Brachial plexus birth palsy Symptoms & Causes

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At Boston Children's Hospital, our Brachial Plexus Program team knows how concerned you are that your baby sustained an injury to her brachial plexus nerve network. We’ve developed innovative non-surgical and surgical treatments for children with all degrees of severity of brachial plexus birth palsy (BPBP). Learning more about this injury will help you feel more confident and in control as we treat—and work toward—healing your child.

What is the brachial plexus?

The brachial plexus is a complex network of nerves between the neck and shoulders. These nerves control muscle function in the chest, shoulder, arms and hands, as well as sensibility (feeling) in the upper limbs.

What is brachial plexus birth palsy (BPBP)?

Brachial plexus birth palsy is an injury to the brachial plexus nerves that occurs during childbirth. The nerves of the brachial plexus may be stretched, compressed, or torn in a difficult delivery. The result might be a loss of muscle function, or even paralysis of the upper arm.

Injuries may affect all or only a part of the brachial plexus:

  • Injuries to the upper brachial plexus (C5, C6) affect muscles of the shoulder and elbow.
  • Injuries to the lower brachial plexus (C7, C8 and T1) can affect muscles of the forearm and hand.

What happens during childbirth to cause an injury to the brachial plexus?

During childbirth, stress can occur across a baby’s neck and head area, injuring the nerve(s). This stress usually happens when the head goes in one direction and the shoulder goes in another direction.

Can injury to the brachial plexus nerve network happen in other circumstances than childbirth?

Yes, a traumatic brachial plexus injury can occur at any age—often as a result of a sports injury or car or work accident.

What are the types of brachial plexus birth palsy?

Brachial plexus birth palsies are often separated into different categories, depending upon the type of nerve injury and the pattern of nerves involved. 

There are four different types of nerve injuries with different patterns that may occur:

  • Stretch (neurapraxia)
  • Rupture
  • Avulsion
  • Neuroma

How common is brachial plexus birth palsy?

Brachial plexus birth palsies occur in approximately 1-3 out of every 1,000 live births. Risk factors for the development of brachial plexus birth palsy include: large gestational size, breech presentation, prolonged or difficult labor, vacuum- or forceps-assisted delivery, twin or multiple pregnancy, and a history of a prior delivery resulting in brachial plexus birth palsy.

What are the risk factors for BPBP?

Risk factors for sustaining brachial plexus birth palsy include:

  • large gestational size
  • breech birth
  • prolonged or difficult labor
  • vacuum- or forceps-assisted delivery
  • twin or multiple pregnancy
  • history of a prior delivery resulting in brachial plexus birth palsy

Does BPBP cause the baby pain?

Usually, the baby is not in much pain despite her BPBP, probably because infants’ nerves behave differently from adults’. Roughly, just 4 percent seem to experience severe pain. If a fracture accompanies the BPBP, the baby will experience some discomfort from the fracture, but not usually intense pain. And any fractures (clavicle, humerus) the baby may have will probably heal quickly—in about 10 days.

This is in contrast to an adult’s traumatic brachial plexus injury caused by accident or sports impact: In these cases, pain from BP injury is acute and disabling, as is pain from any accompanying fractures.

What's the prognosis if my child has brachial plexus birth palsy?

The prognosis is dependent on the extent of the injury, and for this reason, it varies from patient to patient:

  • Most children achieve normal or near-normal arm function without surgery. But not all children recover fully.
  • If a child does not recover fully, surgery can improve her strength and/or motion and help optimize shoulder joint development.
  • One of the common problems with brachial plexus birth palsies can be the abnormal development of the child's shoulder joint, which can happen over time. So, in addition to physical examinations, your child may need ultrasound, magnetic resonance imaging (MRI) and/or computed tomography (CT) scans to monitor her shoulder development.

Will my child be OK?

The good news is that—either spontaneously or with therapy—most of our young patients recover fully or nearly fully by the time they’re 6 to 12 months old. Some may even begin to recover when they’re 6 weeks old. Less than half of children with BPBP need nerve surgery. Some require tendon transfers. The outcomes from these surgeries are favorable for improved long-term function.

If needed, your child’s rehabilitation team will work with you and your child to learn home exercises that are important to her recovery. Most parents perform range of motion (ROM) exercises at home with their child many times a day for several years. These exercises are important for keeping the joints and muscles moving as normally as possible.

Children’s pioneering research into the biology of brachial plexus birth palsy—and our experience in developing innovative treatments—means that your child will receive the most advanced care possible.

What's unique about BPBP care at Boston Children's?

Boston Children’s Brachial Plexus Program is one of the world’s major centers for BPBP treatment. The program stands virtually alone in providing the entire spectrum of BPBP care—from early nerve surgery, to early therapy, to later reconstructive orthopedic surgery and therapy if this is needed. Our experts sub-specialize in BPBP, and we provide the entire spectrum of care all within one program. So, our team can follow your child closely throughout her treatment and recovery. 

Causes/risks of Brachial plexus birth palsy 

  • large gestational size
  • breech birth
  • prolonged or difficult labor
  • vacuum- or forceps-assisted delivery
  • twin or multiple pregnancy
  • history of a prior delivery resulting in brachial plexus birth palsy

Signs and symptoms of plexus birth palsy

The main sign of brachial plexus birth palsy is that one of the newborn’s arms will lie at her side, sometimes in a “waiter’s tip” posture. The affected arm/hand does not move normally, in contrast to her other side.

When to 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 and/or brachial plexus specialist.

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- Sandra L. Fenwick, President and CEO

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