Brachial Plexus Injury: The Condition

In Latin, the word brachial means “arm” and the word plexus means “braid”. So, brachial plexus refers to the braid, or network, of nerves that control the shoulder, arm and hand. Damage to any or all of these nerves is a brachial plexus injury, or BPI. Depending on the nature and extent of the damage, these injuries may be temporary or permanent, disabling or merely uncomfortable. They can occur at any time of life as the result of trauma, infection or tumor growth.

Most pediatric brachial plexus injuries we treat at Lucile Packard Children’s Hospital Stanford are birth-related BPI (or neonatal brachial plexus palsy), which occur during childbirth. These injuries typically occur as a baby’s shoulders are squeezing through the birth canal during delivery. In many cases, the damaged nerves heal themselves over time. In more severe or complex cases, surgery is required to restore joint stability, motion or sensation for the upper limb. In every case, early identification and evaluation are important so that the best treatment choices can be made in order to achieve maximal function.

The brachial plexus is made up of five nerves that run from the spinal cord in the neck down into the arm. These fibers branch to form all the nerves enabling movement and sensation in the hand, forearm, upper arm and shoulder. They are responsible for everything from the broad motions of the biceps to the nimble manipulation and super-sensitivity of the fingertips.

How brachial plexus injuries occur

Many brachial plexus injuries occur during birth when an emerging baby’s shoulder becomes impacted on its mother’s pubic bone, which can cause some or all of the nerves of the brachial plexus to stretch or tear. Birth-related BPIs are one of the more common birth-related injuries and occur in as many as five percent of deliveries.

The most common kind of birth-related brachial plexus injury is Erb’s palsy, an injury of the upper brachial plexus nerves. When these nerves are injured, the child can no longer flex the elbow and loses range of motion around the shoulder. Depending on the severity of the damage, Erb’s palsy can be either permanent or temporary.

Klumpke’s palsy is also common. Like Erb’s palsy, Klumpke’s palsy is usually—but not always—birth related. Also like Erb’s palsy, depending on the severity of the damage, it can be either permanent or temporary. In Klumpke’s palsy, though, the lower brachial plexus is damaged, causing partial paralysis of the hand and wrist. One characteristic expression of Klumpke’s palsy is holding the hand with flexed fingers in what is sometimes described as a “claw-like” position.

Older children and adults may also incur brachial plexus nerve damage as a result of infections, tumors or traumatic injuries such as car or bicycle accidents and sports injuries. Our care team members have broad and deep experience that applies to children of any age who have a BPI, regardless of the cause.

Our team can treat all manner of brachial plexus injury and includes a neurosurgeon, hand surgeons, orthopedic surgeons, neurologists, radiologists and a dedicated pediatric occupational therapist. Together, we evaluate cases from all points of view early on to zero in on the best long-term approach. We customize care to help each patient achieve maximal strength, sensation and range of motion in their shoulder, arm and hand.

Types of brachial plexus nerve damage

The prognosis after a brachial plexus injury depends on which nerves are damaged and how severely each of them is damaged. Because severe cases may initially look similar to less serious ones, early evaluation and regular follow-up examinations are key. The sooner an injured child is evaluated, the easier it is for us to mark their progress, to interpret the change and to optimize our responses. Patients who eventually require surgery should have it before irreversible changes in their muscles occur. Young patients who do not require surgery should be examined regularly to detect possible long-term consequences of the original injury. For example, a shoulder dislocation can result from the long-term muscle imbalance that accompanies the nerve damage.

There are three main classifications of BPI, roughly corresponding to the severity of the injury:

  1. Stretch injury
  2. in which the brachial plexus nerves have been stretched or gently compressed but remains attached and in communication with the spinal cord. Also known as neurapraxia, stretch injuries can often repair themselves over time.
  3. Rupture injury
  4. in which the brachial plexus nerves have been stretched and at least partially torn, but not at the spinal cord. This type of injury rarely heals on its own, but the nerve can sometimes be surgically repaired to restore some motion, sensation and strength.
  5. Avulsion injury
  6. in which the brachial plexus nerves have been pulled out of the spinal cord and all connection and communication has been lost. This type of injury currently has no chance for spontaneous recovery.

See the BPI Treatments section for more detail on the clinical approaches to each of these types of injury.

Research

While research on the use of stem cells, growth factors and other regenerative techniques holds great hope for progress in the future of brachial plexus injury treatment, clinical trials are still some years off. A more immediate advance will likely be the use of donor nerve grafts, which could avoid the need to transplant another nerve from the patient’s own body. Such donor grafts, which could be stored and taken off the shelf as needed, would minimize the extent of surgery and scarring and would eliminate the numbing or other negative effects sometimes associated with the removal of a nerve for transplant.

Summary

Packard Children’s experienced and diverse team of pediatric specialists is dedicated to minimizing the disruption and disability that result from brachial plexus injury. We aim to restore as much function to the injured arm and hand as possible and to help children who have sustained these injuries to best compensate for any losses that cannot be recovered. From the first visit, our clinicians work together with patients and families to navigate the best course toward a long-term outcome that will allow our young patients to lead full and happy lives.