• Brachial Plexus Injury
  • Obstetric Brachial Plexus Injury (OBPI)
  • Birth Brachial Plexus Injury (BBPI)

Brachial Plexus Palsy

Brachial plexus palsy is an injury to a group of nerves called the brachial plexus that run from the spinal cord between the neck and shoulders. This complex bundle of nerves is responsible for movement and feeling from the shoulder to the fingers. 

Brachial plexus injuries are caused by trauma, inflammation, and tumors and occur in both children and adults. The most common occurrence of brachial plexus injury in children is due to trauma sustained in the birth process. This condition is also called obstetric brachial plexus injury (OBPI) or birth brachial plexus injury (BBPI).

Brachial plexus palsy most often occurs during a difficult labor when a baby’s shoulders are impacted, causing great strain on the nerves as the neck and shoulders are pushed in opposition. The resulting nerve injury can cause weakness and loss of motion to one side of the baby’s shoulder, arm, wrist, and fingers. One to two in 1,000 births result in a brachial plexus injury, with severity ranging from partial impediment to complete paralysis. 

Signs of a brachial plexus injury usually appear shortly after birth. They include:

  • A lack of the Moro reflex, also known as the infant startle reaction, on one side.
  • A loss of function on the affected arm/shoulder, resulting in the arm tilting inward towards the body.
  • The head tilting to the opposite side of the injury.

As many as two-thirds of brachial plexus injuries fully heal on their own within a few months.

Conventional Treatment

Because severe injuries require early intervention, it’s important for infants to undergo specialized testing to determine the precise location and level of injury to each nerve within the brachial plexus. Testing normally takes place within a month after the injury. Electromyogram (EMG), magnetic resonance imaging (MRI), X-rays, and ultrasound may be used to determine the exact site and severity of the damage.

Those injuries where the nerves are only stretched, not torn, are generally temporary. Additionally, not all of the nerves may be injured, resulting in injury to only a part of the arm. As many as two-thirds of brachial plexus injuries fully heal on their own within a few months. 

Most children benefit from some form of physical therapy which can maximize motor function and promote increased signals to the brain. Parents can take an active role to facilitate recovery by learning to perform daily range-of-motion exercises with their baby as early as one month after birth.

More severe injuries, in which nerves are partially or fully torn, require early intervention with occupational therapy and surgery. Nerve injuries are difficult to treat because completely severed nerves cannot regenerate on their own. Stretched and strained nerves may heal, but they may also be covered in scar tissue, causing pressure on the affected nerve. Nerve repair surgery, as early as three to six months, may be necessary because muscles that have not been linked to nerves within 18 months of the injury may be too weak to repair. Completely severed nerves, particularly those close to the spinal cord, may be permanently damaged and may only partially recover. However, nerve grafts and nerve transfers from less used muscles have been able to restore nerve function in some children.

Support

At The Brain Possible, our goal is to empower you to take a holistic approach to your child’s treatment. Below are ways in which you can support several aspects of your child’s recovery; before embarking on any, be sure to discuss them with your trusted health care providers.

Physical

Courses of physical therapy may be prescribed if the injury hasn’t healed within three months, or if it’s deemed severe enough to require immediate intervention. Frequent occupational therapy is also prescribed to promote nerve recovery, prevent muscle rigidity, and maintain range of motion. The therapist may also split the joint or perform compression and weight-bearing exercises. The child’s progress in therapy should be closely monitored in order to determine if surgery is necessary. According to Johns Hopkins Medicine, the following are the common surgical procedures for the condition: 

  • Neurolysis: releasing one or more nerves from inflamed, scarred or damaged tissue.
  • Neurotization (nerve transfer): moving a less important nerve to revitalize a more important nerve that has been damaged.
  • Transfer of tendons or free muscles in the arm or shoulder.

For severe injuries, secondary surgical interventions may also be needed to allow children to grow properly and increase the function of muscles and bones. These surgeries include muscle and tendon transfers, repositioning of bones, and joint fusion. 

Unfortunately, another hazard of lingering brachial plexus injuries is the overuse of the non-affected arm, which can result in secondary injuries such as carpal tunnel syndrome and tendonitis.  For ongoing support, caregivers may purchase special slings, orthotics and customized belts to support children in daily activities. 

Emotional/Social

Children who have long-term brachial plexus injuries may suffer from depression due to repeated hospital visits and, possibly, the social isolation that comes from the inability to keep up with peers’ physical development. They may also need discreet help from teachers and aids with grooming and using the restroom at school and in social situations. 

Sensory

Different types of nerves are impacted by brachial plexus injuries. If a sensory nerve sustains damage, a child may have lost feeling in her arms or fingers, making her susceptible to injuries. The occupational therapist may introduce a course of “sensory re-education” exercises to help the child re-learn to identify sensation. Hydrotherapy is also ideal for helping children with brachial plexus injuries improve strength and range of motion.

Intellectual

Brachial plexus injuries can make school challenging. Children may need to learn to use their non-dominant hand, which may make typing and handwriting skills harder to acquire. They may also need help managing the weight of books and backpacks and can have trouble with the fine motor skills required for cutting, coloring, and using a computer. Caregivers may need to arrange extra test-taking time and other accommodations with teachers and school administrators. 

Nutritional/Environmental

Supplementation with B12 is thought to help with nerve health. Brachial plexus injuries can make food preparation difficult, but there are many tools and techniques that can make food preparation safer and easier for those with limited dexterity and mobility. The United Brachial Plexus Network has many resources for improving the daily lives of those with brachial plexus injuries, including this forum on Nutrition.

Physiological

Nonsteroidal anti-inflammatory drugs (NSAIDs) and neuropathic pain medications such as antidepressants and anticonvulsants may be prescribed for nerve pain from brachial plexus injuries. BOTOX injections may also be used to control the muscles and nerves during treatment.