Brachial Plexus Injury in Sports Medicine 

Peripheral nerve injuries are not common in noncontact sports. However, in contact and collision sports such as football and rugby, brachial plexus injuries occur often. The greater incidence of brachial plexus injuries has been suggested to be the result of direct trauma from participation in contact sports.^{[1, 2, 3, 4, 5]}

The result of trauma to the brachial plexus can lead to the cervical "stinger" or "burner" syndrome, which is classically characterized by unilateral weakness and a burning sensation that radiates down an upper extremity. The condition may last less than a minute or as long as 2 weeks, with the latter duration described as a chronic burner syndrome.

Recent studies

Sulaiman et al reviewed the clinical outcomes in patients who underwent nerve transfer operations for brachial plexus reconstruction at Louisiana State University over a 10-year period, evaluating recovery of elbow flexion and shoulder abduction. The authors found that nerve transfers for repair of brachial plexus injuries resulted in excellent recovery of both elbow and shoulder functions. They also noted that patients who had direct repair of brachial plexus elements in addition to nerve transfers tended to do better than those who had only nerve transfer operations.^[6]

Terzis and Barmpitsioti studied the use of wrist fusion in patients with brachial plexus injuries with multiple root avulsions resulting in wrist instability, imbalance, and inability to control the placement of the hand in space. Of 35 patients who underwent wrist fusion and answered questionnaires about their overall perceptions, 97.14% were satisfied with wrist stability and 88.57% reported that the procedure enhanced the overall upper limb function. The Disabilities of the Arm, Shoulder and Hand score was 59.14 +/- 12.9, reflecting moderate ability in daily activities. According to the authors, wrist fusion in patients with brachial plexus palsy is recommended as a complementary procedure, offering a stable, painless carpus, with improvement of overall upper limb function and appearance.^[7]

In a study by Terzis and Kostopoulos, vascularized ulnar nerve grafting was found to be the appropriate solution for brachial plexus injuries with C8 and T1 root avulsion, with outcomes superior to those achieved with conventional nerve grafts. In their study, patients with long denervation times yielded poorer results than those who were operated on early. Pedicle and free ipsilateral ulnar nerve grafts yielded comparable results for biceps muscle neurotization, and neurotization of biceps with a vascularized ulnar nerve graft from the contralateral root was found not to be as effective as neurotization from ipsilateral donors. According to the authors, the use of ulnar nerve grafts for neurotization of multiple motor targets of the median nerve from contralateral donors is under consideration.^[8]

Frequency

United States

Brachial plexus injuries are the most common peripheral nerve injuries seen in athletes. True rate of brachial plexus injuries is difficult to determine due to significant underreporting. Many stingers last briefly, and players do not seek medical attention. Clancy et al reported that 33 of 67 college football players (49%) sustained at least 1 burner during collegiate play.^[9] Sallis et al surveyed Division III college football players and reported that 65% experienced brachial plexus injuries.^[10] In addition, Sallis reported an 87% recurrence rate in these individuals. Meeuwisse reported that 7.2% of all football injuries were brachial plexus injuries.^[11]

International

True measure of international occurrence of brachial plexus injuries is undetermined due to significant underreporting in athletes and lack of studies in rugby and hockey involving brachial plexus injuries.

Injuries to the cervical spine are common. The common level of injury is at C5-C6. Damage to other areas of the spinal area can lead to an array of motor and sensory deficits. The following is a list of cervical nerve roots with the associated area of potential motor and sensory deficits:

• C4 - Trapezius; shoulder; top of shoulders
• C5 - Deltoid, rotator cuff; shoulder abduction; lateral upper arm or distal radius
• C6 - Biceps, rotator cuff; elbow flexion; lateral forearm and thumb
• C7 - Triceps; elbow extension; index and middle finger tips
• C8 - Extension of fingers; distal thumb; fourth and fifth fingers

The following 3 mechanisms are common to brachial plexus injury:

1. Traction caused by lateral flexion of the neck away from the involved side (similar to the mechanism in birth trauma)
2. Direct impact to the Erb point causing compression to the brachial plexus (often associated with poor-fitting shoulder pads)
3. Nerve compression caused by neck hyperextension and ipsilateral rotation (The neural foramen narrows in this mechanism.)