Injury to the brachial plexus nerves is not uncommon in childbirth. For most infants injured in this way, the resulting damage is mild and temporary. For others, it can be serious and may cause lasting damage. The brachial plexus nerves control the arms, so damage to these nerves leads to conditions like Erb’s palsy, which affects the sensation and movement in the arms.
For mild cases of injury, which fortunately includes most affected infants, treatment is no more than gentle physical therapy and time to heal. For those with more serious damage, different types of surgery can help repair damaged nerves and restore some function to the arm. Unfortunately, even surgery cannot completely heal all nerves or correct all damage, and some children will live with some degree of symptoms for the rest of their lives.
Brachial Plexus Injuries and Palsies
The brachial plexus is a bundle of five nerves that attach to the spinal cord and to smaller nerves that control various parts of the arm (from the shoulder down to the fingers). During childbirth, these nerves may be damaged by over stretching. Pulling on the infant’s head as it comes through the birth canal, twisting the head and neck with respect to the shoulder, and even pressure in the birth canal and womb can stretch the brachial plexus.
Another possible cause of stretching is when a child is born breech and their upraised arms stretch the nerves. Risk factors for this kind of damage include a large baby, breech birth, and long, difficult labor.
The injury to the nerves may be mild and cause damage simply by overstretching them, or may be more severe including rips or complete tears away from the spinal cord. The results of damage include paralysis, weakness, and loss of sensation in the arm. These symptoms may range from mild to complete paralysis, depending on the extent of the damage.
The collection of symptoms caused by brachial plexus injury is called brachial plexus palsy or Erb’s palsy. The names are often used interchangeably, but to be most accurate, Erb’s palsy refers to damage that causes symptoms in the upper arm. Lower arm symptoms are sometimes called Klumpke’s palsy. Damage caused throughout the arm due to injury to all five brachial plexus nerves may be called global palsy.
As mentioned earlier, some damage to the brachial plexus during childbirth isn’t rare, and in most instances the injury is mild. A little overstretching, or even a moderate amount, is typically a type of injury that does not require much treatment. Most infants born with this extent of damage will recover naturally as the nerves heal over the course of three to six months.
Infants with noticeable palsy caused by mild to moderate nerve damage benefit from physical therapy as the nerves heal. Physical therapy may include range of motion exercises, strength and muscle building exercises, gentle massage, and mobilization of joints. Aquatic therapy can also be helpful for some children, as can neuromuscular electrical stimulation, which entails mild electrical shocks to stimulate muscle movement.
Most infants with brachial plexus injury will start to recover within a few months with full recovery by six months. If improvements are not seen, or are not adequate by six months, surgery to correct nerve damage may be an option. Surgical treatment for these injuries is only necessary when nerves do not heal on their own. If babies don’t heal within around six months, this could mean the damage was more severe and likely included tearing or complete separation from the spinal cord.
In the case of a nerve that is overstretched, not healing, or that has been torn, a nerve graft may be done to repair damage and restore sensation and movement. This involves using a donor nerve, typically from another part of the patient’s body, and grafting it onto the damaged nerve to bypass the tear and promote healing.
In even more severe cases of damage, particularly when the nerve has been torn away from the spinal cord, a nerve transfer may be needed. This also involves a donor nerve. The donor nerve is used to reconnect the torn nerve to the spinal cord. In some cases a nerve transfer may be used instead of a nerve graft for a nerve that is damaged but not separated from the spinal cord. In this case a transfer can be more targeted than a graft and may restore more sensation and movement to the affected muscle.
Other Surgical Treatments
Other types of surgeries may be used to help a child with brachial plexus injuries recover more movement or sensation. These may include muscle or tendon transfers. This is most often done when surgery on the nerves is not possible because it has been delayed to the age of 12 months or older. Severing and reconnecting muscles and tendons can restore some motion to affected arms and joints. Other surgeries that can help a child with brachial plexus injury include surgery to remove scar tissue from damaged nerves, shoulder and elbow reconstructions, and arthroscopic surgeries.
Another treatment option for brachial plexus injuries is an injection of botulinum toxin A, also known as Botox. This toxin comes from a bacterium and causes paralysis. Injections of the toxin can be localized to cause paralysis only where it is needed. There is low risk that the toxin will spread to other parts of the body.
For brachial plexus injuries Botox is used to help give balance in joints. When the shoulder or elbow is imbalanced it is typically because one muscle, unaffected by the nerve damage, is stronger than another and is overpowering it. Botox can temporarily paralyze or weaken that muscle so that the other one can become stronger with more use. Physical therapy to strengthen that muscle is usually used in conjunction with Botox injections.
Brachial plexus injuries are not always serious, but they can be. If you have a child born with this type of injury you could be facing months of therapy and even surgeries. Your child could be facing lifelong complications. If you believe someone was at fault during childbirth, you may have a case to make for compensation.