Brachial plexopathy is any injury to the brachial plexus—the nerve bundles located on each side of the neck that give rise to the individual nerves controlling the muscles of the shoulders, arms, and hands.
Brachial plexopathy occurs most often during birth, when an infant's neck and shoulders are stretched apart during passage through the birth canal. Injury to the brachial plexus is referred to by various names. Some names, such as obstetric Erb's palsy, refer to the specific region of the brachial plexus where the injury has occurred. Other more general names for the condition include:
The nerves of the brachial plexus are the fifth through the eighth cervical nerves (C5, C6, C7, and C8) and the first thoracic nerve (T1). They run from nerve roots on each side of the upper spinal cord to regions beneath the collarbone where they branch out as the major nerves of the shoulders, arms, wrists, and hands.
Every brachial plexus injury is different, depending on the affected nerve or nerves and the extent and severity of the injury. There are four general types of injury, and an individual brachial plexopathy may include any or all of these injury types, on one or both (bilateral) sides of the body. The types are as follows:
A minor brachial plexus injury can be a stretched nerve that results in a short-circuit in a few of the nerve fibers, causing temporary paralysis. A more severe injury may involve a complete disruption of the nerve, in which the nerve fibers around the injury become disorganized, all nerve function is lost, and scarring prevents the nerve from healing. Such an injury can result in permanent paralysis.
Most injuries to the brachial plexus during birth involve the C5 and C6 nerve roots, affecting the movement of the shoulder, upper arm, and elbow. Limited shoulder motion can affect the function and strength of the hand. Obstetrical brachial plexopathies are classified according to the extent of the injury.
ERB'S PALSY Obstetric Erb's palsy is an injury in the upper brachial plexus involving C5 and C6 and sometimes C7. It usually affects the upper arm and the rotation of the lower arm. Erb's palsy is known also by the following names:
KLUMPKE'S PALSY Klumpke's palsy or Klumpke's paralysis is an injury to the lower brachial plexus: C7, C8, and sometimes T1. Children with Klumpke's palsy have normal use of the shoulder and elbow but weakness or paralysis in the hand and fingers. An infant also may have a drooping eyelid on the opposite side of the body from the affected hand.
TOTAL PLEXUS PALSY Also called Erb/Klumpke palsy, total plexus palsy involves all of the nerve roots of the brachial plexus to at least some extent. The entire upper extremity is affected.
It is estimated that in North America between one and three of every 1,000 newborns are affected to some extent by brachial plexopathy. It appears to be less common than in the past, due to improvements in infant delivery methods and the increased use of cesarean sections (c-sections) to surgically remove the infant through the abdomen. However, some physicians are concerned that the late 1990s and early 2000s trend toward decreasing elective c-section deliveries will result in more cases of brachial plexopathy among newborns.
Erb's palsy is the most common type of obstetric brachial plexopathy. Total plexus palsy accounts for about 10 percent of obstetric brachial plexopathies and Klumpke's palsy accounts for less than 1 percent.
Brachial plexopathy can result when the following events occur. An individual brachial plexopathy may include any or all of these injury types, on one or both (bilateral) sides of the body. The events are as follows:
Causes of brachial plexopathy, other than injuries during birth, include:
RISK FACTORS Although brachial plexus injuries can occur during any birth, there are particular risk factors. The highest rates of brachial plexus injury (7.8%) occur in newborns weighing over 10 lb (4.5 kg) who are born by assisted vaginal delivery to diabetic mothers. Premature and underdeveloped newborns are at a decreased risk for brachial plexopathy. Other risk factors for this injury are as follows:
The symptoms of brachial plexopathy vary greatly depending on the extent and severity of the damage. Some children with brachial plexopathy have the following limitations:
Typical symptoms that may be recognized at birth or shortly thereafter include the following:
Other common symptoms of brachial plexopathy include:
Additional symptoms of brachial plexopathy include:
Symptoms of Erb's palsy include:
Symptoms of total plexus palsy include:
Although obstetric brachial plexopathy usually heals quite rapidly on its own, the infant may begin physical therapy within the first two weeks of life and should be evaluated by a specialist, such as a pediatric neurologist, by six weeks of age.
A newborn lacking movement in an arm is examined first for fractures of the collarbone, ribs, humerus (the long bone of the upper arm, extending from the shoulder to the elbow), and even the femur (thighbone), as well as dislocations of the shoulder or elbow. Symptoms of such fractures and dislocations may be similar to those of brachial plexopathy and can cause infants to not move their arms. Those at risk for obstetric brachial plexopathy are also at risk for fractures and dislocations during birth. An infant who is not moving a fractured arm because of the pain will still exhibit a Moro reflex. However, when the infant is rolled from side to side, a brachial-plexopathy-affected arm may flop.
