AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

History of the Procedure

In 1764, Smellie described bilateral arm paralysis in a newborn. In 1872, Duchenne de Boulogne coined the term obstetrical paralysis. In 1874, Erb described the upper C5-C6 paralysis, and in 1885, Klumpke described paralysis of the lower plexus. In modern times, Gilbert has popularized surgical reconstruction of obstetrical brachial plexus injuries.¹

Problem

Obstetrical brachial plexus paralysis (OBPP) refers to injury to all or a portion of the brachial plexus noted at the time of delivery.^{2, 3} Injuries associated with the upper brachial plexus are termed Erb palsies, and those associated with the lower brachial plexus are termed Klumpke palsies. Obstetrical brachial plexus injuries often are associated with large weight at birth and shoulder dystocia. Obstetrical brachial plexus injuries are rarely (1% of cases) noted in neonates born via cesarean delivery.

Related Medscape topics:
Resource Center  Neonatal Medicine
Specialty Site Orthopaedics
Orthopaedics News

Related eMedicine topic:
Brachial Plexus Injuries, Traumatic

Frequency

With improvement in obstetrical care, the incidence of brachial plexus injuries has decreased significantly. In countries in which obstetrical care is poor, OBPP is noted more frequently. The incidence ranges globally from 0.2-4% of live births. According to the World Health Organization, prevalence is generally 1-2% worldwide, with the higher numbers being in underdeveloped countries. In the United States, the prevalence is approximately 0.2%.

Etiology

Factors associated with obstetrical brachial plexus paralysis (OBPP) include large birth weight, breech delivery, and shoulder dystocia.^{4, 5} Some consider intrauterine pressure neuropathy to be a cause of OBPP, based on the high pressures exerted between the brachial plexus and the mother's pelvis with labor and on the occurrence of OBPP in uneventful cesarean deliveries and in vaginal delivery without significant mechanical difficulty. Vertex presentation accounts for most OBPP cases (94-97%); breech presentations account for 1-2% of cases; and cesarean deliveries account for 1% of cases. Mothers with diabetes and mothers who are multiparous and previously had large babies are also considered to be at some risk for delivering neonates with OBPP.

Related Medscape topics:
Specialty Site Ob/Gyn & Women's Health
Ob/Gyn & Women's Health News
CME/CE Guidelines Issued About Lack of Evidence for Screening for Gestational Diabetes
CME/CE Outcomes of Cesarean Delivery Vary Based on Breech or Cephalic Presentation
CME Elective Cesarean Delivery Linked to Higher Risk for Infant Respiratory Morbidity

Related eMedicine topics:
Pregnancy, Breech Delivery
Diabetes Mellitus and Pregnancy

Pathophysiology

Obstetrical brachial plexus paralysis (OBPP) results from excessive lateral traction on the head away from the shoulder.⁶ This force on the brachial plexus can cause varying degrees of injury to the nerves, including rupture of the nerve roots or trunks, avulsion of the nerve roots from the spinal cord, and traction preserving the continuity of the nerve but causing excessive scarring. Injury to the brachial plexus may result from demyelination, axonal degeneration, or avulsion. Clinically, this injury results in disruption of the sensory and/or motor function of the injured nerve. Spontaneous recovery of function occurs with remyelination with or without axonal regeneration and reinnervation of the sensory receptors, muscle endplates, or both. However, in some cases of severe nerve injury and with avulsion injuries, spontaneous recovery does not occur and surgical intervention is warranted.

The neonate has tremendous susceptibility to nerve injuries, as compared with the older infant, child, or adult. A brachial plexus injury in the neonate results in a more proximal injury and even cell death, as opposed to the result in an older child with the same injury. Gonik et al have suggested that spontaneous endogenous uterine and maternal expulsive forces are 4-9 times greater than the force calculated for clinician-applied forces.⁷

Clinical

At birth, the upper extremity may be flail. Two days following birth, the neurologic examination findings are more reliable. With Erb palsy or upper plexopathy, the arm is internally rotated and pronated with no movement at the shoulder or elbow; hand and wrist flexion are noted. With complete brachial plexus paralysis, the entire arm and hand are flail with no movement. A Horner syndrome (eyelid ptosis and pupillary miosis) may be noted, suggesting avulsion of the lower brachial plexus. Phrenic nerve palsy suggests a very severe avulsion injury, and urgent plication of the diaphragm may be indicated in patients with pulmonary compromise.

