The brachial plexus consists of five nerves that run from the spinal cord at the neck, across the upper chest and down into the armpit. These nerves are what controls sensation and movement in the shoulder, arm and hand. There is a brachial plexus on each side of the body. A brachial plexus injury generally only affects one side.
Each of the five nerves in the brachial plexus has a specific function in the body. The nerves control movement and sensation in the shoulder, elbow, wrist and hand. Damage to the brachial plexus is most often associated with pulling or stretching of the neck, occurring during a vaginal birth.
What is Brachial Plexus Injury?
A brachial plexus injury is a traumatic injury to one or more of the nerves in the brachial plexus network. Injury to these nerves – pulling, stretching, compression or tearing – can cause weakness, loss of movement and loss of sensation.
The term “obstetrical brachial plexus injury” was coined by Duchenne in the 1800’s. Since then, experts have learned a great deal about the causes and dangers associated with harm to the brachial plexus. Unfortunately, it is one of the most common types of birth injuries today, affecting thousands of infants each year.
Brachial Plexus Injury Severity
The severity of a brachial plexus injury varies. Often, how the injury occurs will determine how severe damage is to the nerves. There are three levels of severity to the nerves, which are:
- Avulsion: Avulsion means that the nerve root has been ripped or torn away from the spinal cord. This is the most severe type of nerve injury and may not be treatable, even with surgery.
- Neuropraxia: Neuropraxia means that the nerve has been stretched, but is still attached to the spinal cord. This is a less serious type of damage, and treatment often results in restored function.
- Rupture: If a nerve is stretched more severely, it may tear or rupture. A ruptured nerve may require surgery to correct.
Types of Brachial Plexus Injury
There are several types of brachial plexus injuries, some more common than others. Some injuries are also more severe than others. The most common types of brachial plexus injury affecting infants include:
Neuropraxia is the most common and least severe type of brachial plexus injury. It is marked by minor strains or tears in the brachial plexus nerves. Neurapraxia injuries affect the protective lining and covering of the nerve, yet the actual nerve is usually unharmed. This type of brachial plexus injury generally heals on its own within a few months. Symptoms of neurapraxia can include:
- Muscle weakness in the affected arm
- Burning, tingling and/or numbness in the affected arm
- Extreme sensitivity in the affected arm
- Sensation disturbances
Erb’s palsy is also known as brachial plexus birth palsy. This injury occurs when the brachial plexus nerves in the upper arm are damaged. Erb’s palsy ranges in severity depending upon how the injury happened and the extent of damage to the nerves. Some of the dangers of Erb’s palsy include:
- Full or partial paralysis in the affected arm
- Loss of sensory and/or motor function in the affected arm
- Decreased grip and arm numbness in the affected arm
- The affected arm may be bent towards the body or hang limp
Depending on how serious the injury is, Erb’s palsy treatment options include:
- Physical therapy
- Massage therapy
Klumpke’s palsy is a brachial plexus injury resulting from damage to the lower nerve roots (C8-T1). This condition can cause numbness, loss of feeling and a claw-like appearance in the hand of the affected arm. Klumpke’s palsy often affects the arm, wrist and hand of the affected side of the body. It is typically caused by shoulder dystocia.
Shoulder dystocia occurs when an infant becomes lodged against the mother’s pelvic bone during labor and delivery. This is a common cause of pulling and stretching of the infant’s arms during delivery.
Sometimes, Klumpke’s palsy will heal on its own without treatment, but for severe cases, such as partial or full paralysis, medication and surgery may be required.
What Causes a Brachial Plexus Injury?
When an infant experiences a brachial plexus injury, it can happen to any part of the nerve fibers, and can range in severity depending upon the location of the injury and how it happened. The most common causes for brachial injuries include:
Improper Use of Birth-Assisting Tools
Birth-assisting tools such as forceps and vacuum extraction tools may be used when the baby is stuck or has a difficult time moving through the birth canal naturally. However, improper force and failure to use birth-assisting tools correctly can lead to avulsion, neuropraxia or rupture that can damage any area of the brachial plexus.
Even when doctors do not use birth-assisting tools, they may pull excessively and improperly with their hands when attempting to deliver an infant. Although this may seem necessary in order to deliver the baby, this type of birth trauma can also lead to brachial plexus and other types of birth injuries.
Most infant’s will move into a head-down position in the weeks before delivery. Sometimes, however, the infant remains in an abnormal position, such a breech position. When an infant is in breech position, he or she is positioned with the buttocks or feet down. Brachial plexus injuries that occur during delivery most often occur when the infant is in a breech position.
Shoulder dystocia is a common cause of brachial plexus injuries at birth. This condition occurs when one or both of the infant’s shoulders become stuck behind the mother’s pelvic bone. It is difficult to predict shoulder dystocia, so doctors must act quickly when it happens to prevent additional injuries, such as oxygen deprivation.
Infants with shoulder dystocia are at risk for birth injuries including brachial plexus injuries and fractures. These risks increase if the doctor attempts to force a vaginal delivery when a c-section is a safer option.
