BRACHIAL PLEXUS INJURY

INTRODUCTION

• BRACHIAL PLEXUS IS THE NETWORK OF NERVES WHICH RUNS THROUGH THE CERVICAL
SPINE, NECK, AXILLA AND THEN INTO ARM OR IT IS A NETWORK OF NERVES PASSING
THROUGH THE CERVICO AXILLARY CANAL TO REACH AXILLA AND INNERVATES
BRACHIUM (UPPER ARM), ANTEBRACHIUM (FOREARM) AND HAND.IT IS A SOMATIC NERVE
PLEXUS FORMED BY INTERCOMMUNICATIONS AMONG THE VENTRAL RAMI (ROOTS) OF
THE LOWER 4 CERVICAL NERVES (C5-C8) AND THE FIRST THORACIC NERVE (T1).
THE BRACHIAL PLEXUS IS RESPONSIBLE FOR CUTANEOUS AND MUSCULAR INNERVATION
OF THE ENTIRE UPPER LIMB, WITH TWO EXCEPTIONS: THE TRAPEZIUS MUSCLE
INNERVATED BY THE SPINAL ACCESSORY NERVE (CN XI) AND AN AREA OF SKIN NEAR THE
AXILLA INNERVATED BY THE INTERCOSTOBRACHIAL NERVE.
 INTRODUCTION

• THE BRACHIAL PLEXUS IS THE NETWORK OF NERVES THAT SENDS SIGNALS FROM THE SPINAL CORD TO THE
SHOULDER, ARM AND HAND. A BRACHIAL PLEXUS INJURY OCCURS WHEN THESE NERVES ARE STRETCHED,
COMPRESSED, OR IN THE MOST SERIOUS CASES, RIPPED APART OR TORN AWAY FROM THE SPINAL CORD.
• MINOR BRACHIAL PLEXUS INJURIES, KNOWN AS STINGERS OR BURNERS, ARE COMMON IN CONTACT
SPORTS, SUCH AS FOOTBALL. BABIES SOMETIMES SUSTAIN BRACHIAL PLEXUS INJURIES DURING BIRTH.
OTHER CONDITIONS, SUCH AS INFLAMMATION OR TUMORS, MAY AFFECT THE BRACHIAL PLEXUS.
• THE MOST SEVERE BRACHIAL PLEXUS INJURIES USUALLY RESULT FROM AUTOMOBILE OR MOTORCYCLE
ACCIDENTS. SEVERE BRACHIAL PLEXUS INJURIES CAN LEAVE THE ARM PARALYZED, BUT SURGERY MAY
HELP RESTORE FUNCTION.
 CLINICAL ANATOMY

• THE PLEXUS CONSISTS OF ROOTS,

TRUNKS, DIVISIONS, CORDS AND
BRANCHES.
 MECHANISM OF INJURY

• TRAUMATIC E.G MOTOR VEHICLE

ACCIDENT, CONTACT SPORTS
• NON TRAUMATIC E.G.OBSTETRIC
PALSY AND 
PARSONAGE-TURNER SYNDROME
• THE NETWORK OF NERVES IS FRAGILE
AND CAN BE DAMAGED BY
STRETCHING, PRESSURE- IMPACT AND
TRACTION(UPWARD OR DOWNWARD)
OR CUTTING.
 CLASSIFICATION OF INJURIES- LEFFERT CLASSIFICATION OF
BRACHIAL PLEXUS INJURY (IT IS BASED ON ETIOLOGY AND
LEVEL OF INJURY AND IS AS FOLLOWS)

• I OPEN (USUALLY FROM STABBING) • INFRACLAVICULAR LESION:

