Brachial Plexus Palsy

The team will assess your child’s injury carefully and design a treatment plan that’s right for your child. We will work with you and your child from the time of their injury until your child is an adult. If your newborn is critically ill due to brachial plexus injury, we will provide specialized care in our Neuro NICU – the only neonatal neurocritical care program in Washington, Wyoming, Alaska, Montana and Idaho.

Many of our pediatric orthopedic surgeons have expanded fellowship training in areas such as foot and ankle conditions, sports medicine, tumors, upper extremity surgery, limb deformity, neuromuscular diseases, skeletal dysplasia and spine problems. To restore or improve your child’s health, function and quality of life, we often use nonsurgical methods (like medicines, physical therapy and braces), recommending surgery only when we believe it will give your child the best results.

Our radiologists have special expertise using ultrasound to look for bone and joint changes so we can work with your child to help prevent future problems. We emphasize nonsurgical treatments, including unique splinting options. Seattle Children’s is the only hospital in Washington state to offer these new options, which may reduce the need for surgery in some children. Most children don’t require surgery. For those who do, splinting and therapy combined with surgery have better results than surgery alone.

Your doctor may do imaging studies to decide the right treatment at the right time.

• Ultrasound shows us how your child’s shoulder is developing. We use ultrasound at regular intervals, starting when babies are as young as 3 months. If we see problems with the shoulder joint, we can start splinting early to help hold the joint in the right position.
• In some cases, your doctor may order MRI (magnetic resonance imaging). This can show if a nerve is detached near the spine.

Sometimes, the doctor may also order nerve tests that can help to assess your child’s nerves.

Physical therapists and occupational therapists can help children with a brachial plexus palsy in many ways. Therapists help children:

• Stretch to prevent joint stiffness
• Use their arm and hand actively
• Develop motor skills
• Learn ways to move so they can do as much as possible on their own

Therapists can also teach family members how to provide stretching and encourage a child to use their affected arm and hand at home. The therapists on your child’s brachial plexus team at Seattle Children’s will work with therapists in your community to help your child get the right type of ongoing care.

With brachial plexus palsy, some joints of the arm can be tight. Sometimes a child is at risk for losing joint flexibility because the muscles are weak and not moving the joints through their full range of motion. In these cases, children benefit from a splint or cast that holds the shoulder or arm in the proper position. This keeps the joint more flexible.

Seattle Children’s is the only hospital in Washington state to offer these new splinting options. For many children, splinting combined with surgery results in better, lasting flexibility than surgery alone.

If our team decides this will help your child, we will make a custom brace. Depending on your child’s needs, we may use a molded plastic splint that can be taken on and off or a cast that your child wears for a set time.

We will teach you stretching and strengthening exercises to do at home with your child. We also work with therapists in your community so your child gets the right care closer to home.

We may use splinting to position the shoulder, forearm, elbow, wrist or hand. We readjust the brace as your child grows and their muscles develop. We start working with children as young as 1 month and follow them over time. How long your child may need to wear the brace depends on their injury and how their nerves and muscles are recovering.

Some children may also need injections of a medicine to weaken muscles that are too strong and are pulling a joint into the wrong position. The medicine is botulinum toxin (often called Botox). It will temporarily weaken the strong muscles so they can be stretched to improve the joint’s range of motion. This can allow your child to work on strengthening their weaker muscles.

Four types of surgery are available to help treat brachial plexus palsy, depending on the severity of your child’s condition.

• Nerve graft. This treatment removes a part of the brachial plexus and replaces it with some of the nerves from your child’s leg. This is called a nerve graft. Doing a nerve graft leaves a small area of the leg — usually, the back of your child’s heel — without feeling, but it does not affect movement. This does not usually cause any problems.
• Nerve transfer. Another treatment is to use parts of working nerves from other parts of the body to replace some of the damaged nerves. This is called a nerve transfer. Doing a nerve transfer takes away movement from some muscles. Usually, other muscles can work to make up for this.
• Muscle transfer. Some children may have weakness or imbalance that does not go away because a group of muscles recovered better than another. We may recommend a procedure that moves 1 muscle to do the work of another muscle. This is called muscle transfer or tendon transfer (because the tendon is part of a muscle). We also may do this to balance muscles that pull in opposite ways. It may be done along with a procedure to loosen a joint that has gotten tight.
• Osteotomy. Sometimes the bone grows abnormally because of chronic weakness or imbalance. We will sometimes recommend reshaping or repositioning the bone to improve how your child’s arm works. This is called osteotomy.

Your child’s brachial plexus team will begin surgery with a plan about whether a nerve graft or a nerve transfer will likely be best for your child. At the time of surgery, they will be able to look more closely at the nerves to make sure this is the right plan. Sometimes, they will find that they need to do both a nerve graft and a nerve transfer. No matter what, they will do the surgery that they think is most likely to help your child regain use of their arm.

After surgery, most children stay in the hospital for 2 to 3 days. Before your child goes home, you will get details about what to expect and how to take care of your child as they recover from surgery.

We will do everything we can to help your child get the most use from their arm. Most children have at least some weakness.

As children with brachial plexus palsy get older, they may have differences in the ways their arms develop. Their affected arm may be smaller or shorter, or movement of certain muscles may be limited. This can happen if their nerves do not recover fully and they do not use their affected arm the same way as their other arm. Physical and occupational therapy can help as your child grows by stretching their affected arm and hand, teaching normal movement patterns and teaching them to make changes if they need to.

Some children may also need surgery on their bones, muscles or tendons later on to improve their arm so they can use it better. Surgeons on our brachial plexus team provide this type of surgery too.