BIRTH BRACHIAL PLEXUS INJURY

Birth Brachial plexus  Injury is also sometimes called  Erb’s palsy. Erb’s palsy is actually the most common type of brachial plexus palsy involving the upper part of the brachial plexus (C5-7).

This leaflet is not meant to replace the information discussed between you and your doctor but can act as a useful reminder of the key points. 

What is brachial plexus?

The brachial plexus is a network of 5 nerves coming from the neck into the arm. These nerves provide movement and feeling to the arm and hand. These nerves start in the spinal cord in the neck and are named C5, C6, C7, C8 and T1.

It is through these nerves that the brain sends electrical signals to the muscles and skin of the arm and hand. Each nerve supplies movement and feeling to specific areas in the arm and hand.

How does injury occur?

The incidence of birth brachial plexus injury varies from 0.42 to 2.9 per 1000 births in prospective studies.It is more common in larger babies, but can occur in babies of any weight. After the baby's head is delivered , the shoulders get trapped inside the mothers pelvis, stretching the brachial plexus.

There are also reports to say that fetal malposition and compression , uterine anomalies may also cause brachial plexus injury.

What are the signs and symptoms?

When nerves are injured, the muscles of the arm and hand do not receive all of the instructions from the brain. This results in

• Reduced or no movement in the affected arm .
• Reduced sensations (e.g. of temperature or pain) in the affected arm. 
• There might be associated injuries such as Fractured collar bone (clavicle) or Fractured upper arm bone (humerus)
• Horner's syndrome (the eyelid droops and the pupil of the eye is slightly smaller on the same side as the weak arm).

What is the initial assessment?

Following birth your baby will have been assessed by a paediatrician. If any abnormalities of arm function are observed they may refer for an X-ray to check whether there are any fractures in the arm, and they will refer to the Neuro-Rehabilitation team.

The initial assessment of you child will be done by our expert Neuro-Rehabilitation  team consisting of a consultant pediatric neurologist, pediatric physiotherapist and a consultant pediatric orthopaedic surgeon. Every child and every injury pattern is different, hence you will be provided with a treatment plan customised to you child. 

What are the initial treatment options available?

Generally we advise  positioning  and handling techniques for the first week . 

Caring for your baby- what can you do to help?

In the first 5 days following birth or until review by a physiotherapist, try to follow this advice:

• Provide adequate support to the affected arm at all times to prevent stretching, pulling and pressure on the affected shoulder.
• Sleeping: Baby should be on their back to sleep with feet at the bottom of the cot. This should provide adequate support for the arm. Do not lie your baby on their affected arm.
• Bathing/skincare: When bathing, keep the affected arm still and supported over baby’s chest/tummy. Carefully wipe and clean under the arm without lifting the arm up too far and carefully dry under the arm to prevent any sore skin.
• Dressing: During dressing, put the affected arm into the garment first and when taking clothes off, leave it until last to avoid any pushing twisting and turning of the shoulder.
• Feeding: Find the positions that work best for you and your baby but keep baby’s affected arm down by their side with the forearm over chest/ tummy. Do not let the arm drop and hang without support. Some parents have found wrapping the arm in a thin muslin cloth during feeding helps to ensure the arm is supported. You can stroke baby’s arm during feeds.
• Carrying/ handling: Support the affected arm by holding your baby’s arm close to their body when picking up and carrying your baby to avoid the arm hanging down. Do not pull on your baby’s arm or lift them under the armpits.
• Encourage sensory awareness and gentle guided movement of affected arm. Let your baby’s hand grasp your finger and gently guide their hand to their mouth and let them suck on their hand, avoiding too much shoulder movement. Touch, stroke, massage and kiss your baby’s arm and hand. Giving these sensations remind the brain their arm is there.

 Following this active Physiotherapy /Occupational therapy is recommended, including range of motion, strengthening, neuromuscular electrical simulation, and constraint-Induced Movement Therapy (CIMT). These will be individualized and taught to you by our physiotherapy team.

Others include serial casting, aquatic therapy and use of orthoses, as needed.

Will my child’s arm recover?

In most cases, a full recovery occurs within the first one to three months, however about 25% of babies will have ongoing functional problems of the affected arm. With appropriate treatment, most children make a full recovery or are left with minimal impairment.

How likely is surgery to be successful?

Surgical intervention for Brachial plexus injury  is uncommon and is advocated in select cases with severe nerve injury or if functional recovery does not ensue in the first three to nine months. 

If surgery is needed, microsurgical nerve repair may be undertaken as early as three months post injury. Primary nerve repair is typically completed by approximately six to nine months of age following the injury.

Other Procedures include:

• Botulinum injections
• Tendon transfers
• Muscle transfers
• Shoulder reconstruction
• Rotational osteotomies
• Elbow reconstruction

Surgery is aimed at improving function but will not result in a perfect outcome.

What about long term outlook?

Spontaneous recovery with neuro-rehabilitation occurs over one to three months in many if not most cases of Birth Brachial Plexus Injury, but persistent functional impairment is seen in 18 to 50 percent of patients .Management often focuses on preventing and  minimising deficits while aiming to  maximise the child's capabilities at home and in the community.

It is important to remember that your child is very adaptable. Be supportive and encouraging; focus on what your child can do. Positive reinforcement will help your child to develop a healthy sense of self-esteem and promote independence.

    Dr Rashmi Adiga                                                           Dr Abilash Srivastav

Consultant Paediatric Neurologist              Consultant Pediatric Orthopaedics 

For further information ,please contact us at Rainbow Hospital, Banerghatta Road.