Brachial Plexus Injury

The brachial plexus is a complex network of nerves that emerge from the neck and travel into the arm and hand to provide sensation and to control movement. Injury to these nerves can impair function of the arm and hand. These nerves are susceptible to injury from penetrating injury such as knife or gunshot wounds or from high energy pull or stretch injuries such as from motorcycle accidents and falls from a height. Injuries can range from minor that recover within several weeks to severe that result in lifelong disability of the entire arm and hand. Injuries to the nerves may include a neuropraxia in which the nerve “goes to sleep”, rupture in which the nerve has been partially or completely torn, or avulsion in which the nerve has been torn out from the spinal cord in the neck. Multiple injury patterns may be present in the same patient. Recovery and treatment options largely depend on the type(s) of nerve injury.

Brachial plexus injuries often occur in the setting of high energy trauma with associated injuries including traumatic brain injury, spinal cord injuries, spine fractures, collapsed lungs (pneumothorax), fractured clavicle or ribs, vascular injuries (artery and/or vein), and other injuries. These acute injuries often are treated and stabilized at a trauma center. While certain brachial plexus injuries are treated within days of the injury, such as from a sharp knife injury to the neck, many brachial plexus injuries are evaluated and treated once the acute trauma has been treated.

Initial evaluation by a brachial plexus surgeon will include a history and a meticulous physical examination focused on the neurologic function of the affected extremity. This will include assessing for pain, sensation on different patches of skin, and movement of different joints and muscles. This physical exam may be reassessed over the next several months to monitor for recovery of function. Additional testing may include CT scan, MRI, or electrodiagnostic testing with nerve conduction studies (NCS) and electromyography (EMG). Electrodiagnostics is a special test typically performed by a neurologist or physical medicine and rehabilitation specialist (PM&R or physiatrist). These tests assess the function of the nerves

It is critical that patients with concern for a brachial plexus injury establish care with a brachial plexus surgeon within several weeks of their injury. The course of evaluation, monitoring, and treatment is customized to each unique injury, but surgical treatment should commence within 3-6 months after the injury to optimize results. Delays in referral and treatment beyond 6 months after the injury may result in certain reconstructive options becoming unavailable.

Some injuries will recover function without requiring surgery. However, many injuries will require surgery and potentially multiple operations. The details of each surgery are customized to each patient, their injury, and their goals. Potential surgical options include incisions in the neck and shoulder area to explore the injured nerves, nerve grafting in which donor nerves are taken from the leg to reconstruct injured parts of the brachial plexus, and nerve transfers where functional nerves are transferred to injured nerves to restore critical functions. Additional procedures may include microvascular transplantation of muscles from the leg to the arm to restore elbow and hand function (known as a “free functional muscle transfer”), tendon transfers, or joint fusions.

Recovery of nerve function after brachial plexus is slow and may take many months. This is in part related to the slow regeneration of nerves at one millimeter per day or one inch per month. While awaiting nerve recovery, it is important to work closely with a physical therapist to prevent joints from becoming stiff. Depending on the pattern of the injury, complete recovery of normal function may not be possible, even with optimal surgical management. The treatment goals and recovery expectations are tailored to each individual’s unique injury and should be discussed with the treating brachial plexus team.

Be sure to see an experienced surgeon to treat this condition. Our fellowship-trained specialists at The Buncke Clinic in San Francisco treat patients with brachial plexus injuries from across the Bay Area and Northern California. Contact us to schedule a consultation.

Below are links for third party resources

American Society for Surgery of the Hand

American Academy of Orthopaedic Surgeons