Brachial plexus injuries most commonly result from motor vehicle accidents, gunshot or stab wounds, contact sport accidents, or workplace accidents during heavy physical labour.
Injury may involve the upper 2 or 3 nerve roots (partial injury) or all 5 nerve roots (complete injury). Partial and complete brachial plexus injuries can both be repaired successfully. Complete injuries require multiple major operations over the course of several years, while partial injuries can often be corrected in a single operation.
Complete injuries can be ruptures (roots still connected to the spinal cord) or avulsions (roots detached from the spinal cord). Nerve transfer techniques, which can be successfully applied to both ruptures and avulsions, are the treatment of choice for microsurgical repair.
An injury that does not resolve within a few days will often require major surgical reconstruction. The speed of nerve regeneration after spontaneous recovery or nerve repair is about 1 mm per day (1 inch per month).
Given the time frame to permanent paralysis (about 1 year), surgical repair is best carried out by 4 to 6 months after injury.
Brachial plexus injuries are usually caused by trauma to the roots of the plexus as they exit the cervical spine. This most commonly occurs in road traffic accidents and falls from height. Inflammatory, neoplastic, and compressive causes are also possible. The effects of the injury can include paralysis, loss of sensation, and pain. The specific clinical presentation will depend on the roots involved and the degree of injury to each root.
History and exam
Key diagnostic factors
- presence of risk factors
- presence of polytrauma/multiple injury
- paralysis of shoulder
- paralysis of bicep
- numbness of radial digits of hand and shoulder
- paralysis of triceps
- paralysis of wrist/finger extensors
- flail/insensate extremity
- absent tendon reflexes
- motor vehicle accident
- improper positioning during surgery
- age <50 years
- male sex
- Parsonage-Turner syndrome
- tumours (primary and metastatic tumours)
- rib abnormalities
- metabolic disorders
1st investigations to order
Investigations to consider
upper (C5-6) with or without middle (C7) root injury
isolated lower root (C8-T1) injury
total root avulsion (C5-T1) injury
- Functional or psychogenic weakness (e.g., unilateral loss of motor function or psychogenic parkinsonism)
- Amyotrophic lateral sclerosis (ALS)
- Brain or spinal cord injury
- ACR appropriateness criteria: plexopathy
- Shoulder dystocia
Rotator cuff injury
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