Medscape is available in 5 Language Editions – Choose your Edition here.


Traumatic Brachial Plexopathy Treatment & Management

  • Author: Vladimir Kaye, MD; Chief Editor: Robert H Meier, III, MD  more...
Updated: Aug 27, 2015

Rehabilitation Program

Physical Therapy

Depending on local expertise, the rehabilitation program may be undertaken with a physical therapist and/or an occupational therapist. The goals are to preserve ROM, improve strength, and manage pain.

Patients should undergo physical therapy to maintain ROM and to optimize the recovery of motor function as muscle reinnervation occurs.

The goal of treatment is to return function to the structures supplied by the damaged nerves and to improve the patient's quality of life. The injured nerve and the exogenous sources of nerve injury are treated.

At the onset of injury, early mobilization and icing are used. In the subacute phase, therapy gradually progresses from passive to active motion and from assisted to active ROM, as tolerated.

Heat, ultrasonography, transcutaneous electrical nerve stimulation (TENS), interferential current stimulation, and/or electrical stimulation are used, depending on the predominant symptoms.

Cervical muscle strengthening and the correction of upper extremity muscle imbalances are included in the protocol as well.

The use of appropriate slings, the protection of extremities and joints, and the prevention of subluxation must be considered.

Cervical pillows or collars may be required for patients with combined lesions of the roots and plexus.

Occupational Therapy

During occupational therapy efforts are concentrated on maintaining ROM in the shoulder; fabricating appropriate orthoses to support the function of the hand, elbow, and arm; and addressing edema control and sensory deficits, with testing and therapy.

Occupational therapy may address issues related to the patient's ability to write, type, and find alternate ways of communicating.

Additionally, occupational therapy provides help with retraining for activities of daily living (ADLs), including the use of 1-arm techniques, adaptive equipment, and self-ranging and strengthening exercises.

Recreational Therapy

Recreational therapy should address compensatory strategies and activities that can substitute for altered or lost function in extremities that were required for recreation prior to injury.


Medical Issues/Complications

See the list below:

  • Complications may include intractable pain syndromes, such as persistent neuropathy and complex regional pain syndrome type 2 (CRPS II or causalgia), skin damage and infection, significant muscle atrophy, contractures and capsulitis, subluxations, sensory loss, osteopenia, heterotopic ossification, myofascial pain, and depression and anxiety.
  • Bone dislocation with neurologic deficit requires prompt anatomic reduction to prevent irreversible nerve damage.
  • The use of analgesics can help patients control pain from nerve injuries. Steroids may help to decrease endoneurial edema associated with nerve injury.
  • Hyperbaric oxygen decreases vascular compromise of the vasa nervorum, as well as endoneurial edema and pressure. Hyperbaric oxygen is an approved adjunctive treatment for acute traumatic ischemic reperfusion injury.
  • Ciliary neurotrophic factor (CNTF), which enhances motor neuron survival in vivo and in vitro, is in the investigational stage.

Surgical Intervention

Surgery is reserved for patients in whom symptoms persist despite appropriate conservative treatment.[8, 20, 21, 22, 23, 24] Two important issues to consider before surgery are as follows: (1) whether function can be obtained after the nerve is repaired and (2) whether the potential benefit to the patient outweighs the surgical risks, costs, and loss of productivity. The timing of surgery is important as well.[25]

Other factors to consider are as follows:

  • In clean lacerating injuries in which the nerve ends are visible in the wound or when clinical examination reveals obvious motor and sensory deficits from the laceration, immediate primary repair may be indicated.
  • In blunt transections resulting from lacerations, delayed repair has a better surgical result.
  • Injuries without evidence of early spontaneous recovery, such as those caused by bullets, crushing blows, traction, fractures, or injections, are explored several months after the injury.
  • Brachial plexus stretches or contusions are observed for 4 months. If no evidence of recovery is present, the plexus is explored.
  • Nerve or tendon transfers may be necessary if nerve repair is unsuccessful. [26]

Brachial plexus injuries are not always reparable. In such cases, neurotizations or nerve transfers may offer a better functional outcome.[27]

Sunderland suggests 2 criteria that must be present before fascicular repair or interfascicular grafting is considered[28] :

  • The fascicular bundle must be large enough for suturing.
  • The bundle must be sharply localized or sufficiently well defined so that it can be identified and mobilized for repair.

The spinal accessory or long thoracic nerve can be grafted onto distal arm nerve trunks, with some improvement in elbow flexion.

A literature review by Ali et al indicated that in adult upper trunk brachial plexus injuries, the Oberlin nerve transfer procedure is more effective in restoring elbow flexion than nerve grafting or combined grafting/transfer techniques. The study also found that nerve transfer in general is more effective than grafting or combined procedures in restoring shoulder abduction.[29]

Intraoperative care with proper axial orientation of the fascicles, hemostasis, suture material, and suture line tension leads to better outcomes in brachial plexus surgery. Tension of the suture line and inadequate preparation of the nerve stumps are 2 leading causes of regenerative failure across the suture site (resulting in poor recovery of nerve function).

