Reviewed by Ines C. Lin, MD, Mary Claire Manske, MD, MAS, FAOA
Reviewed on 04/17/2026
What is a brachial plexus injury?
A brachial plexus injury refers to an injury to the nerves that supply the arms and hands. When one or more of these nerves is injured, it can result in weakness or numbness and paralysis in the arms, wrists or hands.
What is the brachial plexus?
The brachial plexus is the group of nerves that makes the muscles of the arm and hand move. These nerves are located on both sides of your body and provide sensation as well. They run from the spinal cord, through the neck and into the shoulder, arm and hand.
All five nerves in the brachial plexus have specific functions.
This means that the location and type of brachial plexus injury will not only determine symptoms, such as the level of brachial plexus pain, but necessary treatment as well.
What are the brachial plexus nerves?
There are five different brachial plexus nerves.
- The axillary nerve activates muscles to move and stabilize your shoulder.
- The median nerve flexes your forearm and hand, including your wrist and fingers. It helps you feel sensation in your palm, thumb and several fingers.
- The musculocutaneous nerve moves the muscles in your upper arm, helping your elbow flex and your forearm turn.
- The radial nerve activates the muscles in the back of your arm and forearm. This allows you to move your elbow and wrist. It also helps you feel sensation in the back of your hand, thumb and several fingers.
- The ulnar nerve activates muscles to help you make hand movements. It also helps you feel sensation in part of your ring and pinky fingers.
What are the types of brachial plexus injuries?
Types of brachial plexus injuries include:
- Pulling
- Stretching
- Tearing
- Compression of the nerve(s)
Some peripheral 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 benefit from surgery and occupational therapy.
What are the causes of brachial plexus injuries?
Brachial plexus injuries can happen to babies and older children.
Common causes of brachial plexus injury include:
- The birthing process, often when brachial nerves are pulled or stretched during delivery
- High impact trauma, such as sport collisions or car accidents
- A deep cut to the neck area
- Peripheral tumors (least common; tumors may be within the nerves, or nearby, compressing the nerves)
No matter the cause, it is important for a brachial plexus injury to be evaluated by a medical team soon after the injury. At Children’s Hospital of Philadelphia (CHOP), our specialists offer multidisciplinary care for brachial plexus birth injuries, focusing on recovery and avoiding unnecessary procedures.
Children treated for brachial plexus injuries at CHOP are followed closely through their healing journey by our dedicated Brachial Plexus Injury Program, with regular in-person office visits and occupational therapy sessions.
Signs and symptoms of brachial plexus nerve injuries
When the brachial plexus nerves are injured, a child’s arm may appear weak, have limited movement or just move differently than the other arm.
Symptoms of a brachial plexus injury in an infant may include:
- Limited or no movement of the arm
- Numbness, though this can be difficult to determine.
- Arm held by their side, elbow straight and the forearm and hand turned in
Older children with brachial plexus injuries may show similar – though slightly different – signs.
- Weakness of the shoulder, arm or hand
- Limited or no movement of the shoulder, arm or hand
- Numbness or tingling
For both babies and older children, other injuries may co-exist alongside brachial plexus injury. These injuries often include broken or fractured bones in places such as:
- The ribs
- Collarbone
- Shoulder
- Upper arm
There may also be other visible nerve injuries such as droopy eyelids or a smaller pupil on the affected side.
Testing and diagnosis of brachial plexus injuries
Your child’s initial evaluation will typically be done by our pediatric specialists and our occupational therapist. These evaluations happen within the first month after injury.
Physical and neurological exams are included, as well as discussions of relevant medical and developmental history.
Doctors and therapists experienced in brachial plexus injury closely monitor overall movement patterns, as well as:
- Shoulder movement
- Elbow bending
- Wrist and hand motion
- Symmetry compared to the other arm
We also monitor whether your child is meeting developmental milestones.
