Brachial plexus birth palsy

At Children’s Hospital Boston, our Brachial Plexus Program team knows how concerned you are that your baby sustained an injury to her brachial plexus nerve network. We’ve developed innovative non-surgical and surgical treatments for children with all degrees of severity of brachial plexus birth palsy (BPBP). Learning more about this injury will help you feel more confident and in control as we treat—and work toward—healing your child.
 

What is the brachial plexus?

The brachial plexus is a complex network of nerves between the neck and shoulders. These nerves control muscle function in the chest, shoulder, arms and hands, as well as sensibility (feeling) in the upper limbs.

What is brachial plexus birth palsy (BPBP)?

Brachial plexus birth palsy is an injury to the brachial plexus nerves that occurs during childbirth. The nerves of the brachial plexus may be stretched, compressed, or torn in a difficult delivery. The result might be a loss of muscle function, or even paralysis of the upper arm. Injuries may affect all or only a part of the brachial plexus:

• Injuries to the upper brachial plexus (C5, C6) affect muscles of the shoulder and elbow.
• Injuries to the lower brachial plexus (C7, C8 and T1) can affect muscles of the forearm and hand.
   

What are the signs and symptoms of BPBP?

The main sign of brachial plexus birth palsy is that one of the newborn’s arms will lie at her side, sometimes in a “waiter’s tip” posture. This arm/hand does not move normally, in contrast to her other side.
 

What happens during childbirth to cause an injury to the brachial plexus?

During childbirth, stress can occur across a baby’s neck and head area, injuring the nerve(s). This stress usually happens when the head goes in one direction and the shoulder goes in another direction.
 

Can injury to the brachial plexus nerve network happen in other circumstances than childbirth?

Yes, a traumatic brachial plexus injury can occur at any age—often as a result of a sports injury or car or work accident.
 

What are the types of brachial plexus birth palsy?

Brachial plexus birth palsies are often categorized according to the type of nerve injury and the pattern of nerves involved.

• four types of nerve injuries

  • stretch (neurapraxia)
    • The nerve has been stretched but not torn—the injury occurs outside the spinal cord.
    • It’s the most common form.
    • Affected nerve(s) may recover on their own—usually within 3 months of the baby’s life.
  • rupture
    • The nerve is torn, but not where it attaches to the spine—the injury occurs outside the spinal cord.
    • It’s a common form.
    • It may require surgical repair.
  • avulsion
    • The nerve roots are torn from the spinal cord—the injury occurs at the spinal cord.
    • This is a less common form (roughly 10 to 20 percent of BP cases)
    • It cannot be surgically repaired directly—damaged tissue must be surgically replaced (nerve transfers).
    • It can injure the nerve to the diaphragm, causing difficulty with breathing.
    • A droopy eyelid on the affected side may indicate a more severe injury (Horner’s syndrome).
  • neuroma
    • The nerve has tried to heal, but scar tissue has formed and presses against the injured nerve or interferes with nerve function.
    • It may require surgical treatment with nerve reconstruction and/or secondary tendon transfers.

• patterns of nerve injury

  • C5-C6-C7 (formerly called Erb’s palsy)
    • This represents roughly 60 to 70 percent of BPBP injuries.
    • It involves the upper portion (C5, C6, and sometimes C7) of the brachial plexus.
    • A child typically has weakness involving the muscles of the shoulder and biceps.
    • Home physical therapy begins when a baby is 3 weeks old to prevent stiffness, atrophy and shoulder dislocation.
  • C5-T1 (total plexus involvement)
    • This represents roughly 20 to 30 percent of BPBP injuries.
  • Horner’s syndrome
    • This represents roughly 10 to 20 percent of injuries.
    • It is usually associated with an avulsion (a tear at the spinal cord).
    • The sympathetic chain of nerves has been injured, usually in the T2 to T4 region.
    • The child may have ptosis (drooping eyelid), miosis (smaller pupil of the eye), and anhydrosis (diminished sweat production in part of the face).
    • The child may have a more severe injury of the brachial plexus.
  • Klumpke’s palsy
    • This almost never occurs in babies or children
    • It involves the lower roots (C8, T1) of the brachial plexus.
    • It typically affects the muscles of the hand.

How common is brachial plexus birth palsy?

Brachial plexus birth palsies occur in about one to three out of every 1,000 births.
 

What are the risk factors for BPBP?

