Brachial Plexus Injury
A brachial plexus injury happens when the network of nerves that control movement and sensation in the arm and hand is stretched, compressed, torn, or pulled away from the spinal cord. Depending on how severely the nerves are damaged, symptoms can range from general weakness and lack of range of motion to long-term disabilities and even paralysis of the shoulder or arm.
What Is a Brachial Plexus Injury?
The brachial plexus is a network of nerves that starts in the neck and travels through the shoulder into the arm and hand. These nerves send motor and sensory signals between the spinal cord and upper limb. When these nerves are damaged, it can cause weakness, numbness, pain, or even paralysis in the shoulder, arm, or hand.
How Common Are Brachial Plexus Injuries?
Unfortunately, brachial plexus injuries can often happen during childbirth. Studies estimate neonatal brachial plexus injuries occur in around 3 of every 1000 births. Luckily, nearly 90% of children recover without surgery and typically regain mobility and strength within the first 6 to 12 months of life.
What Causes Brachial Plexus Injuries at Birth?
Neonatal brachial plexus injuries usually occur during a difficult delivery when there is excessive stretching between the baby's neck and shoulder. This movement can overstretch or tear the nerves, leading to weakness, stiffness, or limited range of motion in the shoulder and arm.
The most common causes of brachial plexus injury include:
- Shoulder dystocia: When the baby's shoulder gets stuck behind the mother's pelvic bone after the head is delivered.
- Lateral traction on the head or neck: Pulling, twisting, or bending the baby's head and neck while the shoulder is still stuck can overstretch or tear the nerves.
- Breech or abnormal presentation: When a baby is born feet-first or bottom-first, the arms may be extended above the head. Using excessive force on the trunk or arms to speed up delivery can injure the nerves.
- Misuse of delivery tools: Forceps and vacuum extractors used repeatedly or too forcefully, especially in the event of shoulder dystocia, can increase the risk of stretch or tear.
- Maternal diabetes or macrosomia: Risks brachial plexus injury are higher if the mother has diabetes or is obese, or if the baby weighs over 8 lbs 13 oz (4000 g).
- Prolonged or difficult labor: Long or difficult labor can increase the necessity of using extra pressure, force, or delivery tools, which can cause nerve strain.
- Other maternal risks: Twin or triplet pregnancy, prior delivery involving shoulder dystocia, or small pelvic anatomy.
Other Causes of Brachial Plexus Injuries
In older children, teens, and adults, brachial plexus injuries can sometimes result from:
- Motor-vehicle collisions (oftentimes motorcycle or ATV crashes)
- Falls from height or contact sports collisions (football or wrestling)
- Severe cuts near the neck or shoulder
- Injuries during surgery near the neck, shoulder, or chest
What Are the Symptoms of Brachial Plexus Injury?
Symptoms in Newborns and Infants
Parents may notice symptoms in their baby immediately after birth, within the first days of life.
Common signs to watch for include:
- Weak or limp arm on one side (appears floppy at the shoulder or elbow)
- Lack of spontaneous movement in the arm or hand compared to the other side
- Arm hanging by the side with the shoulder and forearm turned inward (known as the "waiter's tip position")
- Absent or weaker Moro (infant) reflex on the affected side
- Weak or no grip in the hand
- Difference in muscle tone - one arm may feel unusually floppy or stiff compared to the other
Symptoms in Older Children, Teens, and Adults
When brachial plexus injuries happen later in life, symptoms may appear as:
- Sudden shoulder or arm pain after trauma
- Numbness or tingly sensation down the arm or into the hand
- Weakness when lifting the arm, bending the elbow, or gripping
- Loss of sensation in parts of the shoulder, arm, or hand
It's important to get urgent medical help if you notice any new weakness or loss of movement after birth or injury. If left untreated, severe brachial plexus injuries may lead to:
- Limited range of motion in the shoulder, elbow, or wrist
- Muscle imbalances and contractures (permanent stiffness)
- Differences in arm length or size (muscle mass)
Types of Brachial Plexus Injuries
Doctors classify brachial plexus injuries both by the type of nerve damage and which nerve roots are involved.
Neurapraxia (Stretch Injury)
Neurapraxia, known as brachial plexus neurapraxia, is usually caused by compression or traction on the nerve.
- The nerve is stretched but not completely torn with minor symptoms
- Most times will heal on its own within weeks to a few months (90% of cases)
- Mildest and most common type of brachial plexus injury
Neuroma
- The inner part of the nerve is torn, and scar tissue forms around it after it heals
- Scar tissue can block or slow down nerve signal transmission and cause weakness or range of motion difficulties
- Recovery may be partial and may sometimes require surgery to improve
Rupture
- A more severe type of damage where the nerve is completely torn but is not pulled away from the spine
- Since the body cannot reconnect the nerve ends on its own, surgery is almost always required to restore nerve signals in the arm and shoulder
Avulsion
- The most severe type of nerve damage, where the nerve root is pulled directly away from the spinal cord
- It cannot be reattached to the spinal cord and requires nerve transfers to restore some function
- Even with surgery, permanent damage is likely and often leads to lasting weakness or even paralysis in the arm or shoulder
Types by Nerve Roots Damaged
- Erb's palsy: The most common brachial plexus injury at birth, which affects the upper plexus region of the nerves (usually C5—C6 and sometimes C7). It affects shoulder and elbow movements and can even cause paralysis of the arm in severe cases.
