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Brachial plexus injuries in infants affect the nerves that provide sensation and movement in the shoulder, arm, forearm, hand and fingers. These injuries are also referred to as Erb’s palsies or neonatal brachial plexus injuries. Incidence is between 0.4 and 4 in 1,000 live births.1-3
Risk factors include:
The brachial plexus is made up of the nerves coming from the spinal cord from C5 to T1. These nerves branch out and continue down into the shoulder, arm and fingers.
When the head is stretched away from the shoulder during birth, the nerves that make up the brachial plexus might stretch or tear (rupture). The injury may also pull the nerves’ roots off of the spinal cord (called root avulsion). This results in loss of motor and sensory function of the involved arm.
Signs of a brachial plexus injury usually include:
Babies with suspected brachial plexus injuries benefit from early diagnosis and treatment. Early consultation with a specialized team consisting of peripheral nerve surgeons (orthopaedic, neurosurgery or plastics-trained) and neurologists, along with occupational/physical therapists who specialize in the treatment of these injuries is critical and offers the best chance to maximize the baby’s recovery.
In some cases, surgical treatment may be recommended in order to help restore neurologic function. Most surgeries are done in the first year of life, as early as 3 months of age in the most severe cases.4 Early surgical treatments may include:
After these types of surgery, recovery may take up to several years and continued involvement by a team of brachial plexus specialists is very important. Sometimes additional surgery such as moving tendons and muscles around is necessary to help children achieve their full neurologic potential.
While there are no set criteria for referral, the earlier the better! Any asymmetric upper extremity movement should be evaluated to rule out a brachial plexus birth palsy. The classic teaching was that 92% of patients with brachial plexus birth palsy have a mild injury and recover within the first few months of life without needing surgery.5 More recent studies have shown less optimistic numbers, with 66% recovering spontaneously and between 10-15% left with permanent weakness.2,6
Chief, Division of Neurosurgery
J. Gordon McComb Family Chair of Pediatric Neurosurgery
Attending Surgeon, Children’s Hospital Los Angeles
Professor of Clinical Neurological Surgery, Keck School of Medicine of USC
Director, Muscular Dystrophy Association Neuromuscular Clinic
Attending Physician, Division of Neurology, Children’s Hospital Los Angeles
Associate Professor of Clinical Neurology, Keck School of Medicine of USC
Director, Brachial Plexus Program; Attending Surgeon, Children’s Orthopaedic Center, Children’s Hospital Los Angeles
Assistant Professor of Clinical Orthopaedic Surgery, Keck School of Medicine of USC