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Brachial Plexus

A Special Clinic for the Management of Birth Brachial Plexus Palsy at Ganga Hospital

Ganga Hospital offers the services of a team of Hand and Microsurgeons, Anaesthesiologists and Physiotherapists having special experience in treating children with Birth Brachial Plexus Palsy (commonly also referred as Erb’s Palsy) for the last 25 years. BBPP or Erb’s Palsy as is commonly called, refers to weakness of the hand seen in children immediately after birth. No doubt it causes a lot of concern amongst the parents, since it is an unexpected event. It occurs once in 1per 1000 live births. This percentage remains almost the same even in developed nations and has remained so for decades showing that it has no relations to the quality of Obstetric care available in the society.

Advances in Hand Surgery and the advent of microsurgery offer so much to these children to make them better. The Department of Plastic, Hand and Microsurgery at Ganga Hospital is one of the leading centres in the South Asian region in this field in terms of volume, quality of work and team work in this field

The Team Leads
Dr S Raja Sabapathy, MS., M Ch, FRCS Ed, DNB, Hon FRCS (Glasgow)FAMS, D SC (Hon)
Dr Hari Venkatramani, MS., M Ch. (Plastic), DNB (Plastic), EDHS (Euro. Board)
Dr Praveen Bhardwaj, MS (Ortho); DNB (Ortho); FNB (Hand & Reconstructive Microsurgery)
Mr Gopinath MPT, Chief Physiotherapist

The children with Brachial Plexus injury have varied needs. It may be from physiotherapy, to complex microneural and microvascular procedures to bone work. The team at Ganga Hospital has the capability to do the full spectrum

Fig. 1- A child with brachial plexus injury requires a team of experts for his/her optimal management and life changing recovery

What is Brachial Plexus?
Brachial Plexus is a network of nerves carrying electrical signals from the brain to the hand. This is found in the lower part of the neck. Brachial Plexus is like a network of cables through which signals form the brain pass to provide movement and sensation to the hand.

Why does a brachial plexus injury occur during birth process?
During the birth process, the nerves which form the brachial plexus may suffer from excessive stretch causing injury to the nerves. This may be due to many causes like the birth canal being narrower for the size of the baby or to a condition called shoulder dystocia. This means that there is difficulty in the shoulder coming out after the delivery of the head. In the process of the delivery of the shoulder which has to be completed quickly the nerves in the neck may suffer from stretch injury.

What happens when the brachial plexus is injured?
Injury to the Brachial plexus will cause variable amount of paralysis of the muscles in the hand. This may either be only slight weakness or complete paralysis. It can be total or partial with fingers working but inability of baby to bend the elbow and lift the shoulder. Around 25% need surgical assistance for improvement.

What are the different types of injuries?
Doctors will refer to two types of injuries. One is called Rupture and the other is called Avulsion. Rupture means the nerve is injured after it has come out from spinal cord beyond the bony vertebral column. Whereas Avulsion means nerve cables have been pulled out of the spinal cord. The implication is that in case of rupture, the injured nerve can be joined back but when there is avulsion, the injured nerve can not be joined back to the spinal cord. Recovery and surgical options are better with rupture. Even in children with avulsion injury, some function can be still restored by joining some working adjacent nerve to the injured nerve.

Why do deformities occur in Birth Brachial Plexus Palsy children?
Bones of babies grow at a rapid rate. Normally, growing bones and joints have even pull due to different muscles from all sides. In case of brachial plexus injury, some muscles are paralyzed and some may be working. So, there is an uneven pull on the growing bones and joints leading to deformities.

We just had the baby. The doctor told us that our child has brachial plexus injury. What should we do?
First thing please do not panic. Most babies born with brachial plexus injuries recover naturally. After childbirth when you are fit to travel comfortably, please get the baby seen by doctors who specialize in treating brachial plexus injuries in children.

If you would like to meet us at Coimbatore, please send an e- mail to rajahand@gmail.com stating the date of birth of the child, the place you are from and we will get back to you. You can also consult us through telemedicine and we recommend you to call 9894555669. The telemedicine department will get back to you and fix a mutually convenient time. If you have any specific language preferences, please do inform. We will also try have a doctor who can speak that particular language.


It is good enough to see the doctor by about 6 weeks. The doctor would examine the child and record the recovery and will explain to you the physiotherapy and the pattern of recovery expected which may differ from child to child.

