Brachial Plexus Injury

What is Brachial Plexus?

The brachial plexus is a complex network of nerves located in the neck and shoulder region. It is responsible for sending signals from the spinal cord to the shoulder, arm, and hand, enabling movement and sensation.

This nerve network is formed by the merging of spinal nerves C5 to T1, which branch out to control the muscles and skin of the upper limb.

Damage to the brachial plexus can result in weakness, loss of sensation, or even paralysis of the arm, depending on the severity and location of the injury.

What is the Function of Brachial Plexus?

The brachial plexus serves several vital functions:

• Motor Function: It transmits nerve signals from the spinal cord to the muscles in the shoulder, arm, forearm, and hand. This allows for voluntary movements such as lifting, grasping, and fine motor skills.

• Sensory Function: It carries sensory information from the skin, joints, and muscles of the upper limb back to the brain. This enables sensations such as touch, temperature, and pain.

• Reflexes: The brachial plexus is involved in reflex actions, which are automatic responses to certain stimuli, helping protect the body from injury.

Overall, the brachial plexus is essential for the coordinated and functional use of the upper limb.

What are Brachial Plexus Injuries?

Brachial plexus injuries occur when the network of nerves that send signals from the spinal cord to the shoulder, arm, and hand is stretched, compressed, or torn. These injuries can vary in severity:

• Stretch Injuries: Often result from the nerve being stretched too far, common in minor accidents or during childbirth.

• Compression Injuries: Occur when pressure is applied to the nerve, possibly due to tumors or prolonged pressure on the shoulder.

• Ruptures: Involve the tearing of the nerve and usually result from more severe trauma.

• Avulsions: The most severe type, where the nerve is torn away from the spinal cord, often seen in high-impact accidents.

Symptoms can range from mild weakness to complete paralysis of the affected arm, along with loss of sensation and pain. Treatment depends on the type and severity of the injury, with options including physical therapy, medications, and in some cases, surgery.

Brachial Plexus Anatomy

The brachial plexus is a network of nerves that originates from the spinal cord in the neck and extends through the shoulder to the arm. Its anatomy can be broken down into five key segments:

1. Roots: The brachial plexus begins with five nerve roots that emerge from the spinal cord. These roots are the anterior rami of the C5, C6, C7, C8, and T1 spinal nerves.

2. Trunks: The roots merge to form three trunks:

• The upper trunk is formed by the union of the C5 and C6 roots.

• The middle trunk is a continuation of the C7 root.

• The lower trunk is formed by the union of the C8 and T1 roots.

3. Divisions: Each trunk splits into an anterior and a posterior division. These divisions are responsible for innervating the flexor (anterior) and extensor (posterior) compartments of the arm.

4. Cords: The divisions then regroup to form three cords, named according to their position relative to the axillary artery:

• The lateral cord is formed by the anterior divisions of the upper and middle trunks.

• The medial cord is formed by the anterior division of the lower trunk.

• The posterior cord is formed by the posterior divisions of all three trunks.

5. Branches: Finally, the cords give rise to the major nerves of the upper limb:

• The musculocutaneous nerve, which innervates the muscles of the anterior arm.

• The axillary nerve, which innervates the deltoid and teres minor muscles.

• The radial nerve, which innervates the posterior arm and forearm.

• The median nerve, which innervates most of the anterior forearm muscles and some hand muscles.

• The ulnar nerve, which innervates some forearm and most of the hand muscles.

This intricate arrangement allows the brachial plexus to control the complex movements and sensations of the shoulder, arm, and hand.

Common Causes of Brachial Plexus Injuries

Brachial plexus injuries can result from various factors, ranging from traumatic events to complications during childbirth. Understanding these causes is crucial for prevention, timely diagnosis, and effective treatment. This section explores the primary causes of brachial plexus injuries, dividing them into those occurring at birth and those affecting adults.

Causes of Obstetric Brachial Plexus Injury (Brachial Plexus Injury at Birth)

• Shoulder Dystocia: This occurs when a baby's shoulder gets stuck behind the mother's pelvic bone during delivery, leading to excessive stretching of the brachial plexus nerves.

