Brachial Plexus Birth Injuries

Is your child suffering from a brachial plexus birth injury such as Erb’s palsy or a global palsy?

You may never have heard of brachial plexus birth injuries, but they are not uncommon; one to three out of each 1,000 babies born suffers some kind of brachial plexus birth palsy (BPBP). The group of injuries known as BPBP can affect shoulder, arm, wrist and hand function and movement, and can also cause a lack of sensation to the affected limb or area. The damage done by BPBP can have lifelong effects.

The brachial plexus is the name for a group of nerves that allows the shoulder, arm, wrist, and hand to communicate with the spinal cord. As such, any damage to the brachial plexus network can impact the function of the muscles, making it difficult to lift and bend the arm or to straighten and lower it. The amount of impairment depends on the type and location of the damage done to the brachial plexus.

Brachial Plexus Injury Types and Conditions

From the least severe to the most severe, the possible nerve trauma types are:

Neuropraxia, where the nerve is damaged because it is stretched.
Neuroma, where the nerve injury causes scar tissue to form, disturbing the electrical signal that runs from the nerve to the muscles.
Rupture, where the nerve tears, but not at the point where it attaches to the spinal cord.
Avulsion, where the nerve is ripped from the spinal cord at the attachment point.

Once part of the brachial plexus is damaged, certain conditions can occur:

Erb’s palsy. The upper brachial plexus nerves are damaged, resulting in shoulder and arm movement difficulties.
Klumpke’s palsy. The lower brachial plexus nerves are damaged, resulting in problems moving the wrist and hand.
Global palsy. Both the upper and lower nerves sustain trauma, often resulting in no movement of the shoulder, arm, or hand. A lack of sensation in the arm can also occur.

Signs, Symptoms, and Diagnosis

Because the intensity of the nerve injury can run from mild to severe, and the location of problems can differ because of the specific nerve or nerves involved, symptoms can vary widely. A common sign of Erb’s palsy is a stiff arm that turns inward, with a bent wrist and extended fingers. Serious damage can mean a limp or completely paralyzed arm. With Klumpke’s palsy, the arm may position itself differently, and the fingers and hand may be able to operate even when the arm’s movement is limited.

Symptoms are often noticed at birth, or soon thereafter:

The infant has no movement in an upper or lower arm, or in a hand.
An arm is bent at the elbow and is pressed against the body.
The hand on the injured side has a decreased ability to grip.
The Moro reflex, an involuntary response to stimulation present at birth, is absent.

When symptoms are present, diagnosis usually involves a physical examination, testing the Moro reflex, and X-rays of the injured area. Often special tests are ordered. These can include an electromyogram (EMG), which measures muscle problems due to the nerve injury, and a nerve conduction study (NCS), which determines the distance that electrical signals are traveling along the nerves.

Treatment of Brachial Plexus Birth Injuries

Mild cases, such as neuropraxia, can sometimes be treated with gentle physical therapy, stretching, and massage. More severe cases, such as an avulsion, usually require surgery. However, even with a case that appears mild at first, if range of motion and muscle strength and function do not recur within the first three to six months, other treatments may be indicated. Surgery can be needed if nerve damage either does not heal or if it is extensive.

Further treatments that can assist in recovery are ongoing physical rehabilitation and the use of aids such as braces and splints. If a lifetime of specialized treatment and care is needed, costs can climb to $1 million for BPBP.

Causes of Brachial Plexus Damage

A number of things can go wrong during any baby’s delivery. One of the most common reasons for infant brachial plexus damage is excessive stretching and force used on the part of the doctor or other medical personnel. The excessive force is often caused by the use of forceps or vacuum extraction.

Additional birth situations that can make brachial plexus injuries more likely include:

A breech (feet first) delivery
Unusually large infant size and weight (known as fetal macrosomia)
The infant’s shoulders become stuck in the mother’s pelvic region, although the head may be delivered (infant shoulder dystocia)
Underdeveloped infant neck muscles
Diabetes in the mother
Maternal obesity.

Infant shoulder dystocia can cause injury to the brachial plexus nerves because the doctor might use too much force in an effort to deliver the baby before complications can set in. This circumstance can happen even if no artificial means to assist birth (like vacuum extraction) is used. Infant shoulder dystocia is a common cause of BPBP.

Sometimes a Caesarean section (C-section) is needed to deliver an unusually large baby or to prevent harm to the infant. If it can be shown that the doctor should have performed a C-section but didn’t, and a brachial plexus injury occurred, it could be argued that the child suffered trauma due to malpractice.