Sun Safety & Brachial Plexus Injuries – PediaCast 381
- We begin this week with important reminders on sun safety. Then, Dr Kim Bjorklund stops by to talk about brachial plexus injuries and their treatment. These injuries affect children of all ages, from newborn babies through high school athletes, and can result in debilitating loss of arm and finger movement. We consider cutting-edge microsurgery techniques, recovery time and long-term outlook for those affected. We hope you can join us!
- Sun Safety
- Heat Exhaustion
- Heat Stroke
- Brachial Plexus Injuries
- Burners and Stingers
- Dr Kim Bjorklund
Plastic and Reconstructive Surgeon
Director, Brachial Plexus Program
Nationwide Children’s Hospital
- Sun and Water Safety Tips – American Academy of Pediatrics
- Poison Ivy, Tick Bites, Sunburn – PediaCast 322
- Brachial Plexus Program – Nationwide Children’s Hospital
- Brachial Plexus Injury – American Society for Surgery of the Hand
- Brachial Plexus Injury – American Academy of Orthopaedic Surgeons
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.
It's Episode 381 for July 19th, 2017. We're calling this one "Sun Safety and Brachial Plexus Injuries". I want to welcome everyone to the program.
So, here we are, smacked dub in the middle of summer, and I realized we have not covered sun safety this year on the podcast. It's something we try to talk about every summer on PediaCast because it's important. We all need reminders about the dangers of the sun and how we can protect ourselves and our children while at the same time acknowledging the sun's goodness in our lives.
Sometimes, we have the tendency to focus on the danger without thinking about the good as well. And the bottom line we have not done that this year, at least on the podcast. I have talked with the Central Ohio television audience about sun safety and sunburns and sunscreen on the 10TV, our local CBS affiliate.
And of course, I've talked about sun safety with lots of families in the exam room. And I think somewhere in the back of my mind, I blurred those endeavors with the podcast. I thought I've covered it here. But as I looked back, it's actually been two years since we talked about sunburns and sunscreen. I skipped it last year and I'm truly sorry about that folks. Hopefully, it didn't cause any sunburns last year in listeners or their children who would have otherwise been reminded about the dangers of ultraviolet energy emitted from the sun.
So, in an effort to save some skin this year, we'll cover sun safety, sunburns, sunscreen, all that coming your way shortly. Then, we'll consider brachial plexus injuries. It's a couple of big words but relatively simple concepts. Five nerves come off of the spinal cord in the lower neck and they form a web of sorts, a network, if you will, which is what the word plexus means.
And then, they give way to the nerves which control movements of the arms, the elbow, the wrist, the fingers and also relay skin sensation from those same places to the brain. And when this network of nerves becomes injured, it interferes with sensation and movement in the upper extremity, which in turn can really interfere with the person's day-to-day life.
Now, you may be asking how does the brachial plexus become injured? It's a good question. And the answer that turns out is lots of ways, brachial plexus injuries can occur in babies during child birth. Also to athletes, you probably heard of a shoulder injuries referred to as burners or stingers. Those are actually brachial plexus injuries. Trauma can also injure these nerves. So, things like car accidents, motorcycle crashes, gunshot wounds, lots of ways that can happen.
And then, the next question becomes how do you treat brachial plexus injuries? It's an important consideration because the disturbance in arm and finger movement is often debilitating. It's good to move the arms and fingers.
And as it turns out we have some remarkable microsurgery techniques that can treat these injuries when they're not getting better on their own and to restore function. My guest today will enlighten us on brachial plexus injuries and their treatment, Dr. Kim Bjorklund is a plastic and reconstructive surgeon at Nationwide Children's Hospital and director of our Brachial Plexus Program.
So she'll join us in the studio after the break but first, let's consider sun safety. It's a topic we cover nearly every summer on PediaCast. Okay, we skipped the last year but we try to cover it every summer on the program and I presented it with a few different lenses and focuses over the years. So that we at least get a reminder of the important points without necessarily saying the exact same thing over and over.
So, this year I'm just going to take a simple approach and cover some updated sun safety tips from American Academy of Pediatrics. If you'd like a written copy of these recommendations maybe to print and hang on your refrigerator or to share on Facebook or Twitter, I'll include a helpful link for you so you can do that. It will be in the Show Notes for Episode 381 over at PediaCast.org.
If you're interested in the science behind sunburns, why does your skin turn red with the sunburn? Why does it blister and peel? I'll give you a hint. It's not because your skin is truly burned. Instead, it's actually a protective mechanism, so you can thank your body for creating sunburn which in turn lowers your chance of getting skin cancer.
So if you want to know more about the science of that process and the science behind the sun tan, if you're a science junkie like me and really interested in the why, check out PediaCast Episode 322 which I produced a couple of summers ago. That episode was called Poison Ivy, Tick Bites, and Sunburn. So some great summer topics for you, still up-to-date and relevant and highly recommended content this time of the year. And I'll include a link to that episode in the Show Notes for this one, 381, over PediaCast.org so you can find it easily.
All right, so let's get to it, the sun is great. It warms our air, it gives us light, it helps control the cyclic rhythm of life. It stimulates the production of Vitamin D in our bodies and it keeps some folks from tethering into depression. Lots of good things comes from the sun. Without it, we've simply wouldn't exist. There aren't many objects that can claim that. But the sun can also be dangerous by way of DNA-altering ultraviolet light energy.
So, how can we protect ourselves and our kids from this danger while still enjoying some much needed fun in the sun? Well, according to the American Academy of Pediatrics, for babies under six months, to prevent sunburn, you really want to do your best to just avoid direct exposure to their skin. So, dress them in lightweight, long pants, long shirts, long-sleeved shirts, and brimmed hats that shade the neck to prevent sunburn.
However, when adequate clothing and shade are not available, parents can apply small amount of sunscreen with an SPF (which stands for Sun Protection Factor) of 15 or greater to the exposed areas, such as the infants face and the back of the hands. If an infant does get a sunburn and it's mild, you can apply cool compresses to the area for comfort. But if the sunburn is significant, be sure to have them checked by a medical provider right away because infants are more prone to water loss and infection from disrupted skin.
For all other children and adults, the first and best line of depends against harmful ultraviolet radiation is avoiding sun exposure by covering up. Stay in the shade whenever possible and limit sun exposure during the peak intensity hours between 10AM and 4PM in the afternoon.
