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Birth injuries


from: McGuinness & Kay. Current Orthopaedics. 13:20-26. 1999.

  • Incidence  is approx 2/1,000 births

  •  Risk Factors: 

    • Child

      • weight > 4000g / large for gestational age

    • Maternal

      • multiparity

      • diabetes

      • sibling with shoulder dystocia or OBPP

    • At Birth

      • shoulder dystocia

      • breech

      • long labour 

      • forceps delivery.

  • Investigations:

    • EMG - doesn't correlate with prognosis & can be misleading.

    • MRI - fast spin echo MRI may demonstrate root avulsions.

  • Classification Table:

TYPE (Adler & Patterson)

TYPE (Narakas)





Group 1


Deltoid, cuff, elbow flexors, wrist & hand dorsiflexors - 'waiters tip'


Group 2


Above except with sightly flexed elbow




Wrist flexors, intrinsics, Horners


Total Plexus

Group 3


Sensory & motor, flaccid arm


(Total Plexus + Horners)

Group 4


Sensory & motor, flaccid arm, Horner


  • Natural History:

    • C8-T1 injury with a Horners syndrome has the worst prognosis.

    • Isolated lower root lesions have a poor prognosis, since they are usually avulsion injuries.

    • The rate of recovery and the time of beginning of recovery affect the outcome.

    • Toronto scoring system (Clarke) assesses the child at 3 months of age

    • No biceps function at 3m indicates a poor prognosis.

    • Patients who show evidence of biceps function before 6 months of age have near-normal to excellent function.

    • In borderline cases exploration of the Brachial Plexus is performed.

    • Early repair has the best prognosis.

    • Recovery continues until 1 year old, then little further recovery thereafter.

  • Management: 

    • Early Referral to a specialist unit.

    • Physiotherapy - passive range of motion exercises.

    • Splinting - not popular.

    • Surgery

  • Indications for Surgery:

    • C8-T1 injury with a Horners syndrome

    • C5/6 lesions with no muscle activity & breech baby.

    • Toronto score < 3.5 (Clarke)

    • Failure to progress adequately between 12-24 weeks

    • EMG criteria of Smith where doubt exists.

  • Surgical Technique:

    • Transverse incision

    • Neurolysis

    • Nerve grafting (Sural nerve)

    • Nerve transfers (accesory to suprascapular, intercostal to musculocutaneous)

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