Some children may need additional testing to help the team get a better understanding of their condition and determine the best treatment option. This can include:
- Magnetic resonance imaging (MRI) of the brachial plexus and/or cervical spine
- X-rays of bones in the chest, particularly if there is a history of a fracture or to evaluate the diaphragm for paralysis
- Ultrasound to evaluate the diaphragm or shoulder
Children who sustain brachial plexus injuries for reasons other than birth trauma may need different diagnostic tests, such as:
- An electromyogram (EMG) by our neurologist to assess muscle contraction
- CT myelogram, an imaging test that uses contrast material to get detailed pictures of your spine
Depending on your child's age and the cause of their brachial plexus injury, their care may be coordinated through our Brachial Plexus Injury Program.
The Brachial Plexus Program at CHOP brings together multiple pediatric subspecialists with experience treating children with brachial plexus and peripheral nerve injuries.
Treatments for brachial plexus injuries
Many babies who experience a brachial plexus injury during birth recover well without needing surgery.
Occupational therapy
For all patients, we encourage occupational therapy, whether it is at CHOP or another provider outside the Philadelphia region.
Therapy does not harm nerve recovery and is an important part of treatment, whether on its own or in conjunction with surgery. Most children – especially infants – who have brachial plexus injury benefit from early physical or occupational therapy.
Occupational therapy helps to:
- Maintain joint motion
- Prevent stiffness
- Encourage symmetrical movement
- Teach families safe stretching and positioning
At CHOP, our team of therapists can guide your child toward goals that are safe and most beneficial for their recovery. Goals for occupational therapy often focus on:
- Promoting nerve recovery
- Preventing joint contractures
- Maintaining range of motion in the arms, hands 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
- Alignment in the shoulder and scapula to promote smooth movement in all directions
- Aquatic therapy when indicated
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Apurva Shah, MD: Hello, my name is Apurva Shah. I'm an orthopedic surgeon and co-director of the Brachial Plexus Program at Children's Hospital of Philadelphia. Our team has developed this video content to help families learn to effectively stretch the arm of a baby with a brachial plexus injury. Stretching is the cornerstone of early treatment for this condition, as it helps keep your baby's muscles and joints loose.
I would encourage you to stretch your baby's arm with each diaper change, so it becomes part of your daily routine. It's important to remember it is a common experience for a baby to cry, or become irritated by the stretches, as you will see in some of the video. Please rest assure that these stretches are safe and important for your child.
Incorporating play or singing during the stretching program is a good distraction. However, if you notice a change in your child's comfort level during the program, please discuss this with your child's therapist or surgeon. The occupational therapist in this video will review each stretch in detail. In addition to the video, other resources include our program's webpage, which has general information on brachial plexus birth injury, and our quick reference handout on stretching, which is for use at home.
Narrator 1: Your child must be evaluated by a physician and occupational or physical therapist before attempting any of these exercises. Your child's medical professional should determine which exercises are appropriate and teach you how to complete the exercises before attempting these exercises at home. The exercises reviewed in this video are supplementary to the exercises prescribed and taught by your healthcare providers that are specific for your child's needs.
Please do not start these exercises without the recommendation of your healthcare provider. After you are taught these exercises by your healthcare provider, they're safe and important to complete at home. Be aware it is common for your child to cry or become upset during exercises at home. However, there is one exercise in this video that should be stopped and your healthcare provider consulted if the stretch becomes more difficult or causes any pain to your child.
This specific stretch, the shoulder external rotation with arm against the body, will be identified as it is demonstrated. If you have any questions about your child's level of comfort or any changes you feel during the stretches, consult your child's therapist or physician.
Narrator 2: These stretches are important to maintain muscle length of your child's shoulder and arm. They should be incorporated into your daily routine as a part of your child's daily care. We often recommend completion during all diaper changes. Each position should be held for 10 seconds, three to five times. Stretch until you feel gentle resistance.
Please consult with your child's therapist if any questions about this.
