eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Traumatic Brachial Plexopathy: Follow-up

Author: Vladimir Kaye, MD, Consulting Staff, Departments of Neurology and Psychiatry, Hoag Hospital
Coauthor(s): Murray E Brandstater, MBBS, PhD, Chairman and Program Director, Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Contributor Information and Disclosures

Updated: Sep 25, 2008

Follow-up

Further Inpatient Care

  • If physical therapy is not initiated promptly after surgery, denervation can occur and can result in muscle atrophy and fibrosis, joint stiffness, motor endplate atrophy, and trophic skin changes.
  • Grant and colleagues do not advocate the traditional treatment, which involves several weeks of immobilization.21 Instead, the use of a short period to allow healing and adequate strengthening of the repair site is advised.
  • Repairs (nerve transfer/neurotization, as well as tendon transfer) are protected by means of relaxed joint posturing for about 3 weeks.
  • To prevent disruption of the sutures at the repair site, the patient should avoid strenuous physical activity.
  • In nerve transfers, the extremity is immobilized for 4 weeks after surgery, at which time physical therapy is initiated.
  • Postoperative clinical examinations are performed every 3 months for the first 2 years after surgery and every 6 months after that.
  • At each postoperative visit, the ROM, strength, and sensation in the treated area should be tested, and the results should be documented.

Further Outpatient Care

  • Continuation of physical therapy and/or occupational therapy and follow-up with a surgeon and/or orthotist may be needed.
  • Vocational rehabilitation and modifications at home and/or work are also assessed.
  • In some cases, repeated electrodiagnostic evaluations may be required for prognostication and further treatment planning. These tests can be used to detect early signs of muscle reinnervation several months before clinically evident muscle contractions appear.

Inpatient & Outpatient Medications

  • A variety of medications may be required, mainly for the management of associated painful states.

Transfer

  • When indicated, the patient may be admitted to the hospital for orthopedic or neurosurgical procedures.

Deterrence

  • Measures that the patient can use to prevent setbacks and further damage include the following:
    • Protecting the damaged limb from repeat injury and extremes of motion
    • Maintaining the functional ROM
    • Strengthening muscles in the cervical region and limbs
    • Making appropriate modifications in the workplace and/or at home

Complications

  • Late complications may include the following:
    • Pain syndromes, such as persistent neuropathy, neuroma, and CRPS II
    • Skin damage and infection
    • Significant muscle atrophy
    • Contracture and capsulitis
    • Subluxation
    • Sensory loss
    • Osteopenia
    • Heterotopic ossification
    • Myofascial pain
    • Depression and anxiety

Prognosis

  • The outcome and prognosis of acute injury varies widely, depending on the type and etiology of injury and the timing of therapy.15
    • The extent of injury to neural tissue and the age and medical status of the injured patient are important factors that influence the outcome.
    • Patient compliance and motivation for recovery can also have an important effect on the overall success of therapy.
  • With mild neurapraxic lesions, spontaneous recovery may occur only days or weeks after the trauma has occurred; following a gunshot wound, spontaneous recover may occur as late as 11 months later.
  • Recovery from axonotmetic injuries usually occurs over months.
    • In axonotmesis, although axons regenerate, functional recovery depends on the associated injuries, the amount of healthy proximal axon that remains after injury, and the age of the patient.
    • Recovery is usually complete unless the injury is so proximal that atrophy of the motor endplate or sensory receptor occurs before the axon can grow back to these organs.
    • In cases of a coexisting root avulsion, the above scenario of a very proximal lesion, resulting in atrophy of the motor endplate or sensory receptor, may be possible. Therefore, healing may be greatly delayed or incomplete.
  • In neurotmesis, regeneration occurs, but function rarely returns to its preinjury level.
  • Generally, the rate of spontaneous recovery after shotgun wounds is lower than it is with other mechanisms.
  • Neural injuries associated with fractures have a greater incidence of spontaneous resolution; generally, recovery is less common with neural injuries secondary to dislocations.
  • Lesions resulting from shoulder dislocations heal within 12-45 weeks, depending on severity of the dislocation and, consequently, the type and extent of the associated neural injury or injuries.

Patient Education

  • Educating the patient, family, and rehabilitation team, as well as medical practitioners involved in the patient's postdischarge care, may have several benefits.
    • It facilitates the coordination and planning of services.
    • It hastens the implementation of appropriate interventions.
    • It results in a better recovery.
  • Of equal importance is addressing the associated psychological factors, with the aim of improving the following:
    • The patient's mood stability
    • The patient's coping skills
    • Family functioning
    • Pain management
    • Patient motivation
    • Patient participation in therapy
    • Overall outcome

Miscellaneous

Medicolegal Pitfalls

  • Failing to consider an injury of the cervical spine or spinal cord or a traumatic BI can delay early intervention and result in unwanted residual, long-term sequelae.
  • In the initial assessment after a sports-related injury, the sideline personnel and physician should maintain a healthy degree of suspicion with regard to underlying spine injury or concussion. For example, with persistent symptoms of a burner injury, or postconcussive state, a complete assessment may be needed to prevent premature return to play.
  • Overlooking a brachial plexus injury can lead to further damage that may persist.
  • The precise localization of the lesion on electrodiagnostic studies and the determination of the appropriate prognosis can be challenging in the initial postinjury period or when multiple structures and/or levels are involved.
  • Repeat study or the use of an additional diagnostic investigation (imaging or other) may be considered in cases in which there is poor functional recovery.
 


More on Traumatic Brachial Plexopathy

Overview: Traumatic Brachial Plexopathy
Differential Diagnoses & Workup: Traumatic Brachial Plexopathy
Treatment & Medication: Traumatic Brachial Plexopathy
Follow-up: Traumatic Brachial Plexopathy
References
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Further Reading

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Keywords

traumatic brachial plexopathy, brachial plexus, brachial, plexopathy, peripheral neuropathy, peripheral nerve injury, thoracic outlet syndrome, brachial plexus injury, brachial plexus injuries, traumatic brachial plexus injury, brachial plexus neuropathy, brachial plexus lesion, stinger injury, stingers, burner injury

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Contributor Information and Disclosures

Author

Vladimir Kaye, MD, Consulting Staff, Departments of Neurology and Psychiatry, Hoag Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Murray E Brandstater, MBBS, PhD, Chairman and Program Director, Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Murray E Brandstater, MBBS, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Congress of Rehabilitation Medicine, American Medical Association, Association for Academic Psychiatry, California Society of Physical Medicine and Rehabilitation, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, Canadian Society of Clinical Neurophysiologists, Catholic Medical Association, National Stroke Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, and Royal College of Physicians and Surgeons of the United States
Disclosure: Nothing to disclose.

Medical Editor

Teresa L Massagli, MD, Residency Director, Professor, Department of Rehabilitation Medicine and Pediatrics, University of Washington School of Medicine
Teresa L Massagli, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

 
 
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