Depending on the degree of nerve injury, recovery may be noted within a few days. In most cases, some degree of spontaneous recovery occurs within 1 month, although in some injuries, evidence of full recovery may not appear for up to 3 months.⁸ Seddon and Sunderland each described a classification for nerve injuries.^{9, 10} The classification of nerve injury described by Seddon consisted of neurapraxia, axonotmesis, and neurotmesis. Sunderland expanded the classification system into 5 degrees of nerve injury, as follows:

• A first-degree injury, or neurapraxia, involves a temporary conduction block with demyelination of the nerve at the site of injury. Electrodiagnostic studies elicit normal results above and below the level of injury, and no denervation muscle changes are present. No Tinel sign is present. Once the nerve has remyelinated at that area, complete recovery occurs. Recovery may take up to 12 weeks.
• A second-degree injury, or axonotmesis, results from a more severe trauma or compression. This causes Wallerian degeneration distal to the level of injury and proximal axonal degeneration to at least the next node of Ranvier. In more severe traumatic injuries, the proximal degeneration may extend beyond the next node of Ranvier. Electrodiagnostic studies demonstrate denervation changes in the affected muscles, and in cases of reinnervation, motor unit potentials (MUPs) are present. Axonal regeneration occurs at a rate of 1 mm/d or 1 in/mo and can be followed with an advancing Tinel sign. The endoneurial tubes remain intact, and the recovery, therefore, is complete with axons reinnervating their original motor and sensory targets.
• A third-degree injury, more severe than a second-degree injury, was introduced by Sunderland. Similar to a second-degree injury, Wallerian degeneration occurs, and electrodiagnostic studies demonstrate denervation changes with fibrillations in the affected muscles. In cases of reinnervation, MUPs are present. Regeneration occurs at a rate of 1 mm/d, and progress may be followed with an advancing Tinel sign. However, with the increased severity of the injury, the endoneurial tubes are not intact. Therefore, the regenerating axons may not reinnervate their original motor and sensory targets.

  The pattern of recovery is mixed and incomplete. Reinnervation occurs only if sensory fibers reach their sensory end organs and motor fibers reach their muscle targets. Even within a sensory nerve, recovery can be mismatched if sensory fibers reinnervate a different sensory area within the nerve's sensory distribution. If the muscle target is a long distance from the site of injury, nerve regeneration may occur, but the muscle may not be reinnervated completely, due to the long period of denervation.

• A fourth-degree injury results in a large area of scar at the site of nerve injury and precludes any axons from advancing distal to the level of nerve injury. Electrodiagnostic studies reveal denervation changes in the affected muscles, and no MUPs are present. A Tinel sign is noted at the level of the injury, but it does not advance beyond that level. No improvement in function is noted, and the patient requires surgery to restore neural continuity, thus permitting axonal regeneration and motor and sensory reinnervation.
• A fifth-degree injury is a complete transection of the nerve. Similar to a fourth-degree injury, surgery is required to restore neural continuity. Electrodiagnostic findings are the same as those for a fourth-degree injury.

Mackinnon introduced a sixth-degree injury classification to describe a mixed-nerve injury with a combination of the other degrees of injury in one patient.¹¹ This commonly occurs when some fascicles of the nerve are working normally while other fascicles may be recovering. Other fascicles may require surgical intervention to permit axonal regeneration.

Motor evaluation of patients with obstetrical brachial plexus paralysis (OBPP) is difficult, due to the young age of the child and the variability of presentation. Several classification systems have been described to categorize motor function and particularly OBPP. The Medical Research Council (MRC) uses a grading scale of 0-5, with 0 representing no muscle contraction and 5 representing normal muscle power through full range of motion, as follows:

• M0 - No contraction
• M1 - Flicker contraction
• M2 - Muscle contraction with active motion with gravity eliminated
• M3 - Full range of motion against gravity
• M4 - Full range of motion against gravity with some resistance
• M5 - Full range of motion against gravity with maximum resistance for that muscle

This classification system requires active contraction and movement of the muscle through full range of motion, which is extremely difficult to assess in neonates and infants.

