Brachial Plexus Birth Palsy, BOTOX Injection: Riley's Story

Feeling the squeeze of your newborn’s tiny fist around your finger is a huge thrill for new parents. But soon after Riley’s birth in April 2015, her parents Rebecca and Mike realized they hadn’t yet felt that squeeze from her right hand. In fact, Riley could move only her fingers and wrist ever so slightly. “Her arm laid flaccid,” says Rebecca. 

Child reaching forwardAlarmed, Rebecca and Mike brought their 10-day-old daughter to Children’s Hospital of Philadelphia’s Brachial Plexus Program. A team of specialists led by neurologist Sabrina Yum, MD, and orthopaedic surgeon Apurva Shah, MD, MBA diagnosed Riley with a brachial plexus injury.

This condition results from an injury to the network of nerves that runs from the spinal cord in the neck to the shoulder, arm and hand. Brachial plexus injuries can happen at birth if the nerves get stretched during delivery. In older children, injuries are often related to trauma such as a sports injury or car accident. Normally, these nerves stimulate muscle movement and provide sensation in the upper limb. Depending on how many nerve roots are affected, children will have varying degrees of weakness, paralysis and numbness in the affected arm and hand.

Early and expert intervention is crucial to optimize recovery in children with brachial plexus and peripheral nerve injuries. Children's Hospital is one of few institutions in the country with a comprehensive program to treat these children, with specialized services in neonatology, occupational therapy (OT), neurology, plastic surgery, neurosurgery and orthopedics.

First step: occupational therapy

The first step in Riley’s care was occupational therapy. Her parents met with the team at CHOP Specialty Care, Virtua, which is close to their home in Haddon Township, NJ. The team of OTs taught Rebecca and Mike the stretching exercises to do with Riley at home. They demonstrated the best way to hold and play with her to promote movement and strength in her right arm.

Riley was monitored regularly by a full team of brachial plexus experts. They noted that Riley was showing steady improvement. She could bend and straighten her elbow. She started to reach for things and raise her arm.

“When she first touched her face with her right hand, I remember the date like it was my own birthday,” says Rebecca. “July 10, 2015. She was 13 weeks old. It was one of the happiest days of my life.”

But by 6 months old, Riley still had limited arm movement that made feeding, playing and achieving developmental milestones difficult. Instead of seeing continued improvement, her shoulder was getting tight and she seemed uncomfortable with her stretching exercises.

A new plan for Riley’s recovery

An ultrasound of Riley’s shoulder showed that the bones in her shoulder joint were not positioned correctly. This dislocation, coupled with increasing muscle tightness, meant that Riley couldn’t fully move her arm to reach overhead.

The brachial plexus team worked with Riley’s family to decide on a plan for further treatment, which involved several carefully planned steps and the expertise of orthopedics and neurology. BOTOX® injections to the shoulder joint loosened the baby’s tight muscles. Several weeks in a cast repositioned the shoulder joint to give her full range of motion. And additional occupational therapy after the cast came off strengthened the tiny muscles in her right arm.

The precision of this complex care plan, combined with the ongoing OT, made all the difference. Riley can now clap her hands. She reaches to take off her sunglasses. And she can feed herself her favorite cereal puffs. These little milestones of babyhood have been extra special for her mom and dad to watch.

“We couldn’t ask for a better team by Riley’s side, carefully guiding her arm and shoulder to recovery,” says Rebecca. “Thanks to the entire group of specialists, Riley is now able to do things that were not possible before.”

The biggest breakthrough for Riley? “She can throw a ball to her best buddy, our dog Cindy,” says Rebecca. “You can’t imagine how happy that makes her.” 

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