Risk factors for sustaining brachial plexus birth palsy include:

• large gestational size
• breech birth
• prolonged or difficult labor
• vacuum- or forceps-assisted delivery
• twin or multiple pregnancy
• history of a prior delivery resulting in brachial plexus birth palsy
   

Does BPBP cause the baby pain?

Usually, the baby is not in much pain despite her BPBP, probably because infants’ nerves behave differently from adults’. Roughly, just 4 percent seem to experience severe pain. If a fracture accompanies the BPBP, the baby will experience some discomfort from the fracture, but not usually intense pain. And any fractures (clavicle, humerus) the baby may have will probably heal quickly—in about 10 days.

This is in contrast to an adult’s traumatic brachial plexus injury caused by accident or sports impact: In these cases, pain from BP injury is acute and disabling, as is pain from any accompanying fractures.
 

How is brachial plexus birth palsy diagnosed?

Brachial plexus birth palsy can be diagnosed by your baby’s pediatrician upon a thorough medical history and physical examination. Since the majority of babies with a brachial plexus injury recover in the first month to six weeks of life, these exams can be scheduled with a primary care doctor. Children who continue to have problems beyond six weeks should be seen by an orthopedist or brachial plexus specialist.

In addition to a physical exam, doctors may perform special imaging studies, like an MRI or nerve conduction studies. These tests are not as reliable for babies as for adults, and they require anesthesia. If accompanying fractures are suspected, doctors may take an x-ray. It’s important to find an experienced doctor who will be able to track your child’s progress over repeated exams.
 

Once my child is diagnosed with BPBP, how soon should we see the specialist?

Once your child’s pediatrician has made a diagnosis, it’s safe to wait up to four weeks for a comprehensive evaluation by an orthopedist or specialist.
 

How often should my child be seen/observed by her orthopedist after her initial appointment?

How often your child should be observed depends on her return of function. Typically, she may need to be seen every one to three months until she is 6 months old, then every six months through the time she’s 24 to 36 months old.

How is brachial plexus birth palsy treated?

• observation:
  • Most brachial plexus birth palsies will heal on their own. Your doctor will monitor your child closely.
  • Many children improve or recover by the time they’re 3 to 12 months old. During this time, ongoing exams should be performed to monitor progress.

• physical and/or occupational therapy:
  • Therapy is recommended to help maximize use of the affected arm and prevent tightening of the muscles and joints. It is important to work to prevent shoulder dislocation and/or deformity.
  • With the teaching and guidance of therapists, parents learn how to perform range of motion (ROM) exercises at home with their child several times a day. These exercises are important to keep the joints and muscles moving as normally as possible.

• Botox injections: may be used (mainly for the shoulder) to:
  • help with therapy to maintain full joint motion
  • rebalance muscles
  • prevent contractures and shoulder dislocations

• surgery: Children who continue to have problems after they’re 3 to 6 months old may benefit from one of several surgical options.

For surgery details, see Treatment & care.
 

What's the prognosis if my child has brachial plexus birth palsy?

The prognosis is dependent on the extent of the injury, and for this reason, it varies from patient to patient:

• Most children achieve normal or near-normal arm function without surgery. But not all children recover fully.

• If a child does not recover fully, surgery can improve her strength and/or motion and help optimize shoulder joint development.

• One of the common problems with brachial plexus birth palsies can be the abnormal development of the child’s shoulder joint, which can happen over time. So, in addition to physical examinations, your child may need ultrasound, magnetic resonance imaging (MRI) and/or computed tomography (CT) scans to monitor her shoulder development.
   

Can there be complications after surgery for BPBP?

Complications after surgery are uncommon but can occur, and can be either temporary or permanent. These include:

• stiff joints—can be treated with physical therapy
• pain from nerve damage (very unlikely)
• muscle atrophy due to incomplete recovery
• disability from incomplete recovery
• the biggest worry is that the arm and hand will not get as close to normal as hoped

Generally, surgery does not make children worse, but does not always lead to full recovery.
 

Who will be on my child's BPBP treatment team at Children's?

Your child’s team may include her team of doctors, physical therapist, occupational therapist, mid-level provider (nurse practitioner and/or physician’s assistant) and nurse, who will guide you through the treatment process. As part of our family-centered approach, your child’s nurse will help with all your questions and appointments. The nurse can also help you meet other families whose children have undergone BPBP treatment—in person and/or online.
 

Is there a support group for families of children with brachial plexus birth palsy?

Yes, our Brachial Plexus Program offers support services, and we encourage all families and children we treat to participate in a parent/child support program.
 

Will my child be OK?

