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Brachial Plexopathy

Offering expert diagnosis and treatment of brachial plexus injuries in infants and children.


Under the direction of Edward C. Smith, MD, the Duke Pediatric Brachial Plexopathy Clinic was established to offer multidisciplinary care for children with obstetric brachial plexopathy (OBP). One of our goals is to determine as early as possible which children are not likely to recover adequate function on their own and whether or not surgery is a good option for them. This requires a coordinated approach involving pediatric neurology, neurosurgery, orthopedics and occupational therapy.

What is the brachial plexus?

The brachial plexus is formed by a complex network of nerves that leaves the spinal cord in the neck and provides nerve signals to each arm. When these nerves are injured, the result is weakness in the shoulder, arm or hand on the affected side. There are often problems with sensation (feeling pain or temperature) on the affected side as well.

What causes brachial plexus injuries?

There are many causes of brachial plexus injury (“brachial plexopathy”), including trauma, infection, and cancer. In newborn babies, the most common cause of brachial plexopathy is stretching of the plexus during a difficult delivery. Often, the shoulder on the affected side “gets stuck” during delivery, particularly when the baby is large. This is called “shoulder dystocia.” However, in up to 50% of cases, there is no history of shoulder dystocia.

Brachial plexopathy in a newborn is often referred to as “obstetric brachial plexopathy” (OBP).

Unfortunately, OBP is very common (roughly 1 per 1000 births). This number has not changed significantly over the past 30 years even though the cesarean section rate has increased from 5% to 20% over the same time period. This likely reflects the fact that babies are bigger at birth today than they were several decades ago.

Fortunately, the vast majority of children with OBP make successful recoveries. Full, spontaneous recovery occurs in about 7 out of 10 of children. In the remaining 30%, the children are left with variable degrees of weakness.


Treatments

Treatment options depend on the type and severity of the injury. Mild injuries may heal themselves. More serious injuries will require surgery to repair injured nerves.

There are several therapies available that are used to improve outcome in OBP. Most doctors recommend starting regular physical or occupational therapy as soon as possible in an effort to keep the joints flexible. Therapists work with parents to teach various stretching exercises and devices such as a wrist splint may be prescribed. Depending on the severity of the injury, recovery may be slow, typically taking months, not weeks. If the nerves were simply stretched, the prognosis for recovery is quite good.

If a child is not demonstrating adequate recovery of function, the doctor might order tests to help determine how severe the injury actually is. Magnetic Resonance Imaging (MRI) provides a powerful picture of the spinal cord and nerves of the brachial plexus. It may show evidence that one or more nerves were torn (“avulsed”) from the spinal cord. This is important to know as a torn nerve will not recover on its own and will likely require surgical intervention. Similarly, a test called “electromyography” (EMG) might be done to help the doctor determine whether or not surgery is necessary. As the child grows, the orthopedic surgeon may recommend surgery on bone, tendons or muscle to improve function.

Research. There are many unanswered questions regarding OBP, and our clinic also serves a research purpose. We would like to not only answer which children might benefit from surgery, but how soon should surgery be done? What type of surgery is most effective and carries the least risk? What are the most reliable tools available to help the doctors accurately counsel parents regarding prognosis? Are there effective non-surgical therapies beyond traditional physical or occupational therapy? By following enough children over a long enough period of time we will, hopefully, be able to begin to answer some of these questions more accurately.

If you think your child has arm weakness due to OBP, please feel free to contact us for further information at 919-684-4721.


Physicians and Staff

Physicians

Name Areas of Special Interest
Fraser J. Leversedge, MD Hand, upper-extremity, and microvascular surgery; clinical conditions affecting the upper-extremity distal to the shoulder, including trauma, arthritis, nerve/tendon repair and reconstruction; pediatric/congenital disorders; sports injuries; post-traumatic reconstruction
Jeffrey R. Marcus, MD Craniofacial surgery for children and adults including cleft lip/palate and craniosynostosis; rhinoplasty for cosmetic and/or breathing issues; microsurgical facial reanimation for facial paralysis; microsurgical repair of brachial plexus injuries in infants; broad scope of pediatric plastic surgery including skin conditions, congenital hand surgery, ear reconstruction; assistance to families of internationally adopted children with cleft lip and palate
Edward C. Smith, MD General child neurology with special interest in neuromuscular disorders, brachial plexus injuries, cerebral palsy

Occupational Therapists and Staff

NameRole
Lilie Bonzani Occupational Therapist
Lindsey "Nicki" Tuttle Occupational Therapist
Kimberly Bradsher Administrative Assistant


Clinic Hours and Location

Lenox Baker Children's Hospital
3000 Erwin Road
Durham, NC 27705
Tel: 919-664-6669
Hours: Mondays, 9:00am - 12:00noon


Appointments and Contact Information

The Duke Brachial Plexopathy Clinic is dedicated to providing comprehensive medical and surgical care to infants and children with brachial plexus injuries. Patients will receive diagnostic evaluations, routine follow-up assessments and coordinated, multidisciplinary care.

  • For appointments, please call Kimberly Bradsher at 919-668-4000.
  • For physicians requesting consultations or making referrals, please call the divisional office at 919-668-0477 or the Duke Consultation and Referral Center at 800-MED-DUKE (800-633-3853).