It is estimated that two of every 1000 newborns are born with a brachial plexus injury. An obstetric brachial plexus injury is more commonly observed in children with macrosomia (birth weight over four kg). A newborn with an injury of the brachial plexus has limited or absent motion in one or both upper extremities. The extent of the nerve injury defines the likelihood of recovery without surgical treatment. Fortunately, in most cases (70-80%) the nerves are not severely damaged, and the function of the upper extremity is regained in a matter of months without surgical intervention.
Pediatricians and obstetricians alike most often diagnose brachial plexus injuries in newborns. The diagnosis is clinical and on average rather obvious. Upper extremity of the newborn is in a typical position with complete or partial lack of movement. To avoid joint contracture, physiotherapy and gentle range of motion exercises should be initiated after one month. Regular clinical examinations are necessary so that signs of poor or incomplete recovery can be identified in time. In this case, the child should be referred to our center for further assessment and treatment, if indicated. The child should first be examined by the surgeon when he or she is between two and three months old, as this allows us to assess the extent of the injury and advise surgical treatment on time.
If the recovery of function is not adequate or fast enough, a surgical procedure is necessary as this will allow for better functional recovery. An early surgical procedure at the age of three to six months is indicated for babies who suffer from a complete plexus injury with signs of root avulsions and in babies with a complete absence of elbow joint flexion. If spontaneous recovery has already begun but is deemed imperfect, regular clinical examinations track the progress of any further recovery. If the child is unable to bring their hand to their mouth by the ninth month (“cookie test”), a surgical procedure is indicated. Preferably, all brachial plexus reconstructions should be done within the first year of life, which allows for optimal functional recovery. Due to the high capacity of recovery and learning in childhood, children often achieve very favorable results following brachial plexus surgery.
In late cases, primary nerve reconstruction is not feasible as there are irreversible changes in denervated muscles. Improvement of function can be achieved with various secondary (palliative) procedures. In children, surgery is often needed to improve the external rotation of the shoulders and to improve the lateral elevation of the upper extremities (abduction). The procedures include a weakening of contracted muscles, tendon transpositions and nerve releases.
Physiotherapy has an important role in the treatment of obstetric brachial plexus injuries. Range of motion exercises prevent joint contractures and ensure normal mobility of joints, which is a prerequisite for functional recovery after muscle reinervation.