Also, wear a hat with the three inch brim or bill facing forward, sunglasses, and look for sunglasses that provide 97% to 100% protection against both UVA and UVV rays.
Ultraviolet light exposure has been associated with the development of some eye problems so, in particular cataracts later in life and then some sort of accumulative those response to that. And so, using sunglasses right from childhood is really good idea when you're out in the bright sun because over the course of your life, you're going to get a lot of exposure to those ultraviolet light rays from the sun. So you may be able to prevent something like cataracts down the road like far down the road but something preventative that you can do now.
Also clothing with a tight weave but also breathable and light, since you're out on the sun. And that's something else to consider to prevent sunburns.
On both sunny and cloudy days, use a sunscreen with an SPF of 15 or greater that protects against both UVA and UV rays. And I also ought to mention, so we say cloudy days, those UV light rays do penetrate clouds, light rays do too. I mean, the visible light spectrum penetrates clouds. Otherwise, it would be pitch dark, pitch black on a cloudy day, and it's not. So, we know that light rays including ultraviolet ones do come through the clouds.
Also, this is interesting in the winter time, sunscreen on your face and exposed skin is also a good idea because the sun's energy radiates or reflects off of the snow. And so you can get a sunburn in the winter time as well as the summer.
And then, be sure to apply enough sunscreen, about 1 ounce per application for young adult, a little less for kids. But if you do want to get good coverage, I think the lotion does the best job of that. It's easier to do the roll-ons and the sticks and the sprays, but good all fashion lotion is greasy. It maybe probably provides the best protection in terms of getting the right coverage. It's a little slimy in your hands, I realize that, but it's worth it for the protection that you get.
And then, you want to reapply sunscreen every two hours and also after a swimming or profused sweating, even if it's been less than two hours. So, even if the bottle says, hey, all day protection or something like that, still reapply it every couple of hours. And sooner, if after you've gone swimming or you've been sweating quite a bit.
Also, I mentioned a reflection of UV rays off of snow. They also reflect off of water and sand even, so you do want to make sure that even if you're not… So let's say you're under an umbrella on the beach, so seems like you're in a shade — that's certainly is better than being out in full sun — but you are going to get some reflected UV radiation even in the shade if you're on sand or something else that reflects that light.
The AAP, American Academy of Pediatrics also offers guidelines for reducing heat stress and exercising children, something to think about on those sunny days. They say the intensity of activities that last 15 minutes or more should be reduced whenever high heat or humidity reach critical levels.
The beginning of a strenuous exercise program or after travelling to a warmer climate, the intensity and duration of outdoor activity should start low, and then gradually increase over 7 to 14 days to acclimate to the heat particularly if it is in a very humid environment.
Before outdoor, physical activities children should drink, should drink water freely, and not feel thirsty during activities lasting less than one hour. Water alone is fine but if the activity last more than an hour, particularly if it's strenuous activity, consider adding a sports drink to replenish glucose or sugar and electrolytes, things like sodium or potassium. And take a break to drink every 20 minutes while active in the heat, whether it's water or a sports drink.
Clothing should be light-colored and lightweight and limited to one layer of absorbent material to facilitate operation of sweat. Sweat saturated shirts should be replaced by dry clothing.
Practices, sports practices, and games played in the heat should be shortened and there should be more frequent water and hydration breaks.
Children should promptly move to cooler environment if they fell dizzy, light-headed or nauseated. So teach them to recognize those symptoms and start drinking and get in the shade right away if they are felling funny, feeling dizzy, lightheaded or nauseated.
Heat stress can also be a problem for infants and small children because they're not able to regulate body temperature in the same way as big kids and adults. And every year, we all hear the stories, children die from heat stroke from being left in a hot car, often unintentionally, with the majority of these deaths occurring in children three years of age and under.
So here are a few tips for parents when travelling in a car with infants or young children. Always check the backseat to make sure all kids are out of the car when you arrive at your destination. Just make a habit of doing that whether the kids are in the car or not so that every time you stop, you'll look back there.
Avoid distractions while driving, especially cellphone use, because you forget your kids when you're talking on the phone.
Be especially aware of children in the car when there is a change from the routine. In other words, someone else is driving them in the morning or you take a different route to work or to childcare. Maybe a Waze reroute you a quicker way and now, you got your mind thinking about the driving and you forget.
Have your child care provider call if your child has not arrived within ten minutes of the expected arrival time.
And I love this, place your cellphone — since you shouldn't be using it when you're driving anyway — or a bag or a purse in the backseat, so you have to get it when you go in to work. And then, that does remind you to check the backseat when you arrive at your destination. Love that one, it's a great tip.
The inside of a car can reach dangerous temperatures quickly, even when the outside temperature is not particularly hot. Never leave a child alone in a car even if you expect to come back soon.
And lock your car when it's in a driveway, if it's empty and parked, so children cannot get in and play without supervision.
So, there you have it. Get outside, be active, have fun but also be mindful of the dangers of the sun and the heat in terms of ultraviolet radiation and hydration. And remember to take appropriate precautions.
All right, let's move on with the program. We're going to talk about brachial plexus injuries.
First though, I do want to remind you, it is easy to get in touch with me. If there's a question you have on your mind or you want to direct me to a news article or journal article, there's a particular topic or specialist that you'd like to hear from, I'm all ears and would love to hear from you. Just head over to PediaCast.org and click on the Contact link and ask or suggest away.
Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
Let's take a quick break and I will be back with Dr. Kim Bjorklund to talk about brachial plexus injuries, it's coming up right after this.
Dr. Mike Patrick: Dr. Kim Bjorklund is plastic and reconstructive surgeon at Nationwide Children's Hospital and an assistant professor of plastic surgery at the Ohio State University College of Medicine. She serves as director of the Brachial Plexus Program at Nationwide Children's, helping young patients regain the use of arms and hands and fingers following injury of the brachial plexus.
That's what she's here to talk about today, brachial plexus injuries, so let's give a warm PediaCast welcome to Dr. Kim Bjorklund. Thanks so much for stopping by today.
Dr. Kim Bjorklund: Thanks for having me.
Dr. Mike Patrick: Really appreciate it. So, these are some big words for parents, brachial plexus. Kind of explain to us exactly what those terms mean and what exactly the brachial plexus is.
