Brachial Plexus Injury in Sports Medicine

Updated: Nov 26, 2014
  • Author: Thomas H Trojian, MD; Chief Editor: Sherwin SW Ho, MD  more...
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Overview

Background

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. In a study of Canadian football, brachial plexus injuries were reported to be 26% (21%-32%) of players, during the 2010 football season. [1] In an American football study, the lifetime rate of brachial plexus injuries was 50.3%. [2] The greater incidence of brachial plexus injuries has been suggested to be the result of direct trauma from participation in contact sports. [3, 4, 5, 6, 7]

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

Bertelli et al reviewed the sensory losses and pain symptoms of 150 patients with brachial plexus lesions that were evaluated and operated on. Sensory losses were believed to be documented on the basis of dermatomal root distribution and pain symptoms were believed to be attributed to lower root avulsion. Prior to surgery, patients underwent clinical evaluation and CT myelo scanning with intradural contrast. Hand and finger sensation were evaluated preoperatively; upper root lesions showed hand sensation was preserved. In C8-T1 root injuries, diminished protective sensation was observed on the ulnar aspect of the hand. C8 and T1 injuries always were avulsed from the cord. This indicated an overlapping of the dermatomes, which was not as widely reported. Hand sensation was largely preserved in patients with partial injuries particularly on the brachial side. [8]

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. [9]

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. [10]

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Epidemiology

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. [11] This is supported by Starr's work. [2]

Sallis et al surveyed Division III college football players and reported that 65% experienced brachial plexus injuries. [12] In addition, Sallis reported an 87% recurrence rate in these individuals. Meeuwisse reported that 7.2% of all football injuries were brachial plexus injuries. [13] The positions most frequently involved varies between Canadian and American football but linebackers are common in both. In Canadian football offensive linemen and wide receivers are involved and in American football it is running backs and defensive lineman. [1, 2] This difference may be due to the different rules of the games with the Canadian Football League having 66% passing plays and the National Football League having 56% passing plays.

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.

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Functional Anatomy

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
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Sport Specific Biomechanics

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.)
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