What Can Be Done for the Adolescent Brachial Plexus Patient?
"She is now much more self-confident, more outgoing"
As printed in Issue #16, 2004 of Outreach, a publication of the United Brachial Plexus Network, Kent, Ohio. Article reprinted with persmission from the United Brachial Plexus Network (www.ubpn.org)
Written by the Brachial Plexus Team at Cincinnati Children's Hospital Medical Center
Brachial plexus injuries affect children of all ages. Effective treatment protocols for infants, toddlers and school-aged children are widely used. At times however, older children also require care. As a result, treatment plans tailored for the adolescent patient must be available. Here is an example:
Shaunese was first seen in the Brachial Plexus Center at Cincinnati Children's Hospital Medical Center in August of 2003 when she was 14 years old. She had never seen a specialist for her brachial plexus injury in her right arm, which she was diagnosed with at birth. Her family found out about the center during a doctor's visit last year. The Teen Clinic doctor was concerned with the mild curve in her back that had formed from years of compensating for the lack of movement in her right arm. He and her new occupational therapist recommended the Brachial Plexus Center at Cincinnati Children's.
Shaunese was born premature and weighed 8 lbs., 5 oz. Her parents remembered that there was no movement at all in her right arm, and they did not see any movement until she was about 1 year old. Shaunese's development was affected as she only used her left hand to play and did not crawl.
At just a few weeks of age, Shaunese started seeing an occupational therapist once a week. The treatment sessions decreased over the years until stopping altogether when she went to school at the age of 5. She was followed by a neurologist until she was 8 when the family was told that nothing could be done. The doctor said she would always be delayed. In retrospect, Shaunese's parents said, "Ten years ago people didn't know as much as they do today."
Shaunese had chronic pain for many years, especially in the winter. She went to the emergency room several times when she was younger with muscle spasms and extreme pain. She was put on the pain medication Neurontin" when she was 8 years old. It seemed to help, but she didn't like taking pills. "I could feel the rain and snow coming because the pain would be so bad," Shaunese said. "I always kept my arm wrapped under my clothes in the winter because it stayed so cold."
Shaunese's right arm was shorter and smaller around compared to her left arm. Her right sleeve always had to be rolled up. These differences led to difficulties at school. Since elementary school, kids have made fun of her saying things like, "your arm is broken," "it won't ever be right," "you're different from us." In elementary school, she couldn't play with the other kids on the monkey bars. In high school, she couldn't pursue her dream of being a cheerleader because of the limitations of her arm. Shaunese used to cry and ask her parents why this happened to her.
Shaunese didn't know what to expect when she went to her first Brachial Plexus Center appointment. Her therapist told her about other patients and the successful surgeries they had gone through. The therapist also wanted Shaunese to be realistic and understand that many of those kids were much younger when they had surgery. Her parents were scared for her and worried about the prospect of surgery.
Meeting Other Kids Like Her
When she arrived at clinic, Shaunese was surprised. "There were kids of all ages there which surprised me. I had never seen anyone like me before," she said. Shaunese is happy for the babies she sees at the Brachial Plexus Center, where kids and teens ages birth to 18 are treated. They are getting the assistance they need at a young age even having surgery as early as 3 months old. "It is nice to know children are getting help when they are so little, but it seems to me like the injury is happening more often."
At clinic, Shaunese's range of motion was observed to be very limited. She used numerous trunk and back movements to compensate for the lack of mobility in her arm. She reported having reoccurring pain in her right arm which she described as "muscle tightness" and / or "tingling" throughout her arm, especially when carrying heavy objects. She also reported back pain when she tried to move her right arm. The team determined there was likely impingement on the plexus from a tight pectoralis minor muscle resulting in coracoid pressure syndrome.
Shaunese also reported experiencing a variety of functional difficulties including the inability to fix her hair, scratch her nose, put on earrings, throw a ball, clap appropriately, or raise her hand in class to ask a question. She writes with her right hand, but she has always needed to use her left hand for everything else.
Developing Goals and Plan of Care
Shaunese developed the following goals with the Brachial Plexus Team:
- Reduce pain
- Gain ability to complete self-care tasks
- Improve sensation
- Achieve ability to carry items with her right arm without pain
- Improve supination (rotating her palm up)
Based on those goals, surgical options were discussed including humeral osteotomy with pectoralis minor release. The pros and cons were reviewed with Shaunese and her family. Shaunese decided to go forward with the surgery. "I want it more than anything," Shaunese said. An EMG and MRI were performed prior to surgery, the results were reviewed, and the surgery date was set. On the morning of the surgery, Shaunese woke up and looked in the mirror thinking. "This is the last time my arm will look like this."
Shaunese underwent surgery on December 30 having right humeral derotational osteotomy and pectoralis minor release procedures. A 3-inch incision was made at the front of her armpit and all work was done through it. The humerus bone was cut at the level of the lesser tuberosity (right below the "head" of the bone). The bone was then rotated 45 degrees and set in place with a plate. The pectoralis minor was released, and the arm was placed in a brace to be worn for the next six weeks. The procedure took less then two hours in the operating room.
Life After Surgery
Shaunese's mother thought recovering from surgery would take longer than it actually did. She said Shaunese "snapped right back" and wanted to go back to school immediately.
Since the surgery, Shaunese's range of motion has improved 50 degrees of shoulder abduction and 20+ degrees of external rotation. She can reach the back of her neck and can bring her hand to her mouth without her elbow sticking up. She is able to use her right hand to complete all of the personal self-care tasks she lacked previously. Her scar is only 1-1/2 inches long, and Shaunese reports having no pain.
Shaunese's father said that Shaunese is now more self-confident, is much more outgoing, and is perceived to be more "normal" by society standards.
Shaunese has enjoyed going to clinic for her follow-up appointments and seeing how her arm has improved since the surgery. "At my last clinic visit, I met a younger girl in the waiting room," Shaunese said. "We compared our injuries and what we could do. She hadn't had surgery yet, and it made me feel good to have her look up to me and see what could be done. I saw a little bit of me in her."
Shaunese is thrilled with the surgery results and what it has allowed her to do. She was even able to run track in the spring just a few months after the surgery. When talking about cheerleading next year she said, "I could do it now but don't want to because I play trombone in the band."
Shaunese is looking forward to her 16th birthday next month when she can get a job. In the meantime, she is able to make money being a hair stylist for her friends. "I can hold my arm up above my head long enough to do lots of weaves and braids." Her outlook on life has changed drastically from what she first expected. Her mother summarized it best when she said, "For 14 years doctors said nothing could be done. But then, by the grace of God, the team at Cincinnati Children's said, 'Yes, there is something.'" Shaunese added, "I don't know if the doctors realize how much they change peoples' lives."
