Infant Brachial Plexus Injuries: When to Refer Immediately and When to Wait

Apurva S. Shah, MD, MBA

Disclosures

April 30, 2019

Editorial Collaboration

Medscape &

Who Gets Referred?

Would you suggest that all children with a suspected injury be referred in the immediate newborn period?

I think all of these children should have screening radiography at the time of delivery, because a concurrent clavicle or humerus fracture can occur. Usually just a single upper-limb film, or even a chest radiograph that captures the entire clavicle and the ipsilateral humerus, is important, just to make sure there's not a coexisting fracture. An arm that's not moving very well after delivery may not be a brachial plexus injury. It could be pseudoparalysis that is related to pain from an upper-limb fracture. Once the pain resolves and the fracture heals, the arm starts to move again.

Early access to a physical or occupational therapist is important for this injury, in part because at the outset, we don't know which kids are going to get better and which kids are not.

If, after obtaining radiographs, the pediatric clinician remains concerned about a potential brachial plexus injury, I would encourage early referral. A child who has not recovered neurologic function within 1 month should be referred. A global injury or Horner syndrome should prompt a more immediate referral. Many of the children who don't make a spontaneous recovery may require surgery as early as 3-6 months of age. Early referral allows the brachial plexus team, wherever the patient is being treated, to make early contact with that family, explain to them what to expect, and start to counsel them through the process.

One other thing for the pediatric clinician to look for is paralysis of the hemidiaphragm. Sometimes there can be an injury to the phrenic nerve at the time of the brachial plexus injury. Chest radiography done to screen for a clavicle or humerus fracture might show that the diaphragm is elevated on the side of the injury. That could be a concern for a phrenic nerve injury. If the pediatrician is really concerned, ultrasound of the diaphragm could be obtained to assess this excursion. Just as Horner syndrome could indicate an avulsion injury to the brachial plexus, so could an injury to the phrenic nerve. That would be another finding that should prompt an early referral.

Nonsurgical Management

What about early, nonsurgical intervention? Are there noninvasive strategies that you would recommend?

Therapy is the cornerstone of management. Early access to a physical or occupational therapist is important for this injury, in part because at the outset, we don't know which kids are going to get better and which kids are not. For the kids who don't get better by 1 month of age, getting an early start on therapy is really important for their ultimate outcome. Oftentimes, a therapist is available on an inpatient basis who could see a family or a child before discharge. Sometimes a single therapy visit, even for a child who might be likely to make a recovery, can be useful so that the parents can get started on a stretching program.

Historically, treatment included splinting the arm or pinning the shirtsleeve to the front of the shirt to prevent movement or worsening of the injury. That is outdated advice. There is no evidence to support that practice, but there is a lot of evidence that early joint mobilization and stretching leads to improved neurologic recovery and can maximize a child's outcome

The focus of early physical and occupational therapy will be on stretching not only visibly affected parts of the arm but also the fingers, wrists, elbow, and shoulder.

Figure 1. Infant with loss of elbow flexion due to a brachial plexus injury.

The real watershed line for kids who are going to make a natural recovery versus not is approximately 2-3 months of age. Kids who recover elbow flexion, the ability to bend the elbow against gravity, by 2 months of age by and large go on to be 100% normal. Infants who do not recover elbow flexion or antigravity elbow flexion by 3 months of age typically do not make a full recovery, with or without any intervention.

A referral by 1 month of age allows a brachial plexus team to track recovery during those critical second and third months to make an assessment. Families can know whether the expectation is for their child to recover or not. It is important that a family be prepared, where necessary, for the potential for long-term therapy, surgery, or an incomplete recovery.

Even in 2019, unfortunately, there aren't any diagnostic tests that definitively can predict recovery. You would intuitively think that high-resolution MRI of the brachial plexus, CT myelography, or an electrodiagnostic test would be relatively conclusive. However, none of those studies have been consistently good enough to tell us whether or not a kid has a more severe or less severe injury. There tends to be a high rate of false-positive and false-negative results with any of those diagnostic testing modalities.

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