Dr. Kim Bjorklund: Sure. So, the brachial plexus is essentially a network of nerves that comes from the spinal cord and goes down the arm. Essentially, the spinal cord provides the input or electrical energy to electrical cord essentially that runs through the neck and down the arm. This allows movement of the shoulder, the elbow, the arm, and the hand and fingers.
Dr. Mike Patrick: Yeah. And so the terms themselves brachial just is a fancy word meaning the arm, correct?
Dr. Kim Bjorklund: Essentially, yes.
Dr. Mike Patrick: And plexus is sort of a network, so it comes right off the spinal cord, in the neck. And then, it's not just a single cord. There's like different spinal nerves that actually form this thing. And then some nerves that folks who take an anatomy class may recognize before, things like the radial nerve, the ulnar nerve, the median nerve kind of come off of these plexus. Is that more down on the armpit area or the shoulder, the anterior shoulder?
Dr. Kim Bjorklund: Yeah, exactly.
Dr. Mike Patrick: Where those nerves would come off?
Dr. Kim Bjorklund: Yeah, they come off kind of around the armpit area. But exactly, they come out of the spinal cord and they come from the areas essentially off the spine that are called C5 to T1, if you're thinking about the spinal cord levels.
And then, those basically form a collection of nerves, the network essentially or the plexus in the neck. And then, they basically branch out into these different nerves that you described around the armpit area. Essentially, the radial nerve and median nerve, and kind of nerves that some of us know down in the arm.
Dr. Mike Patrick: Yes. And of course, this is an audio podcast and we're talking about something very visual. So, I would encourage folks if you are particularly interested in this and just want to see a picture of exactly what we're talking about — I think it'll make more sense if it does sound a bit confusing — in the Show Notes for this episode, 381, over at PediaCast.org, I have a couple of links for you.
Really just some nice diagram and pictures, one from the American Society for Surgery of the Hand and another there from the American Academy of Orthopedic Surgeons. And they really just show a nice diagram of what this looks like and the location and exactly what we're talking about.
So the next question really then becomes if we've defined what it is and where it is, why is the brachial plexus important?
Dr. Kim Bjorklund: So it's important because it really provides the movement and feeling for the entire arm. So I guess the spinal cord basically provides sort of that input or electricity to allow the movement and feeling in the arm but this is what really moves your shoulder. For instance, it allows you to reach up over your head to grab something or bring a piece of food to your mouth by flexing your elbow up. It lets your hand make a fist or throw a ball and it provides a sensation to feel and to be able to have tactile sensation and feedback in the use of your hand.
So with any disruption of the brachial plexus, any of those functions can be taken away which clearly makes it pretty important.
Dr. Mike Patrick: Yeah, absolutely. And I mean, if you think about how much we use our hands, they're just really essential and there's a lot of rehabilitation that goes in and learning to do things differently if we lose function of one of our hands. So really important thing here.
Let's talk about, just in terms of mechanisms, what are some of the things that can injure nerves?
Dr. Kim Bjorklund: Sure. So it really depends a lot on age group for what's more common. And kind of age groups we see this in is a large number in babies during delivery, where there can be traction on the nerve in something called shoulder dystocia. Where the shoulder can get stuck and the head sort of gets pulled in the opposite direction of the shoulder, which can put traction on these pretty sensitive nerves and can cause a stretch kind of injury.
That's sort of one mechanism among others in the delivery time where you have a big baby and some other factors related to pregnancy such as forceps and a few other pregnancy related things.
In other age groups, more common causes can be things like sports, can be a tumor that's involving brachial plexus or pressing on it. Sometimes, even injury although much less common in the pediatric population and in adults, where you see things like motorcycle injury and such. But traumatic injuries or even direct injuries which can cut the brachial plexus can all be causes.
Dr. Mike Patrick: Yeah. So if nerves get pulled or stretched, that can be one mechanism also, as you mentioned if it's ruptured. But even spinal nerves can actually come off of the spinal cord, I was reading sort of an evulsion, as we would call it. It that something that happens very often?
Dr. Kim Bjorklund: Sure. Exactly depending on sort of the mechanism, there's a number different ways like you say the nerves can get injured. And one of them with it being sort of like an electrical cord is where the cord essentially can sort get pulled right out of the wall, which is an evulsion where it basically gets pulled out of the spinal cord.
That's a little bit less common than a rapture where the nerves are even just bruised or stung. But it is something that happens and it's certainly the worst category of the injury, where it kind of evulse from the spinal cord.
Dr. Mike Patrick: Sure. Lets' go back and talk about, you were speaking of babies and the brachial plexus getting stretched when there's a particularly difficult delivery. Especially if you have shoulder dystocia, which is really just difficulty getting the shoulder out through the birth canal. And it's not so much of a problem with the shoulder itself, but really manipulating the head, which stretches the neck, which in turns stretches the brachial plexus since it comes off of the spinal cord in the neck.
And then, there you'd mentioned there are other mechanisms as well. I would imagine that in addition to manipulating and stretching, but also if the uterus is really pushing against the baby, that compression, can that also cause some problems?
Dr. Kim Bjorklund: A little bit less common but we certainly have seen brachial plexus injuries even in babies born by C-section or where babies we think sometimes in utero can occur, much less common than during the delivery but, yeah. I think there's a number of different mechanisms, whether it's related to vacuum or forceps or often just to get the baby out safely. There can be traction in different areas and it can result into some stretching of nerves.
Dr. Mike Patrick: Yeah, and what about low oxygen? So especially during a difficult delivery, you could have a period of time when the baby may not have the best oxygen getting into the bloodstream. Can that contribute to these injuries as well?
Dr. Kim Bjorklund: I wouldn't say directly.
Dr. Mike Patrick: Or not so much for the nerves.
Dr. Kim Bjorklund: No, I wouldn't say directly with the nerves. More as a probably result as far as the urgency of the low oxygen to then get the baby out, sort of regardless of the mechanism. And then whether more or less traction on the arm or forceps or other mechanisms that need to be brought in just to save the baby's life are kind of employed at that point. I think the direct correlation of low oxygen wouldn't be something that…
Dr. Mike Patrick: It's probably more just you're more likely to do maneuvers that could injure the brachial plexus because of that low oxygen.
