Brachial Plexus

Newborns with difficult vaginal delivers and children, teens and young adults who are injured at play, in a fall, during sports or in a traumatic accident such as a car crash.

Whenever there is excessive stretching on the area between the neck and shoulder there is a risk for damage to the brachial plexus.

For a newborn, the cause of injury is usually due to a complex birth. This most often occurs when:

• The baby's shoulder catches on the mother's pelvic bone causing the neck and shoulder to stretch (this is called shoulder dystocia)
• The baby is larger than average, especially in cases where the mother is diabetic
• The baby is a breech delivery, meaning that the baby is born buttocks or feet first

For older children, teens and young adults, brachial plexus injuries are most often caused by an accident during play or participation in sports, such as a fall. They can also occur during serious trauma, such as a car crash.

In many cases, children can recover with the help of physical and occupational therapy. However, depending on the severity, certain more serious injuries may require surgery to repair the damage.

The severity of a brachial plexus injury is determined by the type of damage done to the nerves.

• Avulsion is the most severe type and is caused when the nerve root is severed or cut from the spinal cord
• Incomplete avulsion occurs when part of the nerve is damaged, leaving some opportunity for the nerve to slowly recover function
• Neuropraxia, or stretch injury, is the mildest type of injury, where the protective covering of the nerve is damaged, which causes problems with nerve signal conduction, but does not always damage the nerve underneath

Your child's treatment will depend upon the severity of his or her injury. It is important to note that, even in the case of milder injury, if not properly treated, your child could have limited to no use of their arm for life.

If your child has suffered an injury to their brachial plexus, symptoms may include:

• Weakness or limpness of the arm
• Weak or limp wrist or hand
• Problems moving the arm, wrist or hand
• Trouble controlling the movement of the arm, wrist or hand
• Constant pain in the arm or hand
• Can't feel their arm or hand
• Loss of sensation, can't feel other touches to their arm or hand or feel temperature changes
• Arm turns inward or hand seems to curl inward

If your doctor suspects injury to the brachial plexus, he or she will perform a thorough physical exam, including a medical history of your child and, if possible, a description of the injury. Your doctor will also check the strength of your child's muscles and assess how well he or she can move their arm, wrist and hand.

In many cases, your doctor will request either a CT scan or an MRI along with nerve testing, such as electromyography (EMG) or a nerve conduction study.

Because of the complexity of this type of injury, these tests may need to be repeated and your child closely monitored for a period of time to determine the full extent of damage and the type of treatment your child will need.

Once we have a clear understanding the type and severity of your child's brachial plexus injury, our team will work closely with you determine the best plan of care. Depending on your child's diagnose, he or she will either heal on their own with the support of physical and occupational therapy to assure that they regain the fullest use possible of their arm, wrist and hand. If the damage is more serious, we will likely recommend surgery.

Therapy

Our therapy team will create a plan that is custom fit to your child's needs. They will also work with you and other family members so that you can help your child with stretches at home and to help keep them from getting discouraged. Your child's therapy may include, but is in no way limited to:

• Stretching to keep joints loose
• Developing motor skills
• Movement exercises
• Arm and hand exercises

Surgery

If your child's injury is serious and does require surgery your doctor and a team of specialists will carefully go over all of the details with you, including what to expect before, during and after surgery. For most children who undergo surgery, therapy will also be required to assure the best possible recovery. Depending on your child's injury, our highly skilled, experienced neurosurgical team will perform one of the following procedures:

• Neurolysis
• Nerve graft
• Nerve transfer
• Free muscle transfer
• Capsule release
• Tendon transfer

For infants undergoing surgery, the typical stay is two to three days. Your baby's arm will be placed in a soft sling for approximately three to four weeks. Range of motion therapy will typically begin at this time.

For children, teens, and young adults, the length of time of surgery and the hospital stay will depend on the complexity of the surgery.

Pain management is very important for your child's care and will begin on your child's first visit to see your specialist. If your child has surgery, your doctor will prescribe pain medication appropriate to your child's age and intensity of the surgery.