Prolonged Contractions During Labor and Delivery
During a stressful labor and delivery, the mother’s contractions may place undue pressure on the infant’s head and shoulders. This is especially so if the infant is stuck in the mother’s pelvic area. Prolonged labor and pressure on the infant’s head can lead to bruising, fractures, and oxygen deprivation.
If labor is prolonged and the doctor attempts to assist in delivery, he or she may use force to help the infant through the birth canal. This is a common cause of brachial plexus injuries. The doctor may also use forceps or a vacuum extraction tool to assist with delivery, which can also cause injuries.
Can a Brachial Plexus Injury Be Prevented?
According to the National Institutes of Health (NIH), there are several risk factors for obstetric brachial plexus injuries. These risk factors include:
Healthcare providers should recognize these risk factors and take measures to prevent birth injuries, including brachial plexus injuries. Often, a brachial plexus injury could be prevented by ordering a c-section delivery rather than continuing a difficult vaginal birth.
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Brachial Plexus Injury Symptoms
The symptoms of a brachial plexus injury are generally noticeable shortly after birth. Since there are several types of injury and related conditions, there is a wide spectrum of symptoms which vary from one patient to another.
Symptoms of a Minor Injury
When the brachial plexus injury is minor, symptoms may be less noticeable. Because a newborn cannot vocalize their symptoms, parents and healthcare providers must be vigilant. The most common symptoms associated with a minor brachial plexus injury are:
- Weak grip
- Lack of movement
- Awkward hand or arm positioning
Symptoms associated with a minor injury generally resolve within a short amount of time.
Symptoms of a Severe Injury
More severe brachial plexus injuries will result in more noticeable symptoms. Parents and healthcare providers should be on the lookout for symptoms, such as:
- Loss of feeling in the affected arm, hand, or extremities
- Muscle weakness
- Intense pain
- Muscle paralysis in the shoulder or upper arm (may be partial or total)
- Erb’s palsy
- Klumpke’s palsy
- Horner’s syndrome
How a Brachial Plexus Injury Affects Children
Recovering from a brachial plexus injury can take months or even years. In the meantime, infants and children will experience the physical and emotional effects of their injury. Often, children continue to battle weakness and a loss of sensation in the affected arm. This can, no doubt, be frustrating. Physical therapy can help.
If your child has a brachial plexus injury, he or she will also need emotional support. Normal activities may be more difficult due to weakness, and that is understandably frustrating. Your child may feel like they are limited because of their injury.
Tests to Confirm a Brachial Plexus Injury Diagnosis
In order to diagnose a brachial plexus injury, physicians may go through a series of tests and evaluations. For example, a motor evaluation determines how the muscles function via a five-point grading system that assesses an infant’s ability or inability to use certain muscles. A Moro Reflex test is also tests for absent reflexes in the affected area.
In addition, physicians will perform a physical examination, and may conduct the following tests:
An x-ray of the neck and shoulder will tell the doctor if there are fractures or other injuries associated with the brachial plexus injury.
EMG tests evaluate electrical activity in the muscles. A needle electrode is inserted into targeted muscles and reports electrical activity during rest and muscle contraction.
Nerve Conduction Studies
Sometimes nerve conduction studies are done alongside the EMG. These tests measure the speed of conduction in a nerve when a small electrical current is applied. This tells the doctor how the nerve is functioning.
Magnetic Resonance Imaging (MRI)
MRI’s use radio waves and a powerful magnetic field to produce images of the body in great detail. MRI’s can often show the damage done by a brachial plexus injury. They can also show damage to nearby arteries or other tissues.
Computerized Tomography (CT) Myelography
A CT scan uses multiple x-rays to produce cross-sectional images of the body. CT myelography specifically looks at the spinal cord using a contrast material that is injected via spinal tap. This produces a detailed image of the spinal cord and all nerve roots.
Brachial Plexus Injury Treatment
Although recovery after a brachial plexus injury can be unpredictable, most infants who experience minor trauma, such as the nerves stretching or pulling, will go on to heal without incident. Physicians may conduct examinations and X-rays over a span of a few months after the injury, however, to ensure that it is healing properly.
For injuries that do not heal on their own, there are various treatment methods that your child’s healthcare team may recommend. The most common treatment options include:
Physical therapy (PT) is often a good option to help speed up the recovery process. It is important for infants to start PT as soon as possible in order to have the most success. A physician will usually create and guide a physical therapy plan and help ensure that parents understand what’s needed for home care as well as clinical sessions. Plans may vary according to each individual case, and may consist of:
- Range of motion exercises
- Sensory awareness
- Flexibility activities
- Myofascial release exercises
- Home activities such as exercising the infant’s functioning muscles and joints
Mild brachial plexus injuries generally heal within three to six months. With PT, the child may regain full use of his or her arm, wrist and hand.
Neuromuscular Electrical Stimulation
Neuromuscular electrical stimulation (NES) is a popular form of treatment for children, and is usually reserved for ages three and over. NES includes applying currents to the muscles in the damaged area via alternating currents, leading to increased blood flow and muscle function.
