Patient/Family Educational Videos

brachial plexus birth injuries 101:

Delivery

Brachial Plexus Birth Injuries occur in 1 to 3 per 1000 live births. The most common cause is the baby's shoulder getting stuck during delivery after the head is out, an event known as shoulder dystocia. Risk factors for shoulder dystocia include large babies greater than 9 pounds (macrosomia) and gestational diabetes. However, it is impossible to predict based on risk factors alone whether shoulder dystocia will occur. Mom's who encountered a shoulder dystocia in a previous delivery are at the highest risk, however, and we recommend delivery by Cesarian section for all subsequent pregnancies. Once shoulder dystocia occurs, there are a limited number of techniques that can be used to deliver the baby, including suprapubic pressure, McRoberts Maneuver, and the Wood Screw Maneuver. If the child is not delivered in a timely fashion, the consequences can be brain injury and death of the child. 

brachial plexus birth injuries 102:

Nerve injury

Any stretch of the brachial plexus during delivery can result in a Brachial Plexus Birth Palsy. There have also been sporadic reports of brachial plexus injuries occurring without an identified stretch event. 

Brachial plexus birth injuries 201: principles of nerve surgery

If nerve function does not recover by 3 months in complete (global) injuries, or by 5-6 months in incomplete injuries, surgery to reconnect the torn nerves may be indicated. The most commonly performed technique is nerve grafting, where nerve cables are taken from the leg (sural nerve) and spliced into the gap between the torn nerve ends. Other reconstruction techniques include transferring a working nerve that is expendable to a nonworking nerve. Examples of nerve transfers include Spinal Accessory to Suprascapular Nerve Transfer, Intercostal to biceps nerve transfer, ulnar fascicle to biceps nerve transfer, partial triceps to axillary nerve transfer, and contralateral C7 nerve transfer. Nerve transfers can be performed at an older age than nerve grafting, typically between 6 and 12 months of age. 

Brachial plexus birth injuries 201:

the shoulder

The most common long term consequence of a brachial plexus birth injury is limited shoulder motion and scapular winging.

Surgical Techniques

Spinal Accessory to Suprascapular nerve transfer

The Spinal Accessory Nerve can be transferred to the Suprascapular Nerve to reanimate the supraspinatus and infraspinatus muscles of the rotator cuff. The procedure can be performed from the front or, as depicted here, from the back. The goal of the surgery is to improve shoulder movement. The success rate of the surgery has been reported at between 40 and 60%.

ulnar motor to triceps nerve transfer

This video demonstrates the ulnar nerve to triceps nerve transfer, a variant of the standard Oberlin transfer.

intercostal nerve transfers

Intercostal nerves (up to 6) can be transferred to power the biceps, the triceps, the deltoid, and/or the supra scapular nerve. A minimum of 2 intercostals is required to provide sufficient axons to power each muscle, with 3 intercostals being better than 2. When transferring intercostal nerves to 2 muscles, it is important to make sure that the muscles are operating at the same time (synergistically), such as the deltoid and rotator cuff, or the deltoid and triceps. Innervating both the triceps and the biceps usually yields recovery of only one muscle, with co-contraction of the biceps and the triceps at the same time limiting function.

Practicioner Education

basic Overview

Brachial Plexus Birth Injuries occur in 1 to 3 per 1000 live births. The most common cause is the baby's shoulder getting stuck during delivery after the head is out, an event known as shoulder dystocia. Risk factors for shoulder dystocia include large babies greater than 9 pounds (macrosomia) and gestational diabetes. However, it is impossible to predict based on risk factors alone whether shoulder dystocia will occur. Mom's who encountered a shoulder dystocia in a previous delivery are at the highest risk, however, and we recommend delivery by Cesarian section for all subsequent pregnancies. Once shoulder dystocia occurs, there are a limited number of techniques that can be used to deliver the baby, including suprapubic pressure, McRoberts Maneuver, and the Wood Screw Maneuver. If the child is not delivered in a timely fashion, the consequences can be brain injury and death of the child. 

humeral osteotomy

An osteotomy of the humerus can help to realign the shoulder in a better rotational position.

glenoid osteotomy

Glenoid osteomies are used to correct the retroversion of a dysplastic shoulder. Because of the technical challenges and unclear indications, glenoid osteotomies are rarely performed.

Glenohumeral Dysplasia and Shoulder kinematics

Glenohumeral dysplasia alters the kinematics of the shoulder, changing the line of pull of the supraspinatus to make it an internal rotator, and the infraspinatus to an abductor of the shoulder.