Gilbert and Tassin introduced a modification of the MRC scale to be used in children, as follows¹²:

• M0 - No contraction
• M1 - Muscle contraction
• M2 - Movement with gravity eliminated
• M3 - Full movement against weight of extremity

However, this classification system lacks sensitivity.

The Active Movement Scale introduced by Clarke and Curtis is based on overall joint motion rather than individual muscle testing.¹³ The 7-point scale ranges from no contraction to full motion with gravity eliminated and against gravity. Motions assessed include shoulder flexion, abduction, adduction, internal rotation, and external rotation; elbow flexion and extension; wrist flexion and extension; and finger flexion and extension.

Mallet introduced a classification system (grade 0-5) based on voluntary upper extremity movements, including active abduction, external rotation, hand to nape of neck, hand to back, and hand to mouth.

Good intertester reliability has been reported for the Active Movement Scale and the Mallet Classification.¹⁴

Related eMedicine topic:
Horner Syndrome

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Reports vary regarding the timing for surgical intervention for obstetrical brachial plexus injuries. The recovery of biceps function appears to be a significant criterion for deciding whether surgical intervention is necessary. Gilbert recommends surgery if biceps recovery is not evident by 3 months; Hentz recommends waiting 3.5 months; and Waters suggests waiting until 4 months.^{15, 16, 17} Clarke has developed an active movement scale and scores recovery to determine the need for surgery.¹⁸ At 9 months, the infant is assessed with the cookie test, which requires the child to put a cookie to his or her mouth with limited neck flexion. If the infant does not pass the cookie test, then surgery is recommended. Shenaq et al reports that at Texas Children's Hospital, surgery is recommended if the infant does not show improvement in deltoid, triceps, and biceps muscle function within 4 months.¹⁹ Because of the short distance required for nerve regeneration to the target muscle in babies,the authors believe that it is prudent towait 4 months. If recovery of biceps muscle function is not evident by 4 months, then the prognosis for spontaneous recovery is poor, so surgery is indicated.

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

A very detailed knowledge of the brachial plexus is necessary to localize the level of the injury within the brachial plexus. During surgery, knowledge of motor and sensory fascicular topography is critical to ensure correct alignment of the motor and sensory fascicles.

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Patients with brachial plexus injury whose functional recovery continues to improve are not candidates for surgery. Note that each nerve must be evaluated separately (for instance, recovery of hand function without function of shoulder or elbow function is an indication for surgery to reconstruct the upper plexus palsy).

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Lab Studies

• No specific laboratory studies are helpful in diagnosing patients with obstetrical brachial plexus paralysis (OBPP).

Imaging Studies

• MRI is indicated to evaluate for avulsion of the nerve roots from the spinal cord.
• A chest radiograph is used to evaluate patients for phrenic nerve paralysis.
• Fluoroscopy of the diaphragm may be necessary.

Other Tests

Electromyography (EMG) and nerve conduction studies are less useful for patients with obstetrical brachial plexus paralysis  (OBPP) than they are for adults with brachial plexus injuries.

• With electromyography, fibrillations are associated with denervation and will become apparent approximately 4-6 weeks following injury.
• Motor unit potentials suggest reinnervation or collateral sprouting.
• In general, EMG findings may be misleadingly optimistic.²⁰
• Most surgeons believe that clinical examination is a better prognostic indicator than is EMG.

TREATMENT

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Medical therapy

Initial therapy involves protection of the joints and surrounding ligaments and tendons from stress. Physical therapy is used to maintain passive range of movement of the affected joints. In patients with obstetrical brachial plexus paralysis (OBPP), some believe that transcutaneous electrical stimulation is useful in waking up muscles that have been successfully reinnervated over a period of time. However, no scientific studies exist to support this conclusion. The authors do not use transcutaneous electrical stimulation in adults, although they endorse it in the older OBPP population.

