Traumatic Brachial Plexopathy 

  • Author: Vladimir Kaye, MD; Chief Editor: Robert H Meier III, MD   more...
 
Updated: Nov 28, 2011
 

Background

Trauma accounts for a large proportion of brachial plexopathies. The mechanism of an injury and the magnitude, rate, and direction of deforming forces ultimately determine the extent and location of a traumatic brachial plexopathy.

A lesion of the brachial plexus can result in motor, sensory, and sympathetic disturbances. Impairments can be transient, as in stinger or burner injuries in football players, or they may result in intractable palsy. Because of the changing arrangement of the brachial plexus as it progresses distally, injuries to it may result in diverse paralyses, anesthesias, and paresthesias, depending on the exact level of injury and the extent of injury to the various elements at that level.[1]

Anatomy

The anterior rami of the spinal nerves C5 to T1 combine to form the brachial plexus. C5 and C6 merge into the upper trunk, C7 forms the middle trunk, and C8 and T1 merge to form the lower trunk. Anterior divisions from the upper and middle trunks form the lateral cord. The medial cord is the anterior division of the lower trunk. Posterior divisions from all 3 trunks form the posterior cord. Terminal branches originate from the C5 root, trunks, and cords to supply the upper extremity and the shoulder girdle. The spinal nerves emerge from the vertebral foramina and pass between the anterior and middle scalenes; they then pass between the clavicle and the first rib, near the coracoid and humeral head. The plexus is relatively tethered at the prevertebral fascia at its proximal aspect and by the axillary sheath in the midarm.

Diagnosis

Brachial plexopathies may be difficult to accurately diagnose, even with a meticulous investigation. This is not only because the anatomic design of the plexus pose challenges, but also because the types of lesions and injuries that occur are frequently incomplete and complex. Even so, establishing a precise anatomic diagnosis and estimating the severity of the lesion is imperative for prognostic, surgical, and rehabilitative purposes.

Related eMedicine topics:

Acute Nerve Injury

Brachial Plexus Injuries, Obstetrical

Brachial Plexus Injuries, Traumatic

Brachial Plexus Injury

Neonatal Brachial Plexus Palsies

Radiation-Induced Brachial Plexopathy

Traumatic Peripheral Nerve Lesions

Related Medscape topic:

Resource Center Trauma

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Pathophysiology

In traumatic brachial plexopathy, nerve roots may be avulsed from the cord, or the plexus may be subject to traction or compression. Any injury that increases the distance between the relatively fixed points of the prevertebral fascia and the midforearm may injure the brachial plexus.

Traction or compression may result in ischemia, which initially damages the vasa vasorum. Severe compression injuries can result in intraneural hematomas, which can compress adjacent nerve tissue.

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Epidemiology

Frequency

United States

The frequency with which traumatic brachial plexopathies occur varies according the etiology and severity of specific injuries. Brachial plexus injuries are estimated to account for 5% of peripheral nerve injuries. However, the true frequency of injuries to the brachial plexus is undetermined, primarily because of significant underreporting. Prospective studies performed at Tulane University revealed a 7.7% incidence of stingers in a group of college football players; however, other sources have reported a 40% incidence.[2]

International

As noted above, frequency varies according to the etiology and severity of the injury.

Mortality/Morbidity

Coexistent musculoskeletal or central nervous system injury, such as spinal cord injury (SCI) or traumatic brain injury (BI), is common after violent trauma and presents a diagnostic challenge.

  • Narakas reported that 80% of patients with severe traumatic brachial plexopathy had multiple trauma to the head and skeletal system.[3]
  • Root avulsion and contusions of the brachial plexus and cord, which are other frequently occurring coexistent, complicating factors, pose additional diagnostic and prognostic challenges.

Race

No race predilection is reported for traumatic brachial plexopathy.

Sex

In general, traumatic brachial plexopathy is more prevalent in men than in women because of an association with violent trauma and sports.

  • Certain conditions, such as thoracic outlet syndrome (TOS), are statistically more common in women than in men.[4]
  • Other regional differences influence sex- and cause-related statistics.

Age

Because of an association with violent trauma and sports-related injuries, traumatic brachial plexopathy is most prevalent in males in their midteens and in men in their early 30s.

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Contributor Information and Disclosures
Author

Vladimir Kaye, MD  Consulting Staff, Departments of Neurology and Psychiatry, Hoag Hospital

Vladimir Kaye, MD is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Physical Medicine and Rehabilitation, and North American Spine Society

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.

Specialty Editor Board

Teresa L Massagli, MD  Professor 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.

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

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.

Kelly L Allen, MD  Medical Director, Medevals

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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