Brachial Plexus and Peripheral Nerve Program

• The Brachial Plexus team includes doctors and surgeons who specialize in Rehabilitation Medicine, Plastic Surgery, Orthopedics, Radiology, Neurology, General Surgery and Pathology. Your child’s team also includes advanced practice providers, nurses, occupational therapists, physical therapists and social workers who are dedicated to treating children with brachial plexus palsy and other peripheral nerve conditions. We involve the specialists who have the expertise to best manage your child’s condition.
• A unique part of our program is that we can do special tests called electrodiagnostic studies, like electromyogram and nerve conduction velocity (EMG/NCV) studies. Sometimes, we can do them during your first visit, so you can avoid extra trips to the hospital. It also means we can tailor the test to your child’s specific needs. This helps us get the most useful information from the tests and limits your child’s discomfort. 
• Our radiologists have special expertise using ultrasound to look for skeletal changes. This helps us start treatment early and prevent future bone and joint problems that often happen with brachial plexus palsy.
• We can successfully treat many conditions in most children without surgery. Often, this means physical or occupational therapy, splinting, casting, bracing and botulinum toxin shots (Botox injections). We have the largest team of physical and occupational therapists in the region who specialize in babies, children, teens and young adults.
• We recommend surgery only when we believe it will give your child the best results. If your child needs surgery, our surgeons have many years of experience in treating newborns and children with brachial plexus palsy and other peripheral nerve conditions. Many of our pediatric surgeons have special training in areas such as pediatric peripheral nerve reconstruction, upper extremity surgery, limb deformity and neuromuscular diseases.

• We base your child’s treatment plan on the latest evidence about which therapies are most likely to help and when to use them.
• We always try nonsurgical treatments first, including splinting options tailored to your child’s specific needs. In some children with brachial plexus palsy, ultrasound monitoring and splinting may reduce the need for future surgery. We are the only hospital in Washington to offer this. Most children do not need surgery. For those who do, splinting and therapy combined with surgery results in better, lasting flexibility and range of motion than surgery alone.
• Before we recommend surgery, we look at your child as a whole person and consider many factors. These include how serious their condition is, the effects on their health, how much more they will grow and what results you can expect from treatment.
• Our surgeons are experienced in all types of procedures to treat brachial plexus palsy and other problems with peripheral nerves. These include surgeries to reconstruct or release nerves, move muscles, release joints and change the shape or position of a bone.

• We specialize in caring for kids. This means our experts have the knowledge, training and skills to treat the youngest patients to young adults. We have treated many babies and children with peripheral nerve conditions, including brachial plexus palsy.
• The team will assess your child’s injury carefully and design a treatment plan to restore or improve your child’s health and function. We will work with you and your child from the time of their injury until your child is an adult if they need ongoing care.
• Babies, children and teens are still developing. When we evaluate your child’s condition, design their treatment and provide their care, we carefully consider their growth. We think about how growth may affect your child’s body over time. We also consider how their condition may affect the rest of their development and health.
• If your child needs imaging that uses radiation, we use the lowest amount possible (PDF) to make the best image. We have a low-dose radiation X-ray machine, called the EOS. It makes safer full-body images. We also have the largest group of board-certified pediatric radiologists in the Northwest.

• We know it can be stressful to have a child with a peripheral nerve issue and to find the treatment they need. Everyone at Seattle Children’s works to make your experience here as easy as we can on your whole family.
• Your child’s team does more than plan and provide care for your child. We also make sure you and your child understand your child’s condition and treatment options.
• Care is easier for you because your child’s Brachial Plexus and Peripheral Nerve Program team will include experts from Rehabilitation Medicine, Plastic Surgery, Orthopedics, Radiology, Neurology, General Surgery and Pathology, as needed. They work closely with each other and with any other Seattle Children’s programs and clinics your child may need.
• Seattle Children’s supports your family with a range of resources. Our Child Life specialists, Family Resource Center and Guest Services are here to help.

• Doctors at Seattle Children’s are working to advance care for brachial plexus palsies and peripheral nerve conditions and enhance the quality of life for children who are affected. We study ways to diagnose and treat these conditions so even more children thrive.
• Seattle Children’s neuroradiologists are leaders in using specialized MRI (magnetic resonance imaging) to examine nerves as part of brachial plexus care. They designed a plan (called a protocol) that was published in a medical journal and is now commonly used by doctors around the world to assess a child’s needs and plan their treatment.
• Surgeons at Seattle Children’s have come up with innovative ways to use parts of working nerves from other parts of the body to replace damaged nerves (nerve transfer) to treat acute flaccid myelitis and other nerve conditions.
• Our team is at the forefront of improving nerve transfers for children with limited control of their leg or foot due to a nerve injury. We have studied how differences in the procedure can lead to better function for kids.
• Learn more about current research at Seattle Children’s.

Brachial plexus palsies usually happen because of a stretch injury to a child’s head, neck and shoulder. This can happen during birth, especially when the birth is difficult or complex. Read more.

In older children and young adults, a brachial plexus palsy can happen because of an accident where the neck and shoulder get stretched. Motor vehicle accidents and sports injuries are examples. Read more.