Brachial plexopathy is diagnosed by the following:
Nerve regeneration in newborns occurs at 1.8 mm. per day. Therefore, stretch or praxis injuries to the brachial plexus usually heal on their own within about three months, leading to complete recovery. However, many children with brachial plexopathy require treatment. Specialists who may become involved in a child's treatment include:
Gentle massage and range-of-motion (ROM) exercises usually are initiated immediately, even in infants with very mild brachial plexopathy. Therapy regimes are individualized for each child, depending on the specific injury and its effects.
Treatment for brachial plexopathy may include a combination of exercises and focused physical, occupational, and aquatic therapies. Typically the therapist teaches the child's family to perform the following:
At home parents may be instructed to do the following:
Play therapies are used to extend ROM from six months of age on in children with brachial plexopathy. General body activities include:
Activities to increase hand coordination include:
About ten percent of brachial plexus injuries in infants require surgery. Children with total plexus palsy who have not improved by three months of age and children with Erb's palsy who cannot strongly bend their elbow or raise their shoulder by six months of age are candidates for exploratory surgery to examine the nerve damage and perform possible nerve grafting. Surgeries are most successful if performed when the child is five to seven months of age. Surgeries are less likely to be successful if performed after 12 months of age.
Rupture injuries usually require surgery. Avulsion injuries require surgery to reattach the nerve root to the spinal cord. Surgeries that may be performed by a pediatric neurosurgeon include:
Other types of surgery include:
A variety of other surgical procedures may be considered depending upon the specific situation. At least 90 percent of children improve following surgery. Exercise and massage are eventually reinitiated, depending on the type of surgery.
Other treatments for brachial plexopathy can be used. For example, various types of splints are available to position and support the extremity during activities and to increase weight-bearing ability. Also, casts are sometimes used to allow the nerves to heal. Finally, electrical stimulation, in conjunction with EMG, can deliver a small amount of electrical current to the muscle to prevent atrophy; it may be performed either by a therapist or at home. The child is examined regularly, both during and after treatment, for muscle recovery and proper joint development.
About 85 percent of infants with brachial plexopathy make a complete neurological recovery within three to six years. One study of 59 children found that 88 percent recovered by four months of age, 92 percent recovered by 12 months, and 93 percent recovered by 48 months. In another study of 28 infants with damage to the upper brachial plexus and 38 infants with total plexus palsy, 92 percent recovered spontaneously.
However, the prognosis for an individual brachial plexopathy depends on the location, severity, and extent of the damage and may be difficult to predict. In general, damage to the nerve sheath (outer covering) alone has a good prognosis. Praxis-type injuries, in which the nerve is damaged but not torn, usually improve within three months and eventually heal completely. Stretch injuries heal on their own, with 90 to 100 percent of function returning within one to two years. Severed nerves, particularly avulsion injuries in which the nerve is severed at the root, have poorer prognoses. In severe cases there may be permanent partial or total loss of nerve function in the affected nerves and weakness or paralysis of the arm may be permanent.
Erb's palsy has the best prognosis since, although shoulder, elbow, and forearm function may be affected, the hands and fingers are not affected. However, infants with Erb's palsy that involves C7 as well as C5 and C6 have a poorer prognosis. In addition Erb's palsy may lead to secondary deformities as the child grows. The most common problem is internal rotation contracture (permanent muscle contraction) of the shoulder.
Complete recovery from brachial plexopathy may be difficult to define. A Swedish study found that about 30 percent of children who had recovered the use of their shoulder, biceps, and hand by the age of three months still had disabilities at age five, including a weakened hand grip or difficulty dressing or running. The delay in normal functioning caused by brachial plexopathy and any muscle imbalances across a joint can have a major impact on the child's growing skeleton and can result in permanent muscular-skeletal abnormalities.
Long-term effects of brachial plexography may include:
The primary prevention for obstetrical brachial plexopathy is the avoidance of a potentially difficult delivery by choosing cesarean section. Failure to anticipate a particularly large baby before delivery is an important risk factor. Some physicians suggest that women whose previous children had shoulder dystocia should be offered an elective cesarean delivery. However, cesarean deliveries also have risks associated with them, and it appears that increasing the frequency of c-sections would prevent few cases of brachial plexopathy since large-scale studies have shown that 3 percent of brachial plexus injuries occur during cesarean deliveries.
The use of an epidural (local) anesthetic during labor may contribute to the risk of brachial plexopathy since the anesthetic decreases the mother's ability to push during labor and may force the physician to use forceps or a vacuum device to pull the baby out.
