Brachial Plexus Injury in Children

Thrilled to announce our Brachial Plexus Injury in Children guest post series by an extremely knowledgeable and talented Pediatric Occupational Therapist that I have the privilege of calling a colleague and friend, Stacy Kirsch, MS, OTR/L, C/NDT. Stacy currently works at NYU’s Hospital for Joint Diseases, and treats many children with Brachial Plexus injuries.

Brachial Plexus

The brachial plexus is a network of nerves running from the spine, made up of the lower cervical vertebrae (C4-C8) and the first thoracic nerve root (T1). It runs through the neck, the axilla and into the arm. These nerves serve to innervate the upper arm, forearm, and hand.

Brachial Plexus Injury in Children

A brachial plexus injury occurs when the nerves are stretched, compressed or torn. Brachial plexus injuries are common in contact sports, automobile or motorcycle accidents or falls. This post will focus on brachial plexus injuries sustained during birth.

Obstetric brachial plexus injuries (OBPI) occur at a rate of approximately 1-2 births per 1,000 in the United States. During prolonged labor, breech position or other complications in the birthing process, the baby’s shoulders may get stuck and the force taken to free to shoulders may overstretch the nerves of the brachial plexus. This force acted upon the brachial plexus can cause varying degrees of nerve injury, ranging from neurapraxia to complete root avulsion.

Clinically, this injury may result in disruption of the sensory and motor function of the injured nerve. Since the spinal nerve roots are injured at the level of the nerve trunks, divisions and cords, it is classified as a Peripheral Nervous System injury. The area of injury and type of injury (stretch of the nerve, tear of the nerves, or rupture of the nerves) will typically help to predict the prognosis. Early diagnosis and treatment will improve long term outcomes for these injuries. Most children will regain all or most function with Occupational and Physical Therapy intervention if instituted at an early age.

Risk Factors for OBPI

Gestational diabetes
Maternal obesity
High birth weight
Disproportionate birth canal length in relation to the fetus
Prolonged labor with or without use of forceps/vacuum for extraction
Rapid labor which can cause the baby to be pushed out so fast that the arm gets stuck, without access to medical assistance
Breech presentation at birth
Shoulder dystocia, or dislocation
Use of forceps or vacuum suction during delivery

Symptoms of OBPI

Difficulty lifting arm above head
Difficulty bringing objects to mouth
Difficulty moving fingers
Lack of sensation in arm, hand or fingers
Tingling or pain in arm, hand or fingers

Evaluation of Brachial Plexus Injury in Children

Take careful history to elicit risk factors, establish chronology and differentiate brachial plexus and non-brachial plexus etiologies of upper extremity motor weakness.
Perform evaluation with multidisciplinary team, including Physical and Occupational Therapists, to appropriately assess motor function and competency with activities with daily living.
Assess for presence of confounding injuries, such as shoulder dislocation; clavicular, humeral or rib fractures; ecchymosis or scarring.
Assess upper extremity posturing to decipher level of injury within the plexus.
Common presentations include:
- “Waiter’s tip” positioning of arm suggests upper plexus injury, with arm adducted, shoulder internally rotated, elbow extended, forearm pronated, with wrist/fingers flexed
- Winged scapula indicates injury to long thoracic nerve (C5, C6, C7)
- Elbow flexed posture indicates injury to C7 root in isolation
- Flail limb with no motor function suggests pan-brachial plexus injury (including roots C5-C8, with or without T1)
- Horner syndrome (eyelid ptosis, pupillary miosis, and anhidrosis) indicates injury to lower plexus with injury to the T1 root proximal to sympathetic and somatic motor fiber separation.

Motor evaluation of the patient is essential as it is indicative of prognosis and helps to guide therapy.

Types of Obstetric Brachial Plexus Injuries in Children

1) Erb’s Palsy, or Erb’s Duchenne Palsy: involves cervical nerve roots C5, C6, and sometimes C7. These nerves are at the top of the brachial plexus, and send electrical impulses to the shoulder and upper arm.

This group of nerves work on reaching, lifting, and bringing the arm above the head (for tasks such as dressing, assisting in feeding, and of course playing). When C7 is involved, the ability to extend the elbow against gravity is limited as well as picking up wrist (to give high five, throw a ball, etc).

2) Klumpke’s Palsy: impacts the lower nerve roots (C8-T1), in which the shoulder is spared and the elbow is functional, but the wrist and hand are paralyzed.

3) Total Plexus Palsy: involves the entire brachial plexus and results in a flaccid or paralyzed arm. It can also be seen in conjunction with a Horner’s sign, which presents as drooping of the eye on the same side of the affected arm. Additionally, the phrenic nerve can be affected causing some diaphragmatic paralysis on the affected side.

Complications of Brachial Plexus Injury in Children