In a child with a brachial plexus injury that limits elbow extension, forearm pronation, shoulder movement, and causes scapular winging while preserving hand function, which activities of daily living are likely to be problematic?

Expected ADL Problems in Brachial Plexus Injury with Preserved Hand Function

A child with brachial plexus injury affecting elbow extension, pronation, shoulder motion and scapular winging but preserved hand function will primarily struggle with overhead activities, reaching behind the back, bringing objects to the mouth, and bimanual tasks requiring forearm rotation, despite having intact grasp and finger movements.

Primary Functional Limitations

Shoulder-Related ADL Deficits

The most significant problems will involve:

• Overhead activities: Hair washing, combing, and reaching high shelves will be severely limited due to impaired shoulder abduction and external rotation 1, 2
• Behind-the-back activities: Toileting, tucking in shirts, and fastening back closures will be problematic due to limited internal rotation and the scapular winging 1
• Face and mouth activities: Bringing utensils to mouth, face washing, and tooth brushing may require compensatory trunk movements 3

External rotation limitation is the most persistent deficit, found in 60% of children with brachial plexus palsy, often accompanied by posterior glenohumeral subluxation or dislocation 2. This directly impacts the ability to position the hand in space for functional tasks.

Elbow and Forearm Limitations

Despite preserved hand function, the child will experience:

• Elbow extension deficit: Difficulty pushing objects away, performing push-ups, or reaching forward at table height 1
• Supination restrictions: Problems turning doorknobs, accepting change palm-up, or using utensils requiring palm-up positioning occur in 50% of cases 2
• Pronation limitations: Though less common than supination deficits, this affects writing position and tool use in 37% of patients 2

Critical insight: Research demonstrates that even with "good hand function," activities requiring forearm rotation create significant restrictions that are often underestimated 4. The preserved grasp doesn't compensate for inability to position the hand properly in space.

Bimanual Activity Challenges

The affected arm will show:

• Ineffective use as an assist hand: Stabilizing objects while the dominant hand manipulates them becomes difficult 1
• Reduced spontaneous use: Even when capable, children use the affected limb less frequently in daily activities 5
• Compensatory patterns: Over-reliance on trunk movements and the unaffected limb develops 1

Independence vs. Difficulty Spectrum

Important clinical reality: Nearly all children (all except 1 in a cohort of 17 with permanent lesions) achieve independence in ADLs, but 88% experience minor to moderate difficulties performing them 1. This means:

• They complete tasks but with increased time and effort
• Compensatory strategies become necessary
• Quality of movement is compromised even when tasks are accomplished
• One-third may require occasional assistance despite technical independence 3

Common Pitfalls in Assessment

Do not assume that preserved hand function equals preserved upper extremity function. The literature clearly shows that activity-based assessments reveal restrictions related to hand positioning and forearm rotation that aren't apparent when evaluating grasp alone 4.

Avoid overlooking the impact of scapular winging, which compounds shoulder dysfunction and creates additional limitations in reaching and lifting activities beyond what glenohumeral motion alone would predict.

Specific ADL Categories to Expect Problems

Based on the injury pattern described:

1. Self-care: Dressing upper body (especially overhead garments), fastening back closures, hair care
2. Feeding: May manage utensils but with altered mechanics; difficulty with two-handed food preparation
3. Hygiene: Face washing, tooth brushing require compensation; bathing upper body challenging
4. School/play: Writing endurance affected by pronation limits; sports requiring bilateral coordination impaired
5. Instrumental activities: Difficulty with tasks requiring sustained arm elevation or bilateral manipulation

The combination of limited shoulder motion, scapular winging, and forearm rotation deficits creates a functional profile where the child has the "tools" (hand function) but cannot reliably position those tools in space for efficient task completion 4, 1.