Classification of brachial plexus injury:

Preganglionic:
 avulsion proximal to dorsal root ganglion
 involves CNS which does not regenerate – little potential recovery of motor function (poor prognosis)
 lesions suggesting preganglionic injury:
 Horner’s syndrome
 disruption of sympathetic chain
 winged scapula medially- loss of serratus anterior (long thoracic nerve) leads to medial winging (inferior
border goes medial)
 loss of rhomboids (dorsal scapular nerve) leads to lateral winging (superior medial border drops downward
and protrudes laterally and posteriorly)
 presents with motor deficits (flail arm) - both pre- and postganglionic lesions can present with flail arm
 sensory absent
 absence of a Tinel sign or tenderness to percussion in the neck
 normal histamine test (C8-T1 sympathetic ganglion)- intact triple response (redness, wheal, flare)
 elevated hemidiaphragm (phrenic nerve)
 rhomboid paralysis (dorsal scapular nerve)
 serratus anterior (long thoracic nerve)
 normal sensory nerve action potential (SNAP)
 evaluation- EMG may show loss of innervation to cervical paraspinals
Postganglionic:
 involve PNS, capable of regeneration (better prognosis)
 presentation - presents with motor deficit (flail arm), sensory deficits
 evaluation- EMG shows maintained innervation to cervical paraspinals , 
 abnormal histamine test- only redness and wheal, but NO flare
Classification based on location
Upper Lesion: Erb's Palsy (C5,6)
Physical Exam
• Clinically, the arm will be adducted, internally rotated, at
shoulder; pronated, extended at elbow (“waiter’s tip”)
Introduction • C5 deficiency 
• Most common obstetric brachial plexopathy       -axillary nerve deficiency (weakness in deltoid, teres minor)
• Results from an excessive displacement of head to opposite side       -suprascapular nerve deficiency (weakness in supraspinatus,
and depression of shoulder on the same side producing traction on infraspinatus)
plexus.       -musculocutaneous nerve deficiency (weakness to biceps)
• Occurs during a difficult delivery in infants or fall onto shoulder in • C6 deficiency
adults        -radial nerve deficiency (weakness in brachioradialis,
• Best prognosis supinator)

Lower Lesion: Klumpke Palsy (C8,T1)

Introduction
• Rare in obstetric palsy Physical Exam
• Usually avulsion injuries caused by excessive abduction (person •Deficit of all of the small muscles of the hand (ulnar and median
falling from height clutching on an object to save himself) nerves)
• Other causes may include cervical rib, or lung mets in lower • Clinically, presents as “claw hand”
deep cervical lymph nodes     -wrist held in extreme extension because of the unopposed wrist
• Frequently associated with a preganglion injury and Horner's extensors
Syndrome     -hyperextension of MCP due to loss of hand intrinsics 
• Poor prognosis     -flexion of IP joints due to loss of hand intrinsics

Total Palsy (C5-T1)

Introduction Physical Exam
 • A form of brachial plexopathy • Leads to a flaccid arm
• Worst prognosis • Involves both motor and sensory

Physical exam
 Horner's syndrome -features include, drooping of the left eyelid, pupillary constriction, anhidrosis
usually show up three days after injury, represents disruption of sympathetic chain via C8 and/or T1 root
avulsions
 severe pain in anesthetized limb- correlates with root avulsion
 important muscles to test: serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) if
they are functioning then it is more likely the C5 injury is postganglionic    
 pulses
 check radial, ulnar and brachial pulses
 arterial injuries common with complete BPIs