What Is a Brachial Plexus Injury?

If you have loved ones who suffer brachial plexus injuries, you may be wondering what this is and how it will affect their life. A brachial plexus injury is a serious condition that can cause impaired movement and sensation in the arm and hand. For severe brachial plexus injuries, it can lead to paralysis. However, with proper medical treatment and physical therapy rehabilitation, many people are able to recover some or all of their functions. Read on to learn more about this condition and how a brachial plexus injury is treated.

The Brachial Plexus

The brachial plexus is a bundle of nerves derived from nerve roots in the cervical spinal cord (C5-T1) and upper spinal cord (T3-T7) sections of the trunk (C5-T1). There are several nerve roots in each arm that connect to the arm’s nerves. Hands, wrists, and arms are among the functions controlled by these nerves. With these bundles of nerves, you can lift your arm or throw a ball.

Additionally, the brachial plexus nerves extend to the skin and can also be sensory nerves. These nerves will signal the body when you grab a hot pan with your hand, and it is too hot to hold.

Brachial Plexus – Anatomy

Cords, branches, divisions, and trunks are the four sections of the brachial plexus traveling down the arm. These sections provide an explanation of the intricate anatomy of the brachial plexus even though they are functionally identical.

Following the brachial plexus’ exit from the arm, it splits into five main branches:

Musculocutaneous nerve: The musculocutaneous nerve extends from C5-C7 and controls movements of upper arm muscles at both the shoulder and elbow.

Axillary nerve: The C5 and C6 nerve roots help rotate the shoulder and allow the arm to lift away from the body.

Median nerve: It is located in nerve roots C6-T1 and controls forearm and hand movements.

Radial nerve: C5-T1 roots control many muscles in the upper arm, elbow, forearm, and wrist hand.

Ulnar nerve: C8-T1 is responsible for fine motor control of the fingers.


What Is a Brachial Plexus Injury?

There are many ways to injure the brachial plexus – from pressure, stress, or being stretched too far. Cancer and radiation can also cause nerve damage. Minor brachial plexus injuries can sometimes occur during childbirth.

Brachial plexus injuries cut off all or some parts of the communication signal between the spinal cord and other parts of the body that are controlled by the brachial plexus like the arm, wrist, and hand. As a result, your hand or arm may not function. It is common for traumatic brachial plexus injuries or even mild ones to also cause a total sensory loss in the affected area.

Brachial plexus injuries differ in severity depending on which injured nerve is affected and the extent of the damage. Some people are able to regain function and feel normal again, while others may have lifelong disabilities because they cannot use or feel their arms.

Various Types of Brachial Plexus Injuries

An injury to the brachial plexus is classified according to the way the nerves are damaged and how severe it is.

Brachial Plexus Neuropraxia (Stretch)

Neuropraxia occurs when the nerves are stretched to the point of injury. This injury is typically caused by compression or traction. Compression injuries occur when the nerve roots of the brachial plexus are compressed, usually by the rotation of the head. The most common form is compression neuropraxia, which generally affects older adults.

As a result of pulling the nerve, traction neuropraxia occurs. Young adults and adolescents are more likely to suffer this injury than adults.

Injuries to the brachial plexus are sometimes referred to as “burners” or “stingers,” depending on whether the common symptoms experienced are a burning or stinging sensation. These kinds of brachial plexus injuries can also feel like they are electrical shocks.

Brachial Plexus Rupture

A forceful stretch causes the nerve to tear, either partially or completely, in a brachial plexus rupture. The severity of this injury is greater than that of neuropraxia. In addition to causing muscle weakness (shoulder, arm, or hand), fractures can make specific muscles inoperable. They can also cause severe pain and a more severe injury.

These injuries can often be repaired surgically, depending on the severity and location of the rupture.

Brachial Plexus Neuroma

When nerve tissue is injured, such as by a cut during surgery, scar tissue can sometimes form as the nerve tries to repair itself. Neuromas occur when scar tissue forms on one of the brachial plexus’s nerves, causing a painful knot.

Effective treatment for brachial plexus neuromas involves surgical removal of the scarred nerve tissue. In order to prevent another neuroma from forming, the surgeon either caps the nerve or attaches it to another nerve.

Brachial Neuritis

Brachial neuritis, also known as Parsonage-Turner syndrome, is a progressive disorder of the nerves of the brachial plexus. There is sudden, severe pain in the shoulder and upper arm, followed by weakness, muscle loss, and even loss of sensation. Usually, this syndrome affects the arm and shoulder, but it can also affect the legs and diaphragm. The cause of brachial neuritis is unknown, but it may be triggered by infections, injuries, or childbirth.