When nerves in the brachial plexus network get damaged, signals cannot travel from the brain to the arm muscles in the usual way. When this affects only the shoulder and elbow muscles, it is called Erb’s palsy.

Nerves in the arms or legs can be damaged by blunt or stretch injuries. Sometimes, these injuries heal on their own, and sometimes they need treatment. Sharp objects that go through the skin can also damage nerves. If a nerve is cut, it’s important to get care within 3 days to check the injury, repair the nerves and get the best results. If a nerve has been cut for more than 3 days, there may still be ways to help it heal and restore feeling and movement in that part of the body, but surgery may be more difficult. The sooner a cut nerve is fixed, the better.

If a tumor forms in the brachial plexus, it may keep signals from going between the brain and the arm muscles in the usual way. These soft tissue tumors are usually not cancerous (benign). They are usually tumors called schwannomas or neurofibromas. Some tumors do not cause symptoms, but they still need treatment to prevent problems in the future. Read more.

Nerves travel throughout your child’s arms and legs, and some places are tighter than others. Tight areas can pinch or squish a nerve, which may change how much feeling your child has in their shoulder, arm or hand. If the problem gets worse, it may limit how well they can use their arm. Sometimes, the same type of problem happens in the leg to the point that a child cannot lift their foot. Treatment may include splinting, physical or occupational therapy and sometimes surgery to release the nerve (nerve decompression).

Hand and arm paralysis may last after treatment of spinal cord problems such as acute flaccid myelitis, transverse myelitis or a spinal cord injury. Our rehabilitation team, which includes a doctor and physical and occupational therapists, can assess your child’s needs and help them get the best use of their limb. Surgical treatment could include moving working nerves from another part of the body to replace damaged nerves (nerve transfers), moving a muscle to do the work of another muscle (muscle transfer) or bone procedures to improve function. Given the wide range of muscles that may be affected, care is custom-made for your child. Read more.

Imaging studies can help us decide the right treatment for your child at the right time. If your child has brachial plexus palsy, ultrasounds show us how your child’s shoulder is developing. We do ultrasounds on a regular schedule, 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 best position.

Your child’s doctor may order an MRI (magnetic resonance imaging) scan to see if a nerve is detached near the spine or to check for bone and cartilage changes that can happen with nerve palsies. 

When we started the Brachial Plexus and Peripheral Nerve Program, our neuroradiologists created a plan (called a protocol) for using specialized MRI to examine nerves as part of brachial plexus care. At the time, other treatment centers weren’t yet using MRI this way. We published our protocol in a medical journal, and now it has become common practice. Learn more.

If we need more details about your child’s condition, we may recommend special tests called electromyogram and nerve conduction velocity (EMG/NCV) studies. For these tests, we may place needles in your child’s muscles. To make this easier for your child, we use the smallest needles possible (the same size as needles used for acupuncture).

We carefully choose which parts of the body to test. This way, we get the details we need to plan your child’s care, but your child doesn’t go through extra testing they don’t need. Often, other clinics send children out for more general electrodiagnostic studies without saying which parts of the body are most relevant. Here, we have a doctor who does these studies in our Brachial Plexus and Peripheral Nerve Program so we can do focused testing.

Physical therapists and occupational therapists can help children with brachial plexus palsy stretch and strengthen their muscles. They can help your child learn ways to move so they can do as much as possible on their own. Therapists can also teach your family how to work with your child at home. We work with therapists in your community to help your child get the right type of ongoing care. Learn more.

Some children with brachial plexus palsy benefit from a splint or cast that holds their shoulder or arm in the best position. Wearing the brace helps keep their joints more flexible. Some children may also need injections of a medicine called botulinum toxin (Botox) to weaken muscles that are too strong. This lets us stretch the muscles to improve the joint’s range of motion. Seattle Children’s is the only medical center in Washington state to offer these new options.

Most children do not need surgery. For those who do, splinting and therapy combined with surgery has better results than surgery alone. It may reduce the need for surgery in some children. Learn more.

If our team believes this will help your child, we will make them a custom brace. Based 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 may use splinting to position the shoulder, forearm, elbow, wrist or hand. We adjust the brace as your child grows and their muscles develop. We start working with children as young as 1 month old and keep providing care over time. How long your child may need the brace depends on their injury and how their nerves and muscles are healing.

The brachial plexus team may offer surgery to children with serious injuries to their nerves. Surgery involves exploring the injured nerves and reconstructing them if needed. We use nerve graft and nerve transfer, moving working nerves from another part of the body to repair or replace damaged nerves. We recommend surgery only if it is likely to get your child more use of their arm than other, less invasive treatments, such as physical therapy. Learn more.

If a nerve in your child’s arm or leg isn’t working because it is pinched or squished (compressed), we may recommend surgery to release the nerve. This may give the nerve the best chance to recover so your child can control the muscles and feel sensations in the skin served by the nerve.

Some children may have lasting weakness or an imbalance because 1 group of muscles recovered better than another. We may recommend moving a 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 often do these muscle transfers for the shoulder. We can also do them for the wrist, hand, fingers and thumb when needed.

Sometimes the bone grows in a way that’s not typical. This can happen because of chronic weakness or imbalance. We will sometimes recommend changing the shape or position of the bone to improve how your child’s arm works. This is called osteotomy. Learn more.