Surgical therapy

Although variation exists in the recommended timing for surgery for young patients with brachial plexus paralysis (OBPP), the authors believe that if the infant does not show recovery of neurologic function by age 4 months, surgical intervention should be scheduled. Surgical reconstruction involves neurolysis, nerve grafting, and/or nerve transfer.^{21, 22}

Preoperative details

If clinical or electrodiagnostic evidence of recovery is not present at 4 months, the authors believe that surgical exploration should be recommended. Most reports in the literature suggest that the lack of clinical evidence of elbow flexion by 3-4 months is an indication for surgery.

Fracture or dislocation is ruled out in preoperative evaluation at birth. Movements of the fingers, wrist, elbow, and shoulder are noted. Physical examination is obviously more difficult in the newborn, and clinical observation is especially important in this population. Chest radiographs are used to evaluate patients for phrenic nerve paralysis. Fluoroscopy of the diaphragm may be necessary. The MRC grading system (see Introduction, Clinical, above) can be used but is of limited use in young patients with brachial plexus paralysis (OBPP). Gilbert and Tassin have suggested an M0 to M3 grading system (see Introduction, Clinical, above). The Active Movement Scale (see Introduction, Clinical, above) developed by Clarke provides a reliable tool for assessing motor function in infants with OBPP.

Tricks for evaluating the infant's movement include offering them treats or toys. Sensory evaluation is difficult but includes evaluation of the infant's response to nonpainful touch stimulus and painful touch stimulus.

Intraoperative details

Technique

Loupe magnification, preferably 4.3, is used with a microscope for microneurosurgical repairs or grafts. Nerve coaptations are done with 9-0 microsuture so that there is no tension at the repair site. Marcaine is placed at the incision site for postoperative pain relief. A Jackson-Pratt drain is used.

An infraclavicular and supraclavicular surgical approach is recommended for reconstruction. The pectoralis major is divided at the tendinous insertion to expose the brachial plexus and then is reattached at the end of the procedure. The brachial plexus is explored and evaluated with intraoperative electrical stimulation. In some cases, following a neurolysis of the brachial plexus, a good muscle contraction is seen with electrical stimulation, and no further surgical intervention is needed. However, in more severe injuries, nerve transfers or nerve grafts are necessary. The sural nerve or the medial antebrachial cutaneous nerve can be used as a nerve graft for upper plexus injuries.

In patients with upper brachial plexus injuries, the entire upper plexus can be grafted or grafting can be combined with nerve transfer procedures. The upper plexus can be grafted to the suprascapular and axillary nerves. To provide a closer motor nerve to the injured muscle, a nerve transfer using a portion of the ulnar nerve (as described by Oberlin) can be used to reconstruct the musculocutaneous nerve to the biceps.^{23, 24} Mackinnon has described a modification of the Oberlin transfer to augment elbow strength and to provide increased elbow flexion strength by using a portion of the medial pectoral nerve and transferring it to the brachialis muscle.²⁵

In complete avulsion injuries, the distal accessory nerve and intercostal nerves can be transferred for reconstruction. Usually, at least one root can be used as a proximal source of nerves, and nerve grafts can be used to reconstruct shoulder function. The hierarchy of reconstruction is to address elbow flexion, shoulder function, and finally wrist and hand function. Therefore, in avulsion injuries, the intercostal nerves are transferred to the musculocutaneous nerve for elbow flexion, and the distal accessory nerve can be transferred to the suprascapular nerve.

The cross-chest reconstruction with C7 motor root from the normal brachial plexus transferred over to the injured side has been used in some infants with good success. By contrast, in adults, this procedure provides motor function on the injured side only, with movement from the noninjured side. Therefore, both extremities must be moved together for motor function of the injured extremity, making this nerve transfer extremely confusing for the patient. In patients with obstetrical brachial plexus paralysis (OBPP), spontaneous motor reeducation allows the infant to separate function on each side.

Postoperative details

The bulky dressing is removed 2-3 days after surgery, and the drain is then removed. Infants are kept in a papooselike dressing for a month following surgery to allow the pectoralis major muscle to heal if it was detached from the humerus.

Physical therapy is initiated within a month of surgery to recover passive range of movement. Transcutaneous electrical muscle stimulation can be used; however, no scientific evidence indicates that it is efficacious in patients with brachial plexus injuries, and, therefore, in the authors' practice, electrical muscle stimulation is not used in patients with OBPP.