• Breech Delivery: Babies delivered feet or buttocks first are at a higher risk of brachial plexus injury due to unusual positioning and increased traction on the neck and shoulders.

• Large Birth Weight: Babies with a higher birth weight often have more difficulty passing through the birth canal, increasing the likelihood of nerve damage.

• Prolonged Labor: Extended labor can result in increased stress on the baby's shoulders and neck, heightening the risk of brachial plexus injury.

• Instrument-Assisted Delivery: The use of tools such as forceps or vacuum extractors during delivery can sometimes result in excessive force being applied to the baby's head and neck, causing nerve injury.

Causes of Brachial Plexus Injuries in Adults

• Trauma: High-impact accidents, such as car crashes or motorcycle accidents, are common causes. These incidents can cause the nerves to stretch, compress, or tear due to the sudden and forceful movement of the head and neck.

• Sports Injuries: Contact sports like football, wrestling, and rugby pose a risk of brachial plexus injuries. Athletes may experience nerve damage from direct blows to the neck or shoulder or from falls that overstretch the nerves.

• Falls: Falls from significant heights or severe impacts can result in brachial plexus injuries, particularly in older adults or those with underlying health conditions that affect nerve health.

• Tumors: Growths or tumors in the neck or shoulder area can compress the brachial plexus nerves, leading to pain, weakness, and loss of function in the affected arm.

• Inflammatory Conditions: Certain medical conditions, such as brachial plexitis (Parsonage-Turner syndrome), involve inflammation of the brachial plexus, resulting in sudden and severe shoulder pain followed by weakness and atrophy of the shoulder and arm muscles.

Types of Brachial Plexus Injuries

Brachial plexus injuries can manifest in various forms, depending on the nature and extent of the damage to the nerve network. Each type has distinct characteristics, causes, and implications for recovery. This section delves into the different types of brachial plexus injuries, providing a detailed understanding of their nature and impact.

Brachial Plexus Neuropraxia (Stretch)

Brachial plexus neuropraxia, also known as a stretch injury, is the most common and least severe type of brachial plexus injury. It occurs when the nerves are overstretched but not torn.

• Causes: Often seen in contact sports like football and wrestling, or during childbirth in cases of shoulder dystocia.

• Symptoms: Temporary weakness, numbness, or a burning sensation in the arm. Symptoms usually resolve on their own within a few days to weeks.

• Prognosis: Recovery is typically complete, with no long-term damage.

Brachial Plexus Rupture

A brachial plexus rupture involves the tearing of one or more of the nerve fibers, but the nerve itself remains connected.

• Causes: Severe trauma, such as car accidents or high-impact sports injuries.

• Symptoms: Loss of muscle function and sensation in the affected arm, along with severe pain.

• Prognosis: Surgery is often required to repair the torn nerves. Recovery depends on the extent of the injury and the success of surgical intervention.

Brachial Plexus Neuroma

A neuroma occurs when scar tissue forms at the site of a nerve injury, compressing the nerve and causing pain.

• Causes: Can develop after any type of brachial plexus injury, particularly if the nerve heals improperly.

• Symptoms: Chronic pain, tingling, and weakness in the arm.

• Prognosis: Treatment may involve surgical removal of the neuroma or other pain management strategies. Recovery varies based on the severity and treatment effectiveness.

Brachial Neuritis

Brachial neuritis, also known as Parsonage-Turner syndrome, is an inflammatory condition affecting the brachial plexus.

• Causes: The exact cause is often unknown but can be triggered by infections, vaccinations, or autoimmune responses.

• Symptoms: Sudden and severe shoulder pain followed by muscle weakness and atrophy in the shoulder and arm.

• Prognosis: Pain typically subsides within a few weeks, but muscle weakness can persist for a longer period. Physical therapy is essential for recovery.

Brachial Plexus Avulsion

A brachial plexus avulsion is the most severe type of injury, where the nerve is torn away from the spinal cord.

• Causes: Extreme trauma, such as motorcycle accidents or falls from significant heights.

• Symptoms: Complete loss of function and sensation in the affected arm, along with severe, unrelenting pain.

