What is Brachial
Plexus?
What is a Brachial Plexus Injury?
Is there any treatment?
What is the prognosis?
How does it occur?
What happens during treatment?
What is Brachial Plexus?
The
BRACHIAL PLEXUS is the network of nerves within
the neck and shoulder supplied by the C5, C6,
C7, C8 and T1 nerves exiting from the spine. Injury
to this structure can occur at birth. There is
not much that is scarier than injury to an infant
during his or her birth. Mother, father and the
extended family have awaited the birth with anticipation
and joy, only to find that the experience is anything
but what they were expecting, leaving all despairing
over the child's disabilities. The birth that
results in injury is generally a very traumatic
one. The natural tendency is to back away from
the injury expecting that it will heal with a
little time. While this can, in some instances
be the case, experience has shown that infants
with this injury always benefit from treatment.
Consequently, infants with this injury deserve
the attention of a multi-disciplinary group of
physicians and therapists specializing in this
injury if full recovery has not occurred within
the first month of life.
If your newborn can move one arm but not the
other, he or she may have a condition called
Erb's Palsy. The inability to move the arm is
a symptom of an injury to the brachial plexus
(BRAY-key-el PLEK-sis), a network of nerves
that provides movement and sensation to the
arm, hand and fingers. Two to three out of every
1,000 babies have this condition. Some infants
with Erb's palsy will recover both movement
and sensation in the affected arm without surgery.
But parents must be ever watchful and active
participants in the treatment process to ensure
maximum functional recovery.
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What is a Brachial
Plexus Injury?
The
brachial plexus is a network of nerves that
conducts signals from the spine to the shoulder,
arm, and hand. Brachial plexus injuries are
caused by damage to those nerves. Symptoms may
include a limp or paralyzed arm, lack of muscle
control in the arm, hand, or wrist, and lack
of feeling or sensation in the arm or hand.
Although injuries can occur at any time, many
brachial plexus injuries happen during birth.
There are four types of brachial plexus injuries:
avulsion, the most severe type, in which the
nerve is torn from the spine; rupture, in which
the nerve is torn but not at the spinal attachment;
neuroma, in which the nerve has tried to heal
itself but scar tissue has grown around the
injury, putting pressure on the injured nerve
and preventing the nerve from conducting signals
to the muscles; and neuropraxia or stretch,
in which the nerve has been damaged but not
torn. Neuropraxia is the most common type of
brachial plexus injury.
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Is
there any treatment?
Some brachial plexus injuries may heal spontaneously.
There are children who experience some recovery
by 3 to 4 months of age. Treatment for brachial
plexus injuries includes occupational or physical
therapy and, in some cases, surgery.
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What
is the prognosis?
The site and type of brachial plexus injury
determines the prognosis. For avulsion and rupture
injuries there is no potential for recovery
unless surgical reconnection is made in a timely
manner. For neuroma and neuropraxia injuries
the potential for recovery varies. Many patients
with neuropraxia injuries recover spontaneously
with a 90-100% return of function.
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How
does it occur?
The nerves to the arm, hand and fingers
exit the spinal cord between the bones (vertebrae)
of the neck and travel into the arm below the
collarbone (clavicle). The nerves to the arm
exit high in the neck; those that go to the
hand and fingers exit lower in the neck, just
above the chest. These nerves branch and join
together near where the neck joins the shoulder,
in an area called the brachial plexus.
Brachial plexus injuries in newborns usually
occur during a difficult delivery, such as with
a large baby, a breech presentation, or a prolonged
labor, when the person assisting the delivery
must exert some force to pull the baby from
the birth canal. One side (sometimes both sides)
of the baby's neck gets stretched; which can
damage the nerves by stretching or tearing them.
If the upper nerves are affected, the condition
is called Erb's Palsy. The infant may not be
able to move the arm, but may be able to move
the fingers. Injuries that involve both the
upper and lower nerves are more severe and result
in a condition called global palsy.