Follow-up

Initially, patients with obstetrical brachial plexus paralysis (OBPP) are monitored for wound management. Four weeks following surgery, patients are referred for therapy to regain active and passive range of motion of the extremity. Recovery of some motor function usually is evident approximately 6 months following surgery. However, patients continue to improve for 2-3 years following surgery. Secondary procedures, such as muscle transfers, tendon transfers, or shoulder releases, may also be necessary to maximize function.

COMPLICATIONS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Complications of surgery for obstetrical brachial plexus paralysis (OBPP) are similar to those of other surgeries and include infection, hematoma, seroma, and injury to other structures, including vascular structures. Unique to this surgery is the possibility of further inhibiting function by injuring components of the brachial plexus that are normal or recovering. In this patient population, injury to the phrenic nerve can result in devastating pulmonary compromise that could require urgent diaphragmatic plication. In theory, an intercostal motor branch or a nerve to the rectus muscle can be transferred to the distal end of the phrenic nerve, just above the diaphragm, to provide some reinnervation of the diaphragm.

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

The possibility of spontaneous recovery in patients with obstetrical brachial plexus paralysis (OBPP) is usually very good in most infants. Michelow et al evaluated the natural history of OBPP in 66 patients and reported that 92% of these infants recovered spontaneously.²⁶ Shenaq et al reported a 95% spontaneous recovery rate in infants with OBPP and stated that patients without improvement of biceps, triceps, and deltoid muscle function within 3 months have poor functional recovery without operative intervention.¹⁹ Therefore, most infants who present with OBPP recover spontaneously due to the relatively minor degree of nerve injury. However, in patients in whom nerve injury is more severe and spontaneous recovery is not probable, surgical intervention is instituted.

No randomized studies exist to compare surgical management with conservative management for obstetrical brachial plexus injuries. Eng et al did a retrospective chart review of clinical evaluation, electrodiagnosis, and functional outcome with conservative management of 186 patients with OBPP.²⁷ They reported that most patients had an upper brachial plexus palsy; injury was mild in 63% of cases. Most patients did not change in their impairment status as determined by the authors. Because the authors did not indicate the follow-up period in these patients and because of the retrospective nature of the study, it is difficult to draw meaningful conclusions from this study.

Strombeck et al reported on the functional outcome in 247 children (5-year follow-up) with OBPP with and without surgical reconstruction.²⁸ The children were assigned to 1 of 3 groups for evaluation, depending on the number of nerves injured, evidence of recovery in the biceps or deltoid muscle by age 6 months, and whether any nerve reconstructions had been performed, as follows:

• The early-recovery group included children who showed some muscle activity in the biceps or deltoid muscle by age 3 months.
• The nonoperated group included children who showed muscle recovery after age 3 months, who were too old for surgery (age >18 mo), whose parents declined surgery, and who dropped out of the study after the initial evaluation.
• The operated group included children who underwent surgical reconstruction for their brachial plexus palsy.

In this study, 129 children had C5-6 palsy. Of these, 106 had early recovery, 8 children had surgery, and 15 children had neither early recovery nor surgery. In the 85 children with C5-7 lesions, 29 had early recovery, 24 had surgery, and 32 had neither early recovery nor surgery. Stromberg et al concluded that in the C5-6 group, shoulder range of motion was significantly better in those children who had surgery, and no other significant differences existed between those children who had surgery and those who did not have surgery. In the patients with the most root avulsions, a correlation existed between decreased hand function and increased root avulsions. Because of bias in patient selection for surgery, it is difficult to extrapolate these results for decision-making regarding conservative or surgical management for the child with OBPP.

Brown et al evaluated 16 children with prior OBPP using somatosensory and electromyography.²⁹ They concluded that the persistent functional loss may be due to impaired motor unit activation.

Historically comparing conservative management with surgical intervention is difficult because of the likelihood that those patients who have surgery have the most severe nerve injury. Therefore, comparisons between surgical and conservative management would likely compare patients with more severe nerve injuries who had surgery with patients with less severe nerve injuries who did not have surgery.³⁰ However, regardless of the management instituted, patients with lower brachial plexus avulsion injuries rarely recover hand function.³¹

Secondary surgical procedures involving tendon and muscle transfers and releases are available to patients with functional limitations.^{32, 33} Limited shoulder function can be enhanced at a later age with procedures to release the subscapularis muscle or transfer the teres major and latissimus dorsi muscles.³⁴ Recovery of elbow flexion can be augmented at a later date with muscle or tendon transfers.