• II CLOSED (USUALLY FROM MOTORCYCLE ACCIDENT)
• USUALLY INVOLVES BRANCHES FROM THE
• IIA SUPRACLAVICULAR
TRUNKS (SUPRACLAVICULAR);
• PREGANGLIONIC:
• FUNCTION IS AFFECTED BASED ON TRUNK
• AVULSION OF NERVE ROOTS, USUALLY FROM HIGH SPEED
INJURIES WITH OTHER INJURIES AND LOC
INVOLVED
• NO PROXIMAL STUMP, NO NEUROMA FORMATION (NEG TINEL'S)
• III RADIATION INDUCED
• PSEUDOMENINGOCELE, DENERVATION OF NECK MUSCLES ARE
COMMON • IV OBSTETRIC
• HORNER'S SIGN (PTOSIS, MIOSIS, ANHYDROSIS)
• POSTGANGIONIC: • IVA ERB'S (UPPER ROOT) - WAITER'S TIP HAND;
• ROOTS REMAIN INTACT;
• USUALLY FROM TRACTION INJURIES;
• IVB KLUMPKE (LOWER ROOT)
• THERE ARE PROXIMAL STUMP AND NEUROMA FORMATION (POS
TINEL'S)
• DEEP DORSAL NECK MUSCLES ARE INTACT, AND
PSEUDOMENINGOCELES WILL NOT DEVELOP;
 MILLESI CLASSIFICATION OF BRACHIAL
PLEXUS INJURY
1. I: SUPRAGANGLIONIC/PREGANGLIONIC.
2. II: INFRAGANGLIONIC/POSTGANGLIONIC
3. III: TRUNK.
4. IV: CORD.CLASSIFICATION ON ANATOMICAL LOCATION OF INJURY
CLASSIFICATION ON ANATOMICAL LOCATION
OF INJURY

• UPPER PLEXUS PALSY (ERB’S PALSY IN THE OBPI CASES) INVOLVES C5-C6+/-
C7ROOTS
• LOWER PLEXUS PALSY (KLUMPKE’S PALSY) INVOLVES C8-T1 ROOTS (AND
SOMETIMES ALSO C7)
• TOTAL PLEXUS LESIONS INVOLVE ALL NERVE ROOTS C5-T1
• SOME AUTHORS HAVE INCLUDED A FOURTH TYPE,AN INTERMEDIATE TYPE THAT
PRIMARILY INVOLVES THE C7 ROOT.
 ERBS PARALYSIS

• SITE OF INJURY: THE REGION OF THE UPPER TRUNK OF THE BRACHIAL PLEXUS IS
CALLED ERB'S POINT. SIX NERVES MEET HERE. INJURY TO THE UPPER TRUNK
CAUSES ERB'S PARALYSIS.
• CAUSE: UNDUE SEPARATION OF THE HEAD FROM THE SHOULDER, WHICH IS
COMMONLY ENCOUNTERED IN
• BIRTH INJURY
• FALL ON SHOULDER
• DURING ANAESTHESIA
 EPIDEMIOLOGY

• FREQUENCY: AN INCIDENCE OF 0.8-1 PER 1,000 BIRTHS HAS BEEN REPORTED FOR
BRACHIAL PLEXUS BIRTH PALSY (BPBP) IN THE US.[4] ERB'S PALSY ACCOUNTS FOR
ABOUT 45% OF BPBP.[5] ADDITIONAL INJURY TO C7 IS COMMONLY DISCOVERED IN
20% OF CASES OF BPBP
• MORTALITY/MORBIDITY
• INCIDENCE OF PERMANENT IMPAIRMENT IS 3-25%. THE RATE OF RECOVERY IN
THE FIRST FEW WEEKS IS A GOOD INDICATOR OF FINAL OUTCOME. COMPLETE
RECOVERY IS UNLIKELY IF NO IMPROVEMENT HAS OCCURRED IN THE FIRST TWO
WEEKS OF LIFE
 RISK FACTORS

• SHOULDER DYSTOCIA
• FETAL MACROSOMIA
• MATERNAL OBESITY[6]
• GESTATIONAL DIABETES[6]
• DURATION OF SECOND STAGE OF LABOR(OVER 60 MINUTES)
• BREECH PRESENTATION
• NERVE ROOTS INVOLVED: MAINLY C5 & PARTLY C6.
• MUSCLES PARALYSED:
• MAINLY: BICEPS, DELTOID, BRACHIALIS AND
BRACHIORADIALIS.
• PARTLY: SUPRASPINATUS, INFRASPINATUS AND SUPINATOR
• DEFORMITY:
• ARM: HANGS BY THE SIDE, ADDUCTED AND MEDIALLY
ROTATED
• FOREARM: EXTENDED AND PRONATED
• THE DEFORMITY IS KNOWN AS "POLICEMAN'S TIP HAND"
OR "PORTER'S TIP HAND".
• DISABILITY
• ABDUCTION AND LATERAL ROTATION
OF THE ARM (SHOULDER)
• FLEXION AND SUPINATION OF
FOREARM.
• BICEPS AND SUPINATOR JERKS ARE
LOST.
• SENSATIONS ARE LOST OVER A SMALL
AREA OVER THE LOWER PART OF THE
DELTOID.
 DIAGNOSIS