There are four types of nerve injuries to the
brachial plexus.
| · |
Avulsion injuries-
The nerve is torn from its attachment to
the spinal cord. This is the most serious
type of injury. |
| · |
Rupture injuries- The nerve
is torn, but not at the spinal cord. |
| · |
Neuroma injuries- These
injuries result from scar tissue that forms
and puts pressure on the nerve. |
| · |
Stretch injuries- These
injuries, known as neurapraxia (new-rah-PRAK-see-ah)
are the most common. The nerve is damaged
but not torn. Normally, these injuries
heal spontaneously; usually within three
months. |
The
symptoms of a nerve injury (paralysis and loss
of feeling) are the same, regardless of the
type of injury. However, the severity of the
injury does affect both treatment decisions
and the extent of recovery possible. A newborn
with Erb’s Palsy will have the arm straight
down at the side and will not move it. Sometimes,
the arm may be slightly turned, with a bent
wrist and straight fingers. A droopy eyelid
on the affected side may indicate a more severe
injury. The doctor may order an X-ray or magnetic
resonance image (MRI) to see if there is any
damage to the bones and joints of the neck and
shoulder. The doctor may also use an electromyogram
(EMG) or nerve conduction studies (NCS) to see
if any nerve signals are present in the upper
arm muscle.
Because some newborns with Erb's Palsy recover
without surgery, your baby will be examined
again at one month and at three months to see
if the nerves are recovering by themselves.
Even children who seem to fully recover by this
time may experience difficulties in the future.
During this time, range of motion exercises
must be performed and are very important in
keeping the baby's joints from getting stiff
and developing joint contractures.
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What happens during
treatment?
If
there is no change over the first three months,
nerve surgery may be helpful. However, nerve
surgery will not restore normal function or
help infants over 12 months of age. After surgery,
the infant will wear a splint for approximately
three weeks. Because nerves grow slowly, at
a rate of one inch per month, it may take several
months, or even years, for nerves repaired at
the neck to reach the muscles of the lower arm
and hand.
Some children with brachial plexus injuries
will continue to have weakness in the shoulder,
arm and/or hand. They may find it difficult
to raise the hand over the head, to turn the
hand palm up, or to extend the wrist. In some
of these cases, a surgical procedure called
tendon transfer may be helpful. Tendons are
the connective tissues between muscle and bone.
The surgeon will separate the tendon from its
normal attachment and reattach it in a different
place. This is often helpful in improving shoulder
and wrist motions as well as elbow position
and hand function.
Tendon transfers are generally performed when
the child is old enough to follow instructions.
After surgery, the child will have to wear a
cast for about six weeks and a splint at night
for up to six months. Physical therapy may continue
for up to one year after surgery.
Your doctor will discuss the various treatment
options with you and make a specific recommendation
based on your child's individual situation.
It is important to remember that ever injury
is different. Do not hesitate to ask questions;
there is much that parents can do to help ensure
a good functional outcome.
Special considerations:
Because
your baby cannot move the affected arm alone,
it is important that you take an active part
in keeping the joints limber and the functioning
muscles fit. Your doctor will recommend physical
and occupational therapy and passive range of
motion exercises (ROM). Do these exercises with
your baby daily with every diaper change. The
exercises will maintain a range of motion in
the shoulder, elbow, wrist and hand and prevent
the joint from becoming permanently stiff, a
condition called joint contractures.
Sometimes, the affected arm is noticeably smaller
than the unaffected arm. This occurs because
the arm is not used as much. Although the size
difference is permanent, it will not increase
with age. You should also remember that your
child is very adaptable. Be supportive and encouraging;
focus on what your child can do. This will help
your child develop a healthy sense of self-esteem
and adjust to any functional limitations. They
will know how to feel about their injury by
your actions. If you stay positive and upbeat,
they will too. Enjoy your baby, parenting can
be a very rewarding experience!
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