BIRTH INJURIES OF THE BRACHIAL PLEXUS

INCIDENCE AND PROGNOSIS

A. E. HARDY

From the Department of Orthopaedic Surgery, Auckland Hospital, Auckland

Between March 36 babies sustained

1969 and Maybirth injuries 1978,
of the brachial plexus at the
National Women’s Zealand.
Hospital, This gives an incidence
Auckland, ofO.87 per 1000 live births.
New
Nearly 80 per cent ofthese children had made a complete recovery by the age of 13 months, while none of
those with significant residual defects has severe sensory or motor deficit of the hand.

In treating a child with a birth injury it is important Four (one of which was an undiagnosed twin) were
to know the incidence and prognosis of that injury. In delivered by the breech and two by caesarean section.
order to establish the incidence of birth-induced palsy Shoulder dystocia was noted in 10 instances. One of the
of the brachial plexus and to study the prognosis for this bilaterally affected children was delivered by the breech,
injury in Auckland, the author reviewed the recent the other two were forceps-assisted cephalic deliveries.
experience at the National Women’s Hospital. Six of the children were delivered to diabetic or
prediabetic mothers, five mothers had pre-eclampsia
MATERIAL AND METHODS and one was on corticosteroids. Ten babies had an
The National Women’s Hospital is the largest obstetric hospital in New Apgar score of less than four at one minute, but in none
Zealand, a major teaching centre and a referral centre for smaller was it less than four at five minutes.
hospitals. Between March 1969 and May 1978, there were 41 124 live
Gestational age and weight. The mean birth weight of the
births recorded, of which 4404 were delivered by caesarean section
and 2051 were delivered by the breech, including 567 delivered by the 36 babies was 4071 grams (SD 878 grams). The mean
breech at caesarean section. Thirty-six of these babies sustained gestational age was 40 weeks (range 34 to 43 weeks).
injuries of the brachial plexus during delivery, giving an incidence of Measurement against the percentile table of birth weight
0.87 per 1000 live births. The birth records and paediatric notes of all versus gestation drawn up on the basis of 1 1 005
these children were analysed. Fifteen were assessed and examined in
singletons of acceptable dates delivered at the National
detail by the author between December 1 977 and November 1 979 and
a full neurological examination of upper and lower limbs was
Women’s Hospital between 1969 and 1972 (Fig. 1)
performed. The passive range of movement of all joints of the upper shows this mean is above the 90th percentile. The 30
limb was assessed with a goniometer and limb lengths were measured. babies delivered vaginally after a cephalic presentation
An assessment of functional impairment was made. had a mean birth weight of 4263 grams (SD 787 grams)
and a mean gestational age of 40 weeks (range 34 to 43
RESULTS weeks), while the six delivered by caesarean section or
Twenty-three children were white-skinned, 12 vaginally by breech presentation had corresponding
Polynesian and one Chinese ; 1 7 were girls and 1 9 boys. values of 3 1 1 1 grams (SD 542 grams) and 39 weeks
The right side was affected in 1 8, the left in 1 5, and (range 35 to 42 weeks), and were therefore significantly
three were bilateral palsies. In 14 there was another lighter (0.01 >P>0.001 using Student’s t test).
associated birth injury: three fractured humeri, one Recovery. Of the 2 1 babies followed by paediatricians
fractured clavicle, two phrenic nerve palsies, four facial but not examined by the author, six were noted to be
nerve palsies, one combined facial and phrenic nerve “recovering” , “virtually completely recovered” , or
palsy, one fractured parietal bone and two with severe “almost completely recovered” at the time of discharge
bruising of the scalp and face. from the National Women’s Hospital between the
Delivery. Seventeen children were born to primiparous fourth and eleventh days of life, and no further
mothers with an average length of labour of 18.6 hours follow-up was recorded. Ten more had recovered by
(range 1 .3 to 40 hours). Nineteen were born to four months of age and a further four recovered
multiparous mothers with an average length oflabour of completely between four and 1 3 months of age (Fig. 2).
13 hours (range 3.0 to 20.5 hours). Thirty babies were The remaining child has not been seen since six weeks of
cephalic deliveries, of whom 1 8 were assisted with age when she was noted to have a residual deficit. Of the
Kielland’s forceps and six with other types of forceps. 1 5 children examined by the author eight were normal

