Brachial Plexus Treatment

Brachial Plexus injuries can occur during the delivery of new-borns, when after the delivery of the head, the anterior shoulder of the infant cannot pass below the pubic symphysis without manipulation. This manipulation can cause the baby's shoulder to stretch, which can damage the brachial plexus to varying degrees. Such injuries are more common with large babies (high birth-weight) with shoulder dystocia. The incidence of OBPP in the United States is 1.5 per 1000 births, while it is lower in the United Kingdom and the Republic of Ireland (0.42 per 1000 births).

It is, however, established that direct pressure applied by the obstetrician with his fingers or through the forceps are not responsible for these injuries.

1) C56 PALSIES: These result in loss of shoulder function and of active elbow flexion. Thus, the limb lies by the side of the patient with the elbow extended, the forearm pronated and the fingers and wrist in flexion (the classical “policeman’s” or “waiter’s tip” attitude). The retained pectoralis major and subscapularis muscles hold the shoulder in internal rotation. This is the classical ERB’S PALSY (named after the ERB who determined the muscles innervated by the upper trunk by stimulating the confluence of the C5 and C6 roots in the neck). This condition is inevitably associated with absent deep reflexes.

 2) C5T1 PALSIES: This is the next most common pattern where all the roots are affected. The C8T1 roots are the sites of major damage and are often avulsed. Presence of a Horner’s syndrome (miosis, ptosis, enophthalmos) points towards an avulsion of the T1 root. The limb lies totally flail by the side of the baby

There is no need for application of splints. Vigorous mobilization of the limb must be avoided for the first three weeks. The clinical status must be reviewed weekly. After three weeks, gentle mobilization of the shoulder, elbow, wrist and fingers is started in order to avoid contractures. Proper hygiene for the axillary folds, palm and inter-digital clefts is essential.

Recovery in the fingers is often noted very early (2nd to 7th days). However, this usually indicates that the C78T1 roots were not affected. It is important to observe for recovery in the deltoid and biceps muscles.

Less severe injuries of the C56 roots are usually associated with return of shoulder and elbow functions by the second month. External rotation of the shoulder and supination of the forearm are the last to recover. Hence, passive mobilization to maintain these movements is essential.

These are evident at birth in the presence of a totally flail limb with Horner’s syndrome. These signs generally denote affection of all five roots with avulsions of the lower roots. The prognosis for spontaneous return of normal function is nil. Surgical reconstruction offers the only chance of restoration of some useful function in the shoulder, elbow and hand. One must counsel the parents about the gravity of the injury and stress the need for early surgery (by three months of age).

Even patients with C56 or C567 injuries can sustain ruptures of the roots or root avulsions. These are inevitably associated with a slower spontaneous return of proximal muscle function. As mentioned above, the hand starts moving early and is NOT indicative of a better prognosis. If the deltoid (shoulder abduction) does not return by two months and the biceps (elbow flexion) by three months, surgery is necessary to restore proper continuity between the proximal and distal nerve stumps using nerve grafts in order to improve the quality of the eventual function.

This is usually performed at 3-4 months of age. Absence of biceps recovery is the single most important sign indicating the need for surgery. This is usually a clinical decision.

After the first three weeks, nerve recovery occurs at the rate of around 1 mm/day or an inch per month. Hence, shoulder recovery is observed at three months and biceps shortly after that. Recovery continues to occur till six-eight years after surgery. Sensation and motor control in the hand improves steadily over this period.

The nerve surgery at proper time improves the upper limb function and prevent co contraction of muscles.

C5T1 palsies carry a poor prognosis and the affected limb remains smaller and less useful. Nerve surgery improves the shoulder and eventual hand function.

Even after nerve reconstruction surgery, secondary procedures may be necessary at 3 and 6-7 years of age to improve the utility of the restored functions.

Unfortunately, the need for early surgery in birth related brachial plexus palsies is not widely known. Hence, babies who required nerve reconstruction get neglected. Lack of recovery in certain muscles such as external rotators of the shoulder results in contractures in internal rotation and, subsequently, bony deformities affecting the humeral head and the acromion. The child is unable to bring its hand to its mouth and lifts the shoulder in abduction during this movement. This is characteristically termed the “TRUMPET SIGN”. In addition, supination contractures of the forearm are common.

