Brachial Plexus Palsy

Nerves are soft, tube-like structures. 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 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.

If only smaller nerve branches are injured, problems with control and sensation will affect fewer muscles and a smaller area of skin. If the injury happens to the entire set of nerves that go to the arm (the brachial plexus network), it may affect most of the arm’s muscles and skin.

When the injury affects only the shoulder and elbow muscles, it is called Erb’s palsy. When it affects all muscles of the arm, hand and wrist, it is known as a total plexus palsy.

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 parent’s pelvis as the child is being born. This can cause a stretch injury.

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.

Many children with a brachial plexus palsy recover on their own. But if the condition does not get better within 1 month, it usually has lasting effects. Our team likes to see your child 1 month after their birth or injury, so we can monitor their recovery.

If your child needs treatment, it’s important to begin early. Early physical therapy and occupational therapy can reduce stiffness or other problems. Some children need to wear a splint, cast or brace to help position their joints while their nerves heal. Some need surgery to repair their nerves. When children do need surgery, they tend to get better results by having surgery sooner rather than later.

Symptoms of brachial plexus palsy 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 partway or all the way.

• If your child’s nerves are stretched, the brachial plexus palsy 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 get back the use of their arm muscles without treatment.

Your child’s doctor may do imaging studies to decide on the right treatment at the right time.

• Ultrasound shows us how your child’s shoulder is developing. We will do ultrasounds on a regular schedule, starting when your baby is 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.
• In some cases, the doctor may want to do an MRI (magnetic resonance imaging) scan. This can show if a nerve is detached near the spine. Our neuroradiologists designed a way to use specialized MRI in brachial plexus care that is now widely used around the world.

Sometimes, the doctor may also do tests that can help to check your child’s nerves. Electromyogram and nerve conduction velocity (EMG/NCV) studies help us tell if there’s a problem with the nerves, if there is any recovery and how quickly signals travel along the nerves. We are careful to do these tests in a way that provides the details we need for your child’s care — and to avoid extra testing that your child does not need. We have a doctor who does these studies in our Brachial Plexus and Peripheral Nerve Program so we can do focused testing.

Physical 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
• Develop motor skills
• Learn ways to move so they can do as much as possible on their own

Therapists can also teach you how to stretch your child and encourage them to use their affected arm and hand at home. The therapists on your child’s 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 their muscles are weak and not moving a joint through its full range of motion. If this happens with your child, they may benefit from a splint or cast that holds the shoulder or arm in the best position. This keeps the joint more flexible.

Seattle Children’s is the only hospital in Washington state to offer these new splinting options. Ultrasound monitoring and splinting may reduce the need for surgery in the future.

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 will teach you stretches and strength exercises to do at home with your child. We will 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 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.

Some children may need shots (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 weaken the strong muscles for a while so we can stretch them to improve the joint’s range of motion. This can allow your child to work on making their weaker muscles stronger.

Several types of surgery may help treat brachial plexus palsy. The best choice depends on how much recovery has happened on its own and the specific condition of your child’s arm and hand.

• Nerve graft. This treatment removes the damaged part of the brachial plexus and replaces it with some 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 — with less 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 way the affected muscle can receive signals to make it work. This is called a nerve transfer. Doing a nerve transfer can take away movement from some muscles. If this happens, other muscles can usually make up for this.

When trying to get nerves to work again, 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 gain use of their arm.

After surgery, most children stay in the hospital for 1 day. Before your child goes home, you will get details about what to expect and how to take care of your child as they recover.

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 typical movement patterns and teaching them to make changes if they need to.

Some children may 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.

• Muscle transfer. Some children may have weakness or imbalance that does not go away because 1 group of muscles recovered better than another. To help with this, we may recommend surgery to move 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 also may do this to balance muscles that pull in opposite ways. It may be done along with a procedure to loosen a tight joint. We often do muscle transfers for the shoulder. We can also do them for the wrist, hand, fingers and thumb when needed.
• Osteotomy. Sometimes the bone grows in a way that isn’t typical because of chronic weakness or imbalance. We will sometimes recommend surgery to change the shape or position of a bone to improve how your child’s arm works. This is called osteotomy.

After surgery, most children can go home on the same day. Your child will likely be in a cast. Before your child goes home, you will get details about what to expect and how to take care of your child as they recover.

• 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.
• 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 this condition 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. Many of our 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, 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. These include surgeries to reconstruct or release nerves in the brachial plexus, move muscles, release joints and change the shape or position of a bone to help your child have more use of their arm.

• 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 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.
• 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 arm over time. We also consider how their arm 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 brachial plexus palsy 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 team will include experts from Rehabilitation Medicine, Plastic Surgery, Orthopedics, Radiology, Neurology, General Surgery and Pathology and other programs 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 palsy and enhance the quality of life for children who are affected. We study ways to diagnose and treat this condition 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.
• Learn more about current research at Seattle Children’s.