Starting at the shoulder, use one hand to hold your child's shoulder blade. Your hand should be positioned against the side of their rib cage, under the armpit. This is important so that you get a good stretch to the muscles around the front of the shoulder joint, to limit muscle and joint tightness, that may limit movement as your child grows.
First, to stretch the shoulder into flexion, hold the shoulder blade with one hand and support the elbow with the other. The arm should be moved with the thumb up, straight to the front towards the ear as a freezing one's arm in class.
Narrator 3: The next stretch is for shoulder abduction. We are moving the arm overhead again in this stretch, but out towards the side. One hand should continue to support the shoulder blade while the other supports the elbow with the thumb up and move towards the ear. Think of a jumping jack motion during this stretch.
Narrator 2: The next two stretches are both for external rotation of the shoulder. These are the most important stretches to support the shoulder development as your baby grows. First is with the arm positioned out to the side. Keep the elbow bent, while continuing to support the shoulder blade. Then, rotate the arm backwards as if throwing a baseball.
The second external rotation stretch is with the arm held against the body. Again, keep the elbow bent while rotating the arm out to the side towards the table, as if putting on a coat. It is important to remember that if this specific stretch becomes more difficult or if your child seems to start to have pain, please contact your child's therapist and surgeon. This could be a sign that there is an issue with the development of the shoulder joint and should be evaluated as soon as possible
Narrator 3: Moving down the arm, the next stretch is for forearm supination, combined with elbow flexion and extension. One hand should support the back of the elbow, while the other supports the wrist and rotates the palm up.
Avoid excessive pressure on the wrist during the stretch. The wrist should be supported in a straight position. Once in this position, work on gently bending and straightening your child's elbow.
Narrator 2: The following stretch may or may not be recommended for your child, depending on their hand function. To stretch the wrist and fingers, it is important to support the arches of your child's palm while gently moving the wrist back and opening their fingers.
Avoid holding only the fingers and stretching back. Support of the palm is very important.
Narrator 3: Please consult with your child's therapist for tips and feedback to ensure your child's needs are met.
In addition to regular in-person sessions, your child’s occupational therapist will teach you exercises that should be performed every day to keep joints supple and encourage normal development.
If there are no signs of recovery or not enough muscle recovery, patients may need additional evaluation or to consider potential surgical options.
Surgical intervention for brachial plexus and other nerve injuries
Many children with brachial plexus birth injuries do not need surgery. Infants whose hands and fingers are affected more frequently undergo surgery than those infants without hand involvement.
Infants with brachial plexus injury may need surgery at some point between three and 12 months old. The decision for surgery is always individualized and based on careful observation over time. It is considered only in select cases when recovery is limited or not progressing or the injury is especially severe.
Nerve surgery is usually done within the first year, sometimes even the first few months of life.
Procedures geared toward nerve improvement may include:
- Surgical exploration
- Neurolysis (releasing a nerve from scar tissue)
- Nerve grafting (taking a nerve from elsewhere on the body to bridge a gap after cutting away a 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. These are typically done slightly later, and designed to improve function, movement, strength or positioning.
Potential secondary procedures 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 for children with brachial plexus and peripheral nerve injuries
Children with brachial plexus and peripheral nerve injuries are followed by our Brachial Plexus Program, which brings together a multidisciplinary team of pediatric subspecialists to monitor each patient closely for recovery and further treatment.
Every patient's care is tailored to meet individual needs, and may include consultations with pediatric neurologists, neurosurgeons, occupational therapists, plastic and reconstructive surgeons, orthopedic surgeons, and more.
Complications of brachial plexus injuries
Children with mild brachial plexus birth injuries usually go on to live active, independent and fulfilling lives. Sometimes though, there can be lasting effects on a child’s body from birth-related brachial plexus injury and peripheral nerve injury.
These include:
- Pain
- Numbness
- Joint stiffness
- Muscle atrophy
Rarely, permanent disability may occur, with some patients having long-lasting weakness or paralysis.
Other serious complications are also possible due to restricted blood flow caused by a brachial plexus injury. These include sudden cardiac arrest and pediatric stroke.