- Klumpke's palsy: A rare but serious injury that damages the lower plexus nerves (C8—T1), which causes weakness or paralysis in the hand and wrist muscles.
- Global palsy: Affects the entire plexus (C5—T1) and causes extensive weakness in the shoulder, elbow, wrist, and hand.
How Are Brachial Plexus Injuries Diagnosed?
To properly diagnose a brachial plexus injury, a licensed physician will test your baby's shoulder, arm, and hands to evaluate their movement, range of motion, and strength.
For infants, physicians will examine:
- How the arm moves compared to the other side
- Reflexes, such as the Moro reflex
- Muscle tone and response to touch
- Signs of shoulder or elbow dislocation
For older children and adults, physicians will examine:
- Strength of specific muscles supplied by each nerve root
- Sensation in different areas of the arm and hand
- Range of motion and presence of pain
Imaging and Diagnostic Tests
In addition to physical examinations, doctors may order imaging or nerve tests to diagnose the severity of damage. These tests may include:
- Ultrasounds: Usually done for infants, ultrasounds can show shoulder joint position and early deformities with more accuracy.
- MRI / MR neurography: Shows the plexus, nerve roots, and surrounding structures, which helps identify rupture, avulsion, or scarring.
- CT myelography: Less common in infants, this test uses contrast dyes to highlight areas of the damaged root nerves.
- EMG and nerve conduction: Shows whether or not specific muscles are getting signals from the nerve to assess nerve damage.
How Are Brachial Plexus Injuries Treated?
Treatment will depend on the type and severity of damage to the nerves. Fortunately, most cases of brachial plexus injuries heal on their own within a few months to a year. However, if treatment is needed, there are a few different types available.
Physical and Occupational Therapy
Physical and occupational therapy make up a big part of recovery in both infants and older patients. Therapy helps:
- Maintain and improve range of motion in joints
- Strengthen muscles as nerve function returns
- Promote symmetrical use of both arms for play and daily activities
- Prevent contractures and joint deformities
Therapists will also likely incorporate home exercise programs and suggest adaptive strategies or equipment to help with feeding, dressing, and school tasks during recovery.
Medications and Pain Management
In older children and adults, some providers use short-term pain medicines for acute injuries and neuropathic pain medications for burning or shocking nerve pain.
Surgery
In more severe cases of brachial plexus injury, surgery is considered when time and therapy alone are not enough, and significant weakness or paralysis persists beyond 3 to 6 months.
For neonatal brachial plexus injury, many specialists and doctors recommend considering surgery if:
- Little or no return of biceps function (elbow bending)
- Imaging shows rupture or avulsion of nerve roots
- The child has severe global palsy with minimal improvements
There are many different types of surgeries to help reconstruct or reconnect the nerves, such as:
- Neurolysis: Removes scar tissue that is formed around nerves to improve function.
- Nerve grafting: Damaged segments of a nerve are removed and nerve grafts (often taken from the leg) are used to reconnect healthy ends.
- Nerve transfers: Surgeons will reroute a functioning nerve (or part of one) from a less critical muscle to power a more important function in the limb, such as elbow flexion.
- Tendon or muscle transfers / joint reconstruction: Disconnects a tendon from the injured area and reattaches it to a healthy muscle. These procedures are typically done later in childhood (after age 1) and help improve shoulder rotation, elbow function, or hand use when the primary nerves haven't recovered fully.
Note: Most children will usually go through intensive physical therapy and rehabilitation after surgery to protect repairs, retrain movements, and prevent stiffness.
What Is the Prognosis for Brachial Plexus Injury?
The prognosis for a brachial plexus injury depends on multiple factors, including:
- Whether the nerve injury was a stretch, rupture, or avulsion
- How early recovery of the elbow and shoulder movement shows up
- Whether the child has Erb's palsy, Klumpke's palsy, or global palsy
More than two-thirds of infants with brachial plexus injury recover fully or almost fully within the first year of life. However, children with more severe global palsy or avulsions are more likely to have long-term weakness, contractures, or joint deformities even after surgery.
If you notice signs of injury in your child, notify your doctor as soon as possible. If left untreated for too long, brachial plexus injuries can cause long-term complications with limb mobility, muscle tone, skin sensitivity, and chronic pain.
Can Brachial Plexus Injuries Be Caused by Medical Malpractice?
Yes. Some cases of brachial plexus injury are caused by medical negligence if:
- Known risk factors such as macrosomia, uncontrolled diabetes, or prior shoulder dystocia were not recognized or managed correctly.
- Standard shoulder dystocia maneuvers were not used appropriately.
- Excessive traction, force, or improper use of forceps or vacuum extractors caused avoidable nerve damage.
Parents should also know that many injuries occur even when providers follow best practices. If you have concerns about how your child's birth or delivery was handled, the best thing to do is to speak to your child's specialists.
If you suspect medical negligence may have played a role in your child's condition, consulting a birth injury lawyer can help you understand your potential legal options.
Brachial Plexus Injury FAQs
Written and Medically Reviewed by:
Cerebral Palsy Hub Team
Cerebral Palsy Hub was founded to help support children and their families with cerebral palsy and to create a safe space for those affected. We strive to provide the most accurate, up-to-date information, and tools to help give your child the life they deserve.
Last Updated: December 18, 2025
