Neonatal Brachial Plexus Palsies Workup

  • Author: Jennifer Semel-Concepcion, MD; Chief Editor: Robert H Meier III, MD   more...
 
Updated: Jan 18, 2012
 

Laboratory Studies

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

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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.

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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.

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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  Staff Physiatrist, Department of Advanced Rehabilitation Medicine, St.Charles Hospital and Rehabilitation Center, Port Jefferson, NY

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, PT  Clinical Coordinator, Department of Physical Therapy, Children's National Medical Center of Washinton DC

Anne Conway, PT is a member of the following medical societies: American Physical Therapy Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Teresa L Massagli, MD  Professor 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Kelly L Allen, MD  Medical Director, Medevals

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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Brachial Plexus. Image courtesy of Michael Brown, MD.
Mallet classification.
 
 
 
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