Do Birth Brachial Plexus Palsy children need early surgery?
Early surgery, between 6 and 12 months is done for children with severe involvement. If there is no movement at all in the fingers, at the wrist and the elbow even by 6 months we will think of surgery on the nerves in the neck.

My child is unable to bend the elbow joint. What are the options available?
Treatment depends on the age of baby. We can wait up to 6 months to see if recovery occurs. If there is no recovery, then you must see the specialist. The doctor will decide the course of action between surgery / waiting / giving Botox injection to certain muscles.

What is Botox and how will it help?
Botox is a medicine which causes temporary weakness of muscles. It has been commonly used in patients with spasticity and in cosmetic surgery. It is also useful for some children with birth brachial plexus injuries. In babies with partial recovery from injury there can be imbalance between muscles and it may cause some deformities or may restrict some movements. Botox can be used to correct this imbalance and improve the movements. In some children the effects could produce lasting improvement

Do I need to get admitted for Botox injections and if so how long?
Yes, usually the baby is admitted for Botox injection but more as a precautionary measure. Usually baby can go home in 1 day. After the injection we give a splint to the child, which is comfortable

Do surgeons operate directly on the brachial plexus and what is done?
If at 6 months baby does not recover as much movement as doctors want, then there is severe injury to the brachial plexus nerves. Doctors approach the brachial plexus through the neck, to visualize the status of the nerves. If the nerves are found damaged and the ends are available an attempt is made to repair them. The injured nerves will have a gap between the two damaged ends. The surgeon may take a nerve from the leg to bridge the gap (Fig. 2). The leg will have no functional consequences as this is a dispensable nerve (sural nerve) and children can normally run and play like any other child after the nerve is removed (Fig. 3). Sometimes good nerves may not be available at all. In that case doctors set up cross connections with nearby working nerves to get movement in shoulder and elbow. This operation is called nerve transfer (Fig. 4)
Advances in anaesthesia has made operation safe for children.

Fig. 2- Nerve grafting: The procedure involves removal of the injured nerve segments and reconstructing the gap with sural nerve grafts/ cables taken from the leg

Fig. 3- A child who underwent nerve grafting at age of 8 months. He achieved excellent improvement of the shoulder and elbow function and was able to enjoy normal childhood.

Fig. 4- Good improvement in the shoulder and elbow function in a child who underwent nerve surgery at age of 14 months (Pre-op above and Post-op below). He underwent nerve transfer surgery (Spinal accessory to suprascapular nerve, ulnar nerve fascicle to biceps and median nerve fascicle to brachialis motor branch transfer)

We missed seeing the specialist when our child was small. Is it worth consulting the specialist now? Can they offer anything for our child?
Yes. It is always worth seeing the specialist. When we see older children, we operate on the muscles, joints and the bones to improve the range of movement, correct unfavourable postures and improve strength.

My child is unable to lift the upper limb (at the shoulder)? what can be done for this?
Inability to lift arm can be due to the weakness of lifting muscles, too strong opposite pull from neighboring muscles or mostly a combination of the two. When we see older children we release the tightness of the contracted muscles by surgery or make them weak by Botox injection.

What is Mod Quad operation?
Mod Quad is a kind of muscle release and rebalancing operation designed to improve the shoulder movements. It improves lifting of the arm in children who are unable to do so due to the tight muscles in armpit. The tight and overly contracting muscles in the axilla (armpit) are relaxed and pressure on a nerve is released. Muscles are also transferred to restore balance as per the need of the child. Usually after this operation arm can be made to go over head and the children are able to perform the overhead activities much easily (Fig. 5). Day to day activities like combing hair and selfcare become as simple as it should be (Fig. 6).

Pre op

Post op

Fig. 5- A child who underwent Mod Quad operation. The pre-op and post-op images above show marked improvement in the range of shoulder movements

Pre op

Post op

Pre op

Post op

Fig. 6- Results of Mod Quad procedure

How long do we need to stay in the hospital for Mod Quad operation?
- 3 to 5 days.

After Mod Quad operation what do we need to do and when do we expect recovery?
After the surgery there will be a splint keeping the arm up which needs to be retained for 2 -3 weeks. It is reasonably easy to take care of the splint and doctors will demonstrate how to maintain it in position. Children take to it very easily. After 3 weeks the physiotherapist will teach the parents certain exercises to be done at home. Recovery takes up to 3-4 months.

