1.Stretch - which vary in degrees of intensity, however nerves in plexus are often compressed due to swelling an bruising from birth trauma of shoulder getting caught on the pelvic bone. Stretch injuries will spontaneously recover in to 1-2 years of age with 90-100% return of function. neuroma which is scar tissue that compresses the nerves ma occur also and surgical intervention is needed to remove it.

2.Rupture - nerves are torn at either one or several places in the plexus requiring surgery for the nerves to recover.

3.Avulsion (most severe injury) - nerves are pulled from the spinal cord as evidenced by a totally flaccid extremity part of extremity, which requires surgery and possibly muscle transfer to gain function. Horner's syndrome may present if Tl is involved.

PRECAUTIONS/PROBLEMS

Shoulder or elbow dislocation
Frozen shoulder
Soft tissue/joint contractures
Do not lift child under armpit
Do not use electrical stimulation on infant/child

TREATMENT

• Provide patient's parents with home program PROM sheets 2-3 daily x 10 reps in all motions
  
• Begin gentle PROM exercise in supine to increase joint flexibility and muscle tone
  
• Provide tactile stimulation to involved extremity using various textured materials, koosh balls, vibration and massage to increase sensory awareness of that extremity in overall body scheme
  
• Joint compression/weight bearing throughout involved extremity to increase- proprioceptive input/muscle contraction
  
• Active use of involved extremity using a variety of developmental appropriate activities to increase strength and coordination beginning in gravity eliminated then advance to against gravity
  
• Always include bimanual/bilateral motor planning activities
  
• Pool therapy
  
• Scapular stabilization to increase scapulo-humeral mobility

Positioning/splinting

• To hold arm in supination and external rotation you may want to suggest to parent to place pillows or stuffed animals underneath armpit and alongside arm while patient is at rest or sleeping to provide a sustained stretch.
  
• Do not hold arm in elbow flexion on top of chest by restraining it for long periods of time although placing arm while feeding or resting in this position is acceptable to not let arm dangle in space.
  
• For a flaccid hand/wrist, a resting hand splint should be provided to maintain hand in a proper functional position and for protection secondary to deficits in sensory nerves.
  
• A futuro wrist brace or neoprene thumbs abductor splint with synergy wrist extensor support/dycem may increase child's ability to weight bear on involved extremity.
  
• For decreased wrist extension a dorsal cockup splint will increase active grasp of involved hand
• For an elbow flexion contracture a 3 point elbow extension splint is made with an adjustable elbow extension pull.
  
• An elbow conformer splint can also be used for a soft tissue contracture caused by the elbow flexors overpowering extensors. It is also beneficial to maintains the arm in extension for active reaching to strengthen deltoid or in weight bearing activities when the triceps are weak.
  
• For no active elbow flexion but full extension a dynami elbow flexion splint may be fabricated using rubber bands o theratube with thermo plastic or neoprene cuffs or hinges can be used also.
  
• For thumb in palm after 3-4 months of age a Joe Cool splint to increase active thumb abduction and opposition is used.

• May be used on involved extremity to allow for stability in elbow extension to bear weight on involved arm to crawl
  
• May be used intermittently on uninvolved arm to immobilize it to allow involved arm to move actively with assistance
  
• Precautions: watch for circulatory changes, numbness or swelling
  
• Air splints can be ordered from Flaghouse or Sammons catalog for pediatric sizes

Usually you will see first movement patterns at approximately 2-4 months of age which include:

• Shoulder elevation/depression or protraction/retraction
  
• Shoulder flexion 0-90 degrees using pectoral musculature Shoulder abduction 0-45 degrees using supraspinatus musculature
  
• Elbow flexion with forearm pronated bringing hand to mouth and/or hands to midline
  
• Finger flexion/extension with wrist in flexion then later with wrist in extension

• Full shoulder flexion/abduction using deltoid musculature
  
• Supination (children do not actively perform this mot until 11 months of age)
  
• External rotation
  
• Full elbow extension using triceps

* If you do not see any progression of active movement in involved extremity there is a strong possibility that nerves are ruptured or avulsed an immediate referral to The Children's Hospital Brachial Plexus Team is advised evaluation of need of surgery. An EMG and/or CT myelogram is used to determine what nerves are involved. Preferred surgery age is 5-7 months for best prognosis. 10% brachial plexus injuries require surgery and improvement can be expected in at least 90% of them.