Signs and symptoms of brachial plexus injuries

An injury to the brachial plexus or nerve(s) of the arm results in weakness or paralysis. Babies will not move their affected arm. In less severe injuries, some babies will regain function in the fingers and hands over the first few months after birth. They may have numbness in the arm, but this can be difficult to determine. Many babies with brachial plexus injuries hold the affected arm by their side, with the elbow straight, and the forearm and hand turned in.

Older children will also complain of weakness or no movement of the shoulder, arm, or hand. They may have numbness or tingling. For both babies and older children, other injuries may co-exist, such as broken bones of the ribs, collarbone, shoulder, or upper arm. There may also be other nerve injuries that can be seen as ptosis (droopy eyelid) and a smaller pupil on the affected side.

Testing and diagnosis

Your child’s initial evaluation is typically done by our pediatric specialists and our occupational therapist within the first month after injury. It starts with a medical history, a developmental history, a physical exam and a neurological exam.

Depending on your child's age and cause of the injury, your child's care will be coordinated through our Brachial Plexus Program, which can be initiated through any participating division: Neurology, Neurosurgery, Plastic Surgery, or Orthopedic Surgery. The Brachial Plexus Program brings together multiple pediatric subspecialists with experience treating children with brachial plexus and peripheral nerve injuries.

Some children may need additional tests during their care to help the team get a better understanding of their condition and determine the best treatment options.

• An electromyogram (EMG) may be performed by our neurologist to assess muscle contraction.
• Magnetic resonance imaging (MRI) of the brachial plexus and/or cervical spine, or a CT myelogram may also be ordered through CHOP’s Department of Radiology.
• X-rays may be taken to look at bones or the chest, particularly if there is a history of a fracture or to evaluate the diaphragm for paralysis.
• Ultrasound may be used as another way to evaluate the diaphragm or shoulder.

Treatments for brachial plexus injuries

Occupational therapy

Many patients with birth-related brachial plexus injuries recover enough motion and strength and do not need early surgery. For all patients, we encourage regular sessions with occupational therapy, whether it is at Children’s Hospital of Philadelphia or locally if patients live outside the Philadelphia region.

Goals for therapy focus on:

• Promoting nerve recovery
• Preventing joint contractures
• Maintaining range of motion in the upper extremities and neck
• Facilitating optimal use and typical movement patterns

Typical therapy interventions include:

• Range of motion exercises and stretching
• Splinting
• Joint compression and weight bearing to facilitate muscle contraction
• Bilateral motor planning activities
• Facilitating optimal alignment in the shoulder and scapula to promote smooth movement in all directions
• Aquatic therapy when indicated

In addition to these regular sessions, your child’s occupational therapist will also teach you exercises that should be performed every day with your child to keep the joints supple and encourage normal motor development.

Patients are closely followed by our team for signs of functional recovery of the upper extremity. If there are no signs of recovery or not enough muscle recovery, then patients may get additional testing and evaluations to discuss surgical options to improve function.

Surgical intervention for brachial plexus and other nerve damage

Early surgical intervention for brachial plexus and other nerve damage is usually decided between three to six months after injury. We carefully follow each patient for signs of recovery and personalize treatment based on the type and degree of injury. Early surgical treatments include:

• Surgical exploration
• Neurolysis — releasing nerve from scar tissue
• Nerve grafting — taking nerve from elsewhere on the body to bridge a nerve gap after cutting away damaged nerve
• Nerve transfers — using working nerves to stimulate nerves and muscles that are not functioning well

Secondary procedures may be needed as children grow and are designed to augment their function. These surgeries include:

• Tendon or muscle transfers — using working tendons or muscles to power weak or non-working muscles
• Release of tight muscles or joints
• Osteotomies — cutting and repositioning the bones
• Joint fusions

Follow-up care for children with brachial plexus and peripheral nerve injuries

Children with brachial plexus and peripheral nerve injuries are followed by our Brachial Plexus Program, which brings together a variety of pediatric subspecialists who monitor each patient closely for recovery and additional nerve damage that may require further treatment.

Every patient's care is tailored to meet their individual needs, and may include consultations with pediatric neurologists, neurosurgeons, occupational therapists, plastic and reconstructive surgeons, orthopedic surgeons and more.