Brain, Nervous System and Mental Conditions
Brachial Plexus Palsy
What is brachial plexus palsy?
A brachial plexus (BRAKE-ee-uhl PLEKS-uss) palsy happens when the nerves of the brachial plexus have been damaged.
- The brachial plexus is a set of nerves that control the muscles of the arm.
- Palsy means not being able to move muscles in an area (paralysis).
Nerves are soft, tube-like structures inside the body. They contain many small fibers (filaments), like a telephone cable or a thick electrical cord. These small fibers carry signals from the brain to control the muscles. Nerves also carry signals from the skin to the brain. This is how we feel things on our skin.
The nerves of the brachial plexus go out from the spinal cord under the collarbone and into the armpit. From there, they branch out into individual nerves that control the muscles in the shoulder, elbow, wrist and hand.
When nerves in the brachial plexus get damaged, signals cannot travel like usual from the brain to the arm muscles. So some or all of your child’s arm muscles may no longer work. When this affects only the shoulder and elbow muscles, it is called an Erb’s palsy. When it affects all of the muscles of the arm, hand and wrist, this is known as a total plexus palsy.
Brachial Plexus Palsy in Children
Brachial plexus palsies usually happen because of a stretch injury to your child’s head, neck and shoulder. This can happen during birth, especially when the birth is difficult or complex. Sometimes a child’s shoulder will get stuck against the mother’s pelvis. This can result in a stretch injury as your child is being delivered.
In older children, a brachial plexus palsy can occur because of an injury where the neck and shoulder get stretched.
Many children with a brachial plexus palsy recover on their own. But if the condition does not completely resolve within 1 month, it usually has lasting effects. That’s why we encourage you to have your child assessed 1 month after their birth or injury if they have not fully recovered. If treatment is needed, it’s important to begin early and to have ongoing therapy.
Physical and occupational therapy can reduce problems with stiffness or other bone problems that can happen as a result of the injury. Some children need to wear splints to help position their joints while the nerves are recovering. Some need surgery to repair their nerves.
Brachial Plexus Palsy at Seattle Children’s
Seattle Children’s Brachial Plexus Clinic is the only comprehensive clinic in the Northwest for children with this condition. We are 1 of only a few in the country. Our team of doctors, surgeons, physical therapists, occupational therapists, nurses and other health professionals work together closely to provide care for children of all ages with a brachial plexus palsy.
The team will assess your child’s injury carefully and design a treatment plan that’s right for your child. We will work with you and your child from the time of their injury until your child is an adult.
Many of our pediatric orthopedic surgeons have expanded fellowship training in areas such as foot and ankle conditions, sports medicine, tumors, upper extremity surgery, limb deformity, neuromuscular diseases, skeletal dysplasia and spine problems. To restore or improve your child’s health, function and quality of life, we often use nonsurgical methods (like medicines, physical therapy and braces), recommending surgery only when we believe it will give your child the best results.
Our radiologists have special expertise using ultrasound to look for bone and joint changes so we can work with your child to help prevent future problems. We emphasize nonsurgical treatments, including unique splinting options. Seattle Children’s is the only hospital in Washington state to offer these new options, which may reduce the need for surgery in some children. Most children don’t require surgery. For those who do, splinting and therapy combined with surgery have better results than surgery alone.
Symptoms of Brachial Plexus Palsy
Babies and children with brachial plexus palsy may have these symptoms:
- Weak or limp arm and sometimes wrist and hand
- Arm, wrist or hand position that is not normal, like the arm turning inward or the wrist and hand curling down
- Bent elbow because the joint is very tight
- Trouble moving their arm, wrist or hand, or trouble controlling the movement
- Pain in their arm or hand
- Numbness or trouble feeling their arm or hand
- Problems with the position or formation of the shoulder because of muscle weakness or an imbalance
Symptoms may range from mild to serious. This depends on how badly the nerves are damaged. For some children, the nerves only get stretched. For others, the nerves are torn or disconnected.
- If your child’s nerves are stretched, the brachial plexus palsy tends to be only short term. It usually gets better quickly on its own.
- If your child’s nerves are torn, the brachial plexus injury is more serious. If the nerves are only partly torn, they may be able to grow back. But if the injury is too serious, or if it causes a lot of scarring, the nerve fibers may not regrow to reach the muscle. Without treatment, your child may not have enough strength to use their arm muscles in the future.
- If your child’s nerves are completely torn, or if nerves are torn away from the spinal cord, your child will not recover the use of their arm muscles without treatment.
Diagnosing Brachial Plexus Palsy
Your child’s doctor will check your child to learn about their injury and how it affects their arm and hand. An exam can help the doctor assess the strength in your child’s muscles and how well your child can move their joints.
There is no single test that can tell us how serious your child’s injury is. Over time, the brachial plexus team will repeat tests and examine your child again. This can help them know more about where the injury is and how serious it is.
Repeated tests and exams can also help the team tell how quickly your child is getting better. If your child gets better quickly, the injury is probably less serious. If your child does not get better quickly, the injury may be more serious.
Your doctor may do imaging studies to decide the right treatment at the right time.
- Ultrasound shows us how your child’s shoulder is developing. We use ultrasound at regular intervals, starting when babies are as young as 3 months. If we see problems with the shoulder joint, we can start splinting early to help hold the joint in the right position.
- In some cases, your doctor may order MRI (magnetic resonance imaging). This can show if a nerve is detached near the spine.
Sometimes, the doctor may also order nerve tests that can help to assess your child’s nerves.
Nonsurgical Treatment Options for Brachial Plexus Palsy
The team at the Brachial Plexus Clinic 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:
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.
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.
Surgery for Brachial Plexus Palsy
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.
Four types of surgery are available to help treat brachial plexus palsy, depending on the severity of your child’s condition.
- Nerve graft. This treatment removes a part of the brachial plexus and replaces 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 1 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 During Recovery
Infants, children and teens are still developing, so they may need different care than adults do, like treatment that takes their growth plates into account. Here, your child’s team has special training in the medical, surgical, emotional and social needs of young people.
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 too.