Brachial

Plexus Injury
Anatomy
Physiology
Epidemiology
1- Most commonly seen in men 89% (19-34yo) in high-velocity
injury MCC, sports injury, occupational injury

2- 70s Rule: 70 % in MCC, 70 % multi-injuries, 70% of avulsed

roots C7,C8,T1

3- Iatrogenic injury with malposition or prolonged surgery with arms

in abduction, median sternotomy with wide retraction 1% CABG.
Mechanism

A caudally forced shoulder can cause damage to the upper portion

of the brachial plexus.

Forced abduction can cause traction that may damage the lower
roots of the brachial plexus.

Lacerations in the area of the brachial plexus require a full

neurological examination to ensure the plexus remains intact.
Nature of injury

Open injuries require operative intervention as soon as possible.

Closed injuries that involve the entire plexus require early surgical intervention (within 3 to 6 weeks) and are likely
caused by a high mechanism of injury.

Partial injuries can be delayed up to, but not beyond, 6 months.

Direct nerve repair is usually only possible with acute penetrating injuries.

Nerve transfer is possible in some cases.

Occasionally a muscle or tendon transfer is necessary.


Winged scapula from
damage to the long thoracic
Hemidiaphragm
paralysis from phrenic nerve
Horner syndrome from
injuries (which are commonly
damage to C8 and T1
associated
with brachial plexus injuries)

Parascapular muscle Paraspinal muscle

weakness from damage to weakness from damage to
C4-5 C3-C5
 Diagnosis

Radiographs should be performed at the initial evaluation such as cervical spine, chest x-ray (rib, clavicle), and
extremity x-ray (humerus).

CT myelography/MRI for diverticula, pseudo meningocele: This is the gold standard for nerve root injury. The scan
should be performed 3 to 4 weeks after injury as a meningocele may form around the injury and enough time will
have passed for the blood to reabsorb.

Additional studies include electrodiagnostic studies to assess conduction velocity, SSEP (somatosensory evoked
potential), MEP (motor evoked potential), and SNAP (sensory nerve action potential). These studies are important
for precisely localizing lesions and monitoring subsequent regeneration or reconstruction success. They may also
help with diagnosing pre- and postganglionic injuries.
 Staging/Grading

• First degree (neuropraxia): Full recovery within 12 weeks; no surgery required

• Second degree (axonotmesis): Full recovery; no surgery required

• Third degree: Recovery usually occurs after months with conservative treatment; surgical intervention may be
required to release the entrapment sites over the swollen nerve with or without limited neurolysis

• Fourth degree: Not much functional recovery expected without surgery (nerve repair, graft, or transfer)

• Fifth degree (neurotmesis): No recovery expected; requires surgery (nerve repair, graft, or transfer)
Operative Treatment

• Reconstructive priorities: elbow flexion, shoulder abduction/stability, hand sensation,

wrist extension, finger flexion, wrist flexion, finger extension, hand intrinsic muscles
• Nerve reconstruction: primary repair, autologous nerve grafts, neural conduits, acellular
allograft
• Nerve transfer
• Tendon transfer
• Osteotomy/arthrodesis
Operative Treatment

• Typical blunt and traction injuries affect the various nerve roots of the brachial plexus differently.
Some nerve roots may have severe injuries, while others may have only sustained neurapraxia that
will recover spontaneously. Delaying surgical treatment until some spontaneous recovery is seen
may increase the available nerve transfer options and allow for a potentially smaller surgery.
• Pain control is often difficult to obtain in brachial plexus injuries. For nerve root avulsion injuries,
there is some evidence that very early surgical treatment (within days after injury) may help lessen
the chronic neuropathic pain associated with brachial plexus injuries.
• Penetrating and open injuries and high-velocity gunshot wounds warrant immediate exploration
and repair. Reinnervation procedures can be delayed in blunt and traction injuries but should be
performed within 6 months to 1 year as motor end plates degenerate by 18 months.
Regardless of whether surgery is indicated, passive
range-of-motion exercises should be performed to
maintain joint mobility and prevent contractures.

Spontaneous recovery can be superior to iatrogenic

reconstruction, but the extent of recovery depends on
the location and grade of the injury.
References
• Boyd KU, Nimigan AS, Mackinnon SE. Nerve reconstruction in the hand and upper extremity. Clin Plast Surg. 2011;38(4):643-660.
• Plates 417 (axilla), 418 (brachial plexus), and 467 (neurovasculature). In: Netter FH, ed. Netter’s Atlas of Human Anatomy. 5th ed.
Saunders; 2010.
• Spinner RJ, et al. Traumatic brachial plexus injury. In: Wolf SW, et al, eds. Green’s Operative Hand Surgery. 6th ed. Churchill
Livingstone; 2010.
• UpToDate (Publisher subscription required): Brachial plexus syndromes.
• Zhang J, Moore AE, Stringer MD. Iatrogenic upper limb nerve injuries: a systematic review. ANZ J Surg. 2011;81(4):227-236.
• Wu KY, Spinner RJ, Shin AY. Traumatic brachial plexus injury: diagnosis and treatment. Curr Opin Neurol. 2022 Dec