Surgical repairs are most effective within 3 months of the injury.[30] Surgical delays in excess of 5 months dramatically decrease the rate of functional return.

When repair does not provide adequate results, planned tendon transfers can increase extremity function.

Rarely, in cases of a complete multilevel injury (eg, flail injury, anesthetic arm), amputation may result in a better functional outcome, because the patient can use the extremity with an appropriate prosthesis. However, the result may be less cosmetically pleasing than would that obtained with other approaches.

Related Medscape Reference article:

Brachial Plexus Hand Surgery



See the list below:

  • Consultations with an orthopedic surgeon and a neurosurgeon are considered in cases in which there has been poor neurologic and functional recovery.
  • A complete multidisciplinary rehabilitation assessment is indicated. [31] A consultation with a prosthetic specialist may be required for the fabrication of a temporary or permanent prosthetic device.
  • A pain management strategy is of great importance in improving the patient's ability to cope and function and in improving his/her quality of life.

Other Treatment

See the list below:

  • In cases of CRPS II, sympathetic (ie, stellate) blockade may be required, along with the appropriate combination of neuropathic and narcotic medications.
  • For incomplete, painful injuries, and especially in cases of CRPS II, the use of a spinal cord stimulator on a trial basis may be beneficial. If this trial is successful, the stimulator may be implanted.
  • Implantable peripheral nerve stimulators have also been successfully used in some centers.
  • The use of an implantable intrathecal device (eg, pump) may be considered in cases in which the employment of oral medications, therapy, and a spinal cord stimulator fail.
Contributor Information and Disclosures

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 Physical Medicine and Rehabilitation, North American Spine Society, American Academy of Anti-Aging Medicine

Disclosure: Nothing to disclose.


Murray E Brandstater, MBBS Chairman and Program Director, Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine

Murray E Brandstater, MBBS 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, Royal College of Physicians and Surgeons of the United States

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Aishwarya Patil, MD Physiatrist (Rehabilitation Physician), Vice Chair, Immanuel Rehabilitation Center

Aishwarya Patil, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, Association of Physicians of India

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, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Additional Contributors

Teresa L Massagli, MD Professor of Rehabilitation Medicine, Adjunct Professor of Pediatrics, University of Washington School of Medicine

Teresa L Massagli, MD is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

  1. Sköld MK, Svensson M, Tsao J, Hultgren T, Landegren T, Carlstedt T, et al. Karolinska institutet 200-year anniversary. Symposium on traumatic injuries in the nervous system: injuries to the spinal cord and peripheral nervous system - injuries and repair, pain problems, lesions to brachial plexus. Front Neurol. 2011. 2:29. [Medline]. [Full Text].

  2. Clancy WG Jr, Brand RL, Bergfield JA. Upper trunk brachial plexus injuries in contact sports. Am J Sports Med. 1977 Sep-Oct. 5(5):209-16. [Medline].

  3. Narakas AO. Traumatic brachial plexus lesions. Dyck PJ, Thomas PK, Lambert EH, et al, eds. Peripheral Neuropathy. Philadelphia, Pa: WB Saunders; 1984. vol 2: 1394.

  4. Crotti FM, Carai A, Carai M, et al. Post-traumatic thoracic outlet syndrome (TOS). Acta Neurochir Suppl. 2005. 92:13-5. [Medline].

  5. Van Alfen N, Malessy MJ. Diagnosis of brachial and lumbosacral plexus lesions. Handb Clin Neurol. 2013. 115:293-310. [Medline].

  6. Kim DH, Murovic JA, Tiel RL, et al. Penetrating injuries due to gunshot wounds involving the brachial plexus. Neurosurg Focus. 2004 May 15. 16(5):E3. [Medline].

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

  8. Hentz VR. Is microsurgical treatment of brachial plexus palsy better than conventional treatment?. Hand Clin. 2007 Feb. 23(1):83-9. [Medline].

  9. Mansukhani KA. Electrodiagnosis in traumatic brachial plexus injury. Ann Indian Acad Neurol. 2013 Jan. 16(1):19-25. [Medline]. [Full Text].

  10. Barman A, Chatterjee A, Prakash H, Viswanathan A, Tharion G, Thomas R. Traumatic brachial plexus injury: electrodiagnostic findings from 111 patients in a tertiary care hospital in India. Injury. 2012 Nov. 43(11):1943-8. [Medline].

  11. Aminoff MJ, Olney RK, Parry GJ, et al. Relative utility of different electrophysiologic techniques in the evaluation of brachial plexopathies. Neurology. 1988 Apr. 38(4):546-50. [Medline].

  12. Date ES, Rappaport M, Ortega HR. Dermatomal somatosensory evoked potentials in brachial plexus injuries. Clin Electroencephalogr. 1991 Oct. 22(4):236-49. [Medline].

