eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Traumatic Brachial Plexopathy

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

Introduction

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.

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

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.

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.1

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.2
  • 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.3
  • 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.

Clinical

History

History taking should include inquiry into the mechanism of injury, as well as a description of patient symptoms. Common mechanisms of injury involve cervical extension, rotation, lateral bending, and depression or hyperabduction of the shoulder.

Patients should be queried about weakness, sensory loss, paresthesias and dysesthesias, and the location of symptoms in the arm.

Physical

The physician should examine the cervical spine, shoulder, clavicle, scapula, and related joints for range of motion (ROM), alignment, and tender points. A thorough neurologic examination of the upper extremity should include manual muscle testing, sensory examination, and an evaluation of deep tendon reflexes

  • The site of injury can be accurately localized with a precise neurologic examination by using the correlative neuroanatomy.
  • A sensory examination should include testing for light-touch sensation, pinprick sensation, 2-point discrimination, vibration sensation, and proprioception.
  • In an anterior dislocation of the shoulder, the sensory distribution of the axillary and musculocutaneous nerves are tested to detect nerve injury in the early stages.
  • Associated problems that require prompt attention can be identified with the following:
    • Evaluation of joint instability and scapular winging
    • Auscultation to detect hemidiaphragmatic paralysis
    • Observation of patterns of muscle weakness and/or atrophy, in which the injured side is compared with the uninvolved side
    • Testing for SCI and BI

Causes

As previously noted, a large proportion of brachial plexopathies are caused by trauma. The mechanism of traumatic injuries and the magnitude, rate, and direction of deforming forces ultimately determine the extent and location of the injury. Mechanisms include traction, penetrating injury, and crushing or compression.

Closed injuries, such as those caused by motor vehicle accidents, industrial accidents, and sports-related trauma, are more common in civilian life than in military life. Violent torsion of the upper limb, either upward or downward, may damage the plexus. Shrapnel injuries and blast injuries, as well as gunshot wounds and knife injuries to the neck or axilla, can cause lesions in the brachial plexus.4

Iatrogenic injuries occur during surgery, particularly in procedures involving the following: (1) neck or shoulder, (2) opening of the chest, (3) regional anesthetic blocks, and (4) placement of cannulas. Injuries to the brachial plexus of neonates may occur during birth, as a result of the strain placed on the plexus by a wide separation of the head and shoulder or by forced adduction of the shoulder joint during a difficult delivery.5,6

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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