Dr. Kim Bjorklund: Exactly.
Dr. Mike Patrick: In trying to get them out. That's interesting because one of the studies that I was reading show that association. But I think that's a great example of an association does not necessarily mean it's a cause, that two things were associated in time. And when you think about the mechanism of a brachial plexus injury, then you can see how the association would there, but it's not necessarily a cause. Which we hear about all sorts of things in the news — unrelated to the brachial plexus injuries — where things are associated and you get this idea that one causes another, but it's not necessarily the case.
Dr. Kim Bjorklund: True. Exactly.
Dr. Mike Patrick: And then, when you think about that, the mechanism of it and how the urgency of getting the baby out could cause it, that then does not automatically indicate that the practitioner especially the obstetrician was at fault when the brachial plexus injury occurs. This is just a risk of childbirth and, as you said, can even happen with cesarean section.
Dr. Kim Bjorklund: Correct, yeah. It happens in all kinds of different circumstances. And I agree, the babies we see with this injury, generally, someone saved their life by getting them out. And I think no one wants this injury to happen.
Dr. Mike Patrick: Yeah, yeah, absolutely. Let's talk about athletes a little bit more. Folks have probably heard of things like stingers and burners. How does that relate to the brachial plexus?
Dr. Kim Bjorklund: Sure. So, those tend to be like quick isolated injuries whether sort of a brief compression of the brachial plexus often from something like wrestling or football, where there's a tackle and a direct sort of ding to the brachial plexus. But it's often something that goes away quickly as well. Although it can occur multiple times or it could have sort of some short-term lasting affect because it's often it's something that comes and goes.
And then, there's a direct brief compression similar to maybe banging your funny bone or sort of a jolt, where there's a sort of direct hit or compression to the brachial plexus.
Dr. Mike Patrick: And then, other causes of injuries, you'd mentioned anything that can disrupt or stretch or will be a traumatic event around the neck or the shoulder can also do it. So we're talking things like car accidents, motorcycle accidents, gunshot wounds, knife wounds, those kind of things.
Dr. Kim Bjorklund: Exactly.
Dr. Mike Patrick: How common are brachial plexus injuries?
Dr. Kim Bjorklund: So brachial plexus injuries in neonatal brachial plexus or in child birth injuries are typically about 1.5 per thousand births in North America. So, it was sort of 1 to 2 in about a thousand.
Dr. Mike Patrick: So not crazy common but not rare either.
Dr. Kim Bjorklund: Correct. And then of those, there's quite a high percentage, about 60%, or even sometimes a little bit more that recover on their own. So as far as long-term injuries that's even less, but the number that's sustain that injury in birth is about 1.5 in a thousand.
As far as the other mechanisms, I don't really have a great number for you. I think in pediatric trauma, it's less than about 1% — even smaller than that — that actually have a brachial plexus injury from a multi-trauma scenario.
Dr. Mike Patrick: And like a lot of the things that we talk about, even things that aren't really, really, really common, if it affects your family, it's a big deal.
Dr. Kim Bjorklund: Right, exactly.
Dr. Mike Patrick: And this is one of those things that really can have an effect on a person's life. And so, it is important that we talk about it and consider it because you never know when it is going to affect your family.
Dr. Kim Bjorklund: That's right.
Dr. Mike Patrick: So then what symptoms would result from brachial plexus injury? We know that it interferes with functions and sensation of the shoulder, arm, and hand. But it is an all-or-nothing kind of thing or are there degrees of symptoms that you could see?
Dr. Kim Bjorklund: So, that's exactly right. There's more degree of symptoms. And that actually directly relates to severity of the injuries. So before when we briefly talked about what type of injury do the nerves have — was it an evulsion, where they were pulled right out of the spinal cord? Was it where they simply had a rapture between the nerves where you have some good nerves still coming out of the spinal cord? But then actually, were they sort of pulled apart in the middle and then you've got more good nerve on the other side? Or was it were they more like a stinger, a burner and they were just bruised?
And that really depends on the injuries, sort of what type of symptoms you'll. And also, which nerves within that network, within the plexus are affected. So whether it's the top nerve, whether it's the bottom nerves, or whether it's all of the nerves that are really making a difference in the symptoms.
So, things that you see will typically vary from, basically, a baby that is born with an arm that doesn't… And it's usually one arm that's affected only, not usually both. So it's one arm that is not moving after birth.
Often, we talk about a specific kind of posture called a waiter's tip where the arm is essentially straight and not moving at the elbow. So, the elbow's completely straight. The wrist is then flexed in a waiter's kind of position, with the hand then kind of cupped as if it's sort of and again I said it's not a visual…
Dr. Mike Patrick: Yes, yes.
Dr. Kim Bjorklund: Thing here, but with the hand kind of cupped in that waiter's tip type of position.
Dr. Mike Patrick: Yeah.
Dr. Kim Bjorklund: So, that's sort of the typical thing that may be seen, but again it really varies because what in more severe injuries you'll see is an arm that's just floppy and doesn't move at all, and doesn't start to move. And we see everything from that, literally severe injury with the evulsions to one where the stinger or burner, where when the baby's born, there's an arm that's floppy or in that waiter's tip position. And then, even within a few hours or few days, parents will say, "Yeah, his arm didn't seem to work very well." "Her arm work very well, but then just started moving fingers and then a week later, the elbow moved and stuff."
So, really, and that's the type of stinger or burner one where the nerves are bruised and they recover. And all the way to that, the type where you've got the severe injury and the arm doesn't move at all, and even with time, doesn't move.
Dr. Mike Patrick: Yeah. And this is something that usually then would be immediately after birth that you would notice these symptoms? Or is it something that as there's maybe swelling, or there's a progression in terms of the stretch injuries where you would see symptoms getting worse? Or are they pretty much as bad as they're going to be as soon as the baby's born?
Dr. Kim Bjorklund: Yeah, they're as bad as they're going to be when the baby's born. So the most common description again in that usually is sort of 60% of the injuries that occur that then get better. The most common description is that the baby's born and the arm doesn't move and initially it looks its most severe. And then, overtime it does start to get better.
And almost all babies again with the exception of where the nerves are pulled right out sort of above the socket will have some recovery. So typically, you do start to see something even in fairly severe injuries. You do start to see more recovery over time.
