The brachial plexus is a group of nerves located at the base of the neck that carries signals from the spinal cord to the entire arm, from the shoulder to the finger tips.
Injuries to these nerves can occur in various ways in children, ranging from difficult delivery at birth to sports injuries and major traumas. They are not common but can have a profound impact on how a child’s arm functions.
The result can be varying degrees of upper extremity and hand paralysis, loss of sensation or both. This can be permanent if left untreated. Early diagnosis and appropriate treatment of injuries to the brachial plexus are important to get the best recovery.
These physicians provide pediatric brachial plexus care.
Our physicians collaborate with several teams at Children's. Together they provide both medical and surgical care for brachial plexus injuries. They use a knowledgeable and specialized approach to diagnose brachial plexus injuries early and treat them properly.
Groups that may care for your child include:
This team encourages parents and caregivers to take an active role in their child’s care. We work with parents and the child to develop the best plan of care.
Twice a month, we also provide a brachial plexus clinic at the Judson L. Hawk, Jr. Center for Children, located at our Scottish Rite hospital. The staff at the clinic will work with your family so that most of your child’s care can be done at home.
Take a look at what to expect from your first visit.
Frequently Asked Questions
What is the brachial plexus?
The brachial plexus is a group of nerves located at the base of the neck that provide motor function and sensation to the shoulder, arm, elbow, wrist and hand. These nerves are formed directly from five nerve roots that exit the spinal cord.
Those five roots mix together and eventually split into about 20 separate branches that control gross and fine movement in the upper extremities, from the shoulder to the fingertips.
What causes a brachial plexus injury?
Injuries to the brachial plexus most commonly occur as a result stretching the nerves too far, like when the head and neck are forced away from the shoulder. They can occur during childbirth. Later in childhood, brachial plexus injuries can occur in several ways, like automobile accidents or while playing sports. Direct injury to the nerves due to a penetrating wound is less frequent.
What is brachial plexus birth palsy?
Brachial plexus birth palsy (BPBP) is a brachial plexus injury that occurs during the process of childbirth. It can result in paralysis of an arm. Fortunately, many children with BPBP will recover completely. The incidence rate of brachial plexus injuries at birth is approximately one in every 1,000 births. Risk factors for brachial plexus birth palsies include:
- Shoulder dystocia (when a baby's shoulder gets stuck in the birth canal)
- Maternal diabetes
- Large gestational size
- Difficult deliveries
- Previous history of children born with a brachial plexus birth palsy
A child with BPBP will move one arm considerably less than the other. It is very rare to have both arms affected. This movement pattern is not always evident at birth. It sometimes takes two or three weeks to be noticed.
How severe is an injury to the brachial plexus?
The severity of a brachial plexus injury or palsy depends on how the nerves were damaged. There are three ways in which the nerves can be injured:
- Stretched–This is the most common manner in which the nerves are injured. The healing potential of a stretched nerve depends on how far it is stretched.
- Rupture–When a nerve ruptures, it is snapped or broken. This requires surgical intervention, like nerve grafting or transfer.
- Avulsion–This occurs when the nerve root is pulled out from the spine. Like a rupture, there is no way to heal this kind of injury without surgical intervention.
Is the injury permanent?
It is difficult to tell if a brachial plexus injury will result in permanent impairment early on. The severity of the injury to the nerves will likely determine the treatment and any expectations of recovery. While injuries do tend to follow certain patterns, each case must be considered individually.
The earlier a brachial plexus injury is diagnosed, the better the long-term prognosis. With brachial plexus birth palsy, for example, if the child can work toward normal elbow flexion by 3 months, the chances of him having complete function of the arm are good. If elbow flexion isn't met until after 6 months, however, the child could be left with a very impaired arm.
Will my child be in pain after the injury?
Discomfort following a brachial plexus injury can occur. It is not typical with brachial plexus birth palsy. Older patients describe the discomfort as the feeling of “burning” or “pins and needles.” However, newborn babies and infants should not require pain medication following a brachial plexus injury.
Does my child need therapy?
Physical and occupational therapy are important elements of the treatment for a patient with a brachial plexus injury. In the initial stages of recovery, therapy to maintain joint motion is recommended. In all patients who sustain a neurologic injury, therapy to preserve and improve range of motion and strength is vital to maximizing upper-extremity function.
Families are encouraged to participate in the process by performing therapy tasks at home. We will educate families about which exercises to do and how to perform them.
Does my child need an MRI?
Whether or not your child needs magnetic resonance imaging (MRI) will likely depend on his age. Since MRIs do not usually change the treatment plan for infants, it is not our standard practice to order MRIs for the evaluation of a child with brachial plexus birth palsy. In some cases, MRIs are ordered to assess the shape of the developing shoulder joint and guide treatment aimed at maintaining and optimizing shoulder function.
MRIs can help determine the severity of the nerve injury in older children with traumatic brachial plexus injuries and are recommended.
Does my child need an EMG or nerve study?
These studies may be recommended for older children with a traumatic brachial plexus injury but are not typically used on infants. In the setting of brachial plexus birth palsy, electromyography (EMG) evaluations often overestimate the prognosis for recovery and can complicate treatment decisions. The test can also be rather uncomfortable, so we do not routinely order EMGs or nerve studies for infants.
Studies show that physical examination offers the most accurate picture of whether an infant with a birth-related brachial plexus injury will require early nerve reconstruction.
Does my child need surgery?
Surgery may be suggested depending on the child’s age, time since injury and functional status. Our surgeons will work with you to determine if surgery is the best treatment for your child.
The types of surgeries we may use include:
- Nerve grafting/repair–This surgery repairs the brachial plexus nerve if possible or removes the damaged portion of one or more of the nerves and replaces it with an uninjured nerve.
- Nerve transfers–This surgery involves connecting a functioning nerve with a different purpose to a nerve that is not working in order to stimulate a muscle that is not functioning well.
- Free muscle transfers–This surgery involves transplanting an entire muscle, along with its nerve and blood vessels, from one part of the body into the arm. The muscle, usually an unimportant leg muscle, is re-animated by a living nerve and revived by local blood vessels.
- Tendon transfers–This surgery involves the reassignment of muscle-tendon units to new functions to assist where it may have been lost.
- Bone and joint surgery–Bone reconstruction and joint fusion surgeries are at times performed to treat the later consequences of nerve injuries. These are used to reposition joints with the goal of enhancing function.
Surgery does not always guarantee that a child will have a fully functional arm, but it can help more severe cases significantly increase function and ability.