Indications for Referral

All cases of Obstetric Brachial Plexus Injury (OBPI) should be referred immediately to a paediatric physiotherapist.

Advice can also be obtained from the Paediatric Physiotherapy Department at the Royal Hospital for Children. See Children's Physiotherapy or the contact details at the bottom of this page.

Regular clinical review is necessary until complete recovery or referral to the service.

We are happy to receive referrals of children as soon as the diagnosis of obstetric brachial plexus injury (OBPI) is suspected.

We would recommend that referral to the service is essential in the following situations:

• ASAP if there is persisting complete paralysis of the upper limb and/or Horner’s Syndrome
• At age 2 months if there is any persisting deficit in the upper limb

Clinics

Specialised multidisciplinary outpatient clinics are held once or twice per month. Children will normally be offered an appointment at the next clinic.

Initial Management

Physiotherapy input for handling and positioning advice, joint protection and contracture prevention (particularly internal rotation of the shoulder).

Contact Paediatric Physiotherapy at the Royal Hospital for Children for advice. Contact details are at the bottom of this page.

Risk Factors

• High birth-weight.
• Type of delivery: Breech, Caesarean Section, Forceps, Ventouse, Precipitate.

Signs of OBPI

• Upper limb lying in a classic 'waiter's tip' position (Erb's Palsy).
• Loss of active shoulder elevation and elbow flexion ± hand movements.
• Horner's sign.
• Differential diagnosis:
  • Pseudo-paralysis due to infection or fractures of the clavicle or humerus.
  • Cerebral palsy.
  • Arthrogryposis.

Natural History

• Substantial spontaneous recovery in the majority of cases.
• Incomplete recovery: it is usually the shoulder that fails to recover fully.
• Predictors of the degree of recovery:
  • The age at which biceps function recovers:
    • <2 months - full recovery
    • >4 months - full recovery will not occur
  • Extent of the lesion: Narakas classification. More extensive lesions have lower chance of full recovery.

Shoulder Deformity

Weakness of shoulder external rotation and elevation may result in:

• Internal rotation contracture.
• Posterior subluxation or dislocation of the shoulder (signs subtle, prognosis adversely affected).

Motor Assessment

• Shoulder (C5)
• Assess with child sitting or standing.
• Amount of active elevation.
• Elbow (C5, C6)
• Flexion against gravity.
• Hand to mouth.
• Wrist (C7)
• Extension against gravity and when grasping.
• Fingers (C8, T1)
• Flexion (grasp); extension.

Sensory Assessment

It is not possible to assess sensation in this age group.

Investigations

Investigations are not usually necessary before referral. Common investigations are:-

• Radiographs.
• MRI.
• Neurophysiology. (Please discuss with the OBPI Service)