Dr. Mike Patrick: Yeah. And this can be a slower recovery time though, when we're talking about nerves, right?
Dr. Kim Bjorklund: It is. Typically, we start to look for recovery of the elbow in terms of can someone flex their elbow by about two months of age for whether or not they're going to get sort of a more reasonable recovery of the arm.
Dr. Mike Patrick: Yeah. And then, in the older kids and the adult population as well that has a brachial plexus injury, usually then there is some event where this occurs, right? I mean it's not something that just happens out of the blue?
Dr. Kim Bjorklund: Right. The only scenario where I would say and it's very, very uncommon, but the one where it would happen out of the blue is basically a neuritis or an inflammation of the nerves, something called Parsonage-Turner syndrome. That's very uncommon, where you could get a viral illness and then inflammation of the brachial plexus. That would be the only one where it would happen for no reason. And again, very very uncommon.
But otherwise, no. Usually, there's a clear inciting event. Either it's a trauma or accident or an obvious injury.
Dr. Mike Patrick: Are there symptoms, are there conditions I should say that could cause similar symptoms that you wouldn't want necessarily just assume that this is a brachial plexus injury, but there may be other things going on that you might treat differently?
Dr. Kim Bjorklund: Sure. So, I mean it's obviously always important to look at the whole child or baby and figure out what's going on. But some of the more frequent things we see is that particularly in birth, there's also common things such as clavicle fractures or humerus fracture with the collar bone or the arm itself is broken. Those things can lead to the baby not using the arm and giving the same appearance as a brachial plexus injury, where they're not wanting to use it because of pain and often get an X-ray and check for those things.
And sometimes, it's important to remember brachial plexus injuries, almost always one arm only. Because other things we can see are sort of more central condition with children, if there's something going on for instance in the brain that may interfere with muscle movement or arm movement, you know what I mean. Again, we can see that on one side if it's stroke of cerebral palsy or something like that.
Dr. Mike Patrick: And in the older kids and adults and athletes, there are all sorts of injuries that you could have around the arm and shoulder that might cause decreased mobility of the shoulder. In fact, we just had a PediaCast on throwing injuries in athletes and those are some of the things that could potentially cause problems as well.
And then, tumors, I would imagine are far less likely. But could the tumor cause infringement on the brachial plexus and be an issue?
Dr. Kim Bjorklund: They do, yeah. Again, it's much less common but we certainly see that, either tumors that are actually nerve tumors themselves and they're really from the actual nerve and causing that compression sort of within it. But also other types of tumors that can then cause compression of the brachial plexus. And those are often dealt within a multi-disciplinary setting and usually found in conjunction with other things. But they definitely do cause that kind of compression.
Dr. Mike Patrick: Yeah, absolutely. So, as we think about different things that could potentially cause arm weakness or — and I guess when we talk about those, we've been kind of focusing the motor aspects of these injuries — but these nerves also carry sensation back, and so you can have some numbness and tingling, maybe even pain that's associated with these injuries, correct?
Dr. Kim Bjorklund: Yeah, I would say probably the more frequent thing we see would be lack of sensation. Not quite as much description even in sort of older children of pain as maybe you'd think in an adult and stuff, but definitely a lack of sensation that we can sometime see with a more severe injury — chewing on fingers or not being able to feel at all and burns and things like that — with lack of sensation to the arm.
Dr. Mike Patrick: So, as we think of these things and the differential diagnosis, how then do we arrive at the diagnosis that this is brachial plexus injury? What kind of workup do you do in evaluating the condition?
Dr. Kim Bjorklund: So, interestingly, like all of our modern tests and stuff, the diagnosis is really primarily a clinical one. So we often will use other things sort of as adjunct to rule out other conditions, but really, for instance in babies with this type of injury, it's really taking a history of what happened at the birth.
Is this a bigger baby that then had trouble, had shoulder dystocia or was stuck? How was the arm in terms of position? And did it recover? Was there any movement of the hand and elbow?
And then, really it's examining well. We have certain scoring scale that typically a number of team members in the Brachial Plexus Clinic including a dedicated therapist will essentially examine the baby and will basically put them through a number of scoring measures, to be able to see how they use all the aspects to the arms, from the shoulder down to the hand, and checking for sensation and stuff and looking.
Another thing we can see with severe injuries is something called a Horner syndrome where we can actually a droopy eyelid and then a small pupil.
So, basically taking into account all those clinical signs and then examining over time. So, usually after about one month after birth. And then, if we suspect an injury, the next month, and the third month, and looking for any change in any progression and movement.
Some other sort of adjuncts we would use to help with the clinical diagnosis or sometimes, like I mentioned, getting an X-ray to rule out, say, a broken bone in the arm, the humerus or a collar bone break, and that being a reason for the baby not moving an arm.
In older children or with an injury, we'll often rely a little bit more on modern tests as far as getting an MRI. Sometimes an EMG as well to look at the muscle movement. But they don't actually have a lot of helpfulness in babies. So typically, in the babies, we'll really look at clinical exam and scoring them overtime.
Dr. Mike Patrick: In the older kids, when you're talking about getting an MRI, can you actually, with the MRI, visualize the brachial plexus and where the nerves are coming off of the spine? The spinal cord, I should say.
Dr. Kim Bjorklund: We can and sometimes, we'll get something called a CT myelogram that can actually inject dye and look for any basically raptures from the spinal cord. So, we can see that.
Dr. Mike Patrick: Yeah, and be able to tell the location of the injury within the brachial plexus?
Dr. Kim Bjorklund: Basically, what we can tell is whether or not it's been pulled out of spinal cord. We often don't have a great idea otherwise within the MRI if there's a disruption or not.
Dr. Mike Patrick: That can be hard to see because the outer layer of the nerve may still be intact but there could be a disruption in there that you can't visualize.
Dr. Kim Bjorklund: Correct, exactly.
Dr. Mike Patrick: Yup. And then you talked about EMG, that's electromyography. Explain to folks what exactly that entails.
Dr. Kim Bjorklund: So basically, it entails an exam where there's some little sort of electrode needles that are placed into the arm and that test for basically the feeling and movement of electricity, as the nerves basically work from the spinal cord down to the arm. And they can tell if there's a disruption in that movement and feeling in the arm and basically the different nerves. So its real advantage is being to tell us if there is specific nerves injured and it gives us a bit of a picture of where the nerve may be injured.