Prevention of brachial plexus injuries
It is difficult to prevent brachial plexus nerve injury or other peripheral nerve injury. They are the product of various factors and usually occur during the birth process, which is unique to each individual parent and child.
If your child has brachial plexus palsy or other related injury, it is important to get them started with occupational therapy or other at-home exercises soon after injury. This process can start when your child is only a few weeks old.
Why choose CHOP for treatment of brachial plexus injuries
The CHOP multidisciplinary team has decades of experience treating hundreds of children and families affected by brachial plexus birth injury.
Through early care, thoughtful monitoring and a supportive team, families like yours won’t navigate this journey alone.
Support through the Brachial Plexus Program at CHOP includes access to:
- Pediatric brachial plexus specialists, including surgeons and therapists
- Occupational and physical therapists
- Multidisciplinary brachial plexus clinics
- Family support and advocacy organizations
Our team can also help to connect you with other CHOP families that have had similar brachial plexus birth injury experiences.
Frequently asked questions about brachial plexus injuries
How common is brachial plexus birth injury?
Brachial plexus birth injury occurs in about one out of every 1,000 births.
Many cases of brachial plexus trauma are mild and improve significantly over time, especially with early evaluation and therapy.
Did I do something to cause this?
No. Brachial plexus injury can occur even during appropriate, well-managed deliveries. They are not caused by anything a parent did or did not do during pregnancy.
Many factors can contribute, including the baby’s position and size and the natural forces of labor.
In most cases, no one is at fault.
Will this affect my child’s development or intelligence?
No. A brachial plexus birth injury affects the nerves of the arm only. It does not affect brain development, learning ability or intelligence. Children with brachial plexus injury attend school, participate in activities and develop normally.
What happens if a brachial plexus injury is left untreated?
Brachial plexus birth injury does not worsen over time.
However, because this injury can affect muscle and joint development, children are at risk of developing muscle or joint differences as they grow. This is why ongoing follow-ups are important.
What is the prognosis for brachial plexus injury?
Many infants experience partial or full recovery, especially in milder injuries. Some babies begin to regain movement within the first weeks to months of life. Others may have more persistent weakness and benefit from ongoing therapy or, in some cases, surgery.
Our team will educate you about your child’s progress to help you understand your child’s injury and recovery, so you are able to make the treatment decisions that best fit your values and goals for your child.
How long does it take for a brachial plexus to heal?
Nerve healing is slow.
Improvement often occurs gradually over months, not days or weeks. Important changes are typically assessed during the first 3-to-6 months of life, though recovery can continue well beyond the first year. It is important to establish care in infancy so we can detect these early changes. However, even if infants and children present later, we can still help.
Will the affected arm grow normally?
In some children, the affected arm may be smaller than the other side. This occurs more commonly in infants with injuries that affect shoulder, elbow and hand function. Injuries that affect only the shoulder and elbow but not the hand have better growth outcomes.
Our team will closely monitor your child’s growth as they develop.
Will my child be able to use their arm normally?
Many children develop excellent functional use of their arm.
Children will often have differences in strength and range of motion compared to the other arm, but some recover almost completely. Children are very adaptable and learn creative ways to use their arm effectively.
Even if children have one arm that works differently than the other arm, their overall function and ability to engage in activities is excellent and often much better than parents might initially expect.
Will my child be able to play sports or participate in activities?
Yes — many children with brachial plexus birth injury participate in sports, music and recreational activities.
Activity is actually encouraged and helps build strength, confidence and coordination. In some cases, assistance may be needed, but most children are able to participate – and succeed – in all activities without restrictions.
How can we help our child emotionally?
Children often take emotional cues from their families.
When parents speak about the injury calmly and confidently, children are more likely to develop healthy self-esteem. Open, age-appropriate conversations are always encouraged.
Our team at CHOP is always ready to help guide families in discussing brachial plexus birth injury in positive, supportive ways.
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