eMedicine Specialties > Orthopedic Surgery > Trauma

Brachial Plexus Injuries, Traumatic: Workup

Author: Mark R Foster, MD, PhD, FACS, President and Orthopaedic Surgeon, Orthopaedic Spine Specialists of Western Pennsylvania, PC
Coauthor(s): Christopher Chaput, MD, Assistant Professor of Orthopedic Surgery, Texas A&M Health Science Center; Consulting Surgeon, Department of Orthopedic Surgery, Scott and White Memorial Hospital; Robert A Probe, MD, Associate Professor of Orthopedic Surgery, Texas A&M University Health Science Center; Chairman, Department of Orthopedic Surgery, Scott and White Clinic and Memorial Hospital
Contributor Information and Disclosures

Updated: Sep 26, 2008

Workup

Laboratory Studies

  • Laboratory studies generally are not helpful for diagnosis, although they may be indicated in the routine evaluation of any trauma patient.
  • Electrophysiologic studies are crucial in the management of these injuries, but timing (eg, for Wallerian degeneration to occur) must be considered.

Imaging Studies

  • Radiographic evaluation
    • In anteroposterior (AP) chest radiography, specific attention should be directed to the distance between the spinous processes of the thoracic spine and the scapula. If the radiograph is not malrotated, an increase in this distance compared with the contralateral side may indicate scapulothoracic dissociation (see Image 3).
    • AP and axillary lateral views of the shoulder reveal clavicle fractures, most scapular fractures, and most proximal humerus fractures.
    • Cervical spine series including AP, lateral, and odontoid views are useful.
  • Computed tomography (CT) scanning: Adequate plain radiographs may be difficult to obtain, especially of the odontoid and the cervicothoracic junction. A CT scan of the neck can often be obtained in conjunction with CT scanning that is a part of the evaluation of many trauma patients. Plain CT scanning is very helpful in evaluating any cervical fractures, and should be obtained if fractures are suspected based on plain radiographic findings. CT scanning of the chest may reveal subclavian vessel injuries, scapular fractures, humeral fractures, and thoracic spine fractures (see Image 4).
  • Myelography: The most reliable indicator of root avulsion is an absent root shadow on plain myelography.13  A common sign of a root avulsion is a meningocele at the affected level; hence, myelography may best be delayed for 4 weeks so that any blood clot will not be dislodged by the study and the meningocele can be allowed to form.
  • CT myelography (CTM): The literature is still inconclusive regarding the sensitivity and specificity of CTM, but CTM is being performed more often.14  Lower concentrations of contrast medium can be detected by CTM than by standard myelography. Burge states that CTM may be better able to reveal small meningoceles, but artifact from surrounding soft tissues may be problematic at the lower cervical levels.15
  • Magnetic resonance imaging (MRI): MRI is the current criterion standard for visualizing spinal cord injuries, but reports of its utility in evaluating traumatic lesions of the brachial plexus are sparse. MRI is the only technique that can be used to visualize the postganglionic brachial plexus. While the impact of MRI on surgical decision-making is yet to be defined, it no doubt will play a larger role in the evaluation of the brachial plexus in the future.
  • Angiography: Both conventional angiography and magnetic resonance angiography (MRA) are valuable tools in evaluating any suspected vascular disruption.

Other Tests

  • Sensory nerve action potentials (SNAPs): SNAPs are very helpful in differentiating preganglionic from postganglionic injuries. If the injury is proximal to the dorsal root ganglion (DRG), no Wallerian degeneration occurs because the sensory axon is intact. Thus, a SNAP observed in a nerve with an anesthetic dermatome confirms a preganglionic lesion. SNAPs are not useful for C5 evaluation because C5 does not provide a significant contribution to a major peripheral sensory nerve.
  • Electromyography (EMG): In the first week after injury, EMG cannot be used to exclude a complete nerve disruption unless voluntary motor unit action potentials are observed. If no signs of denervation are apparent in a paralyzed muscle by 3 weeks after injury, EMG can be used to confirm neuropraxia.
  • Somatosensory evoked potentials (SSEPs): Intraoperative SSEPs are useful in brachial plexus surgery. The presence of SSEPs suggests continuity between the peripheral nervous system and the CNS via the DRG. SSEPs are absent in postganglionic or combined pre- and postganglionic lesions.

More on Brachial Plexus Injuries, Traumatic

Overview: Brachial Plexus Injuries, Traumatic
Workup: Brachial Plexus Injuries, Traumatic
Treatment: Brachial Plexus Injuries, Traumatic
Follow-up: Brachial Plexus Injuries, Traumatic
Multimedia: Brachial Plexus Injuries, Traumatic
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg. Oct 2005;13(6):382-96. [Medline].

  2. Blaauw G, Muhlig RS, Vredeveld JW. Management of brachial plexus injuries. Adv Tech Stand Neurosurg. 2008;33:201-31. [Medline].

  3. Rovak JM, Tung TH. Traumatic brachial plexus injuries. Mo Med. Nov-Dec 2006;103(6):632-6. [Medline].

  4. Akita S, Wada E, Kawai H. Combined injuries of the brachial plexus and spinal cord. J Bone Joint Surg Br. May 2006;88(5):637-41. [Medline].

  5. Webb JC, Munshi P, Saifuddin A, Birch R. The prevalence of spinal trauma associated with brachial plexus injuries. Injury. Sep 2002;33(7):587-90. [Medline].

  6. Goldie BS, Coates CJ. Brachial plexus injury: a survey of incidence and referral pattern. J Hand Surg [Br]. Feb 1992;17(1):86-8. [Medline].

