The most complicated set of nerves in your body are the nerves that go from your neck down to your fingers. The nerves, called the "brachial plexus", can be injured at birth when excessive traction (pulling) is applied to the head or neck during the emergency called "shoulder dystocia" (when the baby's shoulder gets stuck under the mother's pelvic bone)

How does one tell that a child has a brachial plexus injury? The child's arm will be fully or partially paralyzed. With certain injuries you may also notice that the eye on the affected side might have a droopy eyelid (Horner's Syndrome).

If this injury happens at birth, it is called an Obstetric Brachial Plexus Injury or OBPI. It is also referred to as Brachial Plexus Palsy, Erb's Palsy and/or Klumpke's Palsy. If it occurs at any other time (other than at birth) it is called a Traumatic Brachial Plexus injury or TPBI. Traumatic injuries occur from sports injuries, motorcycle accidents, gun shot wounds, animals bites, from viral causes or from the arm being positioned poorly during a medical procedure.

Concerning OBPI, there are varying degrees of the injury that range from mild and temporary to very severe and permanent. The degree of injury can be partially determined by what movement and at what age recovery is seen. We have read that if a child's injury resolves in the first one or two months of life, they will consider this a full recovery and usually no other intervention is required. If there is no hand, wrist or finger function by one month, then this is considered to be a very serious injury and early surgical intervention is usually recommended. If there is hand/finger function but no shoulder or elbow, then they will evaluate at around 3-4 months of age and will look for biceps function - the hand-to-mouth movement without any assistance from people, the other hand or gravity. So if your baby can sit in a baby seat and bring his or her hand to the mouth all by themselves, then this is a good sign. Late recovery (3-7 months) is very good but quite often these patients require some sort of muscle/tendon surgical intervention to help with muscle imbalances and contractures.

Types of Injuries

Stretch: This is the type of injury where the nerves are just stretched. There are two types of stretches. One is where just the outer wall is stretched but the inner nerve cells are ok and the next one is where both the outer and the inner portions are stretched (being the more serious of the two).

Rupture: The nerve or nerves have been stretched beyond their limitations and have actually partially or fully torn.

If it is partially torn, when the nerves try to grow back together it ends up forming a ball of scar tissue (called a neuroma). Sometimes nerves actually do grow together inside this ball of scar tissue and sometimes they don't. Surgeons can tell what areas of this neuroma are viable or not with intra-operative EMG test. Surgeons may or may not do a nerve graft in this case - it all depends on how well the nerve has connected inside the neuroma - as found in the results of the EMG test.

If the nerve is fully torn, surgeons will do their best at connecting the sections with one or more nerve grafts.

Avulsions: This is considered to be the most severe injury. The nerve has actually been pulled out of the spinal column "socket". Although the nerve cannot be reconnected at the spinal cord level, some specialists have been successful connecting the avulsed nerves into other intact nerves - see the diagram below..

Timeline For Recovery

Nerves grow at a rate of approximately one inch a month and as the nerve grows down the arm it actually grows at a slower rate. The next item which is of most importance is that if a muscle is not attached to a living nerve (innervated), then it will atrophy to the point of no return (completely die) within 12 to 18 months. This is why the brachial plexus specialists want to evaluate infants early on - they want to make sure that the child gets as much recovery as possible and if surgical intervention is necessary, that it is done within the timeframes.

What To Do About It ?

Decisions about what to do about your child's injury are very personal decisions. One of the problems that we face in this community is that each child is so different. No two children are alike, no two children's injury is alike, no two children recover the same way -- so comparing children may give you false information for your own child. The very best thing you can do is educate yourself as much as possible so that you can make informed decisions. Meet with the top BPI specialists and get their opinions and ask millions of questions. (free or discounted air fare is available) Talk with other families and get the kids together. Then when all is said and done, just trust that you will make the best decision for your child. Whether it be do surgery or not do surgery, have therapy or don't do therapy, do daily electrical stimulation or don't do it - whatever it is - parents know what's right for their own child.

More Helpful Information

It's Not Just An Arm

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