• Prognosis: This injury often results in permanent damage. Surgical options, such as nerve grafts or transfers, may provide some functional recovery, but full restoration is rare.

Symptoms of Brachial Plexus Injuries

Brachial plexus injuries can present a variety of symptoms depending on the type and severity of the injury. Recognizing these symptoms is crucial for early diagnosis and appropriate treatment. Below is a list of common symptoms associated with brachial plexus injuries:

• Weakness in the shoulder, arm, or hand

• Numbness or loss of sensation in the arm or hand

• Severe, burning pain in the shoulder or arm

• Inability to use certain muscles in the shoulder, arm, or hand

• Muscle atrophy or wasting in the affected area

• Loss of movement or paralysis in the shoulder, arm, or hand

• Tingling or abnormal sensations in the arm or hand

Diagnosis for Brachial Plexus Injuries

Diagnosing brachial plexus injuries involves a comprehensive evaluation to determine the extent and specific type of nerve damage. Early and accurate diagnosis is essential for developing an effective treatment plan. The diagnostic process typically includes the following steps:

• Medical History and Physical Examination:

• Medical History: The doctor will begin by taking a detailed medical history, asking about the nature of the injury, symptoms, and any previous injuries or medical conditions that could affect the brachial plexus.

• Physical Examination: A thorough physical exam will be conducted to assess muscle strength, reflexes, and sensation in the affected arm. The doctor will look for signs of muscle atrophy and test the range of motion.

• Imaging Studies:

• MRI (Magnetic Resonance Imaging): MRI scans provide detailed images of the soft tissues, including the brachial plexus, helping to identify nerve damage, inflammation, or tumors.

• CT Myelography: This specialized type of CT scan uses contrast dye to highlight the spinal cord and nerve roots, providing detailed images of the brachial plexus and helping to identify avulsions or other injuries.

• Ultrasound: High-frequency sound waves are used to produce images of the nerves and surrounding tissues, which can help detect abnormalities in the brachial plexus.

• Electrodiagnostic Studies:

• Electromyography (EMG): EMG measures the electrical activity of muscles and can help identify which muscles are not receiving proper nerve signals, indicating nerve damage.

• Nerve Conduction Studies (NCS): NCS evaluate the speed and strength of electrical signals traveling through the nerves, helping to pinpoint the location and extent of nerve damage.

• Nerve Block:

• A nerve block involves injecting a local anesthetic around specific nerves to temporarily block pain signals. This can help determine the exact location of the injury and the specific nerves involved.

• Surgical Exploration:

• In some cases, if other diagnostic methods are inconclusive, surgical exploration may be necessary. This involves a direct examination of the brachial plexus during surgery to identify and assess the extent of the injury.

Accurate diagnosis is crucial for developing an effective treatment plan, which may include physical therapy, medication, or surgery. Early intervention can significantly improve outcomes for individuals with brachial plexus injuries.

Brachial Plexus Injury Treatments

Treating brachial plexus injuries involves a range of approaches tailored to the severity and type of nerve damage. The goal is to restore as much function as possible and alleviate symptoms. Treatment can be broadly categorized into surgical and nonsurgical methods. Understanding these options is crucial for determining the best course of action for recovery and rehabilitation.

Surgical Treatments for Brachial Plexus Injury

Surgical treatments for brachial plexus injuries are often necessary when there is significant nerve damage that cannot heal on its own. These procedures aim to restore function and sensation in the affected arm by repairing or reconstructing the damaged nerves. Below are the main surgical options for treating brachial plexus injuries.

Nerve Repairs and Nerve Transfers

• Nerve Repairs: This procedure involves directly suturing the severed ends of a nerve. It is most effective when performed soon after the injury, before scar tissue develops.

• Nerve Transfers: When the original nerve cannot be repaired, surgeons may transfer a healthy nerve from another part of the body to restore function. This involves redirecting nerve fibers to reinnervate the muscles and skin areas affected by the injury.

Free Tissue Muscle Transplant

• Procedure: This technique involves transplanting muscle tissue along with its blood and nerve supply from another part of the body to the affected area. It is used when there has been significant muscle loss.