The good news is that—either spontaneously or with therapy—most of our young patients recover fully or nearly fully by the time they’re 6 to 12 months old. Some may even begin to recover when they’re 6 weeks old. Less than half of children with BPBP need nerve surgery. Some require tendon transfers. The outcomes from these surgeries are favorable for improved long-term function.

If needed, your child’s rehabilitation team will work with you and your child to learn home exercises that are important to her recovery. Most parents perform range of motion (ROM) exercises at home with their child many times a day for several years. These exercises are important for keeping the joints and muscles moving as normally as possible.

Children’s pioneering research into the biology of brachial plexus birth palsy—and our experience in developing innovative treatments—means that your child will receive the most advanced care possible.
 

What's unique about BPBP care at Children's?

Children’s Brachial Plexus Program is one of the world’s major centers for BPBP treatment. The program stands virtually alone in providing the entire spectrum of BPBP care—from early nerve surgery, to early therapy, to later reconstructive orthopedic surgery and therapy if this is needed. Our experts sub-specialize in BPBP, and we provide the entire spectrum of care all within one program. So, our team can follow your child closely throughout her treatment and recovery.
 

What research on BPBP is coming out of Children's?

Within Children’s Orthopedic Center, the Brachial Plexus Program and the Clinical Effectiveness Research Center (CERC) are doing extensive research on brachial plexus birth palsy, including grant-funded research through the American Society for Surgery of the Hand (ASSH) and the Pediatric Orthopaedic Society of North America

This research is an effort to establish a standard of care at all hospitals, and to determine the natural history (spontaneous recovery) and microsurgery results for brachial plexus injuries. Our program is coordinating this multi-center TOBI study over the next five years to determine the timing of microsurgery, tendon transfers and osteotomies.

We present all of our research papers on a national basis and publish these results in peer review journals. Numerous papers have already been published and presented in these areas and will continue to be published prospectively.

For more details, see Research & innovations.
 

FAQ

Q: What is the brachial plexus?

A: The brachial plexus is a complex network of nerves between the neck and shoulders that controls muscle function in the chest, shoulder, arms and hands, as well as sensibility (feeling) in the upper limbs.

Q: What is brachial plexus birth palsy (BPBP)?

A: Brachial plexus birth palsy is an injury to the network of brachial plexus nerves sustained during childbirth. These nerves may be stretched, compressed or torn in a difficult birth. This may cause a child to lose muscle function, or even have paralysis of the upper arm. Injuries may affect all or, more often, only a part of the brachial plexus.

Q: What are the four types of brachial plexus birth palsy?

• stretch (neurapraxia)
  • The nerve has been stretched but not torn—the injury occurs outside the spinal cord.
  • It’s the most common form.
  • Affected nerve(s) may recover on their own—usually within 3 months of the baby’s life.
• rupture
  • The nerve is torn, but not where it attaches to the spine—the injury occurs outside the spinal cord.
  • It’s a common form.
  • It may require nerve surgical repair or secondary muscle transfers.
• avulsion
  • The nerve roots are torn from the spinal cord—the injury occurs at the spinal cord.
  • This is a less common form (roughly 10 to 20 percent of BP cases)
  • It cannot be surgically repaired directly—damaged tissue must be surgically replaced (nerve transfers).
  • It can injure the nerve to the diaphragm, causing difficulty with breathing.
  • A droopy eyelid on the affected side may indicate a more severe injury (Horner’s syndrome).
• neuroma
  • The nerve has tried to heal, but scar tissue has formed and presses against the injured nerve or interferes with nerve function.
  • It may require surgical treatment with nerve reconstruction and/or secondary tendon transfers.

Q: How does Children’s treat BPBP?

A: Depending on the severity and nerve pattern of the BPBP, Children’s treats an affected child with:

• observation
• physical and/or occupational therapy
• Botox injections
• surgery

For treatment details, see Treatment & care.

Q: If my child has surgery for BPBP, will she be OK?

A: The good news is that—either spontaneously or with therapy—most of our young patients recover fully or nearly fully by the time they’re 6 to 12 months old. Some may even begin to recover when they’re 6 weeks old. Less than half of children with BPBP need nerve surgery. Some require tendon transfers. The outcomes from these surgeries are favorable for improved long term function.

Q: What are the signs and symptoms of BPBP?

A: The main sign of brachial plexus birth palsy is that one of the newborn’s arms will lie at her side, sometimes in a “waiter’s tip” posture. The affected arm/hand does not move normally, in contrast to her other side.