Although exercises required to treat brachial plexopathy in infants may be painful, they are essential for preventing much more serious pain and suffering as the child grows. In addition to performing prescribed massage and ROM exercises, parents should:
Parents should help their child to become self-sufficient in the movements involved in the following daily tasks:
Daily activities that increase ROM are essential even if the child is seeing a physical therapist. Parents should do the following:
Numerous activities have been found useful for promoting a child's recovery. Activities to increase shoulder flexibility include:
Activities to increase shoulder abduction (movement of the arm away from the body) include playing bird or airplane and turning a jump rope.
Activities to increase elbow flexion (bending) include:
Activities to increase elbow extension include crawling and reaching out for objects.
Activities to increase wrist extension include:
Abduction—Turning away from the body.
Adduction—Movement toward the body.
Avulsion—The forcible separation of a piece from the entire structure.
Brachial plexus—A group of lower neck and upper back spinal nerves supplying the arm, forearm and hand.
Cervical nerves—The eight pairs of nerves (C1C8) originating in the cervical (neck) region of the spinal cord.
Cesarean section—Delivery of a baby through an incision in the mother's abdomen instead of through the vagina; also called a C-section, Cesarean birth, or Cesarean delivery.
Computed tomography (CT)—An imaging technique in which cross-sectional x rays of the body are compiled to create a three-dimensional image of the body's internal structures; also called computed axial tomography.
Contracture—A tightening or shortening of muscles that prevents normal movement of the associated limb or other body part.
Dystocia—Failure to progress in labor, either because the cervix will not dilate (expand) further or because the head does not descend through the mother's pelvis after full dilation of the cervix.
Electromyography (EMG)—A diagnostic test that records the electrical activity of muscles. In the test, small electrodes are placed on or in the skin; the patterns of electrical activity are projected on a screen or over a loudspeaker. This procedure is used to test for muscle disorders, including muscular dystrophy.
Erb's palsy or paralysis—A condition caused by an injury to the upper brachial plexus, involving the cervical nerves C5, C6, and sometimes C7, affecting the upper arm and the rotation of the lower arm.
Flexion—The act of bending or condition of being bent.
Klumpke's palsy or paralysis—A condition caused by an injury to the lower brachial plexus, involving the cervical nerves C7 and C8, and sometimes the thoracic nerve T1, causing weakness or paralysis in the hands and fingers.
Magnetic resonance imaging (MRI)—An imaging technique that uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct detailed images of internal body structures and organs, including the brain.
Moro reflex—A startle response in a newborn, characterized by spreading the arms with the palms up and fingers flexed; the reflex usually disappears by two months of age.
Nerve condition velocity (NCV)—Technique for studying nerve or muscle disorders, measuring the speed at which nerves transmit signals.
Neurolysis—The destruction of nerve tissue or removal of scar tissue surrounding a nerve.
Neuroma—Scar tissue that forms around a nerve; a tumor derived from nerve tissue.
Neuroplasty—Surgery to repair nerves.
Palsy—Uncontrolable tremors.
Total plexus palsy—Erb/Klumpke palsy; a condition resulting from injury involving all of the brachial plexus nerves and affecting the entire upper extremity of the body.
If a child has no hand function, double sided Velcro can be placed around the hand and used to hold rattles and toys with Velcro attached to them. An older child can use a Velcro mitt and balls.
There are numerous support groups across the United States for the families of children with Erb's palsy and other brachial plexopathies. Support groups offer encouragement and advice on the following topics:
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Bavley, Alan. "Birth Injury Begins to Receive More Attention." Kansas City Star (May 7, 2000).
Brachial Plexus Palsy Foundation. 210 Spring Haven Circle, Royersford, PA 19468. Web site: membrane.com/bpp.
Erb's Palsy Lawyers Network. Web site: http://www.erbspalsy.com/index.htm.
National Brachial Plexus/Erb's Palsy Association Inc. PO Box 23, Larsen, WI 54947. Web site: http://www.nbpepa.org.
National Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institutes of Health, 1 AMS Circle, Bethesda, MD 20892–3675. Web site: http://www.nih.gov/niams.
United Brachial Plexus Network. 1610 Kent St., Kent, OH 44240. Web site: http://www.ubpn.org.
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"Erb's Palsy/Brachial Plexus Play Therapy Exercises." United Brachial Plexus Network, 2000. Available online at http://www.ubpn.org/resources/playtherapy.html (December 24, 2004).
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Margaret Alic, Ph.D.
The following comments are not guaranteed to be that of a trained medical professional. Please consult your physician for advice.