• Purpose: The transplanted muscle helps restore movement and function. Surgeons connect the blood vessels and nerves of the transplanted muscle to those in the affected area to ensure it becomes functional.

Tendon Transfers

• Procedure: Tendon transfer surgery involves redirecting tendons from functioning muscles to replace damaged ones. The surgeon reattaches a tendon from a working muscle to a paralyzed muscle or joint.

• Purpose: This method aims to restore specific movements and improve the range of motion in the affected limb, compensating for lost muscle function due to nerve damage.

Who Can Perform This Type of Surgery?

• Specialized Surgeons: Brachial plexus surgery is complex and requires specialized skills. Orthopedic surgeons, plastic surgeons, and neurosurgeons with expertise in peripheral nerve surgery typically perform these procedures.

• Multidisciplinary Teams: Often, a team approach is employed, involving different specialists to address various aspects of the injury and ensure comprehensive care.

• Qualifications: Surgeons performing these procedures have extensive training in microsurgery and nerve reconstruction techniques. They often work in specialized centers equipped with advanced surgical tools and technologies.

These surgical interventions offer hope for individuals with severe brachial plexus injuries, providing the potential for significant functional recovery and improved quality of life.

Surgeons

Assoc. Prof. Ahmet Hamdi Sakarya

Assoc. Prof. Ahmet Hamdi Sakarya, a leading Plastic, Reconstructive & Aesthetic Surgeon with Care in Turkey, specializes in innovative aesthetic solutions.

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Nonsurgical Treatments for Brachial Plexus Injury

Nonsurgical treatments for brachial plexus injuries aim to alleviate symptoms, improve function, and promote nerve healing. These approaches are often used for less severe injuries or in conjunction with surgical treatments to enhance recovery. Here are the primary nonsurgical treatments for brachial plexus injuries.

Physical Therapy

• Exercises: Tailored exercises help maintain muscle strength and flexibility, prevent joint stiffness, and promote nerve recovery.

• Techniques: Physical therapists may use techniques such as range-of-motion exercises, strength training, and functional training to restore movement and improve daily function.

• Goals: The primary goal is to enhance mobility, prevent muscle atrophy, and support overall arm and hand function.

Occupational Therapy

• Activities: Occupational therapists assist patients in relearning daily activities such as dressing, eating, and writing.

• Adaptive Devices: They may recommend and train patients to use adaptive devices or modifications to improve independence and safety.

• Focus: The focus is on improving fine motor skills, coordination, and hand function to maximize independence in daily life.

Pain Management

• Medications: Over-the-counter pain relievers, anti-inflammatory drugs, and prescribed medications can help manage pain and reduce inflammation.

• Nerve Blocks: Injections of anesthetic near the nerves can provide temporary pain relief and help in diagnosing the exact location of the injury.

• Therapies: Techniques such as transcutaneous electrical nerve stimulation (TENS), heat or cold therapy, and acupuncture can also be effective in managing pain.

Bracing and Splinting

• Support Devices: Braces and splints can stabilize joints, support weakened muscles, and prevent contractures (permanent tightening of muscles or tendons).

• Customization: These devices are often custom-made to fit the patient’s specific needs and ensure optimal support and comfort.

• Usage: Bracing and splinting are used to maintain proper alignment, improve function, and protect the affected limb during recovery.

Electrical Stimulation

• Purpose: Electrical stimulation uses mild electrical currents to stimulate nerves and muscles, promoting muscle contraction and preventing atrophy.

• Application: This treatment can be applied during physical therapy sessions to enhance the effectiveness of exercises and improve muscle strength.

• Benefits: It helps in maintaining muscle mass, improving blood circulation, and accelerating nerve regeneration.

Lifestyle Modifications

• Activity Modification: Patients are advised to avoid activities that exacerbate symptoms and to implement ergonomic adjustments to reduce strain on the affected area.

• Healthy Habits: Maintaining a healthy diet, staying hydrated, and avoiding smoking can support overall nerve health and recovery.

• Education: Patients are educated on proper body mechanics and posture to prevent further injury and support healing.