March 26th, 2015
What Is Brachial Plexus Injury (Erb’s Palsy / Klumpke’s Palsy)
An injury to a baby’s brachial plexus is a mechanical injury related to how the baby was delivered. These types of injuries occur in one out of every 1,000 births.
The brachial plexus is a network of five nerve groups that travel from the spinal cord to the fingers, wrists, arms and shoulders. They come out of the spinal cord at the cervical (neck) vertebrae (C5, C6, C7 and C8) and at the thoracic (back) vertebrae (T1). Each nerve group is composed of a root (near the spinal cord), trunk, division, cord and branches.
Each nerve group controls the movement and sensation ability of specific areas of the body, from the fingers to shoulder.
Brachial plexus injuries are caused by nerve damage. There are four types (listed in order of severity):
- Avulsion: The avulsion is the most severe type of injury. It is a complete tearing of the nerve root from the spinal cord. These types of tears are rarely treatable with surgery.
- Rupture: Ruptures are tears of the nerve root beyond the spinal cord. Though nearly as serious as avulsions, they can sometimes be surgically repaired.
- Neuroma: Scar tissue has formed around the injury, restricting signals from the nerve to the muscle.
- Praxis/Neurapraxia: The nerve is stretched and damaged, but not torn.
Medical Malpractice Causing Brachial Plexus Injuries
Brachial plexus injuries in babies are caused by improper delivery. During vaginal birth, a baby’s shoulder may become lodged behind the mother’s pubic bone. This is an emergency because the head is outside of the birth canal, but the baby’s neck has not emerged. The mother’s contractions put pressure on the baby’s neck and body, which can be fatal.
At the first sign that the baby’s shoulder is stuck, the delivery team must work quickly to deliver the baby to prevent brain injury or death. As early as medical school, obstetricians are trained to perform the following procedures in this order:
- McRoberts Maneuver: the mother’s legs are bent up toward her chest, which widens the pelvis and flattens the spine of the lower back. If the baby’s shoulder does not dislodge, the medical team should move to the next procedure.
- Suprapubic Pressure: One person should push on the mother’s stomach at a forty-five degree angle to rotate and push the trapped shoulder below the mother’s pubic bone. The pressure should be applied to the lower abdomen only.
- Woods/Rubens Maneuver: The obstetrician puts his hand inside the birth canal next to the baby’s shoulder and rotates the baby to dislodge the shoulder.
- Episiotomy: There is debate about whether episiotomy is a proper technique to prevent brachial plexus injuries. An episiotomy is a surgical cut to the area between the vagina and the anus. The theory is that it gives the baby more room for delivery.
- Zavenelli Maneuver: This is rarely used, and requires the obstetrician to push the baby back into the vagina, and deliver the baby by cesarean section.
- Symphsectomy: Also rarely used, the symphsectomy surgically cuts the mother’s pubic bone to allow room for the baby’s shoulder to come through.
Obstetricians often defend their actions in brachial plexus cases by arguing that it was an emergency situation and they had little time to react. While true that these are emergencies, they are not unexpected. Obstetricians know that babies get stuck in approximately 0.5% to 1.5% of deliveries—meaning that obstetricians encounter this problem roughly once in every 100 births. That’s not a high number for an obstetrician who has been in practice for any amount of time. Furthermore, there are a number of risk factors that place obstetricians on notice that a brachial plexus injury is more likely. These risk factors include an extremely large baby and maternal diabetes. These complications are expected, and should be prepared for like any other emergency.
Types of Brachial Plexus Injuries
Erb’s palsy is caused by damage to the upper C5 and C6 nerves. Children with Erb’s palsy have partial or full paralysis of the arm, possibly involving loss of sensation. The affected arm hangs to the side, and cannot be fully raised.
Klumpke’s palsy involves paralysis of the forearm and hand muscles, caused by damage to the lower C8 and T1 nerves. This primarily affects the wrist and fingers, and often appears as a “clawed” hand.
Diagnosing and Treating a Brachial Plexus Injury
Brachial plexus injuries are usually diagnosed by a baby’s pediatrician. If the baby’s parents or doctor notices arm weakness, the doctor may order tests, including an MRI, electromyogram (EMG) or a nerve conduction study (NCS). These tests help to determine whether there is any damage to the nerves.
Treatment options fall into two categories. These injuries can be treated surgically—an initial exploratory surgery on the nerves is performed, which may bring back some amount of function. Additional follow-up surgeries may be able to remedy continued weakness. The other option is daily physical therapy, where a therapist and the baby’s parents manually move the affected limb to keep it limber and healthy. This physical therapy can begin very soon after birth.
What can I expect for my child?
Most brachial plexus injuries resolve within six months. However, about 10% of these injuries cause some degree of permanent impairment. These injuries, affecting the shoulders, arms, wrists or fingers, may cause some loss of sensation, or may cause full paralysis.
Children with brachial plexus injuries require extensive medical treatment, possibly including surgery and physical therapy, to achieve their maximum potential. Some children with brachial plexus injuries have emotional and self-esteem difficulties caused by the injury. Those children can benefit from counseling.
Was my Child’s Brachial Plexus Injury Caused by Medical Malpractice?
If your child has a brachial plexus injury like Erb’s palsy or Klumpke’s palsy, and you would like to know if that injury could have been prevented by your doctor, contact our medical malpractice attorneys at (855) 712-7818 or online for a free consultation. Your child may be entitled to money that can pay for expensive therapies and medical care.
Resources for Parents
- Mayo Clinic: Brachial plexus injuries
- National Institute of Neurological Disorders and Stroke: Brachial plexus injuries
- United Brachial Plexus Network: Extensive resources and support for parents of children with brachial plexus injuries.