A. E. Hardy, FRACS. Orthopaedic Surgeon, Auckland Hospital, Park Road, Auckland 1 , New Zealand.

© 1981 British Editorial Society of Bone and Joint Surgery 0301-620X181/00130098 $2.00

98 THE JOURNAL OF BONE AND JOINT SURGERY

 BIRTH INJURIES OF THE BRACHIAL PLEXUS 99

6000 time of follow-up (Table I). None of these seven had

5800 Homer’s syndrome, abnormal neurological signs in the

5600 legs, any obvious sensory deficit of the hand, any joint
contracture distal to the elbow, or a dislocated radial
5400
head. Losses of shoulder movement less than 30 degrees
5200
are not shown in the table but all other limitations of
5000
passive movement are shown. Muscle testing of these
4800 children was tedious, but an attempt was made to assign
4600 an MRC grade to each muscle group. Five of the
4400 C children with a deficit at final assessment had extensive
4200 90tti Percentile...._. lesions involving roots CS, C6, C7 and C8, and two had
- lesions consistent with involvement of the CS and C6
c 4000
roots. Only two of the seven had obvious gross weakness
3800
of the serratus anterior or other parascapular muscles.
3600 rcentil
None of the children has been subjected to a surgical
3400
procedure.
3200 Before leaving the maternity hospital all mothers
3000 were instructed in putting the joints of the affected limb
2800 through a full range of passive movement three times
2600#{149} b daily. In 1 1 instances shoulder abduction splintage using
cloth splints was introduced in the neonatal period and
2400
a continued for up to three months. An abduction splint
2200
was used only once among the seven children with
2000.
4b #{149};i
residual deficit and this was the only child to develop a
Gestational Age in Weeks medial rotational contracture of the shoulder.
Fig. 1 DISCUSSION
Percentile chart of birth weights versus gestational age based on
1 1 005 singletons of acceptable dates born at the National Women’s Historical analysis. Specht (1975) traced 1 1 patients
Hospital between 1969 and 1972, showing the mean birth weight (±2 with birth injury of the brachial plexus from 1 9 340 new
SD) of (a) all 36 cases; (b) the 30 normal deliveries; and (c) the six
delivered by breech or caesarean section. births in the San Francisco area between 1 963 and 1972,
an incidence of 0.57 per 1000 live births. Adler and
(except for the loss of 10 degrees of extension of the Patterson (1 967), studying deliveries at the Hospital for
elbow in one child), six having recovered fully by four Special Surgery, New York, between 1939 and 1962,
months of age, and the other two by eight months of age. deduced the incidence to be 0.35 per 1000 live births in
Residual signs. Seven children had residual signs at the 1962 compared with 1.56 per 1000 live births in 1938.
Gordon et al. (1 973), reporting the results of a
collaborative study, found 60 cases from 3 1 700 live
births from throughout the USA, but suggested that this
incidence of 1.89 per 1000 live births should not be
considered as the national average, as the survey was
heavily weighted with families of low income; the time
span of this study was not clearly stated.
.
Specht (1975) suggested that the severity as well as
the incidence of birth-induced brachial plexus injuries
might well have decreased with the refinement of
obstetric techniques: he followed up eight of his 1 1
patients and found no significant residual deficit.

I Gordon et al. (1 973) reported

year in all but three
complete
of the 59 patients
recovery
they followed
by one
up.
Adler and Patterson (1967), reporting on the follow-up
of 88 of their 1 23 patients seen between 1 939 and 1962,
noted 62 had had a total of 98 operations; 28 had
developed fixed adduction and medial rotation of the
shoulder, seven had pronation contractures, 1 1 had
Age In Months
flexion contractures of the elbow greater than 45
Fig. 2 degrees and 1 3 had less severe contractUres of the
Age at time of full recovery for 28 patients. elbow, 14 had dislocation of the radial head, and one had

VOL. 63-B, No. I. 1981

100 A. E. HARDY

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THE JOURNAL OF BONE AND JOINT SURGERY

