Brachial Plexus Palsy

Overview

The brachial plexus is a group of nerves from the neck that go to the arm.  These nerves control muscle strength and feeling in the arm. Neonatal Brachial Plexus Palsy (NBPP) is a nerve injury that occurs around the time of birth.  This happens when the nerves in the brachial plexus get stretched or torn during birth.  NBPP is sometimes also called Erb’s palsy.  About 2 out of 3 infants who have NBPP will recover fully in the first 3 months of life.   Frequent observation by your doctor is needed to make sure the arm function recovers.  Patients who do not recover function may need surgery to reconnect the damaged nerves.  Older children with NBPP may also benefit from surgery to improve the arm function.

 

Description

The mildest type of NBPP injures the upper part of the brachial plexus that controls the shoulder and elbow. This is the most common form of NBPP and is called “Erb’s palsy”.  The worst type affects all of the nerves to the arm. This type affects the entire arm including the fingers.  This is called a “global” or “total” palsy.  In rare cases, known as ”Klumpke Palsy”, only the lower part of the brachial plexus is injured.  In these patients the hand and wrist do not work.
 
The injured nerve can have various forms of damage. There may even be different types of damage in different nerves. However, the symptoms (weakness and lack of feeling) are the same after the nerve is injured.  The least severe injury is called a neurapraxia.  This happens when the nerve is just stretched a little.  The nerve will usually recover on its own within a few months. With more stretching, scar tissue may form in damaged areas of nerve. This is called a neuroma.  Some nerve function can still recover, but it is not complete. A nerve rupture occurs when the nerve is stretched to where it breaks apart. The nerve is not able to recover on its own. The worst type of injury, an avulsion, occurs when the nerve is torn from the spinal cord in the neck. With a rupture or avulsion, nerve surgery is recommended to improve recovery.

 

Doctor Examination

NBPP can be diagnosed without any special tests or studies. The pediatrician can usually make the diagnosis after the baby is born. The main signs are arm weakness with a posture of the arm by the side with no ability to bend the elbow (Figure 1). A referral to a specialist is recommended. The doctor will check for how well the baby can move his or her arm and fingers and check the range of motion of the joints. Repeat examinations by the doctor are important to see if the nerves are recovering.
 

Other Studies

The doctors may order an X-ray to look for a break in either the collarbone or the arm bone. Sometimes special nerve tests are also ordered, but these are not always necessary.  An ultrasound or MRI is used to look at the baby’s shoulder if the shoulder is not moving well.
 

Treatment

It is important to start therapy in the first month to move the joints of the affected arm. This includes visits with a therapist and a daily home exercise program. Because the baby can’t move his/her arm, the parents must do it for him/her to prevent stiffness. If the joints become stiff, casting or surgery may be required.  Therapy is the mainstay of treatment for NBPP. Many children recover enough nerve function that surgery is not needed.
The doctor may recommend operating on the nerves if they don’t recover in the first 3-6 months. Surgery can improve arm function. It is important to know that even with nerve surgery, the arm will still not function normally. Nerve surgery might involve removing scar tissue. It may also involve connecting nerves that work into nerves that do not work.
 
Sometimes the joint stiffness in the shoulder is so bad that the shoulder joint will start coming out of place. Mild cases may be treated with Botox and casting.  Sometimes the doctor may suggest surgery to put the shoulder back in place.  This is often combined with surgery to move muscles around the shoulder. This helps stabilize the shoulder and can prevent the shoulder from coming out again.   
 
Older children with weakness and/or limitations of motion can sometimes be helped with bone and muscle surgery to improve function. The surgeries that the doctors may offer can be very different for each individual patient and are tailored for each child.

More Information

• OrthoInfo - Erb's Palsy (Brachial Plexus Birth Palsy)

Q. What is Neonatal Brachial Plexus Palsy (NBPP)?

Neonatal refers to the period of time right around the birth of a child. The brachial plexus is a network of nerves from the neck that supplies all function and sensation to the arm. These nerves provide feeling as well as motion to the entire arm. Palsy means weakness or paralysis. NBPP occurs when, during the time of birth, there is an injury to the nerves of the arm that causes weakness or paralysis.
 

Q. Why do I hear it referred to as Erb’s palsy?

Wilhelm Erb was one of the doctors who first described NBPP. Today, the terms Erb’s palsy, Klumpke palsy, and Total palsy are used to describe different patterns of NBPP.
 

Q. What causes NBPP?

Between 1 to 2 of every 1,000 babies have NBPP. It is believed to be caused when the nerves that exit the baby’s neck are stretched during a difficult delivery. This may be due to a large baby, breech delivery, a difficult and long labor, or a complicated delivery where the baby must be delivered quickly to save the baby and/or mother’s life. However, there are many babies born with NBPP who do not have any of these risk factors, and NBPP has been found in babies born from cesarean sections.
 

Q. Does NBPP cause pain to my child?

NBPP does not seem to cause pain in infants. Studies of children or young adults with NBPP show that NBPP does not cause chronic pain or nerve pain as patients get older. ¹
 

Q. When should I take my child to the doctor for NBPP?

NBPP is generally diagnosed by the baby’s pediatrician very early, usually in the first few days after birth. A referral to a specialist should occur as early as possible in order to start physical therapy and range of motion exercises within the first month of life.
 

Q. How is NBPP treated?

Therapy, protection of the arm, and observation are the mainstays of treatment in the early period. It is important to maintain range of motion of all the joints in the arm. Frequent visits to the doctor are needed to examine your baby as the nerves often recover on their own. Sometimes treatments such as injections with botulinum toxin type A (Botox) may be used if some of the joints are becoming stiff and tight. It can take up to 2 years to see full recovery of the nerves on their own.
 

Q. Will my child need surgery?

If there is no recovery of the nerves in the first 3 to 6 months of your baby’s life, your doctor may recommend surgery to reconstruct the nerves. However, even patients who have nerve surgery do not regain normal function.
 
Older children with continued weakness or joint stiffness may benefit from surgeries to correct the stiffness or connect good muscles to weak muscles. The type of surgery is different for every patient, depending on what part of the arm is affected.
 

Q. Will my child be able to participate in sports and activities?

Studies have shown that children with NBPP participate in sports and activities at the same level as children who do not have NBPP.² While your child may have difficulty placing his or her affected arm in particular positions for certain motions, most children learn to compensate and participate in activities such as football, baseball, band, orchestra, and cheerleading. Enjoying extracurricular activities and sports is important for your child’s physical and mental health!
 

Q. Will the NBPP get worse as my child gets older?

NBPP does not worsen as your child gets older. You may notice as your child gets bigger, that the arm with NBPP is smaller than the other arm (Figure 1). This is because the nerve injury may affect growth. The affected arm will grow, but it will grow more slowly than the other arm. As children with NBPP get older, the imbalance between weak muscles and strong muscles may lead to loss of motion of joints. Surgery can sometimes help when this happens.