Q: When/why should we see a doctor for a diagnosis?

A: If you notice that your child’s arm lies by her side and does not move normally compared to her other arm, take her to her pediatrician, who will perform an exam and may refer you to a pediatric orthopedic specialist.

Q: How is BPBP usually diagnosed?

A: Brachial plexus birth palsy can be diagnosed by your baby’s pediatrician upon a thorough medical history and physical examination. Since the majority of babies with a brachial plexus injury will recover in the first month to six weeks of life, these exams can be scheduled with a primary care doctor. Children who continue to have problems beyond six weeks should be seen by an orthopedist or brachial plexus specialist

In addition to a physical exam, special imaging studies like an MRI or nerve conduction studies may be performed to obtain more information, although for babies, these tests are not as reliable as for adults, and they require anesthesia. If accompanying fractures are suspected, an x-ray may be taken.

For more details on diagnostic exams and tests for BPBP, see Tests.

Q: What’s the long-term outlook for a child who’s had surgery for BPBP?

A: The good news is that—either spontaneously or with therapy—most of our young patients recover fully or nearly fully by the time they’re 6 to 12 months old. Some may even begin to recover when they’re 6 weeks old. Less than half of children with BPBP need nerve surgery.

If needed, your child’s rehab team will work with you and your child to learn home exercises that are important to her recovery. Most parents perform range of motion (ROM) exercises at home with their child many times a day for several years. These exercises are important for keeping the joints and muscles moving as normally as possible.

Q: What is Children’s experience treating BPBP?

A: The Brachial Plexus Program within the Orthopedic Center is among the largest in the world—seeing more than 500 children with brachial plexus birth palsy each year. As a national and international referral center for children with brachial plexus birth palsy, our program’s surgeons, nurses and therapists provide comprehensive care to infants and children with acute and chronic brachial plexus palsy.

Causes/risks

• large gestational size
• breech birth
• prolonged or difficult labor
• vacuum- or forceps-assisted delivery
• twin or multiple pregnancy
• history of a prior delivery resulting in brachial plexus birth palsy

Signs and symptoms

The main sign of brachial plexus birth palsy is that one of the newborn’s arms will lie at her side, sometimes in a “waiter’s tip” posture. The affected arm/hand does not move normally, in contrast to her other side.

When to see a specialist

Once your child’s pediatrician has made a diagnosis, it’s safe to wait up to four weeks for a comprehensive evaluation by an orthopedist and/or brachial plexus specialist.

Questions to ask your doctor

If your child is diagnosed with BPBP, you may feel overwhelmed with information. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise—that way, when you talk to your child’s doctors, you can be sure that all of your concerns are addressed.

Some of the questions you may want to ask include:

• What is happening to my child, and why?
• What tests will you perform to diagnose my child?
• What actions might you take after you reach a diagnosis?
• Are there alternative therapies?
• Will my child be OK if she has BPBP?
• Will there be restrictions on my child’s activities?
• What will be the long-term effects?
• What can we do at home?

Complications

Complications after surgery are uncommon but can occur, and can be either temporary or permanent. These include:

• stiff joints—can be treated with physical therapy
• pain from nerve damage (very unlikely)
• muscle atrophy due to incomplete recovery
• disability from incomplete recovery
• the biggest worry is that the arm and hand will not get as close to normal as hoped

Generally, surgery does not make children worse, but does not always lead to full recovery.

Long-term outlook

The good news is that—either spontaneously or with therapy—most of our young patients recover fully or nearly fully by the time they’re 6 to 12 months old. Some may even begin to recover when they’re just 6 weeks old. Less than half of children with BPBP will need nerve surgery. Some require tendon transfers. The outcomes from these surgeries are favorable for improved long-term function.

If needed, your child’s rehabilitation team will work with you and your child to learn home exercises that are important to her recovery. Most parents perform range of motion (ROM) exercises at home with their child many times a day for several years. These exercises are important for keeping the joints and muscles moving as normally as possible.

For parents

Many parents whose babies are diagnosed with BPBP feel disappointed and frustrated that the birth of their child didn’t turn out the way they’d dreamed it would. Your child’s treatment and recovery may be fairly easy. Or, the journey may be more complicated—requiring surgery for your child, and several years of your dedication to her home therapy.

Even though you understand the importance of surgery and therapy for your child with BPBP, you still might experience her treatment and recovery as a difficult time and process. If you feel frustrated or depressed, speak to your doctor or counselor to get help. Professionals in the Brachial Plexus Program and The Center for Families can provide you with important resources and referrals.

