Changing attitudes to brachial plexus palsy

Nerve damage resulting from injury to the brachial plexus at birth (Erb’s or Klumpke’s palsy) has been recognised for a long time, and traditionally there has been a tendency for paediatricians to watch and wait, with some physiotherapy input, rather than act. In recent years there has been a recognition that 20-30% of people with neonatal brachial plexus palsy (NBPP) have a persistent subtle deficit even when they appear to have recovered. This, along with advances in surgical management, should make us re-think.

A review article summarises the current state of knowledge nicely (Smith B et al. JAMA Peds 2018. doi:10.1001/jamapediatrics.2018.0124). They describe laboratory work which delineates the micro-anatomical grades of nerve fibre damage: neurapraxic, axonotmetic and neurotmetic. These studies can indicate the time window within which such damage may become irreversible: 18 to 24 months without active re-innervation. Although imaging and electrophysiological studies can help in planning for surgery, the mainstay of assessment remains clinical examination. They describe a simple and reproducible Active Movement Scale which can quantify progress. As well as the well-known risk factors for acquiring NBPP (high birth weight, shoulder dystocia) they also identified factors which predispose to incomplete spontaneous recovery: cephalic presentation, labour induction or augmentation, vaginal delivery, and …