Brachial Plexus Avulsion

When there is a complete separation of the nerve root from the spinal cord, it is called a brachial plexus avulsion. Motorcycle or motor vehicle accidents typically result in this kind of injury. When an avulsion occurs, it usually causes severe pain. In addition to causing permanent weakness, paralysis, and loss of feeling, avulsions are difficult and usually impossible to reattach to the spinal cord.

Upper-Trunk Palsy Injury

During a fall, for example, the shoulder may be forced down, and the head may be forced to the opposite side, leading to upper-trunk palsy.

Patient with upper-trunk palsy cannot raise their arms away from their bodies, has weakness in the arm, and may be unable to bend their elbows. The shoulder, outside of the arm, and the thumb may lose sensation.

If the upper trunk sustains severe injuries, the shoulder muscles (deltoids and rotator cuff) may be paralyzed, as well as the muscles in the upper arm (biceps.)

Lower-Trunk Palsy Injury

Lower-trunk palsy is caused by a forced widening of the angle between the chest wall and the arm. Nerves in the lower trunk may be damaged as a result.

With lower-trunk palsy, a patient retains shoulder and elbow function but loses their hand function. This can lead to the fingers contracting into claw positions over time, and the patient will be unable to perform fine motor tasks. Additionally, patients usually experience hand numbness in at least the ring and small fingers.

Pan-Plexus Palsy Injury

When the force of the injury is extreme, a pan-plexus palsy can occur. The nerves and trunk are damaged on all levels in pan-plexus palsy. The result is complete paralysis of the arm and hand, a condition known as “flail limb.”

Injuries Caused by Gunshots

In most cases, gunshot wounds to the brachial plexus do not cause a severe injury or damage the nerve.

Based on the bullet’s caliber, velocity, and angle of entry, the severity of the brachial plexus injury varies. Nerves are usually damaged by low-velocity bullets that impact them directly. Nerves can be injured by high-velocity bullets by either direct impact (bruising) or by shockwaves that stretch them. This kind of injury heals on its own. As a result of a gunshot wound, arteries or veins may be damaged and require immediate or delayed repair.

Penetrating Wounds

Injuries to the brachial plexus may be caused by penetrating wounds, such as laceration wounds (laceration). Nerve damage of this type rarely recovers on its own, requiring more immediate treatment.

Additional Injuries

The brachial plexus is commonly injured by high-energy, forceful events, causing additional injuries in many patients. Injuries to arteries and veins, fractures of the shoulder or arm, rib fractures, a collapsed lung, bleeding into the chest cavity, spine fracture, spinal cord injury, and traumatic brain injuries are among the most common.

How Is a Brachial Plexus Injury Diagnosed?

When a brachial plexus injury is suspected, a health care provider will examine the arm and hand and test for sensations and function. Some other methods include imaging tests like X-ray, MRI scan, CT scan, and needle electrodes.

Among the other diagnostic tests frequently used are:

  • Testing using an X-ray to the neck or shoulder area is used to determine if there are any fractures, dislocations, or injuries to the bone and dense tissue around the brachial plexus nerves.
  • Images such as an MRI or Computed Tomographic (CT) scan may be used to show the damage to the nerves of the brachial plexus via the injection of contrast dye.
  • Tests using needle electrodes to measure nerve function and electrical activity, such as using electromyograms and nerve conduction study.
  • A doctor may repeat these tests every few weeks or months to determine how you are progressing.

Brachial Plexus Injury Treatment

Nonsurgical management is also essential to the treatment process.

Occupational and/or physical therapy may include a range of motion exercises, strengthening exercises, neuromuscular electrical stimulation, Kinesio taping, joint mobilization, aquatic therapy, and orthoses.

Surgical Treatment for Brachial Plexus Injuries

In cases when the nerves can’t regenerate on their own or cannot regenerate enough to restore the arm or hand’s function, surgery is usually recommended. Although surgery can improve arm or hand function to some extent, it may not necessarily restore them to their pre-injury state.

The recovery depends on the timeframe of surgical repair. It is possible that the muscles that have not already connected to nerves may lose their strength within 18 months.

If surgical repair is not done in a timely manner, avulsion and rupture injuries cannot be fully repaired. The potential for improvement varies for neuromas and neurapraxia injuries. A fair prognosis exists for patients with neurapraxia injuries, as 90-100 percent of patients will recover spontaneously.

Even three months after an injury, surgery to repair damaged nerves can be performed. After an injury, the nerves are typically repaired within six months.

Surgical Procedures Used for Brachial Plexus Injury Treatment

There are several types of surgical treatment available for nerve injury, depending on the type of injury and the age of the patient.

Neurolysis

Nerves that have been constricted by scar tissue are removed.