Related eMedicine topic:
Tendon Transfers

FUTURE AND CONTROVERSIES

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Controversy exists in the United States over the timing of surgical reconstruction for obstetrical brachial plexus paralysis (OBPP). Many reports in the literature suggest that surgical intervention should be left until the child is aged 4 months and the surgeon does not excise portions of the brachial plexus that are demonstrating clinical or electrical evidence of recovery. Some surgeons suggest that surgeries performed on patients younger than 4 months with aggressive excision and reconstruction of the brachial plexus are decreasing function for brachial plexus elements that have potential to recover spontaneously. Note that the vast majority of infants with OBPP recover well without surgery.

Donor-related nerve grafts (allografts) have been used in a small number of patients for brachial plexus reconstruction following traumatic nerve injuries. The authors' group has performed a number of nerve allografts in older children and young adults with otherwise unreconstructable injuries. The authors do not recommend the widespread use of nerve allotransplantation for patients with OBPP until the side effects of immunosuppression and transplantation have been resolved. With success in studies in inducing tolerance to the nerve allograft, the side effects of immunosuppression and transplantation would be eliminated. The authors' group has shown the benefits of FK506 (an immunosuppression transplantation drug) to enhance nerve regeneration. Use of this drug at an immunosuppressive subtherapeutic dose or use of an FK506 analogue may be considered to enhance nerve regeneration.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

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3. Omer GE Jr, Spinner M, Van Beek AL. Management of Peripheral Nerve Problems. 2nd ed. Philadelphia, PA: WB Saunders Co; 1998.
4. Al-Qattan MM. Obstetric brachial plexus palsy associated with breech delivery. Ann Plast Surg. Sep 2003;51(3):257-64; discussion 265. [Medline].
5. Gherman RB, Ouzounian JG, Satin AJ, Goodwin TM, Phelan JP. A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies. Obstet Gynecol. Sep 2003;102(3):544-8. [Medline].
6. Allen RH. On the mechanical aspects of shoulder dystocia and birth injury. Clin Obstet Gynecol. Sep 2007;50(3):607-23. [Medline].
7. Gonik B, Walker A, Grimm M. Mathematic modeling of forces associated with shoulder dystocia: a comparison of endogenous and exogenous sources. Am J Obstet Gynecol. Mar 2000;182(3):689-91. [Medline].
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9. Seddon HJ. Three types of nerve injury. Brain. 66;237:1943.
10. Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain. 1951;74:491-516.
11. Mackinnon SE, Dellon AL. Surgery of the Peripheral Nerve. New York, NY: Thieme; 1988.
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21. Marcus JR, Clarke HM. Management of obstetrical brachial plexus palsy evaluation, prognosis, and primary surgical treatment. Clin Plast Surg. Apr 2003;30(2):289-306. [Medline].
22. Hentz VR. Operative repair of the brachial plexus in infants and children. In: Operative Nerve Repair and Reconstruction. Philadelphia, PA: Lippincott; 1991:1369-83.
23. Oberlin C, Beal D, Leechavengvongs S, et al. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg [Am]. Mar 1994;19(2):232-7. [Medline].
24. Al-Qattan MM. Oberlin's ulnar nerve transfer to the biceps nerve in Erb's birth palsy. Plast Reconstr Surg. Jan 2002;109(1):405-7. [Medline].
25. Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg [Am]. Sep 2005;30(5):978-85. [Medline].
26. Michelow BJ, Clarke HM, Curtis CG, et al. The natural history of obstetrical brachial plexus palsy. Plast Reconstr Surg. Apr 1994;93(4):675-80; discussion 681. [Medline].
27. Eng GD, Binder H, Getson P, O'Donnell R. Obstetrical brachial plexus palsy (OBPP) outcome with conservative management. Muscle Nerve. Jul 1996;19(7):884-91. [Medline].
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Article Last Updated: Jul 16, 2008