Brachial Plexus and Limb Paralysis Clinic Overview

How is the Brachial Plexus injured?

• Birth-related:
  • Brachial plexus birth palsy (BPBP) affects approximately 1 in 1,000 live births. The cause of injury is a stretch or tear of nerves that make up the brachial plexus during childbirth. The amount of force, the position of the arm, and position of the neck determine the pattern and severity of the injury. Most commonly, the shoulder and elbow are affected although a complete paralysis of the arm is possible.
  • Risk factors for BPBP include large gestational age infants, infants of mothers with diabetes, twin births, prolonged labor, difficult labor, or assisted (vacuum or forceps) delivery. Other injuries can occur with BPBP and include fractures in the arm, shoulder, or ribs.
  • The majority of newborns recover function without requiring surgical intervention though some injuries are more severe and require occupational therapy, surgery, or a combination of interventions.  

• Traumatic:
  • Children and adults can suffer high-energy trauma that results in direct impact or traction to the nerves of the brachial plexus. This affects approximately 2 per 100,000 patients each year. Often times, this can be the result of a motor vehicle collision, motorcycle crash, or fall from height. Many different patterns of injury can result and the level of dysfunction is variable for each patient.
  • Brachial plexus palsies can be associated with other injuries such as fractures of the arm, shoulder, and ribs, or head and chest trauma. Several patients also experience posttraumatic stress disorder (PTSD) and depression as a result of the trauma.  

Diagnostic options available:

• The clinical exam and medical history are critical to making the correct diagnosis for each patient. In addition to having a surgical team with specialty training in hand surgery, nerve reconstruction, tendon transfers, and shoulder reconstruction, our clinic also involves multiple additional providers who assist in diagnosing and managing these devastating injuries. Several tests may be performed at our clinic during your visit. 
• Electromyography and Nerve Conduction Studies
  • We are able to provide in-office, real-time testing of the nerve function in our new and established patients. These tests directly assess the function of nerves and muscles and can be extremely helpful in diagnosing the injury, monitoring recovery, and determining the best treatment plan. Direct communication between the surgical team and the physicians performing the test improves its accuracy.

• X-rays 
  • X-rays are helpful to look for fractures around the area of the brachial plexus, to see if any deformity is present, or to evaluate the chest. We can perform this in the clinic at the time of patient evaluation.  

• Magnetic resonance imaging (MRI) 
  • MRI is a helpful tool to evaluate patients with brachial plexus injuries. In infants with brachial plexus birth palsy or adults, it can help us evaluate the integrity of nerves as the roots come off of the spinal cord. It can also assess for any associated injury to the soft tissues such as tendon or ligament injuries. We also work closely with our radiology team to offer magnetic resonance neurography – a technique specifically evaluating nerves of the extremity.

Treatment options available:

• Treatment for brachial plexus injuries range from therapy and observation to surgical reconstruction. Our treatment plans are individualized for you.  
• Nonoperative
  • The typical non-operative treatment involves occupational and physical therapy to maintain range of motion, re-train nerves, and strengthen muscles. Common therapy treatments include stretching, splinting, bracing, soft tissue techniques and neuromuscular re-education. Our therapy team is present in the clinic at the time of patient evaluation and have their own facility on site. For patients who live further away, our therapists can help facilitate and direct care for them closer to home as well as assist with home exercise programs.   

• Surgical 
  • There is a wide array of surgical options to treat brachial plexus and peripheral nerve injuries. Options include: 
    • Neurolysis – surgery to remove surrounding scar tissue from nerves and enable them to recover function.  
    • Nerve repair and nerve grafting– When nerves have been cut or torn apart, they must be repaired to regain function. On other cases a gap may exist between the ends of the nerve and direct repair is not possible. In these cases, a nerve graft is needed to span the gap. Either an allograft (processed cadaver nerve tissue) or autograft (nerves taken from your own body that can be sacrificed without significant loss of sensation or function) can be used in these cases.  
    • Nerve transfer –If a nerve function is injured or lost, healthy nerves from nearby muscles or muscles with redundant function can be moved to the nonworking nerves or muscles to provide function. This can be thought of like splicing wires to re-route electricity to the desired location.  
    • Tendon and muscle transfer – In some cases, nerve reconstruction is not possible. In these cases, functioning muscles can be transferred to reproduce the lost function. A free functioning muscle transfer refers to a specific type of distant muscle transfer that brings donor blood vessels and nerves with the muscle to re-animate the function of interest.  
    • Osteotomy – Bones that have developed deformity as a result of an injury at birth or from abnormal healing from a fracture (malunion) can be realigned to improve the position and function of the limb.   
    • Arthrodesis (joint fusion) – Joints that are either painful or are not candidates for any of the other described procedures may benefit from a joint fusion that will remove the motion in the joint and allow for improvement in pain and appropriate positioning of the limb.