The diagnosis at the time of the birth is relatively easy when forceps have been used during the delivery.
Hypotonic paralysis and muscle atrophy are poor prognostic factors. It is important to examine the controlateral upper and lower limb in order to rule out the dreadful situation of neonatal tetraplegia.
Two basic clinical types of newborn palsy can be identified:
The upper limb is held in internal rotation and pronation and active abduction is not possible. The elbow is slightly flexed (paralysis C5, C6, C7) or fully extended (paralysis C5, C6) and the wrist and sometimes the fingers are flexed.
The upper limb is flail and the hand is clutched, without any tonus. There is sensory and vasomotor impairment. Phrenic palsy and Claude Bernard Horner's sign indicate a severe lesion and particularly an avulsion of the roots.
Radiographs may depict a fracture of the clavicle or of the upper humerus.
The evolution is variable and a re-evaluation is necessary at the third week. At this time one of the following situations can be recorded:
• In cases of paralysis of the upper roots there is a partial recovery.
• Complete paralysis evolves towards a paralysis of the upper roots or remains unchanged.
An EMG and occasionally a myelography define the lesions very precisely; they can be performed safely at the third month.
Physical therapy is initiated immediately after birth to avoid internal retraction of the arm. Splints in external rotation and abduction of the arm are dangerous and their use should be avoided because they lead to abduction contractures.
The natural history of brachial plexus palsy (Tassin, 1983) indicates that spontaneous recovery and good final result should be expected in infants with initial contraction of the biceps or the deltoid before the age of 3 months. Thus, surgical exploration in newborn palsy is indicated when there is no clinical recovery of the biceps at three months of age. 5
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