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Brachial plexus injuries: what parents need to know.

What would you do if your child were born with a paralyzed arm?

This is a question three out of every two thousand new parents in the United States face each year. This condition, known as neonatal brachial plexus palsy, or Erb's palsy, is more common than Down syndrome and muscular dystrophy. But surprisingly, many families and medical caregivers are unfamiliar with the symptoms and treatment options.

According to experts at Cincinnati Children's Brachial Plexus Center, the greatest challenge is often in early detection and diagnosis because of the lack of understanding surrounding this injury.

"Before our families find our center with brachial plexus specialists, many are told that their children will heal on their own own or that nothing can be done for them," says Linda Michaud, MD, co-director of Cincinnati Children's Brachial Plexus Center.

Mohab Foad, MD, orthopedic surgeon, stresses the importance of early intervention: "This injury should be identified early enough that these children are able to receive the treatment they need. My preference is to proceed with nerve reconstruction as soon as it becomes clear that it is needed. The optimal time for surgery is before nine months, although it is still an option after 9-12 months."

Although not ideal, Foad says there is still hope for those families who miss the opportunity to repair the nerves: "After six-to-nine months, other treatment options are still available. But repairing the nerves is no longer a viable option."

What is a Brachial Plexus Injury?

The brachial plexus is a network of nerves in the neck area that controls movement and sensation in the shoulder, elbow, wrist, hand and fingers.

An injury to the brachial plexus ranges from mildly stretched nerves to nerves completely torn from the spinal cord.

Symptoms of Erb's Palsy

Erb's palsy is the most common type of neonatal brachial plexus injury and occurs when the nerves that control the shoulder and elbow are damaged. Many parents notice their child's arm is limp immediately following the birth.

Other visible signs include an internally rotated shoulder, a straightened elbow, and a wrist stuck in a position known as "waiter's tip" because it looks as though the child is asking for a tip. Although unable to move the shoulder or bend the elbow, children with Erb's palsy can often move their fingers, wrist and hand.

In addition, a child with a brachial plexus injury can experience one or more of the following symptoms:

* Pain

* Limited range of motion

* weakness

* Loss of sensation

* Partial to complete paralysis of the arm and hand

Complete Brachial Plexus Palsy

A more severe (and less likely) injury occurs when all the nerves in the brachial plexus are damaged. Complete brachial plexus palsy can result in a flaccid arm with no sensation or reflexes. Eye muscles can also be affected, which is visibly noticeable by a droopy eyelid and a smaller pupil, known as Horner Syndrome.

Risk Factors

A newborn is at the greatest risk of sustaining a brachial plexus injury when his shoulders become stuck in the birth canal, known as shoulder dystocia.

Other risk factors include large gestational size, maternal diabetes, prolonged labor and difficult instrumental delivery. However, approximately 54 percent of all brachial plexus injuries may occur without any known explanation.

Traumatic Brachial Plexus Injuries

Not all brachial plexus injuries are birth-related. Children and adults at any age can damage the brachial plexus as the result of motor vehicle, sports and bike accidents. Gunshot wounds can also cause traumatic brachial plexus injuries.

Treatment Options

Studies show that 65 percent of children will recover with minimal intervention, which includes occupational and physical therapy. Nerves that are stretched but not ruptured have the potential to heal within a few months. However, more severely damaged nerves may require surgical intervention.

Treatment options include:

* Physical and Occupational Therapy. "Therapy should be prescribed almost immediately following the injury," says Allison Allgier, OTR/L. Infants can begin exercises with their parents and therapists at two weeks of age.

* Nerve surgery. This must be performed within six months of the injury to repair the damaged nerves. For children who miss this window of opportunity, non-nerve related surgeries and treatment options are considered to improve the overall function of the limb.

* Botox. Well-known for its cosmetic use to treat facial wrinkles, Botox can improve muscle balance as well. By temporarily weakening relaxing stronger arm muscles with Botox injections, the weaker muscles are able to build strength and improve balance.

* Additional surgeries. In addition to nerve surgery, some children require orthopedic procedures, such as transferring tendons and muscles, elbow and shoulder reconstructions, joint fusions or osteotomies. Unlike nerve surgery, these procedures do not need to be performed within a certain window of time. The results have yielded life-changing benefits for patients, even for children who did not have nerve surgery.

Take-Home Message

"Early intervention is key," says Allgier. "If you suspect your child has a brachial plexus injury, find a multidisciplinary team of medical experts that specialize in this field to ensure your child is receiving the most up-to-date and highest quality of care."


Cincinnati Children's Brachial Plexus Center is one of a few centers in the world that offers a team of multidisciplinary medical specialists to treat children with brachial plexus injuries. Their website features patient stories, information and an option to receive feedback from a specialist. A parent-to-parent support program is also available for parents to share and learn from their experiences. For more information, call 513-636-PLEX (7539) or visit

The United Brachial Plexus Network is a non-profit organization that promotes education and awareness. Their resources include a message board for families to interact and share their experiences, a directory listing medical professionals who specialize in treating brachial plexus injuries, and Outreach, a quarterly magazine. For more information, call 1-866-877-7004 or visit their web site at

Carrie Schmitt Harrison is a medical writer for Cincinnati Children's Hospital Medical Center. Her work has been published in various magazines, journals and textbooks, including The American Journal of Orthopedics and The Writer magazine.
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Author:Harrison, Carrie Schmitt
Publication:Pediatrics for Parents
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2009
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