Brachial Plexus Palsy

The Brachial Plexus

The brachial plexus is a network of nerves that carry signals from the spinal cord to the shoulders, arms and hands. An injury to the brachial plexus can severely affect movement and feeling in the arm. The symptoms are typically confined to one side of the body, and they occur in roughly one to two of every 1,000 births worldwide. Fortunately, the frequency of these injuries is declining over time.

An injury that damages the brachial plexus results in a condition that goes by several names depending of the specific part of the nerve that is damaged. Its names include Erb’s palsy, Klumpke’s paralysis and Erb-Duchenne paralysis. It is sometimes called left brachial palsy or right brachial palsy to indicate the side of the body affected.

Symptoms of Brachial Plexus Palsy

The symptoms of a brachial plexus injury during childbirth are evident shortly after birth, if not immediately after. They include:

• A lack of movement in the hand or arm
• Decreased grip
• Arm bent at the elbow against the body
• A lack of standard involuntary reflexes in the affected arm

In some instances, the symptoms will fade within a few months. In other cases, however, the symptoms will persist and require surgery or other intervention, which may or may not be successful in returning proper function to the limb. When the symptoms persist beyond the early stages of an infant’s life, it is typically because the affected nerves have been torn from the spinal cord, which is known as avulsion.

Eventual complications include muscle contractions that may permanently tighten muscles, muscle atrophy and complete paralysis of the affected arm.

Causes

What Causes Brachial Plexus Palsy?

While serious trauma to a person of any age can damage the brachial plexus, brachial plexus palsy typically stems from a birth injury — an injury sustained to a newborn during the childbirth process.  Doctors are trained to know what can cause these injuries, but they still can occur due to negligence, carelessness or accident.

There are several instances during childbirth that can cause an injury to the brachial plexus:

• Shoulder dystocia: This is the most common cause of such an injury. It occurs when the baby’s shoulder becomes lodged behind the mother’s pubic bone during delivery. When this happens, a surgeon must perform a specific maneuver to avoid putting pressure on the shoulder. If this procedure is done incorrectly, the nerve tissue of the shoulder can be stretched, partially torn or ruptured, resulting in brachial plexus palsy. While shoulder dystocia is more common in vaginal deliveries, it can occur during a Caesarian section as well.
• Breech birth: If a baby is born feet-first, an injury to the brachial plexus can occur if too much pressure is applied to the baby’s raised arms when they are still within the birth canal.
• Excess pressure: If too much pressure is applied to the shoulders during a head-first delivery, the brachial plexus can be injured. The use of forceps can increase the risk of injury to the baby.

Babies with a higher-than-average birth weight and/or babies born to diabetic mothers are at an increased risk of sustaining an injury to the brachial plexus. There are other factors that can increase the risk of a birth injury, as well; doctors are trained to look for these factors. A Caesarian section may be ordered if the doctor believes a substantial risk of injury exists.

Types of Brachial Plexus Injuries

The extent of symptoms, and whether or not they are correctable, depends on the exact nature of the injury sustained to the nerves. There are four different kinds of injuries recognized. From least severe to most severe, they are:

• Neurapraxia: The most common form of injury to the brachial plexus, neuropraxia occurs when the nerves stretch, but do not tear. This injury typically heals itself with three months.
• Neuroma: If the brachial plexus stretches and nerve tissue is damaged, scar tissue will often develop and press on the healthy portion of the nerve. This is known as neuroma, and this condition typically will not completely correct itself.
• Rupture: This is a tear in the nerve itself. It will not heal.
• Avulsion: The most serious injury to the brachial plexus is called avulsion. This occurs when the nerve is torn from its base at the spinal cord, resulting in a substantial loss of function in the arm. Avulsion may or may not be correctable with surgery.

What to Do if Your Baby is Diagnosed with Brachial Plexus Palsy

Diagnosis

It should be apparent to your doctor after birth if your baby’s arm or hand is not functioning properly. The affected limb will typically flop as the child is turned over, and it will lack a Moro reflex – a standard involuntary reflex a doctor will check for, much like how a doctor might check for the patellar reflex by striking your knee with a hammer. A doctor may order an X-ray or other imaging procedures to get a better look at the affected nerve and to rule out a bone fracture as the cause of the symptoms.

Treatment Stages

The approach taken in treating brachial plexus palsy changes as a baby grows. At the Brachial Plexus Palsy Clinic at St. Louis Children’s Hospital, the following timeline is followed in addressing these nerve injuries:

• Newborn to two weeks: A physical therapist guides the newborn through specialized exercises.
• One month: Additional exercises are implemented and a consultation with a surgeon takes place. Surgery is rarely recommended at this stage, however.
• Three months: A more formal surgical evaluation takes place.
• Three to five months: Isolated nerve transfers may be performed, if necessary.
• Six to nine months: If surgery occurs, it is typically during this stage.

Surgical Options

Even if surgical intervention is recommended, it is not always successful in returning function to the affected arm. But several procedures are possible, including:

• Neurolysis: This procedure removes scar tissue from a damaged nerve that can press on healthy nerves.
• Nerve grafting: This is done to connect two severed pieces of nerve tissue.

Later in life, additional procedures may be performed the improve function of the arm, including:

• Joint fusion
• Elbow or shoulder reconstruction
• Muscle or tendon transfers
• Arthroscopic surgery

Prognosis

If serious symptoms persist after several months, it is unlikely that the nerves will heal on their own.

If this occurs to your baby, there is no guaranteed way to heal the damaged nerve. A regular regimen of exercise and physical therapy will likely continue through much of your child’s youth.

What are the Different Types of Brachial Plexus Palsy?

There are two main types of brachial plexus palsy. They result from an injury to a different portion of the nerve, causing different symptoms:

• Erb’s palsy: This is the term for the palsy caused by an injury to the upper portion of the brachial plexus, near the shoulder. This is the most common form of brachial plexus palsy, representing approximately 75% of all cases. Infants with this form of brachial plexus palsy cannot raise the affected arm or flex it at the shoulder.
• Klumpke’s palsy or Klumpke’s paralysis: When the injury is to the lower portion of the brachial plexus, in the arm, it is known as Klumpke’s paralysis or palsy. In this condition, the muscles of the hand and forearm are often paralyzed. It may also be associated with a drooping eyelid, which is known as Horner’s syndrome.

Preventing Brachial Plexus Injuries

Typically, injuries sustained during childbirth are completely preventable. Brachial plexus injuries normally result from medical error or negligence on the part of the doctor and attending staff. This is because there are several warning signs a doctor should look for – such as the position of the baby, the baby’s size, the mother’s medical history and previous issues during pregnancy, and more. Know these risks and talk to your doctor ahead of time about ensuring a safe delivery. Insist on a Caesarian section if warning signs are present and your doctor doesn’t recommend one.

Even when a vaginal birth is underway, there are steps doctors are trained to take to avoid injuring your baby. Injuries to the brachial plexus are nothing new, and doctors are taught how to prevent them. When they occur, it is typically because of an oversight or error that was completely preventable. It should not happen.