TN 4 (09-05)
DI 24580.030 Information about Brachial Plexus Injuries (BPI)
Most of the following information on brachial plexus injuries (BPI) was originally prepared in collaboration with the United Brachial Plexus Network (UBPN), and presented in a Factsheet that was distributed in an administrative message. This information pertains primarily to infant birth injuries, however, much of it is also relevant to adults and older children who sustain BPI injuries. For more detailed information about BPI, and the latest developments in this specialized field of medicine, visit the UBPN website at www.ubpn.org and the National Institute of Neurological Disorders and Stroke’s BPI page at http://www.ninds.nih.gov/disorders/brachial_plexus/brachial_plexus.htm.
B. Information about Brachial Plexus Injuries (BPI)
The brachial plexus is a network of nervous tissue that organizes sensory and motor messages going to the upper body trunk and extremities from the central nervous system. It is composed of nerve fibers from the last four cervical and first thoracic spinal nerves. Fibers of the various spinal nerves are combined within the plexus to form the multiple peripheral nerves that innervate the upper chest wall, the diaphragm, the shoulder, and the arm and hand. Injury to the brachial plexus can result in complete or partial sensory and/or motor impairment. Bilateral injuries can occur.
2. Causes of Brachial Plexus Injuries (BPIs)
Injuries can occur at any age, but most often occur during the birth of large infants, when traction is applied to the infant’s head during delivery. Stretching without the tearing of nerve fibers may result in a temporary loss of motor and/or sensory function (neurapraxia). When nerve fibers are torn, or avulsed (usually at the site of exit from the spinal canal), permanent motor and sensory loss may result. Sometimes torn nerve root fibers will begin to grow in an abnormal pattern and produce a benign tumor (neuroma). A neuroma can be painful and may block the proper reconnection of nerve root fibers.
Brachial plexus injuries can also occur during motor vehicle accidents, sport mishaps, and falls. On occasion, penetrating injuries to the brachial plexus occur during acts of violence. The extent of the initial functional loss depends on both the number of nerve fibers injured and the severity of the injury to the fibers.
3. Most Common Types of BPIs
Injuries to the upper brachial plexus affect the shoulder and upper arm (Erb’s palsy) and spare the hand. These injuries are the most common and have the best prognosis because most of these injuries are related to nerve fiber stretching (neurapraxis) rather than tearing (avulsion or rupture).
Injuries to the lower brachial plexus affect the forearm and hand (Klumpke’s Palsy). These injuries have a worse prognosis.
Extensive injuries that involve the entire plexus result in anesthesia and total paralysis of the hand, arm, shoulder and the diaphragm and chest wall musculature on the side of the injury. Such injuries have the poorest prognosis.
Most of the recovery from a BPI occurs during the first three months post injury. BPI may occur in combination with other injuries or impairments. Other medical terms that might be found in medical reports describing BPI include: Erb’s Palsy (upper plexus injury), Klumpke’s Palsy (lower plexus injury), Brachial Plexus Palsy (BPP), Erb-Duchenne Palsy, Horner’s Syndrome (when sympathetic fibers are affected), and “Burners” or “Stingers” (usually associated with sports-related injuries).
4. Occurrence Rate of BPI
Generally, it is believed there are about 2-3 newborns with BPI per 1,000 births, but due to the limitations of the current reporting systems designed to monitor injuries, such as BPI, it is only possible to give “ballpark” figures. Changes in obstetrical practice toward the more rigorous use of Caesarean Section delivery have been directed toward reducing the incidence of BPI.
5. Treatment Options
The evaluation and treatment of BPI varies with the cause of the injury. When spontaneous recovery is not noted within the first few weeks following an injury sustained during delivery, it is essential that a medical professional who specializes in treating BPI be consulted. When spontaneous improvement does not result during the first three months post injury, significant functional recovery usually is not expected despite aggressive physical therapy and surgery. Early treatment most likely will include occupational and/or physical therapy to help maximize use of the affected arm while preventing contractures. If there is no evidence of improvement in function by the age of 4-6 months, further evaluation to address the potential for a surgical repair may be indicated. The clinical recovery noted following the initial surgery determines the need for other surgical procedures. The evaluation and treatment of other types of traumatic BPI usually proceed at a more rapid pace because such injuries are more commonly associated with the severance of nerve fibers. Maximizing functional use of the injured area is generally the overall goal of affected individuals, families and medical professionals.
