Peripheral Nerve Disorders in Infants and Children / Obstetric Brachial Plexus Palsy (OBPP)
Although birth trauma and associated neonatal brachial plexus palsy have become less frequent over the past decade due to modern obstetric care, such cases continue to occur. Macrosomic infants born to mothers with gestational diabetes or obesity represent a well-recognized risk group. Often, neonatal brachial plexus injury is first noticed by the parents shortly after birth. Typically, the affected limb is held internally rotated and adducted against the trunk, with noticeable limitation of active movement—ranging to complete paralysis—of elbow flexion and shoulder elevation. The underlying lesion may range from stretch or traction injuries to complete nerve rupture or preganglionic root avulsion. In mild stretch injuries, neural regeneration is usually rapid and effective under targeted physiotherapy. In these cases, functional recovery is clearly apparent within two to three months. Approximately 50% to 60% of infants with obstetric brachial plexus palsy recover spontaneously without surgical intervention. However, in cases of persistent paralysis or developmental arrest despite active physical therapy and tight clinical monitoring, the child should be evaluated early for microsurgical nerve reconstruction. Because peripheral nerves in infants and young children possess tremendous regenerative capacity and plasticity, the long-term prognosis after early reconstruction is remarkably favorable.
One of the most common residual deficits following birth-related plexus injury is an external rotation deficiency of the shoulder joint. Affected children are unable to elevate the arm above head level normally. Young children often compensate for this limitation by hyper-extending the upper body backward when attempting to reach overhead objects. Over time, this chronic compensatory posturing causes asymmetric biomechanical strain on the spine, frequently resulting in secondary spinal scoliosis. This postural imbalance predisposes to chronic spinal problems and pain in later adult life.
Therefore, correcting the external rotation deficit and shoulder imbalance during early childhood or school age is necessary and strongly indicated. Depending on joint mobility, reconstruction is achieved either through tendon transfer surgery (e.g., the L'Episcopo latissimus dorsi and teres major transfer, when passive joint mobility is well preserved) or through a functional derotational osteotomy of the humerus (when the shoulder joint has developed secondary stiffness or glenoid dysplasia; see clinical figures below).
- Timeline & Protocol for Plexus Reconstruction in Infants and Children:
- Biceps function restored by 3 months – Continue non-operative physical therapy.
- Biceps function absent at 3 months – Surgical exploration and microsurgical reconstruction as soon as possible.
- External rotation deficit of the shoulder with preserved passive mobility at age 4–10 years – Tendon transfer surgery (modified L'Episcopo procedure).
- External rotation deficit with fixed contracture / lack of passive mobility – Derotational humeral osteotomy.
- As needed – Muscle transfer for scapular stabilization during early childhood or adolescence.
Selected clinical examples: Primary brachial plexus reconstruction and secondary functional reanimation in infants and children:
