Paediatric brachial plexus surgery · UK
Correction of brachial plexus injuries in children, by a specialist team.
A dedicated paediatric brachial plexus service — serial assessment, nerve reconstruction where it is needed, secondary surgery for residual deformity, and a hand therapist alongside from the first weeks.
Why families choose us
- 01
A specialist paediatric BPI team
Not a general orthopaedic clinic. A dedicated brachial plexus injury team who see these children every week and follow them for years.
- 02
A fellowship-trained nerve surgeon
Primary reconstruction — nerve grafts and nerve transfers — is done by a surgeon who trained specifically in peripheral nerve surgery in children.
- 03
A paediatric hand therapist alongside
Splinting, range-of-motion work and family coaching begin in the first weeks and continue throughout — the therapy is as important as the surgery.
Indicative pricing
What paediatric brachial plexus care costs, privately.
Indicative ranges across our specialist paediatric centres. Send the details and we quote firm figures across the options that apply to your child.
In short
A specialist BPI consultation and initial workup: £950–£1,800. Primary reconstruction: from £12,000.
| Procedure | Indicative range | Typical duration | Stay / turnaround |
|---|---|---|---|
| Specialist BPI clinic consultation | £350–£600 | 45–60 min | Same visit |
| EMG and nerve conduction studies (child) | £600–£1,200 | 30–45 min | 1 week |
| MRI brachial plexus under GA (infant) | £1,800–£3,200 | Half-day | 3–5 days |
| Primary nerve reconstruction (grafts / transfers) | £12,000–£22,000 | 4–8 hrs | 2–3 nights |
| Secondary tendon transfer (Hoffer / L’Episcopo) | £8,000–£14,000 | 2–4 hrs | 1–2 nights |
| Humeral rotational osteotomy | £9,000–£15,000 | 2–3 hrs | 1–2 nights |
Prices vary by centre, by which surgeon leads the case, and by whether combined nerve transfers are needed. Every plan is bespoke to the child. We come back with a firm quote and an honest opinion on urgency within one working day.
The problem
The right team, at the right time, for the right child.
Obstetric brachial plexus injury is uncommon, and away from specialist centres the three-month decision point is easy to miss. Get it right and reconstruction is possible; get it late and the muscle windows begin to close.
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Not sure if surgery is needed?
Many babies recover without operation. A specialist assessment tells you whether yours is one of them, before any surgical decision is made.
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Worried about missing the window?
No biceps recovery by three months is the classic trigger for reconstruction. We watch this actively — you are not left to notice it yourself.
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Left with a stiff shoulder later?
Residual deformity in older children can still be helped. Tendon transfers and rotational osteotomy improve the arm’s position and function.
The journey
From referral to review — what happens, in order.
One specialist team from the first BPI clinic visit through primary reconstruction, secondary surgery and long-term follow-up.
Phase 1 · Before reconstruction
Referral, serial assessment, investigations
Phase 2 · Surgery
Primary and, if needed, secondary reconstruction
Phase 3 · After
Therapy and long-term review
- 01
Before
Referral to the BPI clinic
Most babies are referred from the postnatal ward or the GP in the first weeks of life. We accept referrals up to school age for children with residual weakness or deformity.
- 02
Before
Serial assessment in clinic
Repeat examinations at monthly intervals. Movement is scored, spontaneous recovery is tracked, and photographs and videos are kept for comparison.
- 03
Before
EMG, nerve conduction and MRI
Nerve studies around three months, and an MRI if root avulsion is suspected — pseudomeningoceles on the scan point to a nerve torn from the spinal cord.
- 04
Surgery
Primary reconstruction, 3 to 9 months
If there is no biceps recovery by three months, nerve grafts and nerve transfers (for example Oberlin — ulnar fascicle to biceps) are done under GA in a paediatric theatre.
- 05
Surgery
Secondary reconstruction, later
For residual shoulder, elbow or hand deformity — modified Sever release, latissimus or teres major transfers (Hoffer, L’Episcopo), humeral rotational osteotomy, or wrist and hand tendon transfers.
- 06
After
Physio and splinting throughout
Passive range-of-motion at home from the first weeks, splinting to prevent contractures, and hand therapy sessions that continue for years after any surgery.
- 07
After
Long-term follow-up to skeletal maturity
The shoulder is watched for glenohumeral dysplasia and the arm is measured for length differences. Review continues into the teenage years.
Typical timeline: first BPI clinic within weeks of birth. Decision on primary reconstruction by three months. Follow-up continues to skeletal maturity.
Presentations we see
The patterns of injury and the risk factors behind them.
The clinical presentations we assess most often, the birth-related risk factors, and the one red flag that means urgent specialist review.
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Erb’s palsy (C5–C6)
The classic pattern — a “waiter’s tip” posture with a limp shoulder and elbow. The commonest form and the one most likely to recover.
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Extended Erb’s (C5–C7)
Shoulder, elbow and wrist extension all weak. Recovery is less predictable and reconstruction is often needed.
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Total plexus injury (C5–T1)
A flail arm with no active movement at all. Always requires specialist assessment and usually primary reconstruction.
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Klumpke’s palsy (C8–T1)
A rare pattern with a weak hand and preserved shoulder. Often associated with Horner’s syndrome and root avulsion.
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Shoulder dystocia at delivery
A stuck shoulder at birth is the commonest mechanism — stretch or rupture of the upper trunk of the plexus.
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Macrosomia and instrumental delivery
Large-for-dates babies, breech deliveries and forceps or ventouse extractions all raise the risk of an obstetric brachial plexus injury.
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Residual deformity in older children
Internal rotation contracture of the shoulder, limited hand opening, or a short arm — all can be improved by secondary surgery.
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Red flag: Horner’s or breathing trouble
A drooping eyelid and small pupil, or fast breathing from a paralysed diaphragm, suggest root avulsion — an urgent specialist referral.
Procedure options
The reconstructive options, by Narakas grade and by procedure.
What each option actually involves — from the first primary reconstruction in infancy to the tendon transfers and osteotomies used later.
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Narakas I — Erb’s (upper trunk)
Most recover spontaneously by three to six months. Primary reconstruction only if elbow flexion has not returned by three months.
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Narakas II — extended upper
C5–C7 involvement. Nerve grafts to the upper trunk with a spinal accessory to suprascapular transfer for shoulder external rotation.
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Narakas III — total palsy
C5–T1 without Horner’s. Combined nerve grafts and multiple transfers — Oberlin ulnar-to-biceps for elbow flexion is a workhorse.
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Narakas IV — total palsy with Horner’s
The most severe grade, strongly suggesting root avulsion. Priorities become elbow flexion and basic hand function.
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Nerve graft (sural nerve donor)
Ruptured nerves are bridged with cable grafts of the child’s own sural nerve — the leg is a common donor site with little long-term deficit.
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Oberlin nerve transfer
A fascicle of the ulnar nerve is rerouted to the motor branch of biceps to restore elbow flexion — reliable when done in the first year.
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Modified Sever release + tendon transfer
For internal rotation contracture of the shoulder — soft-tissue release with latissimus and teres major transfer (Hoffer, L’Episcopo) to restore external rotation.
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Humeral rotational osteotomy
Later in childhood, if the glenohumeral joint is already remodelled, rotating the humerus itself puts the hand in a more useful position.
Our vetted UK network
A small panel of paediatric BPI teams, we picked them.
Multidisciplinary paediatric brachial plexus services across the UK. Introductions are made privately, once we understand your child’s pattern and timing.
Selection criteria
How we choose every team in our network.
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Consultant paediatric brachial plexus surgeons — not general orthopaedic trainees
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Fellowship training in peripheral nerve reconstruction and paediatric microsurgery
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A named hand therapist assigned to every child from the first clinic visit
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Long-term follow-up through the multidisciplinary Erb’s Palsy clinic to skeletal maturity
Safety and recovery
What to expect afterwards — honestly.
Reconstruction is safe in the right hands, but nerve recovery is slow and therapy is central. Here is what matters most for parents to plan for.
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Many injuries recover on their own
Around two-thirds of babies with obstetric brachial plexus injury recover useful function without surgery. The key is not to miss the ones who won’t.
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Three months is the decision point
No biceps contraction by three months is the classic trigger for considering primary nerve reconstruction — delaying much beyond nine months reduces the chances.
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MRI needs a general anaesthetic
A high-quality plexus MRI in a small child needs a GA to keep them still. It is not needed for every baby — only when root avulsion is suspected.
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Nerves regrow slowly
After a nerve graft or transfer, muscle recovery takes months. Movement is not expected in the first few months and does not mean the surgery failed.
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Splinting prevents contractures
The main risk of not doing therapy is a stiff, internally rotated shoulder that becomes hard to correct later — passive stretching is not optional.
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Glenohumeral dysplasia can develop silently
Even a well-recovered Erb’s palsy can leave a shallow shoulder socket. We rescan the shoulder around age two to three if there is any residual weakness.
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Psychological impact matters
Older children notice the difference in their arm — school, sport and body image all need thinking about, and the therapy team supports the whole family.
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Missed diagnosis is still common
Away from specialist centres, a subtle Erb’s palsy is easy to miss in the first weeks. If in doubt, ask for a paediatric BPI referral.
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Red flags
A drooping eyelid, fast breathing, a totally flail arm, or no biceps by three months are all reasons to insist on specialist review.
Reading your clinic letter
Your clinic letter in four parts. Read the last one first.
Whichever stage of the journey you are at, the letters from the BPI team keep to the same shape.
A quiet reminder
Surgical and neurological language is precise and can read coldly — we translate it for you.
If you would like us to talk you through the letter before your next appointment, just ask.
- 01 History
Birth history and mechanism
Weight, presentation, whether there was shoulder dystocia, forceps or ventouse — and when the arm was first noticed to be weak.
- 02 Examination
Movement grading and Narakas class
Active movement at shoulder, elbow, wrist and hand is scored. The Narakas grade (I–IV) frames the likely prognosis and the reconstructive plan.
- 03 Investigations
EMG, nerve conduction and MRI
Nerve study results and MRI findings — presence or absence of pseudomeningoceles pointing to root avulsion.
- 04 Plan
Surgery, therapy and review timing
Read this first: whether primary reconstruction is planned, what secondary options are on the horizon, and when the child will next be seen.
Recognised by major UK insurers
Cover for paediatric brachial plexus reconstruction varies by insurer and by individual plan — usually funded when medically indicated. We confirm cover with your insurer before booking.
Frequently asked
Everything parents ask about brachial plexus injury.
Straight answers on the three-month decision, the Oberlin transfer, the therapy schedule, and how the shoulder is watched over the years.
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What is an obstetric brachial plexus injury?
A stretch or tearing injury of the nerves in the neck and shoulder (C5–T1) that happens during birth — most often when a baby’s shoulder gets stuck (shoulder dystocia) or the baby is large. It causes weakness in the arm on the affected side. It affects roughly 1 to 2 babies per 1000 births.
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Will my baby’s arm get better on its own?
Many do. Somewhere between half and two-thirds of babies with obstetric brachial plexus injury recover useful function without surgery, usually within three to six months. The specialist clinic watches for the ones who are not recovering and offers surgery to those children in time.
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When does my child need nerve reconstruction?
The classic rule is: if there is no biceps contraction (no elbow flexion) by three months of age, primary reconstruction with nerve grafts or nerve transfers is considered, usually between three and nine months. Waiting much longer reduces the muscle’s ability to recover.
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What is the Narakas classification?
A four-grade system that describes how much of the brachial plexus is injured. Grade I is Erb’s palsy (C5–C6). Grade II adds C7. Grades III and IV are total palsies affecting all five nerve roots, with grade IV also including Horner’s syndrome and the worst prognosis.
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What is an Oberlin transfer?
A specific nerve transfer where a small fascicle of the ulnar nerve at the upper arm is rerouted to the motor branch of the biceps muscle, restoring the ability to bend the elbow. It is reliable, sacrifices very little hand function, and is now standard for restoring elbow flexion after upper-trunk injury.
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What are secondary procedures?
Operations done later in childhood to improve residual deformity — commonly a modified Sever release with a latissimus or teres major tendon transfer (Hoffer, L’Episcopo) to improve shoulder external rotation, or a humeral rotational osteotomy if the shoulder joint has already remodelled.
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Does my child need physiotherapy for life?
Formal therapy is most intense in the first years — daily passive stretches at home, weekly sessions in clinic, and splinting to prevent contractures. It reduces over time, but reviews continue into the teenage years to watch for shoulder dysplasia and arm length differences.
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Why does the shoulder joint develop dysplasia?
When the muscles that pull the shoulder inward (internal rotators) recover before the external rotators, they pull the head of the humerus backwards and reshape the socket. This glenohumeral dysplasia can develop even when the arm looks reasonably well recovered, which is why the shoulder is imaged around age two to three.
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What is the emotional impact on families?
It is real and it matters. A birth injury is not the arrival most families imagined, and older children notice differences at school and in sport. Every specialist BPI service includes psychological support for the child and the parents alongside the surgical and therapy plan.
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When should I insist on a specialist BPI referral?
A totally flail arm, a drooping eyelid with small pupil (Horner’s), fast breathing suggesting a paralysed diaphragm, no biceps movement by three months, or a shoulder that is becoming stiff — any of these mean the child should be seen in a specialist paediatric brachial plexus clinic without delay.
Related
Looking for something else?
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Clavicle fixation
Surgical fixation of a broken collarbone — a related birth injury.
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Musculoskeletal MRI
MRI of the plexus, shoulder or limb for children and adults.
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Nerve conduction studies
Electrical testing of nerve and muscle function.
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All tests & procedures
Every test and procedure we arrange.
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Migraine
Related condition guide.
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Multiple Sclerosis
Related condition guide.
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Eeg
Related diagnostic test.
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In practice, in London
Booking correction of brachial plexus injuries in children privately in London — what actually happens
For correction of brachial plexus injuries in children, the private London route is mostly about consultant fit and hospital choice rather than raw waiting time. Waiting lists on the NHS for correction of brachial plexus injuries in children vary widely by borough and by how the GP letter reads. Privately in London, we can normally offer a slot inside the same week, sometimes within 48 hours if there’s a cancellation. The difference isn’t clinical quality — the consultants are frequently the same faces you’d see on the NHS — it’s the calendar.
Once you’re in the private system for correction of brachial plexus injuries in children, the pace picks up noticeably. Consultant slots run to time, imaging is usually available in the same building or a short walk away, and the report comes back typed and detailed. It’s the coordination that tends to feel different — one person on the other end of the phone, not a switchboard. For correction of brachial plexus injuries in children in particular, we bias towards consultants who do this every week rather than every month.
There are a lot of consultants in London who can technically handle correction of brachial plexus injuries in children. Fewer who do it week in, week out for the exact question you’re bringing. We spend most of our time working out which is which — and being straight when a different test or a different specialist would serve you better. Everything runs to CQC, GMC and Royal College standards; the choice is about fit, not floor.
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