Traumatic Brachial Plexus Injuries Workup

  • Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: Jul 7, 2011
 

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.

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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 below).

Brachial plexus injuries, traumatic. This is the iBrachial plexus injuries, traumatic. This is the initial anteroposterior chest radiograph of a patient involved in an accident with an 18-wheeled truck. The clavicle fracture observed on the initial chest radiograph was important in signaling the need for further evaluation of the injury because he was intubated and unresponsive secondary to a closed head injury. Scapulothoracic dissociation was suspected on close review of a CT scan of the chest, and a brachial plexus injury was noted once the patient became responsive.

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 below).

Brachial plexus injuries, traumatic. This is a plaBrachial plexus injuries, traumatic. This is a plain CT scan obtained during the initial workup of the same patient as in image above. A fracture of the right scapula is visible, as is a right pulmonary contusion and significant periscapular swelling. Scapulothoracic dissociation was suspected based on the patient's clavicle fracture, scapula fracture, brachial plexus palsy, and high-energy mechanism of injury (ie, accident with an 18-wheeled truck). The CT scan is oblique, so a high-quality anteroposterior chest radiograph demonstrating lateral displacement of the right scapula was obtained later to confirm the diagnosis.

Myelography

The most reliable indicator of root avulsion is an absent root shadow on plain myelography.[14] 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.[15] 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.[16]

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.

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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.
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Contributor Information and Disclosures
Author

Mark R Foster, MD, PhD, FACS  President and Orthoedic Surgeon, Orthopedic 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.

Specialty Editor Board

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

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Samuel Agnew, MD, FACS  Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; 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.

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

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.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Christopher Chaput, MD, and Robert Probe, MD, to the development and writing of this article

References

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Brachial plexus injuries, traumatic. This patient has ptosis and myosis of his right eye secondary to a complete lower brachial plexus lesion.
Brachial plexus injuries, traumatic. This is a human cadaveric dissection of the right brachial plexus. The clavicle and some soft tissues have been resected. The nerve roots are exiting their respective foramen at the right-hand border of the picture. The uppermost nerve root observed is C5, and C6, C7, and C8 are also visible. The cords of the plexus can be observed at the left-hand margin of the picture. Note the axillary artery at the bottom of the picture.
Brachial plexus injuries, traumatic. This is the initial anteroposterior chest radiograph of a patient involved in an accident with an 18-wheeled truck. The clavicle fracture observed on the initial chest radiograph was important in signaling the need for further evaluation of the injury because he was intubated and unresponsive secondary to a closed head injury. Scapulothoracic dissociation was suspected on close review of a CT scan of the chest, and a brachial plexus injury was noted once the patient became responsive.
Brachial plexus injuries, traumatic. This is a plain CT scan obtained during the initial workup of the same patient as in image above. A fracture of the right scapula is visible, as is a right pulmonary contusion and significant periscapular swelling. Scapulothoracic dissociation was suspected based on the patient's clavicle fracture, scapula fracture, brachial plexus palsy, and high-energy mechanism of injury (ie, accident with an 18-wheeled truck). The CT scan is oblique, so a high-quality anteroposterior chest radiograph demonstrating lateral displacement of the right scapula was obtained later to confirm the diagnosis.
Table 1. Deep Pressure Test
Location of Deep Pressure TestAffected Spinal NerveNerveAffected Cord
ThumbC6Median nerveLateral cord
Middle fingerC7Median nerveLateral cord
Little fingerC8Ulnar nerveMedial cord
Table 2. Guide to Motor Testing
Cervical RootClinically Relevant Gross Motor Function
C5Shoulder abduction, extension, and external rotation; some elbow flexion
C6Elbow flexion, forearm pronation and supination, some wrist extension
C7Diffuse loss of function in the extremity without complete paralysis of a specific muscle group, elbow extension, consistently supplies the latissimus dorsi
C8Finger extensors, finger flexors, wrist flexors, hand intrinsics
T1Hand intrinsics
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