Like any medically determinable impairment, BPI can be disabling if it is sufficiently severe. Because BPI usually affects only one upper extremity, the condition ordinarily does not fulfill SSA’s disability severity requirements. Children with particularly severe BPI injuries (e.g., bilateral BPI), or BPI together with another impairment(s), can be found disabled. Some children with BPI will have various limitations in their ability to: put on or remove shirts/jackets, socks, shoes, tie a shoe, maneuver a zipper or button, pull their pants up/down, hold a piece of paper down so they can write, wear winter gloves (they fall off due to no hand movement), potty train, use bathroom facilities without assistance, wash hair, clasp bra, sharpen pencils, participate in two-handed activities in school and in physical education class, buckle or unbuckle seat belts that require two hands, floss teeth, cut fingernails, apply deodorant, style hair, open milk containers, boxes or jars, cut meat, squeeze toothpaste onto a toothbrush, carry anything requiring two hands, or scratch the side of the body.
2. BPI and Pain
Brachial plexus injuries may result in a chronic pain syndrome despite the fact that there is reduced sensation in the affected area. Pain is less commonly associated with birth injuries. Areas with diminished sensation are at risk for further injury, such as burns and/or pressure sores.
First and foremost, as with any childhood impairment, it is critical to have complete medical records that show not only medical findings but also describe the child’s development and functioning. In addition to their local treating source, children may have medical or surgical evaluations, occupational therapy or surgical procedures in facilities outside their home state.
It is also important to obtain information from medical sources AND family members about the child’s progress in achieving milestones. This is especially important in evaluating any child who is under age 3. The degree of success in achieving developmental milestones, together with the effects of BPI, may be critical in evaluating the functional effects on any child. If the evidence of record does not give this information, contact the child’s treating physician and family members to obtain it.
If medical and other evidence indicate there may be other injuries or problems, obtain information about any other impairment and its effects on functioning. It is imperative to consider the combined effect of all impairments when assessing functional limitations. Also, if other impairments are involved, remember to consider additional appropriate listings. As always, if evidence of record does not provide sufficient information to assess severity, consider a consultative examination.
4. Listings Most Likely to Apply
For a bilateral BPI, listings 111.08, spinal cord disorders and 111.14, peripheral neuropathy must involve two extremities and can be considered, these listings are not applicable to unilateral BPIs. Because this listing states that the dysfunction must involve two extremities, 111.06 is not applicable to unilateral BPIs.
Listing 101.08, Soft tissue injuries of an upper or lower extremity could also be considered. Surgery may be needed in BPI, and the child may undergo multiple procedures and other associated treatments related to restoration of functional use of the extremity. The usual circumstance is that a procedure is done and function is reassessed at the appropriate time. If return of function is still not considered adequate, another procedure is considered. For injuries sustained at birth, nerve surgery is most effective when done between ages 5 and 12 months, and is usually not as successful after 1 year of age. When nerve surgery is not successful, then muscle transplant surgery may help restore some function.
Also, if other impairments are involved, consideration must be given to additional appropriate listings. As in all childhood cases, the total impact of any one impairment or a combination of impairments on the child’s ability to function in all age-appropriate areas must be considered.
5. If the Impairment Does Not Meet or Medically Equal a Listing
As in all childhood cases, when a child’s BPI is severe but does not meet or medically equal a listing, consideration must be given to whether the impairment-related functional limitations are disabling. When we evaluate the functional effects of an impairment, using the functional equivalence domains, we look at activities that are pertinent to the child’s age. We also consider how a child’s limitations in any one domain affect his or her development or functioning in other domains. Marked limitations in any two of the domains, or extreme limitation in one, mean the impairment functionally equals the listings. As in all childhood cases, each child may be affected differently by any given impairment.