eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Neonatal Brachial Plexus Palsies: Differential Diagnoses & Workup

Author: Jennifer Semel-Concepcion, MD, Director, Department of Physical Medicine and Rehabilitation, St Charles Hospital and Rehabilitation Center; Chair, Assistant Professor of Physical Medicine and Rehabilitation, State University of New York at Stony Brook School of Medicine
Coauthor(s): Jennifer M Gray, DO, Resident Physician, Department of Physical Medicine and Rehabilitation, State University of New York at Stony Brook; Hany Nasr, MBBCh, Staff Physician, Department of Physical Medicine and Rehabilitation, State University of New York at Stony Brook; Anne Conway, BS, PT, Clinical Coordinator, Department of Physical Therapy, Children's National Medical Center of Washington, DC
Contributor Information and Disclosures

Updated: Jan 14, 2009

Differential Diagnoses

Traumatic Brachial Plexopathy

Other Problems to Be Considered

Preplexus lesions are manifestations of the effects caused by the tearing of a rootlet, root, or spinal nerve that feeds the brachial plexus; these lesions may produce the same clinical findings as brachial plexus palsy, but electrodiagnostic testing can distinguish them from BPP lesions.

Cervical spinal cord injury (SCI) may be involved. Bowel and bladder function should be assessed carefully. Magnetic resonance imaging (MRI) of the spine should be performed in any child with bilateral BPP to rule out an associated SCI.

Patients with hemiparesis should demonstrate the presence of DTRs, an absence of apparent abnormalities in EMG findings, and an exaggerated (not a depressed) Moro reflex.

Patients with hypotonia of central origin should have preserved DTRs and an absence of findings on EMG.

Amyoplasia congenita (a form of arthrogryposis) can be distinguished from BPP by rigidity of the joint and skin dimpling.

Children who have sustained humeral fracture demonstrate pseudoparalysis secondary to pain.

Anterior horn cell injury is unusual, but children with congenital varicella or congenital cervical spinal atrophy can present with a weak or flaccid arm accompanied by reduced sensation.

Workup

Laboratory Studies

  • Lab studies generally are not necessary for the diagnosis of brachial plexus palsy.

Imaging Studies

  • Until the advent of MRI, computed tomography (CT) myelography was the standard method for evaluating the integrity of the brachial plexus, and it remains arguably the most sensitive radiographic study to detect nerve root injuries. A water-soluble dye is injected intrathecally, and CT scans of the area in question are obtained. The main drawbacks to the procedure are radiation exposure, the need for sedation, a significant false-positive rate, and the lack of information on the distal brachial plexus. Some medical centers have abandoned the use of CT myelography, because direct observation during surgical exploration does not always correlate with CT myelographic findings.
  • High-resolution MRI is the best imaging study available for evaluating neonatal brachial plexus palsy. MRI requires no radiation exposure, is noninvasive, and provides more detail than does CT myelography. This test is most useful preoperatively to show the extent of trauma, including pseudomeningocele, and the presence of roots in the neural foramen.
  • While of little use in providing information on the anatomy of the brachial plexus, plain radiographs can be helpful in diagnosing hemidiaphragm paralysis from phrenic nerve involvement and fractures of the clavicle or humerus. Axillary radiographs also should be performed in children who show progressive loss of external rotation, to rule out posterior shoulder dislocation.

Related eMedicine topic:
Brachial Plexus, MRI

Other Tests

  • Electrodiagnostic studies are used as an extension of the physical examination and can provide data on the severity and timing of the injury. The initial study usually is performed 2-3 weeks after injury, when signs of denervation are seen in children with moderate or severe injuries. Some authors feel that EMG provides useful information to track the reinnervation process and guide in surgical decision-making. Others feel that EMG does not provide prognostic information.
  • The examination typically includes study of latencies of musculocutaneous and axillary nerves in Erb's palsy. In complete injuries, motor and sensory nerve conduction studies (NCS) of median, ulnar, and, on occasion, radial nerves are performed. Sensory NCS are useful in discerning an avulsion injury; if the sensory nerve potential is intact in the context of a clinically insensate arm, an unfavorable prognosis is suggested. If respiratory distress was noted at birth, ipsilateral phrenic nerve conduction also is tested. Needle EMG is performed on muscles innervated by the affected nerve. In Erb's palsy, these muscles include the supraspinatus, deltoid, infraspinatus, triceps, and biceps; in cases of total brachial plexus palsy, the muscles tested include those above, as well as the dorsal interossei and opponens pollicis.

More on Neonatal Brachial Plexus Palsies

Overview: Neonatal Brachial Plexus Palsies
Differential Diagnoses & Workup: Neonatal Brachial Plexus Palsies
Treatment & Medication: Neonatal Brachial Plexus Palsies
Follow-up: Neonatal Brachial Plexus Palsies
Multimedia: Neonatal Brachial Plexus Palsies
References
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References

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Further Reading

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Keywords

neonatal brachial plexus palsies, palsy, plexus, brachial plexus, brachial plexus injury, brachial plexus palsy, brachial plexus injuries, Erb palsy, obstetric brachial plexus palsy, obstetrical brachial plexus palsy, brachial plexus birth palsy, birth brachial plexus palsy, traumatic peripheral nervous system injury, congenital brachial plexus palsy, Erb's palsy, Klumpke's palsy, Duchenne-Erb's palsy, Erb palsy, Klumpke palsy, Duchenne-Erb palsy

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Contributor Information and Disclosures

Author

Jennifer Semel-Concepcion, MD, Director, Department of Physical Medicine and Rehabilitation, St Charles Hospital and Rehabilitation Center; Chair, Assistant Professor of Physical Medicine and Rehabilitation, State University of New York at Stony Brook School of Medicine
Jennifer Semel-Concepcion, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Jennifer M Gray, DO, Resident Physician, Department of Physical Medicine and Rehabilitation, State University of New York at Stony Brook
Jennifer M Gray, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Hany Nasr, MBBCh, Staff Physician, Department of Physical Medicine and Rehabilitation, State University of New York at Stony Brook
Disclosure: Nothing to disclose.

Anne Conway, BS, PT, Clinical Coordinator, Department of Physical Therapy, Children's National Medical Center of Washington, DC
Anne Conway, BS, PT is a member of the following medical societies: American Physical Therapy Association
Disclosure: Nothing to disclose.

Medical Editor

Teresa L Massagli, MD, Residency Director, Professor, Department of Rehabilitation Medicine and Pediatrics, University of Washington School of Medicine
Teresa L Massagli, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

 
 
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