Brachial Plexus Birth Injury

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.

Brachial plexus birth injury, also known as brachial plexus injury, is an injury to the brachial plexus nerves that occurs in about one to three out of every 1,000 births.

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.

Brachial plexus birth injuries are often categorized according to the type of nerve injury and the pattern of nerves involved. There are different types of nerve injury.

Stretch (neurapraxia)

• Nerve has been stretched, but not torn
• Injury occurs outside the spinal cord
• Most common form
• Affected nerve(s) may recover on their own, usually within first three months of the baby’s life

Rupture

• Nerve is torn, but not where it attaches to the spine
• Injury occurs outside the spinal cord
• Common form
• May require surgical repair

Avulsion

• Nerve roots are torn from the spinal cord
• Injury occurs at the spinal cord
• Less common form (roughly 10 to 20 percent of cases)
• Cannot be surgically repaired directly — damaged tissue must be surgically replaced (nerve transfers)
• Can injure the nerve to the diaphragm, causing difficulty with breathing
• Droopy eyelid on the affected side may indicate a more severe injury, such as Horner’s syndrome

When a newborn has brachial plexus injury they may experience:

• Muscle weakness or paralysis in the affected arm or hand
• Decreased movement or sensation in the upper extremity

Usually, the baby is not in much pain, 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 brachial plexus injury is acute and disabling, as is pain from any accompanying fractures.

The causes of brachial plexus injury may 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 injury

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

Brachial plexus birth injury 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 after they’re born, these exams can be scheduled with a primary care doctor. Children who continue to have problems beyond six weeks should be seen by a pediatric orthopedist or brachial plexus specialist.

In addition to a physical exam, doctors may conduct special imaging studies like an MRI or nerve conduction studies — although for babies, these tests are not as reliable as they are for adults. If doctors suspect that your child also has a fracture, they may take an X-ray, too. It’s important to find an experienced doctor who will be able to track your child’s progress over repeated exams.

Observation

Most brachial plexus injuries will heal on their own. Your doctor will monitor your child closely. Many children improve or recover by 3 to 12 months of age. During this time, ongoing exams should be performed to monitor progress.

Physical therapy or occupational therapy

Therapy is recommended to help maximize use of the affected arm and prevent tightening of the muscles and joints. 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.

Children who continue to have problems 3 to 6 months after birth may benefit from surgical treatment. Your child's doctors have several surgical options for treating brachial plexus birth injury, including:

This depends on the extend of the injury and varies from patient to patient. Most children develop normal, or near normal, arm function without surgery. But not all children recover fully. For these children, surgery can improve strength and motion and support healthy development of their shoulder joint.

As a national and international referral center for children with brachial plexus injury, the Brachial Plexus Program within the Orthopedics and Sports Medicine Department at Boston Children’s Hospital is among the largest in the world. The program has treated hundreds of babies and children — as well as adolescents, young adults, and even professional athletes who’ve sustained traumatic brachial plexus injury.

We’ve developed innovative non-surgical and surgical treatments for children with all degrees of severity of brachial plexus injuries. We can provide your child with expert diagnosis, treatment, and care — as well as the benefits of some of the leading clinical and scientific research.