Dr. Mike Patrick: So, if you can't visualize with an MRI where the nerve is injured, but then if you can localize what parts of the arm are affected, then you can trace backward and know, well, this part of the brachial plexus has that particular motor function or sensation going through it. And so, we can localize where the injury is based on that kind of a test.
Dr. Kim Bjorklund: Exactly. Yeah, they're sort of parts of a puzzle that help us put things together.
Dr. Mike Patrick: Yeah. Are there ever times when you don't know exactly where the injuries. We're going to kind of move into talking about we treat brachial plexus injuries, but is there ever a time when you're not exactly sure where the injury is and you still go in and look around?
Dr. Kim Bjorklund: Yeah. I would actually say that's probably most of the time, because what you typically see is there's fair bit of crossover of some of the nerves where different nerves — we can talk about that different level of the spinal cord, the C5 to T1 — some of them do some different functions. And they can kind of help each other to do the same thing.
And when the nerves are injured — so if you have some good nerve but then you've got an injury and the nerves are disrupted — and then you've got more good nerve, those nerves like to find other nerve and to regrow. So they like to find their own little path. So, when they're injured, they'll basically send out little sprouts and try to find a way to find a new nerve.
So often what we'll see is that a baby can have sort of some movement and things in the arm that maybe isn't quite right, but what's happened is the nerves that were injured are sending out little sprouts and they're regrowing into other nerves. So that can give us a pretty mixed pictures as far as what's injured and what's recovering.
So, it is often quite a surprise when we go in to fix these. Most often, the injuries are little bit more severe than we think or there's more nerves involved.
Dr. Mike Patrick: When you're actually exploring, can you see those sprouts? So does that give you an idea that, hey, there may be an injury in this location because of what I'm seeing, the nerve trying to reach out to other nerves? Is that something that you see surgically or is that more microscopic? For she used microscopes, but we'll get to that.
Dr. Kim Bjorklund: We do. No, we can see it. It's definitely, it's easier to see. We wear some magnifying glasses and as you mentioned the microscope, but even without that, you can generally kind of see a clump or sort of scar. And then within that, you can basically see sort of where these nerves have grown together kind of a in scar and a little mixed up.
Dr. Mike Patrick: Yeah, very interesting. So let's talk about, well, first I guess one thing when we talk about brachial plexus injuries, not all brachial plexus injuries need surgery, correct? What sort of treatment would you consider to start? Maybe there is partial movement, you're going to give it some time to see if things get better but you also don't want to give it too much time, right? So, how do you start treating and when do you know that you need to move on to surgery?
Dr. Kim Bjorklund: Exactly, so typically what happens is starting, say, with that new born baby who we suspect have brachial plexus injury, typically, they'll be seen really early in life, even within the first couple of weeks, if we suspect that by one of our dedicated brachial plexus therapists.
So they will start actual movement of the arm. And I think one of the misconceptions that people may have is that if someone has a brachial plexus injury, unlike if you have a broken bone or something that needs to heal, the treatment is actually not to swaddle and wrap and not to move the arm. The treatment actually opposite. And it's basically, even if the baby can't move the arm is to help the baby move the arm and move it for him or her. So that the joints don't get stiff and as the nerves can recover, that the arm is still able to have the joint movement and muscle movement that you're basically doing for the person, because they can't.
So really within the first couple of weeks, it's getting them involved in a sort of dedicated physical occupational therapy program. And often, a lot can be done at home by the parents but just where the arm is gently being stretched and moved around and things like that. So that the arm is moving.
We'll then typically see the baby as a team and examine them. Sometimes in that early period, we can talk about some things like doing Botox injections or occasionally splinting if an arm was just be really stiff. But usually, it's mostly therapy and then clinic visits for examinations of the arm of recovery for about the first two months or so.
We typically think about the recovery of the elbow as a good marker for how the arms can recover. So, if someone can bend their elbow, flex it up against gravity, or kind of getting it up to their mouth by about two months of age, then we know that the arm, the whole arm is likely to recover and completely.
So if we see that at two months of age, then we really know someone has a good prognosis, we'll continue to follow them, make sure that the stretching and everything is going well and there's no stiffness or problems with the joints. But we typically then expect a full recovery.
That's sort of a decision-making point. And then, at about two months, if we're not seeing that elbow recovery, we then start to go down kind of a train of thought of whether or not surgery's going to be needed.
Dr. Mike Patrick: So two months is kind of a critical period in terms of seeing where function is and deciding whether you are going to need to go to surgery route?
Dr. Kim Bjorklund: Right.
Dr. Mike Patrick: Yeah, and I want to go back to one thing you said real quick. So folks in the audience, if you're not familiar, you've probably heard of Botox related to taking wrinkles out of faces. But it really paralyzes muscles, right?
Dr. Kim Bjorklund: Exactly.
Dr. Mike Patrick: It's that mechanism of action. If you have muscle stiffness, Botox injection help paralyze the muscles so that it loosens things up a little bit.
Dr. Kim Bjorklund: Exactly.
Dr. Mike Patrick: And the reason it gets rid of wrinkles is by paralyzing muscles on the face.
Dr. Kim Bjorklund: Right. We use it for the same reason. We basically, exactly, just want to make muscles that are pulling really tight, we want to make them weak. So that basically, again, that you're able to rid in a baby or person who's able to move their arm and not have to deal with these really stiff muscles, tight muscle.
Dr. Mike Patrick: Yeah. While you're waiting on the healing process to complete or begin.
Dr. Kim Bjorklund: Right. Right.
Dr. Mike Patrick: Yeah. So, let's say you get to that two month period and you're not seeing any elbow movement and you're deciding that you probably are going to need to take a surgical approach, how do you do this? Just explain to folks how do you fix a broken nerve?
Dr. Kim Bjorklund: So, let's say there's sort of two approaches and it just depends on the injury again, whether the nerve is sort of pulled out of the spinal cord or whether there's kind of an injury within the nerve.
So if the nerve has an injury within it, so you have good healthy nerve coming out of the spinal cord. And then, you've got what we were talking about earlier, kind of scar where the nerves have tried to regrow but a big kind of scar and then you've got more good nerve. Essentially, it basically involves then finding where the good nerve is at the start and then cutting out that unhealthy nerve or scar.
