partially damaged with the outer sheath still intact. Such nerves are likely to recover over time, to a greater or lesser extent, depending on the magnitude of damage
- Neurotmesis/Rupture: nerves stretch to a point where they tear at a region some distance from their origination from the spinal cord.
- Avulsion: the nerve roots are torn completely out from the spinal cord.
Injury to the brachial plexus can occur during the birthing process when the baby’s shoulder gets lodged in the birth canal requiring external force for the baby to be delivered. This force may stretch or tear the nerves of the brachial plexus. This type of injury is commonly seen in larger than average babies born to diabetic mothers.
Other causes for brachial plexus injury in babies include:
Extended period of labor.
Breech presentation- baby positioned with feet or buttocks near the vaginal opening.
Mothers with a small birth canal.
Signs and Symptoms.
You may be able to observe the symptoms of injury in your child immediately after birth. Common symptoms include:
- Limp arm and loss of flexion in elbows.
- The baby does not actively move or rotate the arm from the shoulder.
- The baby is unable to actively move fingers, or has a decreased grip strength on the affected side.
When your child presents with symptoms of brachial plexus injury, the paediatrician will first take your child’s medical history, conduct a physical examination and order tests to diagnose Erb’s or birth palsy. Physical examination will help the doctor identify the limited movement and range of motion of the upper extremity.
Imaging tests such as X-rays, computed tomography (CT) and Magnetic resonance imaging (MRI) may be used to detect damage to the bones, joints or nerves. The purpose of the physical examination and X-rays is to rule out other conditions which may mimic Obstetrical brachial plexus injury, such as fracture of the humerus.
Most obstetric brachial plexus injuries heal or recover on their own by the age of 3-12 months. During this time, your doctor will regularly monitor your child.
Physiotherapy may be recommended to maximise the use of your child’s affected arm. Your child’s physiotherapist will educate you on the range of motion exercises to be performed on your baby to improve the functioning of the shoulder, elbow, wrist and hand, and avoid joint stiffness.
In infants with mild obstetrical brachial plexus injury of the C5 or C6 nerves, 80percent generally recover spontaneously and do not require surgery. Recovery depends on the type and severity of nerve injury.
Doctors usually follow Gilbert’s criteria to indicate a requirement for surgery. This criteria states that when the injury fails to recover, surgery should be indicated at 3 months in infants with Erb’s palsy and before 3 months for global birth palsy cases.
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