Brachial Plexus and Peripheral Nerve Injuries

  • What is brachial plexus and peripheral nerve injury?

    What is Brachial Plexus Image The brachial plexus is a network of nerves running from the cervical spinal cord in the neck do the shoulder, arm and hand. Brachial plexus and peripheral nerve injuries refer to injuries to the group of nerves that supply the arms and hands. These injuries include birth-related palsies, trauma and peripheral tumors.

    The brachial plexus is a network of nerves that run from the cervical spinal cord in the neck to the shoulder, arm, and hand. These nerves are responsible for stimulating the muscles of the upper extremity as well as signaling sensation or feeling of the arm. An injury to one or more of these nerves can result in varying degrees of upper extremity weakness or paralysis and numbness.

    Types of injury include pulling, stretching, tearing, or compression of the nerve(s). Some nerve injury is temporary, and patients recover most, if not all, function on their own with occupational therapy and time. However, some nerve damage is more severe, and patients with these conditions benefit from surgery and occupational therapy.

  • Causes

    Brachial Plexus Causes Image Brachial plexus injury caused during childbirth when nerves are stretched. Brachial plexus injuries may be related to the birthing process, when the nerves get pulled during delivery. Many of these babies recover well without needing surgery. Nevertheless, it is still important for them to be followed by a medical team early after the injury to monitor their recovery and ensure that additional treatment is not needed. Children treated at CHOP for brachial plexus injuries that happened during delivery are followed closely with regular office visits and occupational therapy sessions.

    Older children can also have brachial plexus injuries. These injuries are often related to high impact trauma, such as sport collision or car accident. The brachial plexus can also be injured from a deep cut to the neck area. It is important for these patients to be evaluated and followed closely by a team that specializes in brachial plexus injuries, as some surgical procedures should be done within several months after the injury.

  • Signs and symptoms

    An injury to the brachial plexus or nerve(s) of the arm results in weakness or paralysis. Babies will not move their affected arm. In less severe injuries, some babies will regain function in the fingers and hands over the first few months after birth. They may have numbness in the arm, but this can be difficult to determine. Many babies with brachial plexus injuries hold the affected arm by their side, with the elbow straight, and the forearm and hand turned in.

    Older children will also complain of weakness or no movement of the shoulder, arm, or hand. They may have numbness or tingling. For both babies and older children, other injuries may co-exist, such as broken bones of the ribs, collarbone, shoulder, or upper arm. There may also be other nerve injuries that can be seen as ptosis (droopy eyelid) and a smaller pupil on the affected side.

  • Testing and diagnosis

    Your child’s initial evaluation is typically done by our pediatric specialists and our occupational therapist within the first month after injury. It starts with a medical history, a developmental history, a physical exam and a neurological exam.

    Depending on your child's age and cause of the injury, your child's care will be coordinated through our Brachial Plexus Program, which can be initiated through any participating division: Neurology, Neurosurgery, Plastic Surgery, or Orthopedic Surgery. The Brachial Plexus Program brings together multiple pediatric subspecialists with experience treating children with brachial plexus and peripheral nerve injuries.

    Some children may need additional tests during their care to help the team get a better understanding of their condition and determine the best treatment options.

    • An electromyogram (EMG) may be performed by our neurologist to assess muscle contraction.
    • Magnetic resonance imaging (MRI) of the brachial plexus and/or cervical spine, or a CT myelogram may also be ordered through CHOP’s Department of Radiology.
    • X-rays may be taken to look at bones or the chest, particularly if there is a history of a fracture or to evaluate the diaphragm for paralysis.
    • Ultrasound may be used as another way to evaluate the diaphragm or shoulder.
  • Treatments

    Occupational therapy

    Brachial Plexus Nerve Transfer Image Nerve transfer: A nerve fascicle is transferred from a functioning nerve (bottom) to a damaged distal nerve target (top), supplying the muscle with a new, functioning proximal nerve to power it. Many patients with birth-related brachial plexus injuries recover enough motion and strength and do not need early surgery. For all patients, we encourage regular sessions with occupational therapy, whether it is at The Children’s Hospital of Philadelphia or locally if patients live outside the Philadelphia region.

    Goals for therapy focus on:

    • Promoting nerve recovery
    • Preventing joint contractures
    • Maintaining range of motion in the upper extremities and neck
    • Facilitating optimal use and typical movement patterns

    Typical therapy interventions include:

    • Range of motion exercises and stretching
    • Splinting
    • Joint compression and weight bearing to facilitate muscle contraction
    • Bilateral motor planning activities
    • Facilitating optimal alignment in the shoulder and scapula to promote smooth movement in all directions
    • Aquatic therapy when indicated

    Brachial Plexus Nerve Repair Image Nerve repair: A damaged, scarred portion of a nerve, or neuroma, can be seen in the top image. This portion is resected, and, in the bottom image, nerve grafts are placed across the gap to repair the nerve. In addition to these regular sessions, your child’s occupational therapist will also teach you exercises that should be performed every day with your child to keep the joints supple and encourage normal motor development.

    Patients are closely followed by our team for signs of functional recovery of the upper extremity. If there are no signs of recovery or not enough muscle recovery, then patients may get additional testing and evaluations to discuss surgical options to improve function.

    Surgical intervention

    Early surgical intervention for brachial plexus and other nerve damage is usually decided between three to six months after injury. We carefully follow each patient for signs of recovery and personalize treatment based on the type and degree of injury. Early surgical treatments include:

    • Surgical exploration
    • Neurolysis — releasing nerve from scar tissue
    • Nerve grafting — taking nerve from elsewhere on the body to bridge a nerve gap after cutting away damaged nerve
    • Nerve transfers — using working nerves to stimulate nerves and muscles that are not functioning well

    Secondary procedures may be needed as children grow and are designed to augment their function. These surgeries include:

    • Tendon or muscle transfers — using working tendons or muscles to power weak or non-working muscles
    • Release of tight muscles or joints
    • Osteotomies — cutting and repositioning the bones
    • Joint fusions
  • Follow-up care

    Children with brachial plexus and peripheral nerve injuries are followed by our Brachial Plexus Program, which brings together a variety of pediatric subspecialists who monitor each patient closely for recovery and additional nerve damage that may require further treatment.

    Every patient's care is tailored to meet their individual needs, and may include consultations with pediatric neurologists, neurosurgeons, occupational therapists, plastic and reconstructive surgeons, orthopedic surgeons and more.

Reviewed by Ines C. Lin, MD on November 30, 2013