Brachial Plexus Palsy Treatment Options
The Brachial Plexus Clinic at Seattle Children's provides care for children who have brachial plexus palsy. We like to see children 1 month after their birth or injury if they are not fully recovered on their own. That way, we can start treatment as soon as possible.
Your child's brachial plexus team will develop an individual treatment and therapy plan for your child. Over time, the team will learn more about your child's injury. Then the team will be able to recommend what seems to be the best treatment to improve your child's arm.
The team might suggest that the best option for your child is to recover on their own. Or the team might suggest that your child will do better with splinting or surgery. Our goal is to create a plan that is most likely to help your child, based on the latest knowledge about brachial plexus palsy treatment in children.
Your child's team may include healthcare professionals from many departments at Seattle Children's, such as Rehabilitation Medicine, Plastic Surgery, Orthopedics, Radiology and others, as needed.
Brachial plexus therapy
Physical therapists and occupational therapists can help children with a brachial plexus palsy in many ways. Therapists help children:
- Stretch to prevent joint stiffness
- Use their arm and hand actively
- Develop motor skills
- Learn ways to move so they can do as much as possible on their own
Therapists can also teach family members how to provide stretching and encourage a child to use their affected arm and hand at home. The therapists on your child's brachial plexus team at Seattle Children's will work with therapists in your community to help your child get the right type of ongoing care.
Brachial plexus splinting and casting
With brachial plexus palsy, some joints of the arm can be tight. Sometimes a child is at risk for losing joint flexibility because the muscles are weak and not moving the joints through their full range of motion. In these cases, children benefit from a splint or cast that holds the shoulder or arm in the proper position. This keeps the joint more flexible.
Seattle Children’s is the only hospital in Washington state to offer these new splinting options. For many children, splinting combined with surgery results in better, lasting flexibility than surgery alone.
If our team decides this will help your child, we will make a custom brace. Depending on your child’s needs, we may use a molded plastic splint that can be taken on and off or a cast that your child wears for a set time.
We will teach you stretching and strengthening exercises to do at home with your child. We also work with therapists in your community so your child gets the right care closer to home.
We may use splinting to position the shoulder, forearm, elbow, wrist or hand. We readjust the brace as your child grows and their muscles develop. We start working with children as young as 1 month and follow them over time. How long your child may need to wear the brace depends on their injury and how their nerves and muscles are recovering.
Some children may also need injections of a medicine to weaken muscles that are too strong and are pulling a joint into the wrong position. The medicine is botulinum toxin (often called Botox). It will temporarily weaken the strong muscles so they can be stretched to improve the joint’s range of motion. This can allow your child to work on strengthening their weaker muscles.
Brachial plexus surgery
Some injuries to the nerves of the brachial plexus are serious enough that they may not get better on their own. The brachial plexus team may offer surgery to children with serious injuries to these nerves. However, the team will only offer surgery if they think it gives your child a better chance to have more use of their arm than if it is left to recover on its own.
- Nerve graft. One treatment is to remove a part of the brachial plexus and replace it with some of the nerves from your child's leg. This is called a nerve graft. Doing a nerve graft leaves a small area of the leg - usually, the back of your child's heel - without feeling, but it does not affect movement. This does not usually cause any problems.
- Nerve transfer. Another treatment is to use parts of working nerves from other parts of the body to replace some of the damaged nerves. This is called a nerve transfer. Doing a nerve transfer takes away movement from some muscles. Usually, other muscles can work to make up for this.
- Muscle transfer. Some children may have weakness or imbalance that does not go away because a group of muscles recovered better than another. We may recommend a procedure that moves one muscle to do the work of another muscle. This is called muscle transfer or tendon transfer (because the tendon is part of a muscle). We also may do this to balance muscles that pull in opposite ways. It may be done along with a procedure to loosen a joint that has gotten tight.
- Osteotomy. Sometimes the bone grows abnormally because of chronic weakness or imbalance. We will sometimes recommend reshaping or repositioning the bone to improve how your child’s arm works. This is called osteotomy.
Your child’s brachial plexus team will begin surgery with a plan about whether a nerve graft or a nerve transfer will likely be best for your child. At the time of surgery, they will be able to look more closely at the nerves to make sure this is the right plan. Sometimes, they will find that they need to do both a nerve graft and a nerve transfer. No matter what, they will do the surgery that they think is most likely to help your child regain use of their arm.
After surgery, most children stay in the hospital for 2 to 3 days. Before your child goes home, you will get details about what to expect and how to take care of your child as they recover from surgery.
What to expect
Most recovery happens during the first year after an injury. The injury might keep getting a little better during the second year. During this time, it is important to continue with your child’s exercise and splinting therapy. This helps to prevent stiffness and to strengthen the arm over time.
Most children will regain good function and be able to use their arm. However, they will usually still have some weakness, especially around the shoulder and the shoulder blade.
If your child is treated with surgery, it also takes a few years for them to recover from this. Most of the recovery happens during the first year after surgery. Sometimes, a child's arm keeps getting better during the second year, too. During this time, it is important to keep doing exercises with your child. Your child will regularly see the Brachial Plexus Clinic therapist, who will check on how your child is doing. Your child will also come to clinic every 6 to 12 months to see the rest of the brachial plexus team.
We will do everything we can to help your child get the most use from their arm. Most children have at least some weakness.
As children with brachial plexus palsy get older, they may have differences in the ways their arms develop. Their affected arm may be smaller or shorter, or movement of certain muscles may be limited. This can happen if their nerves do not recover fully and they do not use their affected arm the same way as their other arm. Physical and occupational therapy can help as your child grows by stretching their affected arm and hand, teaching normal movement patterns and teaching them to make changes if they need to.
Some children may also need surgery on their bones, muscles or tendons later on to improve their arm so they can use it better. Surgeons on our brachial plexus team provide this type of surgery.