My child's upper limb is turned inside and is unable to eat normally. What can be done?
There are surgical procedures to correct this problem. Treatment choice is dependent on child’s age. For children up to 6-7 years of age, tendon transfers or Triangle Tilt Operation is helpful (Fig. 7). Older children are corrected by a procedure on the arm bone and this operation is called ‘Derotation Osteotomy’. Most children can be improved. The choice of the procedure will be decided by the surgeon after careful clinical examination.

In tendon transfer operation, some muscles which are working well but are expendable are rerouted to achieve a more useful function. Triangular Tilt operation and Derotation Osteotomy are both done on the bone. By cutting the bone and rotating their position surgeons help the children to perform better. Most often eating improves (Fig. 8). They offer satisfactory good results.

What is the post-operative course after the tendon transfer and bone operations?
Children are in the hospital for about 4 to 5 days. If the children and the parents are comfortable many leave even early. These operations need good physiotherapy in the post-operative period. This is easy to learn and our physiotherapists teach the parents. Therapists are friendly and they are used to taking care of these children. The exercises are also recorded in video and given to the parents. The therapists can always be contacted by phone and we also coordinate with the therapists in the home towns of the patients.

The therapy extends for about 6 weeks and children achieve the maximum potential of the surgery by 3 to 6 months.





A) Pre-op

B) Pre-op

C) Post-op

D) Post-op

Fig. 7- Children who had severe ‘trumpet sign’ while trying to reach the mouth (a and b) and gross limitation of external rotation at the shoulder achieved good correction after the surgery.(c and d)

Pre op

Post op

Fig. 8 - Good correction of the hand to mouth reach posture with the humerus osteotomy in this child. The child was very conscious while eating lunch at school because of the awkward position of the arm while she reaches mouth. Now she is happy eating and sharing!

My child is unable to turn the palm downwards (pronate). What can be done?
Doctors like to find out whether joints are stiff or smooth. If joints are smooth and muscles in forearm are working doctors can adjust the muscles so as to make palm face down but many times this itself may not be adequate and the orientation of the bone needs to be changed to get desired movement (Fig. 9, 10).

Fig. 9- The aesthetic and functional changeover following corrective osteotomy in a child who was unable to turn her palm downwards

Fig. 10 - Showing the improvement in the appearance and the function after the forearm osteotomy in this child. The procedure tremendously improved the child’s confidence and outlook to enable her to enjoy her childhood and now she is grown to becomes part of medical team.

My child is unable to turn the palm upwards (Supinate). What can be done?
Approach to this will be similar to above mentioned plan. Only things will be done reverse of above.

Fig. 11 - A child who is able to eat comfortably after we restored up turning (supination) of the forearm by tendon transfer surgery. Another child who was so thrilled to have been able to take the offerings at the temple in the right hand finally!

My child has problem in bending his/her fingers? What can be done?
Usually if within 2-3 months after birth, fingers are not bending then early nerve surgery is recommended. Since the fingers are far away from the area of nerve injury the recovery takes longer and may not be perfect. However depending on what muscles are working, the hand muscles can be shifted to make fingers bend. If sufficient muscles are not available, a major microsurgical procedure called free functioning muscle transfer may be done.

What do you mean by Free Functioning Muscle Transfer (FFMT) and why is it done for brachial plexus injuries?
Free functioning muscle transfer is a surgery where a muscle is taken from one area of the body with its blood vessels and nerve and transferred to a new place where it will work to give some movement. In children with very severe affliction, FFMT is done either to get elbow movement of finger movement.

A muscle from the thigh is transferred to the arm or forearm and its blood vessels and nerves are connected in the new location. It will take about 6 to 9 months to function in the new location. This is a surgical advance and is regularly done in few centres around the world in children with Birth Brachial Plexus Palsy. We are happy that we regularly do this procedure

Most Children could be improved…………

In short, a child with birth brachial plexus palsy at any age can he helped in various ways to improve the function and eventually made capable to ‘look normal’ and perform all the day to day activities and enjoy life of a normal child and grow up to achieve whatever he/she wants to be. At Ganga we strive to help them to live up to their dream (and that of their parents)!