 BIRTH INJURIES OF THE BRACHIAL PLEXUS 101

a complete disruption of the elbow. Wickstrom (1962), had a transient facial palsy had a residual palsy of the
reporting on 87 children treated between 1944 and brachial plexus. This association of birth-induced palsies
1958, stated that 10 of the 75 who were first seen in of the facial nerve and the brachial plexus was also noted
infancy had excellent results, 32 had abduction of the in four of the 25 patients reported by Eng (1971). No
shoulder greater than 90 degrees, but 33 never gained child with a residual deficit at the age of 1 3 months
satisfactory function of the shoulder, forearm and hand. recovered completely, though minor improvements
Eng (1 97 1) reported on the follow-up of 20 infants born were noted between 1 3 and 24 months of age in the two
in Washington DC between 1967 and 1969, and noted children followed at intervals during that period. No
three to have significant handicaps at one year, and child recovered further after two years of age.
another 1 1 to have moderate residua including persis- Six babies recovered in the first two weeks oflife, an
tent weakness, delay in bone growth, peculiar posturing additional 1 6 by four months of age, and a further six by
and dislocation. Neither Wickstrom, nor Adler and 13 months of age (Fig. 2). Of the remaining eight, one
Patterson, nor Eng reviewed patients from a consecutive child with a residual deficit was lost to follow-up at six
series of live births, and for this reason possibly offer a weeks of age, five had a definite residual deficit, and a
false impression of the overall gravity of prognosis. further two (Cases 6 and 7, Table I) will almost certainly
Obstetric techniques have improved, and obstetricians have a residual deficit, having made little recovery
have become more willing to proceed with caesarean during the four months before the final follow-up
section since the time when Wickstrom and Adler examination.
carried out their studies. The author does not believe in the use of abduction
Present study. Analysing the results of this study to splintage, and recommends that the parents be carefully
determine prognostic factors, the following points instructed how to put all upper limb joints of the affected
emerge. One of the seven with residual deficit was limb through a full range of movement, each time the
delivered by the breech. Six were delivered vaginally child is fed after the first week oflife. A physician should
after cephalic presentation, and these six were not check that this technique is being properly practised at
significantly heavier (birth weight 4576 grams, SD 363), regular intervals.
than the other 24 delivered in this manner who On the basis of this study, the author agrees with the
recovered (birth weight 4184 grams, SD 872; suggestion of Specht that the prognosis of birth-induced
0.5>P>0. 1 with Student’s t test). Five of these six were palsy of the brachial plexus is not as severe as previous
delivered with Kielland’s forceps; but there were 19 reviews indicate (Wickstrom 1 962 ; Adler and Patterson
other palsies in children born by assisted vaginal 1967; Eng 1971), and suggests that an approach of
cephalic delivery which recovered. There was no cautious optimism be taken in discussing the prognosis
prognostic significance apparent on comparing the of this lesion with the parents in the neonatal period.
gestational age and Apgar score of those who recovered Nearly 80 per cent of these children had made a
and those who did not recover. All the facial palsies complete recovery by 1 3 months of age while none of
developed in children delivered with the assistance of those with significant residual defects had severe sensory
forceps, and all recovered completely. One child who or motor deficits in the hand.

I would like to acknowledge the assistance and helpful advice of Professor Howie, Dr J. D. Matthews and the other paediatricians at the National
Women’s Hospital. Professor Howie prepared the percentile chart of birth weight versus gestational age, part of which is shown in Figure 1.

REFERENCES

Adler JB, Patterson RL Jr. Erb’s palsy: long-term results of treatment in eighty-eight cases. ) Bone Joint Surg lAm] 1967;49-A:1052-64.
Eng GD. Brachial plexus palsy in newborn infants. Pediatrics 1971 ;48:18-28.
Gordon M, Rich H, Deutschberger J, Green M. The immediate and long-term outcome of obstetric birth trauma. Am ) Obstet Gynecol
1973;117:51 -6.
Specht EE. Brachial plexus palsy in the new born: incidence and prognosis. Clin Orthop 1975;11O:32-4.
Wickatrom J. Birth injuries to the brachial plexus: treatment of defects in the shoulder. Clin Orthop 1962;23:187-96.

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