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Brachial Plexus Injuries

Chances are, you’d never heard the term brachial plexus until you were told that your child had a health concern. The brachial plexus is a complex network of nerves that controls the muscles in your child’s shoulder, arm, elbow, wrist, hand and fingers. Brachial plexus injuries are usually just on one side.

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Copyright ©2008 Children's Healthcare of Atlanta Inc.
Illustration by Bernie Kida

They happen most often during a baby's birth as a result of shoulder dystocia (see image below), but can also happen as the result of an injury sustained in an auto accident or other kinds of trauma. Whether due to a shoulder dystocia birth injury as a baby, or a trauma injury, if left untreated, a brachial plexus injury can lead to severe disability of the shoulder, arm and hand.

Babies, infants and children with brachial plexus injuries are affected in different ways. Some children may be able to move their wrist and hand well, but may not have control of the shoulder and elbow. Children with more extensive injuries may have no muscle control or feeling anywhere along the affected arm.

 

Shoulder Dystocia
This image shows the stretching and injury of the baby's left shoulder and brachial plexus nerves during a vaginal delivery. The baby's shoulder is partially trapped beneath the mother's pubic bone. As the mother exerts more pressure to deliver the baby, the brachial plexus nerves stretch and are injured.

Types of nerve injuries

There are three types of brachial plexus nerve injury that can occur:

  • Neuropraxia
  • Rupture
  • Avulsion

Neuropraxia
Neuropraxia can lead to a scar tissue around a nerve or between nerve cells that interrupts the nerve signal. In less severe cases, surgeons can remove the external scar tissue and restore the connection. Often, however, the scar tissue must be cut out, and the neural pathway reconstructed with a nerve graft. The new nerve graft provides a pathway for new nerve growth to the muscle.

Rupture
A rupture is a complete tear of the nerve. The best chance for recovery involves surgically bridging the gap with a nerve graft.

Avulsion
Sometimes a nerve root is pulled out of the spinal cord. The nerve root cannot be reimplanted directly, but nerves can be rerouted from another root of the brachial plexus or from another nerve outside the plexus to provide stimulation for the affected muscles. Your child’s brain will enable him to adapt to these new pathways.

Brachial plexus damage can involve one or more of the C5, C6, C7, C8 and T1 nerves. Each nerve affects different muscle movements and sensations. For example, an injury to the upper brachial plexus (C5 and C6) has been called Erb-Duchenne palsy or Erb’s palsy. Erb’s palsy affects the shoulder and upper arm, causing weakness of the shoulder and elbow. A child with Erb’s palsy will not be able to lift his arm over his head or bend his elbow. Total plexus palsy also involves the C8 and T1 nerves, which go to the hand. Children with total plexus palsy have problems with opening and/or closing the hand and are more likely to require surgery than children with Erb’s palsy.

Magnetic Resonance Imaging (MRI) provides some valuable information about your child’s nerve damage for presurgical evaluation. Functional assessments indicate which nerves are damaged and the extent of the damage. Ultimately, the course of treatment may change based on what is seen during your child’s reconstructive surgery.

Treatments

Occupational and Physical Therapy
Up to 90 percent of brachial plexus injuries will heal better on their own than with surgery. For these children, the emphasis is therapy to preserve the flexibility in the joints of the arm as the natural healing occurs.

Children with brachial plexus injuries may also need stretches for their neck or positioning during sleep, because they tend to turn to one side and this can flatten the back of the head. Our physical therapists provide a parent-centered program of therapy to preserve flexibility in these infants. Even children who will go on to have surgery will need stretching in order to get the maximum benefit.

Reconstructive Surgery
Sometimes the initial brachial plexus injury causes a complete tear of the nerves or the brachial plexus nerves pull out of the spinal cord. When this happens, recovery is not possible without brachial plexus reconstructive surgery. If our doctors suspect a severe injury, an MRI will be ordered to look carefully at the injured area and see whether the nerves are still connected to the spinal cord. Surgical repair of the brachial plexus consists of removal of the scarred, damaged nerves and rebuilding the plexus with “extra” nerves from other areas of the body, such as the neck or legs.

After brachial plexus reconstructive surgery, your child will be in the hospital for one or two days. His arm will be placed in a soft dressing, which keeps the arm against the body so it can heal. Each child heals and improves at a different rate.

Sometimes older children with a brachial plexus injury are not able to get maximum use from their arms, even after surgery. In these children, brachial plexus reconstructive surgery to correct the position of the shoulder or wrist and improve arm function may sometimes be recommended. Our therapists can also recommend strategies to make everyday living easier for these children, from modifying bicycle handles to special ways of tying shoelaces.

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