  13. Insola A, Caliandro P, Pirrone R, et al. Usefulness of a comprehensive neurophysiological assessment for early diagnosis and prognosis of traumatic brachial plexus injuries. Electromyogr Clin Neurophysiol. 2005 Jun. 45(4):209-17. [Medline].

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

  15. Brunelli GA, Brunelli GR. Preoperative assessment of the adult plexus patient. Microsurgery. 1995. 16(1):17-21. [Medline].

  16. O'Shea K, Feinberg JH, Wolfe SW. Imaging and electrodiagnostic work-up of acute adult brachial plexus injuries. J Hand Surg Eur Vol. 2011 Nov. 36(9):747-59. [Medline].

  17. Chanlalit C, Vipulakorn K, Jiraruttanapochai K, et al. Value of clinical findings, electrodiagnosis and magnetic resonance imaging in the diagnosis of root lesions in traumatic brachial plexus injuries. J Med Assoc Thai. 2005 Jan. 88(1):66-70. [Medline].

  18. West GA, Haynor DR, Goodkin R, et al. Magnetic resonance imaging signal changes in denervated muscles after peripheral nerve injury. Neurosurgery. 1994 Dec. 35(6):1077-85; discussion 1085-6. [Medline].

  19. Brogan DM, Carofino BC, Kircher MF, et al. Prevalence of rotator cuff tears in adults with traumatic brachial plexus injuries. J Bone Joint Surg Am. 2014 Aug 20. 96 (16):e139. [Medline].

  20. 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].

  21. Krishnan KG, Martin KD, Schackert G. Traumatic lesions of the brachial plexus: an analysis of outcomes in primary brachial plexus reconstruction and secondary functional arm reanimation. Neurosurgery. 2008 Apr. 62(4):873-85; discussion 885-6. [Medline].

  22. Tender GC, Kline DG. The infraclavicular approach to the brachial plexus. Neurosurgery. 2008 Mar. 62(3 Suppl 1):180-4; discussion 184-5. [Medline].

  23. Kachramanoglou C, Li D, Andrews P, East C, Carlstedt T, Raisman G, et al. Novel strategies in brachial plexus repair after traumatic avulsion. Br J Neurosurg. 2011 Feb. 25(1):16-27. [Medline].

  24. Dafydd H, Lin CH. Hand reanimation. Curr Rev Musculoskelet Med. 2014 Mar. 7 (1):76-82. [Medline].

  25. Kim DH, Cho YJ, Tiel RL, et al. Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center. J Neurosurg. 2003 May. 98(5):1005-16. [Medline].

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

  27. Wang SF, Li PC, Xue YH, Yiu HW, Li YC, Wang HH. Contralateral C7 nerve transfer with direct coaptation to restore lower trunk function after traumatic brachial plexus avulsion. J Bone Joint Surg Am. 2013 May 1. 95(9):821-7, S1-2. [Medline].

  28. Sunderland S. Nerves and Nerve Injuries. 2nd ed. London, England: Churchill Livingstone; 1978.

  29. Ali ZS, Heuer GG, Faught RW, et al. Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques. J Neurosurg. 2015 Jan. 122 (1):195-201. [Medline].

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

  31. Wynn Parry CB. Rehabilitation of patients following traction lesions of the brachial plexus. Clin Plast Surg. 1984 Jan. 11(1):173-9. [Medline].

  32. Grant GA, Goodkin R, Kliot M. Evaluation and surgical management of peripheral nerve problems. Neurosurgery. 1999 Apr. 44(4):825-39; discussion 839-40. [Medline].

  33. Hattori Y, Doi K, Ikeda K, et al. Vascularized ulnar nerve graft for reconstruction of a large defect of the median or radial nerves after severe trauma of the upper extremity. J Hand Surg [Am]. 2005 Sep. 30(5):986-9. [Medline].

  34. Jeon IH, Neumann L, Wallace WA. Scapulothoracic fusion for painful winging of the scapula in nondystrophic patients. J Shoulder Elbow Surg. 2005 Jul-Aug. 14(4):400-6.

  35. Kerr AT. The brachial plexus of nerves in man, the variations in its formation and branches. Am J Anat. 1918. 23:285.

  36. Pitt M, Vredeveld JW. The role of electromyography in the management of the brachial plexus palsy of the newborn. Clin Neurophysiol. 2005 Aug. 116(8):1756-61. [Medline].

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

  38. Tagliafico A, Succio G, Serafini G, Martinoli C. Diagnostic accuracy of MRI in adults with suspect brachial plexus lesions: A multicentre retrospective study with surgical findings and clinical follow-up as reference standard. Eur J Radiol. 2011 Nov 7. [Medline].

  39. Trumble TE. Peripheral nerve injury: pathophysiology and repair. Feliciano DV, Moore EE, Mattox KL, eds. Trauma. 4th ed. New York, NY: McGraw-Hill; 2000. 1047-55.

  40. Yilmaz C, Eskandari MM, Colak M. Traumatic musculocutaneous neuropathy: a case report. Arch Orthop Trauma Surg. 2005 Jul. 125(6):414-6. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.