Shoulder deformities require soft-tissue corrective surgery at three years. Further delay leads to bony deformation, which may warrant osteotomies for improvement of the position and function of the limb. Similarly, surgery is required to release the supination contractures and the biceps tendon has to be re-routed to improve pronation.

In the absence of early nerve surgery, spontaneous nerve re-growth often results in co-contractions i.e. simultaneous contractions of opposing groups of muscles such as the biceps, triceps, deltoid and pectoralis major. This interferes with the use of the limb and is disabling. Disconnection of the musculocutaneous nerve (to the biceps) and nerve transfer using the intercostal nerves has been proposed by certain surgeons in Japan. Muscle transfers are also performed to improve the utility.

These nerves can be damaged by stretching, pressure or cutting. Stretching can occur when the head and neck are forced away from the shoulder, such as during a motorcycle fall or car accident. If severe enough, the nerves can tear out of the spinal cord in the neck (root avulsion). Pressure could occur from the crushing of the brachial plexus between the collarbone and first rib, which can happen during a fracture or dislocation. Swelling in this area from excessive bleeding or injured soft tissues can also cause an injury.

Nerve injuries can stop signals to and from the brain, preventing the muscles of the arm and hand from working properly, and causing loss of feeling in the area.

When all roots are affected, there is complete loss of shoulder, elbow and hand function. When two or three roots (C5,6 or C5,6,7) are affected than there is loss of shoulder and elbow function but hand function is preserved.

Very rarely only lower roots (C8, T1) are damaged and patient loses hand function with preservation of shoulder and elbow function.

Many adult injuries will not recover on their own, and early evaluation by physicians who have experience treating these problems is essential. Some injuries can recover spontaneously, when the stretching of the roots is minimal. The time for recovery can be 4-6 weeks. If a patient has persistent motor deficit at 6 weeks, his injury is unlikely to improve. Several surgical techniques can be used to improve the recovery.

To help decide which injuries are likely to recover, we will rely upon multiple examinations of the arm and hand to check the strength of muscles and presence of feeling in different areas. Additional testing, such as an MRI scan or CT scan/myelography, may be used. A Nerve Conduction Study/Electromyogram (NCS/EMG), a test that measures the electrical activity transmitted by nerves and muscles, may also be performed but not much useful in decision making about the surgery.

Open and penetrating injuries should be operated immediately.

We usually operate the close injuries between 6 weeks to 3 months. We can operate the cases up to 6 months and still expect good results.

When patient presents after 6 months, we can offer only salvage procedures like free functioning muscle transfer, tendon transfer or arthrodesis with limited improvement.

The patient must do several things to keep up muscle activity and prevent the joints from getting stiff. We recommend therapy to keep these joints flexible. If the joints become stiff, they will not move even after muscles begin to work again, like a hinge that has rusted.

When a sensory nerve has been injured, the patient must be extra careful not to burn or cut fingers while there is no feeling in the affected area. During nerve recovery, the brain may not interpret the new nerve signals properly, and a procedure called sensory re-education may be needed to optimize muscle control and feeling in the hand or fingers. We recommend the appropriate therapy based on the nature of your injury and type of surgery.

You may start seeing the results of surgery after 6 months and they improve up to 2 years. You need to have regular follow up with us for two years, post-surgery. Sometimes, we may recommend secondary procedures to enhance the recovered functions.

Factors that may affect results after a brachial plexus injury include patient age and the type, severity and location of the injury, duration between injury and surgery. Though these injuries will result in lasting problems for the patient, care by a Brachial plexus surgeon and proper therapy can maximize function. 

In cases of total palsies, nerve transfers and nerve grafting have produced consistent results in the restoration of the control at the shoulder and elbow. However, the efforts in regaining distal functions in global palsies have not met with similar success.

In cases of partial palsies, we can get good functional results in majority of patients. ( see our videos)