Surgical Procedures
Brachial Plexus Surgery Treats an Infant’s Erb’s Palsy

By Kerry Breen

Edited By Allison Elyse Gualtieri

/ CBS New

Read the article on CBS News

Tyler Theroux came into the world with a brachial plexus birth injury that kept his left arm dysfunctional and contorted in pain. As a child, he couldn’t engage in playground activities like the monkey bars, and his classmates would bully him about the injury.

Eventually, Theroux dropped out of school to be homeschooled. While the teasing stopped, the pain didn’t: His parents watched him experience fresh agony with every growth spurt. The brachial plexus is the group of nerves that sends signals from the spinal cord to the shoulder, arm and hand, and that nerve pain kept him awake at night, despite multiple attempts at surgery and therapeutic treatment.

A Rare, Yet Catastrophic Injury

A pediatric patient with Erb’s palsy experienced a remarkable recovery after specialists at NYU Langone Health teamed up to perform early microsurgical reconstruction and intensive occupational therapy. The patient first presented to the pediatric orthopedic hand surgery clinic at Hassenfeld Children’s Hospital for evaluation of her right upper extremity by Andrew E. Price, MD and Jacques H. Hacquebord, MD, attending surgeons on the case.

“Brachial plexus birth injuries require a team of highly specialized experts, including surgeons and occupational therapists,” says Dr. Price. “After birth, these injuries are usually treated conservatively using custom splints, electrical stimulation, and occupational therapy—we’re one of the few centers capable of doing all three.”

“These injuries are usually treated conservatively using custom splints, electrical stimulation, and occupational therapy—we’re one of the few centers capable of doing all three.“
Andrew E. Price, MD

Despite conservative management, the patient failed to regain biceps function at 6 months of age. The best treatment was determined to be brachial plexus neurolysis with double fascicular nerve transfer. Dr. Price, Dr. Hacquebord, and their team also injected botulinum toxin into several antagonist muscle groups during the procedure to improve shoulder and elbow motion.

“The prognosis of Erb’s palsy depends on several factors including the extent of the injury, size and severity of the post-ganglion tears, speed of recovery, and quality of initial treatment,” says pediatric occupational therapist Lori B. Ragni, MS, OTR/L. “While surgical repair is not always needed, in the right setting it will enable better functional outcomes, especially when combined with occupational therapy.”

“While surgical repair is not always needed, in the right setting it will enable better functional outcomes, especially when combined with occupational therapy.“

Lori B. Ragni, MS, OTR/L

Upon discharge, the patient continued outpatient rehabilitation with Rusk Rehabilitation. Two years after surgery, the patient is doing extremely well, with sustained improvements in several clinical and functional outcomes.

Surgeon's view of a large neuroma in the next of an infant

The patient’s right upper extremity was held with shoulder internally rotated, elbow extended, wrist flexed, and forearm pronated. She demonstrated excellent triceps strength but had no biceps function. Moreover, she did not exhibit shoulder elevation or active wrist extension. The patient was referred for occupational therapy and splinting, with surgery ultimately deemed necessary.

Surgeon's view while identifying nerves in the patient's arm

Upon exploration of the right brachial plexus. the C6 nerve was found to have significant scarring and lack of stimulus conduction. There was contractility of the deltoid with stimulation at 2mA of C5 proximally, but no contractility with stimulation of C6. The team proceeded with the procedure that included neurolysis of the brachial plexus and double fascicular nerve transfer.

Surgeon's view of nerves in the patient's arm after transfer

At 2-year follow up, the patient demonstrated significant improvement. She had regained shoulder elevation to above 130 degrees, full passive shoulder external rotation, negative clarion, active elbow flexion, supination to 10 degrees, no elbow flexion contracture, and some active extension of the wrist.

Related Articles

From inspiring patients to thorough research, our blog is for doctors seeking answers and information.

View All
Redefining the Management of Fuchs Dystrophy

Redefining the Management of Fuchs Dystrophy

Since its introduction in the United States in the mid-2010s, Descemet stripping only (DSO) has revolutionized the surgical management of Fuchs dystrophy. Although similar procedures were originally explored in the 1950s and for some time after, these met with little success.

The current technique—pioneered in the United States by Kathryn A. Colby, MD, PhD, the Elisabeth J. Cohen, MD, Professor of Ophthalmology and chair of the Department of Ophthalmology at NYU Grossman School of Medicine—involves removal of the diseased endothelium and mound-shaped aggregates, known as guttae, without the need for a donor graft.

NYU Langone Convenes World’s Experts on Bionic Reconstruction

NYU Langone Convenes World’s Experts on Bionic Reconstruction

From early on in his career, Jacques Hacquebord, MD, performed major reconstructive work on patients at NYC Health +
Hospitals/Bellevue, including many with hand and arm amputations. Caring for these patients introduced him to the fascinating
world of prosthetic devices. Working with occupational therapists, mental health experts, and those who make and fit artificial
limbs, known as prosthetists, he saw a field brimming with potential.