Brachial Plexus Program Diagnosis and Treatment

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How is brachial plexus birth palsy diagnosed?

Brachial plexus birth palsy can be diagnosed by your baby’s pediatrician upon a thorough medical history and physical examination. Since the majority of babies with a brachial plexus injury recover in the first month to six weeks of life, these exams can be scheduled with a primary care doctor. Children who continue to have problems beyond six weeks should be seen by an orthopedist or brachial plexus specialist.

In addition to a physical exam, doctors may perform special imaging studies, like an MRI or nerve conduction studies. These tests are not as reliable for babies as for adults, and they require anesthesia. If accompanying fractures are suspected, doctors may take an x-ray. It’s important to find an experienced doctor who will be able to track your child’s progress over repeated exams.

Brachial Plexus Anatomy

Once my child is diagnosed with brachial plexus birth palsy, how soon should we see a specialist?

Once your child’s pediatrician has made a diagnosis, it’s safe to wait up to four weeks for a comprehensive evaluation by an orthopedist or specialist.

How often should my child be seen/observed by her orthopedist after her initial appointment?

How often your child should be observed depends on her return of function. Typically, she may need to be seen every one to three months until she is 6 months old, then every six months through the time she’s 24 to 36 months old.

How is brachial plexus birth palsy treated?

Our brachial plexus team has developed innovative non-surgical and surgical treatments for children with all degrees of severity of brachial plexus birth palsy.

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Observation

  • Most brachial plexus birth palsies will heal on their own. Your doctor will monitor your child closely.
  • Many children improve or recover by the time they’re 3 to 12 months old. During this time, ongoing exams should be performed to monitor progress.

Physical and/or occupational therapy

  • Therapy is recommended to help maximize use of the affected arm and prevent tightening of the muscles and joints. It is important to work to prevent shoulder dislocation and/or deformity.
  • With the teaching and guidance of therapists, parents learn how to perform range of motion (ROM) exercises at home with their child several times a day. These exercises are important to keep the joints and muscles moving as normally as possible. 

Botox injections: may be used (mainly for the shoulder) to:

  • Help with therapy to maintain full joint motion
  • Rebalance muscles
  • Prevent contractures and shoulder dislocations

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Surgery

Children who continue to have problems after they’re 3 to 6 months old may benefit from one of several surgical options.

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Microsurgery (10 to 20 percent of all brachial plexus birth palsy surgery)

  • Recommended if recovery is still inadequate three to six months after birth
  • To repair or reconstruct the injured nerves
  • Can be “nerve grafts,” usually from the leg (sural nerves) between nerve root and nerve to muscle
  • Can be “nerve transfers” from other areas of the brachial plexus (or other areas of the body): for more serious brachial plexus birth palsy(avulsion)
  • Nerve reconstruction is best performed between 3 and 9 months of life and is usually not beneficial for children beyond 1 year of age

Tendon transfers

  • Involves separating the tendon from its normal attachment and reattaching it to a new location
  • Allows a healthy muscle to help a weaker or injured muscle perform its desired function
  • Usually performed around the shoulder to improve the ability to raise the arm, but may be used in forearm, wrist or hand
  • Done between 1 year of age and adulthood
  • Patients usually in a cast for four to six weeks after surgery
  • Extensive post-operative therapy
  • In some cases, shoulder weakness may cause limitations in motion that aren’t amenable to tendon transfers

Open reduction of the shoulder joint (capsulorraphy)

  • Reducing (placing the humeral head back in joint) and surgically tightening loose tissue around the shoulder joint
  • Usually performed when persistent muscle weakness has caused shoulder joint instability or dislocation
  • Performed through a surgical incision (“open”) -or- using arthroscopy (pencil-sized camera is inserted into the shoulder via smaller incisions)
  • Often performed in conjunction with other surgical procedures

Osteotomy

  • Procedure in which bones are cut and reoriented
  • May improve upper extremity function by better positioning the hand and arm
  • Most commonly performed on the humerus (upper arm bone) or forearm

Free muscle transfers

  • Typically using muscle (gracilis) from patient’s leg(s)
  • Extensive surgery requiring reconnection of blood vessels and nerves under microscope
  • Used only when there are no local muscles in the arm or hand to replace dysfunctional muscles

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