• HISTORY- AIMS TO GATHER INFORMATION ABOUT PREGNANCY COMPLICATED EITHER

BY GESTATIONAL DIABETES OR MATERNAL OBESITY, FETAL MACROSOMIA, • OUTCOME MEASURES
PROLONGED SECOND STAGE LABOUR, SHOULDER DYSTOCIA, USE OF ASSITIVE
TECHNIQUES-FORCEPS TO AID DELIVERY.
• PHYSICAL EXAMINATION- MOST OFTEN SHOWS DECREASED OR ABSENT MOVEMENT
• TORONTO TEST SCORE
OF THE AFFECTED ARM.
• NEUROLOGIC EXAMINATION- ASSESSES MUSCLE POWER, SENSATION, REFLEXES- • ACTIVE MOVEMENT SCALE
MORO REFLEX IS ABSENT ON THE AFFECTED ARM.
• PRESENCE OF CERVICAL RIB
• MALLET SCALE
• INVESTIGATIONS
• X-RAYS OF THE CHEST - TO RULE OUT CLAVICULAR OR HUMERAL FRACTURE
• MRI OF THE SHOULDER- MAY DEMONSTRATE SHOULDER DISLOCATION; PRESENCE OF
• TODDLER ARM USE TEST
PSEUDOMENINGOCELES INDICATES AVULSION INJURY OF THE AFFECTED SPINAL
ROOTS
• CT SCAN OF THE SHOULDER- MAY DEMONSTRATE SHOULDER DISLOCATION;
PRESENCE OF PSEUDOMENINGOCELES INDICATES AVULSION INJURY OF THE
AFFECTED SPINAL ROOTS
• EMG/NERVE CONDUCTION STUDIES- PRESENCE OF FIBRILLATION POTENTIALS
INDICATE DENERVATION
 DIFFERENTIAL DIAGNOSIS

• CLAVICULAR FRACTURE
• OSTEOMYELITIS OF THE HUMERUS OR CLAVICLE
• SEPTIC ARTHRITIS OF THE SHOULDER
 INTERVENTION MANAGEMENT

• INDICATIONS FOR SURGERY IS NO CLINICAL OR EMG EVIDENCE OF BICEPS

FUNCTION BY 6 MONTHS. THIS REPRESENTS 10% TO 20% OF CHILDREN WITH
OBSTETRIC PALSIES.
• THE THREE MOST COMMON TREATMENTS FOR ERB'S PALSY ARE:
• NERVE TRANSPLANTS (USUALLY FROM THE OPPOSITE LEG)
• SUB SCAPULARIS RELEASES
• LATISSIMUS DORSI TENDON TRANSFERS.
 PHYSIOTHERAPY MANAGEMENT

• INITIAL TREATMENT IN THE FIRST 1-2 WEEKS AFTER BIRTH WILL CONSIST OF:
• EXTREMES OF MOTION ARE TO BE AVOIDED FOR THE FIRST 1 TO 2 WEEKS 
• AVOID PICKING A CHILD UP BY THE ARM. OR FROM UNDER THE ARMPIT. THIS
CAN COMPRESS OR STRETCH THE BRACHIAL PLEXUS AND CAUSE FURTHER
INJURY
• PLACING A CHILD ON THEIR BACK OR IN SIDE-LYING, WITH AFFECTED LIMB UP,
TO AVOID COMPRESSION OF THE INJURED LIMB
• PLACE THE AFFECTED ARM INTO SLEEVES BEFORE THE UNAFFECTED ARM
• ACTIVITIES AND EXERCISES TO PROMOTE RECOVERY OF
MOVEMENT AND MUSCLE STRENGTH
• EXERCISES TO MAINTAIN RANGE OF MOVEMENT IN THE JOINTS
TO PREVENT STIFFNESS AND PAIN
• SENSORY STIMULATION TO PROMOTE INCREASED AWARENESS
OF THE ARM
• PROVISION OF SPLINTS TO PREVENT SECONDARY
COMPLICATIONS AND MAXIMISE FUNCTION
• EDUCATING PARENTS ON APPROPRIATE HANDLING AND
POSITIONING OF THE CHILD AND HOME EXERCISES TO MAXIMISE
THE CHILD’S POTENTIAL FOR RECOVERY
• CONSTRAINT INDUCED MOVEMENT THERAPY MAY BE USEFUL
• ELECTRICAL STIMULATION MAY BE BENEFICIAL
 ORTHOTIC MANAGEMENT