BPBP glossary

• arthroscope: a thin, fiberoptic scope introduced into a joint for diagnostic and treatment procedures inside the joint; can be used in shoulder repair in BPBP (see open reduction shoulder joint below)

• avulsion: a detached tear; in BPBP, a tear of the nerve at, and from, the spinal cord

• Botox: a highly purified preparation of botulism toxin; used as treatment for BPBP to help with joint motion, rebalance muscles and prevent contractures and shoulder dislocations

• brachial plexus: a complex network of nerves between the neck and shoulders. These nerves control muscle function in the chest, shoulder, arms and hands, as well as sensibility (feeling) in the upper limbs.

• brachial plexus birth palsy (BPBP): an injury (stretch, compression or tear) to all or part of the brachial plexus nerve complex; occurs during childbirth; can result in loss of muscle function or paralysis of upper arm

• Erb’s palsy: former name (sometimes still used) for one of the patterns of nerve injury in BPBP—an injury to any or all of the C5-C6-C7 vertebrae; accounts for roughly 60 to 70 percent of BPBP injuries; typically results in weakness involving the muscles of the shoulder and biceps

• free muscle transfer: a microsurgical option for treating BPBP that transfers muscle tissue, usually from the gracilis muscle in the patient’s thigh, to the affected brachial plexus area to restore flexion and extension functions in elbow, wrist and fingers

• Horner’s syndrome: one of the patterns of BPBP nerve injury; associated with an avulsion (see avulsion above); involves injury to the sympathetic chain of nerves; can indicate more severe injuries of the brachial plexus

• Klumpke’s palsy: one of the patterns of BPBP nerve injury; involves injury to the lower roots of the brachial plexus; almost never seen in babies and children

• MRI (magnetic resonance imaging): produces detailed images of organs and structures within the body; shows the amount of damage to the brachial plexus

• microsurgery: surgery performed on extremely small structures or cells of the body using a microscope and other instruments

• neuroma: scar tissue that has formed when a nerve has tried to heal; can interfere with nerve function
   
• nerve conduction studies (NCS, nerve conduction velocity, NCV, electromyography, EMG): a two-part test consisting of nerve conduction studies (NCS) and electromyography (EMG). EMG can evaluate nerve disorders such as brachial plexus injuries (Erb’s palsies and avulsion injuries).

• nerve graft: a microsurgical procedure in which the damaged segment of an injured nerve is removed, and a segment of nerve from the leg (usually sural) is attached to the remaining healthy section of the nerve

• nerve transfer: a microsurgical procedure in which the damaged segment of an injured nerve is removed, and a segment of nerve from another area of the brachial plexus (or another area of the body) is attached to the remaining healthy section of the nerve; often used for avulsions (see avulsion above)

• open reduction shoulder joint: placing the humeral head back in the joint (glenoid) and then surgically tightening loose tissue around the shoulder joint; can be performed through surgical incision or using arthroscopy

• orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments

• orthopedic surgeon, orthopedist: a physician specializing in surgical and non-surgical treatment of the spine, skeletal system and associated muscles, joins and ligaments
   
•  osteotomy: controlled breaking or cutting and realigning of bone into correct position; may improve upper extremity function; often used when shoulder weakness and/or joint deformity cause limitations in motion that are not amenable to tendon transfers

• physical therapy: a rehabilitative health specialty that uses therapeutic exercises and equipment to help patients improve or regain muscle strength, mobility and other physical capabilities
   
• post-operative (post-op): occurring after surgery

• pre-operative (pre-op): occurring before surgery

• range of motion (ROM) exercises: physical therapy exercises designed to improve or restore flexion and extension of joints
   
• reconstructive surgery: surgery performed to repair and/or restore a body part to normal or as near normal as possible

• rupture: in BPBP, a tear of the nerve, but not where it attaches to the spine; can be repaired surgically

• stretch (neurapraxia): a type of BPBP in which the nerve has been stretched but not torn; the most common form; affected nerve may recover on its own

• tendon transfer: a surgical procedure that involves separating a tendon from its normal attachment and reattaching it to a new location, often improving shoulder and wrist motion as well as elbow position and hand grip

• total plexus involvement: a BPBP of the C5-T1 vertebrae; accounts for roughly 20 to 30 percent of BPBP
   
• “waiter’s tip” position: a sign of BPBP; baby’s hand is turned away from the body