====== Birth brachial plexus injury ======

Incidence is 0.3–2.0 per 1000 live births (0.1% in infants with birthweight<4000 gm
((Rouse DJ, Owen J, Goldenberg RL, et al. The effec- tiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. JAMA. 1996; 276:1480–1486))).
Rarely, a congenital case may be mistaken for BBPI
((Gilbert A, Brockman R, Carlioz H. Surgical Treatment of Brachial Plexus Birth Palsy. Clin Orthop.)).
Some contend that the plexus injury may occur when uterine contractions push the shoulder against the mother’s pubic bone or with lowering of the shoulder with opposite inclination of the cervical spine
((Gilbert A, Brockman R, Carlioz H. Surgical Treatment of Brachial Plexus Birth Palsy. Clin Orthop.)).

Classification of BBPI injuries: Upper plexus injuries are most common, with about half having C5 & C6 injuries, and 25% involving C7 also
((Boome RS, Kaye JC. Obstetric Traction Injuries of the Brachial Plexus: Natural History, Indications for Surgical Repair and Results. J Bone Joint Surg. 1988; 70B:571–576)).
Combined upper and lower lesions occur in ≈ 20%. Pure lower lesions (C7–1) are rare, constituting only ≈ 2% and seen most commonly in breech deliveries. Lesions are bilateral in ≈ 4%. 


===== Risk factors =====

1. shoulder dystocia

2. high birth weight

3. primiparous mother

4. forceps
((Piatt JH, Hudson AR, Hoffman HJ. Preliminary Experiences with Brachial Plexus Explorations in Children: Birth Injury and Vehicular Trauma. Neurosurgery. 1988; 22:715–723)) or [[vacuum assisted delivery]]

5. breech presentation
((Hunt D. Surgical Management of Brachial Plexus Birth Injuries. Dev Med Child Neurol. 1988; 30: 821–828))

6. prolonged labor

7. previous birth complicated by BBPI


===== Management =====

Most surgeons observe all patients until age 3 months. Conservative surgeons may wait up to 9 months. More aggressive surgeons will explore the [[plexus]] at age 3 months if not antigravity in deltoid, biceps or triceps. In cases of proven [[avulsion]] ([[pseudomeningocele]] and EMG indicative of a [[preganglionic injury]]), nerve transfers are a valid option at 3 months
((Anand P, Birch R. Restoration of sensory function and lack of long-term chronic pain syndromes after brachial plexus injury in human neonates. Brain. 2002; 125:113–122)).
EMG may show signs of reinnervation, but the recovery may not be robust enough.

===== References =====