WRIST HAND ORTHOSIS SUPINATOR ORTHOSIS

 HOME EXERCISE

• MAINTAIN MOVEMENT AT THE JOINTS – PASSIVE,

ASSISTED AND ACTIVE EXERCISES.
• INCREASING THE STRENGTH OF MUSCLES IN THE
AFFECTED LIMB.
• INCREASING THE CHILD’S AWARENESS OF THE ARM
THROUGH TACTILE TOUCH AND CONTACT.
• TEACHING PARENTS, CARERS AND THE CHILD HOW TO
HANDLE THE AFFECTED LIMB AND HOW TO POSITION IT
FOR BOTH COMFORTS, PREVENTION OF COMPLICATIONS
AND PRACTICALITY.
• USE OF CONSTRAINT-INDUCED MOVEMENT THERAPY
(CIMT) AND BIMANUAL/BILATERAL THERAPY
 KLUMPKE'S PARALYSIS

• SITE OF INJURY: INJURY TO THE LOWER TRUNK OF THE BRACHIAL PLEXUS IS CALLED KLUMPKE'S
PARALYSIS
• CAUSE OF INJURY:
• UNDUE ABDUCTION OF THE ARM, AS IN CLUTCHING A TREE BRANCH WITH THE HAND DURING A
FALL FROM A HEIGHT, OR SOMETIMES IN A BIRTH INJURY.
• NERVE ROOTS INVOLVED :MAINLY T1 & PARTLY C8
• MUSCLES PARALYSED:
• INTRINSIC MUSCLES OF THE HAND (T1)
• ULNAR FLEXORS OF THE WRIST AND FINGERS (C8).
• ACCORDING TO THE NATIONAL INSTITUTE OF NEURAL • RISK FACTORS FOR KLUMPKE PARALYSIS ARE:
DISORDERS AND STROKE (NINDS), THERE ARE FOUR TYPES OF 1. LARGE BIRTH WEIGHT BABIES,
BRACHIAL PLEXUS INJURIES THAT CAUSE KLUMPKE’S : 2. MATERNAL DIABETES, 
1. AVULSION, IN WHICH THE NERVE IS SEVERED FROM THE 3. MULTIPARITY,
SPINE. 4. DIFFICULT PRESENTATION,
2. RUPTURE, IN WHICH TEARING OF THE NERVE OCCURS BUT 5. SHOULDER DYSTOCIA,
NOT AT THE SPINE.
6. FORCEPS OR VACUUM DELIVERY,
3. NEUROMA, IN WHICH THE INJURED NERVE HAS HEALED BUT 7. BREECH POSITION,
CAN’T TRANSMIT NERVOUS SIGNALS TO THE ARM OR HAND
8. PROLONGED LABOR,
MUSCLES BECAUSE SCAR TISSUE HAS FORMED AND PUTS
9. PREVIOUS CHILD WITH OBSTETRIC PALSY,
PRESSURE ON IT.
10.INTRAUTERINE TORTICOLLIS.
4. NEUROPRAXIA OR STRETCHING, IN WHICH THE NERVE HAS
11.LESS COMMON INCLUDES TUMORS (NEUROMAS, RHABDOID TUMORS),
SUFFERED DAMAGE BUT IS NOT TORN.
INTRAUTERINE COMPRESSION, HEMANGIOMA AND EXOSTOSIS OF THE
FIRST RIB IN THE CHILD.
 DISABILITY

• CLAW HAND: FOREARM IS SUPINATED AND THE WRIST AND FINGERS ARE FLEXED.
• CUTANEOUS ANAESTHESIA AND ANALGESIA IN A NARROW ZONE ALONG THE
ULNAR BORDER OF THE FOREARM AND HAND.
• HORNER'S SYNDROME: PTOSIS, MIOSIS, ANHYDROSIS, ENOPHTHALMOS AND LOSS
OF CILIOSPINAL REFLEX- MAY BE ASSOCIATED. THIS IS BECAUSE OF INJURY TO
SYMPATHETIC FIBRES TO THE HEAD AND NECK THAT LEAVE THE SPINAL CORD
THROUGH NERVE T1.
• VASOMOTOR CHANGES: THE SKIN AREAS WITH SENSORY LOSS IS WARNER DUE TO
ARTERIOLAR DILATION. IT IS ALSO DRIER DUE TO THE ABSENCE OF SWEATING AS
THERE IS LOSS OF SYMPATHETIC ACTIVITY.
• TROPIC CHANGES: LONG STANDING CASE OF PARALYSIS LEADS TO DRY AND
SCALY SKIN.THE NAILS CRACK EASILY WITH ATROPHY OF THE PULP OF FINGERS.
• REFLEXES IN THE AFFECTED ROOTS ARE ABSENT.
• ASSOCIATED INJURIES CLAVICULAR AND HUMERUS FRACTURES, TORTICOLLIS,
CEPHALOHEMATOMA, AND FACIAL NERVE PALSY.
1. ERB'S PALSY
2. DISTAL NERVE ENTRAPMENT OF THE ULNAR NERVE AT EITHER THE MEDIAL EPICONDYLE OF GUYON’S
TUNNEL
3. THORACIC OUTLET SYNDROME:
4. APICAL LUNG TUMOR
5. NEUROFIBROMA
6. DISC HERNIATION
7. SHOULDER IMPINGEMENT
8. CLAVICULAR OR VERTEBRAL FRACTURE
 MANAGEMENT