Neuroma Excision

When the neuroma is large, it is removed, and the nerve must be reattached by either end-to-end techniques or nerve grafts.

Nerve Repair

During this procedure, a surgeon will attempt to reattach the two torn edges of a severed nerve. A knife wound, for example, could cause sharp lacerations to the nerves that need to be repaired immediately.

Neurotization

An avulsion is generally treated with this procedure. Nerves from a donor are used to repair the damage. Avulsed nerves can be donated from the roots still attached to the spinal cord.

Nerve Graft

A nerve graft is a surgical procedure where a healthy nerve is placed between two lacerated nerve ends taken from another part of the body. Nerves transplanted into injured ends serve as scaffolds to support their regeneration, healing, and regrowth. In order to perform nerve grafting on the spinal cord, there must be a functioning nerve stump. To facilitate nerve regeneration and eventually restore nerve signals to power paralyzed muscles, the transplanted nerve is intended to guide such growth.

Nerve Transfer

If there are no functioning nerve stumps in the neck to attach nerve grafts to, then a nerve transfer procedure is used. During a nerve transfer procedure, a healthy donor nerve is cut and reattached to a paralyzed nerve to provide a signal to the paralyzed muscle. Sometimes the healthy nerve is connected closer to the muscle that is paralyzed. Another option is to interconnect the healthy nerve with the damaged nerve within the brachial plexus.

Tendon & Muscle Transfers

More than 12 months after an injury, patients who delay seeing their doctor are more likely to have poor outcomes with nerve reconstruction surgery. Surgery focusing on tendon reconstruction (tendon transfer) or muscle reconstruction (free-functioning muscle transfer) is preferable for these patients.

What Do Brachial Plexus Birth Injuries Look Like?

A newborn with brachial plexus injury may experience weakness or paralysis of the affected arm or hand, and a decrease in movement or sensation in the upper extremity.

It is likely that infants’ nerves behave differently than adults because they are not as sensitive. Only about 4 percent of infants experience severe pain. The baby may experience some discomfort from a fracture that occurs along with the BPBP, but it is not usually very painful. Any fractures (clavicle, humerus) and any damaged nerves heal slowly, usually within ten days.

As opposed to an adult’s traumatic brachial plexus injury caused by an accident or sports impact, as with any brachial plexus injury, brachial plexus pain is acute and disabling.

Conditions Related to Brachial Plexus Birth Injuries

Erb’s Palsy

  • Nerves C5, C6, and sometimes C7 are involved
  • Often presents with arms straight and wrist fully bent (waiter’s tip)
  • May have good hand function but not a full movement of the arm
  • May have instability of the shoulder joint
  • Often presents with weak biceps and deltoid muscles (unable to bend the elbow or lift arm at the shoulder)
  • About 75 percent of all brachial plexus injuries occur in children

Global Palsy

  • (C5-T1) All five nerves of the brachial plexus are involved
  • Presents without moving the shoulder, arm, or hand
  • May have no sensations throughout the arm
  • Horner’s Syndrome
  • The result of nerve damage to the eye, causing the pupil to constrict (miosis) or the eye to droop (ptosis).
  • Occasionally associated with nerve root avulsions of the brachial plexus.

Natural Nerve Recovery for Brachial Plexus Birth Injuries

The brachial plexus nerves arise in the neck, in the cervical spine. These nerves re-grow along the arm and hand. Healing occurs at a rate of 1 millimeter per day or 1 inch per month.

If the nerves do not fully reattach to their original motor and sensory targets, a mixed or incomplete recovery may occur.

Only when sensory fibers reach their sensory end targets and motor fibers reach their muscle targets will there be a full recovery.

By the third month of life, the ability to bend the elbow (biceps function) is a good indicator of recovery. In addition to bicep muscle function, active movement of the wrist upward, as well as straightening of the thumb and fingers, are even stronger indicators of excellent spontaneous improvement. Performing gentle range-of-motion exercises performed by parents, as well as repeating the doctor’s examinations, maybe all that is needed for patients who show strong signs of recovery.

Two-thirds of children suffering from a brachial plexus birth injury recover on their own with minimal treatment. There may still be some limitations associated with brachial plexus birth injuries that are not improving. There may be limitations in one or more movements, weak muscles, or decreased sensation (feeling) in the arm. Our remaining treatment efforts are directed towards these children.

Conclusion

If you have a loved one who has suffered from a brachial plexus injury, it is important to seek help immediately. Getting early treatment can help lessen the complications and speed up recovery. Do you suspect that you or someone you love may have a brachial plexus injury? Get medical help right away. We hope this article was helpful in understanding these injuries and their treatments.

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