And then, you need a bridge because there's going to be a big gap between that healthy nerve at the beginning and then more healthy nerve at the end.
So, this is nerve grafting. We actually take a nerve from the leg, from by the calf, called the sural nerve. And this is basically an expendable nerve that just provides a little area on the edge of the ankle, of feeling that really, when use in turn, they don't typically notice as they grow.
So, we typically use both sural nerves from both lower legs and we use that, sort of as a bridge between the healthy nerve and then the other end of the healthy nerve once we've cut off the scar. And we can put those nerves together like a cable. And then, that lets the healthy nerve grow through the right path down into the other healthy nerve and over time can basically then provide the electricity or the input and power to work the arm.
Dr. Mike Patrick: So, the important thing here is you're not sewing these nerves end on end to make a new continuous nerve. You're really using, I mean you're doing that but it's really more to make a scaffolding. So that the nerve cells can grow through that and reach the other nerve.
Dr. Kim Bjorklund: Exactly.
Dr. Mike Patrick: The other part of the good nerve.
Dr. Kim Bjorklund: Yeah.
Dr. Mike Patrick: So, that would mean that when you do this, you're not going to have normal nerve impulses down the entire cable immediately.
Dr. Kim Bjorklund: Right. And that's one of things that is sometimes doesn't make a lot of sense at first — is that if you fix a nerve, you'd think it would just work right away, but it actually doesn't. The nerve actually takes a little bit of time, takes about a month or so to even get going again once it was injured or worked with. It has one month of time where it just relaxes and then it starts up again. But when it starts to grow, it actually grows at a millimeter a day or an inch a month.
Dr. Mike Patrick: Yeah, wow. Yeah.
Dr. Kim Bjorklund: So, it's pretty slow.
Dr. Mike Patrick: Yeah. Is there any research — and I did not warn you I was going to ask you this question, I apologize — is there any research looking into speeding up that process? Are there chemicals in the body that come on after a month that stimulates this growth and is there any way to help that happen faster?
Dr. Kim Bjorklund: Yeah. I don't think we have, nothing as to we're using right now, but there's definitely work into nerve growth factors and axon growth factors and certainly in the basic science realm of trying to, sort of right now we're still in the kind of petri dish area of how to stimulate nerve growth and that kind of thing. And I would say nothing we're using in surgery or anything right now, but it's certainly on the horizon.
Dr. Mike Patrick: And as I was researching this, I came across some ideas that I had never really considered before. But if you have a paralyzed muscle, apparently, you can utilize other working muscles in that area to move the finger, the hand, the arm where the non-working muscles normally would be the mover. But you can sort of transfer tendon, is that something that you do?
Dr. Kim Bjorklund: Yeah. So, there's basically kind of two nerve operations that we do in brachial plexus. And the first one is what I already described, which is basically the anatomic reconstruction and nerve grafting. And that's where you've got that healthy nerve to work with and then you put in that nerve graft in between that we borrow from the lower legs. And then you've got that bridge to the other healthy nerve and use that as the scaffold for the nerve to grow down.
Now, if you're in the scenario where you have no healthy nerves, so you've got a nerve put right out of the spinal cord and you don't have a nerve to start with, then we have to think about how else can we get that nerve supply to those muscles? And one way is what you mentioned, which is what we call nerve transfers. And that's actually where we take a little branch of a working nerve away from one of their muscles. So, usually, we find one that's expendable or that's not going to be a problem for the muscles and is working.
So, for instance down, up in the arm, if we want to try to make the bicep moves or we want to try to make the elbow bend, what we can actually do is we can take a little branch, for instance, of the median and the ulnar nerve that bends the wrist. So, if those are working well — there's a lot of little branches that bend the wrist — so we can take one tiny little fascicle, little tiny nerve branch, and we can use that actually transfer that to the nerve right beside the muscle that works the bicep muscle.
So we could actually cut that little nerve branch and then we could connect to the elbow bending biceps muscle nerve. And that takes a little bit of time again to get going just because of what we were talking about before with nerves. But it's quite a bit quicker and it's usually kind of more within about six months.
And then, that nerve supply can actually work the bicep muscle and we can do that for number of different nerves. Kind of the common, we have one for the shoulder that we talked about and then one for the arm. And then, particularly, the elbow bending.
Dr. Mike Patrick: Since the brain is use to sending signals through that pathway to bend the wrist, is the retraining involved in terms of the brain figuring out what path the signals need to take in order now to bend the elbow.
Dr. Kim Bjorklund: You would think so. And certainly, in some other areas where we do that, there is some retraining. But in this, particularly, I think children are so plastic, we really don't see that. It actually, one that kind of regrows, they just are able to move it.
Dr. Mike Patrick: That so interesting and so many options. And I would imagine you have to think a little bit on the fly then, when you actually get in there. If a lot of the cases you don't know exactly the extend of the injury or where it is, in terms of technique, you may have to sort of change things up while you're doing surgery.
Dr. Kim Bjorklund: Yeah. No, that's exactly true and I think that's one of the hardest things not only for us, but also to talk to families about — is to say, "Well, we might do this, but maybe we'll do that. And may be that'll change."
And we talk about all these different areas where we may operate. And I think it's a little bit overwhelming at times, but you're right. Sometimes, if we think that we do have healthy nerves, that we end up getting in there and realize that either it's been pulled right out of the spinal cord. Or more often, it's just been damaged so close to where it starts in the spinal cord that we actually can't get right all the way back in there because it's just so close to the actual spinal cord. That then we have to move to the other nerve transfer option.
Dr. Mike Patrick: Another one of the techniques that I came across — and may be this is more in the adult world — but are there times when you would move a muscle itself along with its artery vein, nerve bundles, to the arm in order to get function back that otherwise, you couldn't get in any other way.
Dr. Kim Bjorklund: Sure. So this is typically a free-functioning muscle transfer. And this is something we would do in brachial plexus and if basically an arm doesn't have any function or has very poor function for instance and the injuries where all those nerves are affected, and they really don't get great recovery.
This is often after the initial operations and if they're just injured so badly, they don't have a good recovery. We'll typically try to get elbow bending and finger bending back. And one way we can do that is we can take the gracilis muscle, one of the thigh muscles on the inside of the thigh — again that sort of an extra that you don't really miss them.