Neurolysis is a procedure in which doctors apply chemicals to the affected area for pain relief and to freeze or burn off injuries affecting the nerves. For brachial plexus injuries, neurolysis is generally used for neuroma, a type of injury that occurs when scar tissue forms over the damaged nerve. Development of scar tissue causes added pressure and pain to the damaged area.
Neurolysis may involve a combination of hot and cold applications, and in some instances, chemical agents such as alcohol, glycerol or phenol.
More severe brachial plexus injuries may require surgery. Most often, surgery is only necessary for cases where the affected area has not improved within three to six months after the injury. There are several surgical options for a brachial plexus injury. The type of surgery recommended will depend on the details of your child’s injury.
Nerve graft surgery takes a healthy nerve from another part of the body. The healthy nerve is then transferred to the damaged brachial plexus nerve. For example, an undamaged nerve in the leg or in between the rib bones can be taken out and transferred to the damaged nerve area, and then grafted into place. The success of nerve graft surgery greatly depends upon how serious the injury is. Those with less severe injuries have a much better chance of full recovery after surgery.
According to Dr. Scott W. Wolfe of the Hospital of Special Surgery (HSS), if nerve grafting is successful, the patient should have function of the affected area within several months.
“What is amazing is the degree of redundancy within the peripheral nervous system that allows us to detach a portion of a functioning nerve without causing a loss of strength or sensation, but then re-attach the same nerve elsewhere and regain lost muscle function in a matter of months,” Dr. Wolfe said.
A nerve transfer is useful when there are no functioning nerve stumps in the neck. In such cases, a nerve graft is not possible. During a nerve transfer, a healthy nerve is cut and the surgeon connects it to the damaged nerve. This sends a signal to the paralyzed muscle. Sometimes the nerve is connected to the affected muscle, and other times it is connected directly to a brachial plexus nerve.
During nerve repair surgery, the surgeon reattaches the torn edges of a nerve that is completely severed. This occurs most often when there is a clean laceration. For example, if the nerve was severed with a knife.
Medication can help relieve pain and help relax muscles. Doctors often prescribe pain medications and muscle relaxers for patients who have tight muscles or painful muscle contractions. If surgery is necessary, the infant will be given a light anesthesia medication for pain.
Brachial Plexus Injury Prognosis
The damage caused by a brachial plexus injury at birth may be temporary or permanent. The prognosis for a brachial plexus injury will depend on:
- The site of the injury
- Severity of the injury
- The type of damage to the nerves
- Other injuries in the area
This makes predicting a prognosis of brachial plexus injuries difficult. As a general rule, however, the sooner you get a brachial plexus injury diagnosis and treatment begins – the better.
Early detection and timely treatment of brachial plexus injuries are the most important factors that lead to a positive prognosis. Exact outlooks are difficult to determine due to the number of variables involved. In most cases, particularly those where there is stretching or compression, an infant with a brachial plexus injury can recover between 90-100 percent of arm function with appropriate treatments within three to six months.
Is Surgery the Best Option?
Per the National Institute of Neurological Disorders and Stroke (NINDS), it is not clear if surgical interventions can help in every situation, especially with more serious injuries. Nevertheless, pediatric neurologists and neurosurgeons do attempt to repair this type of injury as evidence shows that success is possible. Surgeons prefer to perform these procedures when the infant is between four and nine months old. This prevents the nerve damage from becoming more serious and irreversible.
In addition, since most brachial plexus injuries clear up without surgery within three months, doctors usually allow time to see if the infant heals without surgical intervention. Another consideration is whether surgery is likely to be successful. The more serious the injury is, the less chance of a full recovery.
According to the NYU Langone Medical Center, the surgical success rate for severe injuries is 50 percent, meaning that the patient has a 50 percent chance of recovering and having full use of the affected arm. For less severe brachial plexus injuries that still require surgery, the success rate is as high as 90 percent.
How to Optimize Your Child’s Prognosis
Now let’s consider what you can do as a parent to optimize your child’s prognosis. As a parent, you play an active role in your child’s development. You also play an active role in the healing process. Brachial plexus injuries can take months to heal, and during that time, you will work alongside your child’s healthcare team. While at home, here are some things you can do to help optimize your child’s prognosis and support treatments at home.
Ways to Help Your Child at Home
- Do not be afraid to move your child’s arm. Be gentle and look for cues of discomfort.
- When you are dressing your infant, place the injured arm into clothing first so that you don’t have to overstretch that same arm when dressing the other side.
- For sleeping, place your infant on his or her back. Place a small blanket or rolled towel under the affected side of the body.
- During feedings or when toting your infant, use both sides so he or she practices turning to each side and using each side of the body.
- During playtime, place toys on the side of the body with the brachial plexus injury. This encourages your child to turn toward the toys and try to get them.
- Make sure your infant has adequate tummy time every day. This is critical to developing muscles.
In addition to supporting your child’s physical health and wellbeing, you are also the primary support system for his or her emotional wellbeing. The healing process can be frustrating and painful for children. They will need your love and support to help them be strong and move beyond their injury.