Brachial Plexus injuries

Brachial plexus injuries

Brachial plexus injuries result in the paralysis of the upper limb. These are generally serious and devastating injuries.

The injury involves the Brachial Plexus (Figure 1)
The brachial plexus consists of the nerve roots C5-T1 originating form the spinal cord.

Paralysis of the limbs can be reversible and non-reversible. Stopping blood supply to the nerves of the upper limb ( i.e. while lying on your arm when in a deep slumber) can cause temporary paralysis. However most injuries are sustained from falls and road traffic accidents in adults. When in occurs in newborns, termed Birth Brachial plexus injury, it is secondary to injuries sustained at the time of birth.

Non reversible injuries occur when the nerves that make up the Brachial plexus are either pulled from the spinal cord (avulsed) or the nerves break(ruptured) . This results in no connection between the spinal cord and the end muscle and skin resulting in loss of power and sensation. This is termed a flaccid paralysis. The area where there is a paralysis corresponds to the nerve roots that are injured and involved.

There can be some recovery in the paralysis over time if the injury is not too serious.

It is generally taken that if no significant recovery occurs by 3 months of the injury, there will be likely to have poor outcomes.

There are several types of brachial plexus injuries:

1. In newborn children

Birth Brachial plexus occurs when there is injury to the Brachial plexus at the time of birth. The nerves are stretched and injured. It is associated with a high birth weight. Most recover by 3-4 months to an acceptable degree. However those with poor recovery at 3 months will require surgery to repair the nerves involved.

2. In adults or older children, these are secondary to accidents.

  • Incomplete or Upper Type
  • Complete or Total type
  • Delayed presentation with partial recovery

There is increasing severity from the incomplete to the complete type. There is a also an decreased recovery in those who have a delayed presentation.

Early appropriate intervention in the younger patient with incomplete type or upper type (C5/6 lesions) have the best outcomes. Complete and total type can achieve a degree of upper limb function usually as an assist arm.

Brachial plexus surgery involves the exploration of the brachial plexus and repair of the nerves injured or in some cases nerve transfers to help reconnect the muscles that have been disconnected by using nearby nerves. Some examples of donors include the ulnar nerve, radial nerve, spinal accessory nerve or intercostal nerves (those who help you expand your chest). These nerves are available as donors.

The recovery of these nerve transfers will take 3 months to 1 year to see results and require a high degree of rehabilitation. Figure 2 ( to mask out face)

Delayed presentations will usually need local muscle transfers or free muscle transfers (moving muscles from one part of the body to another and connecting the nerves up) to reconstruct function. These are more complex procedures that have a higher risk. The recovery time will take usually more than 6 months to 2 years.

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