  7. Narakas AO. The treatment of brachial plexus injuries. Int Orthop. 1985;9(1):29-36. [Medline].

  8. Leffert RD. Green's Operative Hand Surgery. 4th ed. New York, NY:. Churchill Livingstone;1999:1557-1587.

  9. Rohde RS, Wolfe SW. Nerve transfers for adult traumatic brachial plexus palsy (brachial plexus nerve transfer). HSS J. Feb 2007;3(1):77-82. [Medline].

  10. Moiyadi AV, Devi BI, Nair KP. Brachial plexus injuries: outcome following neurotization with intercostal nerve. J Neurosurg. Aug 2007;107(2):308-13. [Medline].

  11. Suzuki K, Doi K, Hattori Y, Pagsaligan JM. Long-term results of spinal accessory nerve transfer to the suprascapular nerve in upper-type paralysis of brachial plexus injury. J Reconstr Microsurg. Aug 2007;23(6):295-9. [Medline].

  12. Millesi H. Brachial plexus injuries. In: Chapman MW, Szabo RM, Mann RA, et al, eds. Chapman's Orthopaedic Surgery. Philadelphia, Pa:. Lippincott Williams & Wilkins;2001:1703-1720.

  13. Boome RS. The hand and upper extremity. In: Boome RS, ed. The Brachial Plexus. Vol 14. Philadelphia, Pa:. WB Saunders Co;1997:1-18.

  14. Amrami KK, Port JD. Imaging the brachial plexus. Hand Clin. Feb 2005;21(1):25-37. [Medline].

  15. Burge P. Diagnostic investigations. In: Boome RS, ed. The Brachial Plexus. Vol 14. Philadelphia, Pa:. WB Saunders Co;1997:19-29.

  16. Carlstedt TP. Spinal nerve root injuries in brachial plexus lesions: basic science and clinical application of new surgical strategies. A review. Microsurgery. 1995;16(1):13-6. [Medline].

  17. Jivan S, Kumar N, Wiberg M, Kay S. The influence of pre-surgical delay on functional outcome after reconstruction of brachial plexus injuries. J Plast Reconstr Aesthet Surg. May 15 2008;[Medline].

  18. Ahmed-Labib M, Golan JD, Jacques L. Functional outcome of brachial plexus reconstruction after trauma. Neurosurgery. Nov 2007;61(5):1016-22; discussion 1022-3. [Medline].

  19. Parry CB. Management of Deafferentation Pain. In: Boome RS, ed. The Brachial Plexus. Vol 14. Philadelphia, Pa:. WB Saunders Co;1997:165-168.

  20. Thomas DG, Sheehy JP. Dorsal root entry zone lesions (Nashold's procedure) for pain relief following brachial plexus avulsion. J Neurol Neurosurg Psychiatry. Oct 1983;46(10):924-8. [Medline].

  21. Doi K, Muramatsu K, Hattori Y, et al. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results. J Bone Joint Surg Am. May 2000;82(5):652-66. [Medline].

  22. Kandenwein JA, Kretschmer T, Engelhardt M, Richter HP, Antoniadis G. Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases. J Neurosurg. Oct 2005;103(4):614-21. [Medline].

  23. Birche R. Surgical Disorders of the Peripheral Nerves. 1st ed. Churchill Livingstone:1998:157-207.

  24. Miller MD. Review of Orthopedics. 3rd ed. Philadelphia, Pa:. WB Saunders Co;2000:519-527.

  25. Tavakkolizadeh A, Saifuddin A, Birch R. Imaging of adult brachial plexus traction injuries. J Hand Surg [Br]. Jun 2001;26(3):183-91. [Medline].

[ CLOSE WINDOW ]

Further Reading

For a further review of adult traumatic brachial plexus injuries, see Shin et al. 1

Plexopathy .
American College of Radiology.  2006.  13 pages.  NGC:005539
 

[ CLOSE WINDOW ]

Keywords

traumatic brachial plexus injury, lesions of the brachial plexus, supraclavicular injuries, upper plexus injuries, lower plexus injuries, shoulder injuries

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Mark R Foster, MD, PhD, FACS, President and Orthopaedic Surgeon, Orthopaedic Spine Specialists of Western Pennsylvania, PC
Mark R Foster, MD, PhD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Physical Society, Christian Medical & Dental Society, Eastern Orthopaedic Association, North American Spine Society, Orthopaedic Research Society, and Pennsylvania Orthopaedic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher Chaput, MD, Assistant Professor of Orthopedic Surgery, Texas A&M Health Science Center; Consulting Surgeon, Department of Orthopedic Surgery, Scott and White Memorial Hospital
Christopher Chaput, MD is a member of the following medical societies: Texas Medical Association
Disclosure: Nothing to disclose.

Robert A Probe, MD, Associate Professor of Orthopedic Surgery, Texas A&M University Health Science Center; Chairman, Department of Orthopedic Surgery, Scott and White Clinic and Memorial Hospital
Robert A Probe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, AO Foundation, Orthopaedic Trauma Association, and Texas Medical Association
Disclosure: Stryker Orthopaedics Consulting fee Consulting

Medical Editor

Jeffrey L Visotsky, MD, Assistant Professor, Department of Clinical Orthopedic Surgery, Northwestern University
Jeffrey L Visotsky, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American College of Physician Executives, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, Arthroscopy Association of North America, Chicago Medical Society, and Illinois State Medical Society
Disclosure: Depuy Consulting fee Speaking and teaching; Pegasus Honoraria Board membership

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center
Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.