• IMMOBILISATION • PT MANAGEMENT
1. IMPROVING FLEXIBILITY,
• SURGERY: 1. SURGERY ON THE
2. RANGE OF MOTION,
NERVES (E.G., NERVE GRAFTS AND
3. STRENGTH, AND
NEUROMA EXCISION).
4. DEXTERITY
2. TENDON TRANSFERS 5. PAIN CONTROL
3. MUSCLE TRANSFER 6. CIMT/ HABIT
7. TAPING
8. ORTHOSIS
 INJURY TO LATERAL CORD

• CAUSE: DISLOCATION OF HUMERUS ASSOCIATED WITH OTHERS

• NERVE INVOLVED: MUSCULOCUTANEOUS, LATERAL ROOT OF MEDIAN.
• MUSCLES PARALYSED: BICEPS, CORACOBRACHIALIS & ALL MUSCLES SUPPLIED BY THE MEDIAN NERVE, EXCEPT
THOSE OF HAND.
• DEFORMITY AND DISABILITY:
• MIDPRONE FOREARM
• LOSS OF FLEXION OF FOREARM
• LOSS OF FLEXION OF THE WRIST
• SENSORY LOSS ON THE RADIAL SIDE OF THE FOREARM
• VASOMOTOR AND TROPHIC CHANGES.
 INJURY TO MEDIAL CORD

• CAUSE: SUBCORACOID DISLOCATION OF HUMERUS

• NERVES INVOLVED
• ULNAR, MEDIAL ROOT OF MEDIAN
• MUSCLES PARALYSED
• MUSCLES SUPPLIED BYE ULNAR NERVE
• FIVE MUSCLES OF THE HAND SUPPLIED BYE THE MEDIAN NERVE.
• DEFORMITY AND DISABILITY
• CLAW HAND
• SENSORY LOSS ON THE ULNAR SIDE OF THE FOREARM AND HAND
• VASOMOTOR AND TROPIC CHANGES AS A BONE.
 MEDICAL MANAGEMENT

• PAIN CONTROL
• NSAID
• TRICYCLIC ANTIDEPRESSANTS
• ANTICONVULSANTS
• ORAL OR TRANSDERMAL OPIOIDS
 INTERVENTION MANAGEMENT

• CONTINUOUS BRACHIAL PLEXUS BLOCK

• TRANSCUTANEOUS NERVE STIMULATION
• DORSAL ROUTE ENTRY ZONE (DREZ) ABLATION OR IMPLANTABLE DORSAL
ROUTE STIMULATORS.
• SURGICAL TECHNIQUES INCLUDE NEUROLYSIS, NERVE GRAFTING, AND NERVE
TRANSFER. INTERCOSTAL NERVES ARE COMMONLY USED TO REINNERVATE
MUSCLES AFTER A BRACHIAL PLEXUS INJURY WITH AVULSION OF SPINAL NERVE
ROOTS.
 PHYSIOTHERAPY MANAGEMENT

1. DEVELOPMENT OF STRENGTH, FLEXIBILITY, STAMINA AND CO-ORDINATION

2. MAINTAINING ROM VIA PASSIVE MOVEMENTS, EXERCISE THERAPY, SPLINTING
AND POSITIONING AND PROTECTION OF DENERVATED DERMATOMES.[19]
3. FUNCTIONAL TRAINING AND ADOPTION ADAPTIVE DEVICES IF NEEDED.[20]
4. PAIN CONTROL VIA ACUPUNCTURE AND TENS
5. MANAGING CHRONIC OEDEMA VIA EDUCATION, COMPRESSION GARMENTS AND
MASSAGE THERAPY