We can use the artery and vein and nerve form that and actually use that as a working muscle and hook it up into, basically, the collar bone area and then to the elbow. And that muscle can actually work as the biceps muscle. And we would do a second one that can work as the finger-bending muscles.
It's not sort of a the first reconstruction we would start with. And it's typically a little bit older in childhood if there's not really much going on at all with the arm. But it's definitely something we do sort of as a salvage for being able to get more function.
Dr. Mike Patrick: Yeah, which is not going to be necessarily normal function but a little bit can be helpful.
Dr. Kim Bjorklund: For sure.
Dr. Mike Patrick: In terms of abilities and functioning at life.
Dr. Kim Bjorklund: For sure.
Dr. Mike Patrick: What about long-term outlook for those with brachial plexus injuries? Once you have good function back, does it stay? Is there concern for losing that movement again? And are there times when it takes a long time but you still do get full function back?
Dr. Kim Bjorklund: Yeah. So, again because the nerve takes so long to regrow, we typically talk about not seeing function for somewhere within the first year. Six to 12 months is when we start to see something and then we can see recovery about to three years.
Typically, function that people get back is not lost. Where we do see, kind common issues with brachial plexus is the shoulder continues to be a problem for children. So even a good recovery with a good working arm, what we can see as children get older is they start to have trouble with their shoulder.
And we're quite vigilant about following people for any problems with their shoulder, dislocations, and basically kind of looking at the shoulder joint, the glenohumeral joint sometimes with MRIs in childhood.
So, often what people will describe is that motion that was there in the shoulder starts to decrease. So certain actions that maybe someone was able to do, they're not. And what we typically see is that some of the muscles that are weaker stay weaker. And then some of the really strong muscles take over and that basically makes it hard to get the motion where you're reaching up above your head or reaching out to the side in something called external rotation.
And so, some of the treatments for that can extend from like the Botox we talked about before, the stretching and splinting, some other secondary surgeries to loosen up the shoulder joint and even to move some tendons around there to help with shoulder movement.
Dr. Mike Patrick: Very interesting. So, first let me say thank you for putting up with my sometimes ignorance on this topic. This is all brand new to me and I think to a lot of folks out there.
And in fact, you guys have a pretty unique multi-disciplinary program here at Nationwide Children's Hospital with the Brachial Plexus Program. And there really aren't a lot for multi-disciplinary programs like this. And so, this really is one of the areas where there are a lot of experts out there, right?
Dr. Kim Bjorklund: That's right. No, I mean we're really fortunate here to be able to have a group of people. We have some really excellent therapists dedicated to them, therapists who routinely work with only this type of injury. We assess children together. And then, we work as a multi-disciplinary team, from orthopedic to physical medicine and rehabilitation. And basically can combine our skills in order to be able to treat these children uniquely.
We're also fortunate to have a great nursing team and social work so that we can kind of really truly provide the team approach to this injury.
Dr. Mike Patrick: Yeah. So, folks can come from one clinic visit and see whatever specialist that they need. They don't need multiple appointments?
Dr. Kim Bjorklund: Yeah.
Dr. Mike Patrick: Or it depends.
Dr. Kim Bjorklund: It sometimes depends. We'll typically try to assess them as a team and certainly the therapist or surgeon but sometimes it's depending on your particular needs. They may need other separate appointments, but we definitely try to take a team approach to it.
Dr. Mike Patrick: Yeah. And we do have a lot of patients who come from outer state because of the uniqueness of this program. And I would imagine for those who are travelling along distance, there's more effort put in to making sure that their appointments are all in a nice compacted time frame.
Dr. Kim Bjorklund: Yeah. I know it's definitely important. Sometimes, too, if it's an ultrasound to look at shoulder or X-rays and to look for other injuries or anything like that, sometimes it's important to try to coordinate those things as well.
Dr. Mike Patrick: And for those folks who are travelling a distance, I would imagine there's also then coordination with their care providers back home because you don't necessarily want them travelling to Ohio too frequently. You wanted the things that can be done at home should be done at home and so there's probably a lot of figuring things out in that manner, too.
Dr. Kim Bjorklund: Yeah, exactly. Like you say, I really want to stress how important the therapy aspect of this is. There's only so much a surgeon can do with making, putting nerves together, or doing an operation if the joints are stiff and the muscles are tight. So, trying to get home exercise programs and trying to get therapists near a child's home, it's just critical to their outcome. Because that's really what makes the difference for these injuries.
Dr. Mike Patrick: Yeah. And I would imagine our therapists can talk to those local therapists and say, "Hey, if you've not seen this before, here's how we do it, here's the exercises and how often, the frequency." And give them an idea of sort of where to go based on their experience.
Dr. Kim Bjorklund: Exactly.
Dr. Mike Patrick: That's fantastic. And then, in terms of getting in contact with the programs. So, let's say there's a provider who maybe is a distance away and has a baby who's not moving their arm, how they can get in touch to make a referral to the Brachial Plexus Program here at Nationwide Children's?
Dr. Kim Bjorklund: So, they can either give us a call or go to the website and get a referral to the Brachial Plexus Program. There's a specific referral to Brachial Plexus through the section of Plastic Surgery. Then, the number is 614-722-6299. And they can get in touch with us and refer directly to our program.
Dr. Mike Patrick: Great. And we'll put a link to the Brachial Plexus Program and all the contact information in the Show Notes for this episode, 381, over at PediaCast.org, so folks can get connected with the program in an easy way.
So, Dr. Kim Bjorklund, plastic and reconstructive surgeon here at Nationwide Children's and director of the Brachial Plexus Program, thanks again for putting up with all my questions, even the ones that like, "Oh, what about this? What about that? Because I really don't know about these things.
Dr. Kim Bjorklund: No, thank you so much. It's wonderful to talk about these.
Dr. Mike Patrick: Yeah. Thanks so much for stopping by.
Dr. Kim Bjorklund: Thank you.
Dr. Mike Patrick: We are back with just enough time to say thanks to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also thanks to Dr. Kim Bjorklund, plastic and reconstructive surgeon at Nationwide Children's and director of our Brachial Plexus Program. Really do appreciate her taking time out of her busy schedule to drop by the studio and explain brachial plexus injuries to all of us.
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