Brachial plexus injuries occur when the brachial plexus nerves are stretched, compressed, torn, or ripped away from their connection to the spinal cord. The brachial plexus nerves connect the arm and hand to the brain, so brachial plexus injuries affect arm and hand function. Treatment for brachial plexus injuries depends on the type and severity of the injury.
Neuropraxia is the least severe type of damage to the brachial plexus nerves. It refers to stretching or compression of the nerves without tearing or rupture. These types of nerve injuries will often heal on their own or with modest physical therapy. The damaged portions of the nerves will regrow over time from the neck down at a rate of about 1 inch per month. If your baby’s nerves are healing well, you’ll typically see the elbow start to bend within about 3 months. Movement of the fingers and wrist are also good signs.
For these minor injuries, you may not have to do anything. Your doctor may recommend a set of gentle exercises to improve the baby’s range of motion in the affected arm. You’ll be able to do these exercises at home. Your doctor may also want to monitor your baby frequently to keep track of the healing process and keep an eye out for any other issues.
About two-thirds of babies with a brachial plexus injury will recover fully with minimal treatment or no treatment at all.
Very severe neuropraxias and other types of nerve injury will not heal on their own and may require surgery. Surgery to repair damaged nerves must be done within a relatively short time-frame after the original injury. Otherwise, the muscles in your baby’s arm will weaken too much and the nerves won’t reattach to them. These surgeries may be performed as early as 3 months after birth for severe injuries.
Surgery is always risky, especially for newborns. Your doctor will perform a range of tests to determine if your baby is a good candidate for surgery. Surgery will not give your baby perfect use of the arm, but can offer some improvement. If the injury is less severe, you and your doctor may decide to wait for a few months to see how much the injury improves on its own. More severe injuries may require earlier surgical treatment.
Because baby’s can’t talk about their symptoms and don’t have the coordination to perform tests of nerve and muscle function, the surgeon may not be able to judge what type of surgery will be needed or even what type of damage your baby has suffered until she can actually look at the nerves. Your surgeon will give you her best guess as to what to expect, but the plan may change depending on the type of damage she finds and what will be required to fix it.
The type of surgery needed to repair a brachial plexus injury depends on the type of damage your baby’s nerves have sustained.
Neuroma refers to a buildup of scar tissue on a nerve that compresses and damages the nerve. Surgery to repair a neuroma depends on the severity of the damage. A “neurolysis” procedure may be required to remove the scar tissue surrounding a nerve, relieving the pressure on the nerve and allowing it to heal on its own. If the neuroma is larger and more severe, a “neuroma excision” may be required. A neuroma excision is a procedure in which the surgeon removes the section of the nerve surrounded by scar tissue. The undamaged nerves on either side of the section that was removed may be long enough to connect directly. Otherwise, the surgeon will use a nerve graft to bridge the gap between the two ends.
A “nerve graft” is a procedure in which the surgeon takes healthy nerves from somewhere else in the body and uses them to fill in the gap between damaged nerves. The grafts provide a guide that shows the damaged nerves where to grow as they heal. In infants, the nerves used in the graft are typically taken from the baby’s calf or heel. A small part of the calf or heel may lose some sensation, but should have full movement.
Rupture and Avulsion
Rupture refers to the tearing of a nerve somewhere along its length. Avulsion refers to the tearing of the nerve from its connection to the spinal cord. These are very serious injuries and can have a major impact on the function of your child’s arm. Ruptures and avulsions may require nerve grafts to reconnect the nerve where it has torn. If the damage is very severe, your surgeon may need to use donor nerves in place of or in addition to nerves taken from your baby’s leg.
In some cases, brachial plexus injuries may be treated with a “nerve transfer.” Where a nerve graft simply acts as a path along which the damaged nerves can regrow, a nerve transfer actually replaces the damaged nerves. Your surgeon will take an undamaged nerve from a nearby part of the body and connect it to the muscles that were served by the damaged nerve. This can restore some sensation and movement to the affected muscles. The muscles that were originally controlled by the undamaged nerve will lose function, but other nearby muscles will typically take up the slack to make up for that loss.
Brachial plexus injuries may not heal evenly, causing imbalance and weakness as certain muscle groups recover better than others. If that imbalance is severe, your child may need a muscle transfer procedure. In a muscle transfer procedure, your surgeon will move stronger muscles and tendons into place to support weaker ones.
Your baby may benefit from physical therapy to improve flexibility and range of motion in the affected arm. Physical therapy is particularly important if your child has had surgical treatment for a brachial plexus injury. Physical therapy can improve blood flow and muscle tone to promote healing and avoid side effects such as muscle cramps and joint stiffness.
Brachial plexus injuries may cause one group of muscles to be too weak to fully exercise a joint. For example, your child may not be able to fully straighten the elbow. If you don’t use the full range of motion in your joints, you start to lose it. If your child can’t fully exercise a joint, your doctor may recommend the use of a splint to hold the arm in the proper position. The splints will be periodically upgraded as your child grows and develops. Splints may be used in conjunction with physical therapy and after surgery.
Some brachial plexus injuries may cause a group of muscles to tense up and pull a joint into the wrong position. If this tension is very strong, your child may need an injection of botulinum toxim (Botox) to relax those tense muscles and allow the joint to return to its natural position. With Botox relaxing the very tense muscles, your child will be able to exercise and strengthen weaker muscles and use the full range of motion of the affected joints.
As mentioned above, about two-thirds of children with brachial plexus injuries will recover completely with little to no treatment. These cases typically clear up within a year or two and won’t require any followup.
If your child needed surgery to repair a brachial plexus injury, recovery may take longer. Most of the healing and recovery will still happen within the first year, but improvement will continue for several years. Your child will likely need regular physical therapy for a couple of years to ensure that the arm is developing properly. The arm affected by the brachial plexus injury may not develop like the unaffected arm – it may be smaller, shorter, and weaker. Regular physical therapy can improve the functionality of the affected arm, but children with injuries severe enough to require surgery typically do not regain full function.