Clinical features of neonatal brachial plexus injuries

Associated spinal level	C5	C6	C7	C8	T1
Pattern of injury	Upper brachial plexus (Erb palsy)
	Erb palsy plus
				Lower brachial plexus (Klumpke palsy)
	Total brachial plexus palsy
Neurologic signs on observation	Winged scapula Upper arm adducted and internally rotated Respiratory impairment^*	Forearm extended at elbow Wrist flexed ("waiter's tip" posture)	Hand flexed	"Claw hand": Fingers extended at metacarpophalangeal joints and flexed at interphalangeal joints Horner syndrome (ipsilateral ptosis and miosis)^¶	"Claw hand": Fingers extended at metacarpophalangeal joints and flexed at interphalangeal joints Horner syndrome (ipsilateral ptosis and miosis)^¶
Neurologic findings on examination	Impaired shoulder abduction (supraspinatus and deltoid muscles)	Impaired elbow flexion (biceps muscle) Impaired wrist extension (forearm extensor muscles)	Impaired elbow extension (triceps muscle) Impaired wrist flexion (forearm flexor muscles)	Impaired finger flexion (flexor muscles)	Impaired finger extension (lumbrical and interossei muscles)

Neonatal brachial plexus injuries cause ipsilateral arm weakness that vary according to the severity and location of the injury. Common patterns of injury may be identified by clinical observation and neurologic examination. These nerve injuries can be associated with other clinical findings in some cases including clavicle and humerus fractures, shoulder and cervical spine subluxation/dislocation, cervical spinal cord injury, and facial palsy.

* Ipsilateral diaphragmatic paralysis from phrenic nerve dysfunction is an uncommon finding that may cause weak cry, poor feeding, asymmetric chest expansion, respiratory distress, vomiting.

¶ Horner syndrome may sometimes occur in the setting of brachial plexus injuries due to disruption of the sympathetic nerve pathway as it courses over the lung apex and adjacent to the C8 to T2 spinal nerve roots.

References:

Volpe JJ. Injuries of extracranial, cranial, intracranial, spinal cord, and peripheral nervous system structures. In: Neurology of the Newborn, 6th ed, Volpe JJ, Inder TE, Darras BT, et al (Eds), Elsevier 2018.
Bowerson M, Nelson VS, Yang LJ. Diaphragmatic paralysis associated with neonatal brachial plexus palsy. Pediatr Neurol 2010; 42:234.
Executive summary: Neonatal brachial plexus palsy. Report of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Brachial Plexus Palsy. Obstet Gynecol 2014; 123:902.

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Clinical features of neonatal brachial plexus injuries