A brachial plexus injury occurs when the nerves that connect your arm and spinal cord get stretched or torn. This usually happens when your shoulder is pressed down forcefully while your head is pushed up and away from that shoulder.

The brachial plexus is the network of nerves that travels from your neck and passes under your collarbone to serve your arm and hand. Injuries to these nerves are common in contact sports, especially football, but they can also result from auto accidents and falls. Babies sometimes sustain a brachial plexus injury during birth.

Minor injuries to the brachial plexus often resolve on their own within a few weeks, but some injuries can be so severe that they require surgical repair. In some cases, full function of the arm - especially the hand - can never be recovered.

The mechanism of injury should be considered. The index of suspicion for a brachial plexus injury is much higher for severe motorcycle and motor vehicle accidents.

The patient may present with the following symptoms:

Causes:

A brachial plexus injury can occur in a variety of scenarios:

  • Contact sports. Many football players have experienced burners or stingers, which can occur when the nerves in the brachial plexus get stretched beyond their limit during collisions with other players.
  • Difficult births. If an infant’s shoulders get wedged within the birth canal, the force used to pull the baby free may damage the nerves in the brachial plexus. This can result in a loss of sensation and movement in the arm, commonly called Erb’s palsy.
  • Trauma. Vehicular accidents, especially if you’re riding a motorcycle, can result in brachial plexus injuries. Bullet or knife wounds also can damage the brachial plexus.

Is there any treatment?

Many brachial plexus injuries heal without specific treatment. Physical and occupational therapy may be useful in regaining strength and use of the arm and hand. Pain medicine may be needed to reduce pain and allow more use of the arm. With severe traumatic injuries, surgery may be indicated. Corticosteroids are sometimes used to treat inflammation in Parsonage-Turner syndrome but may not necessarily improve outcome.

Treatment of pain and inflammation aims to facilitate movement and improve coordination of muscles and joints. Nondrug treatments, often provided by physical therapists, include heat, cold, electrical stimulation, cervical traction, massage, and acupuncture. These treatments are used for many disorders of muscles, tendons, and ligaments.

Heat:

Heat provides temporary relief in subacute and chronic traumatic and inflammatory disorders (eg, sprains, strains, fibrositis, tenosynovitis, muscle spasm, myositis, back pain, whiplash injuries, various forms of arthritis, arthralgia, neuralgia). Heat increases blood flow and the extensibility of connective tissue; heat also decreases joint stiffness, pain, and muscle spasm and helps relieve inflammation, edema, and exudates. Heat application may be superficial or deep. Intensity and duration of the physiologic effects depend mainly on tissue temperature, rate of temperature elevation, and area treated.

Cold:

The choice between heat and cold therapies is often empiric. When heat does not work, cold is applied. However, for acute injury or pain, cold seems to be better than heat. Cold may help relieve muscle spasm, myofascial or traumatic pain, acute low back pain, and acute inflammation; cold may also help induce some local anesthesia. Cold is usually used during the first few hours or the day after an injury; consequently, it is seldom used in physical therapy.

Cold may be applied locally using an ice bag, a cold pack, or volatile fluids (eg, ethyl chloride, vapocoolant spray), which cool by evaporation. The spread of cold on the skin depends on the thickness of the epidermis, underlying fat and muscle, water content of the tissue, and rate of blood flow. Care must be taken to avoid tissue damage and hypothermia. Cold should not be applied over poorly perfused areas.

Electrical stimulation:

Transcutaneous electrical nerve stimulation (TENS) uses low current at low-frequency oscillation to relieve pain. Patients feel a gentle tingling sensation without increased muscle tension. Depending on the severity of pain, 20 min to a few hours of stimulation may be applied several times daily. Often, patients are taught to use the TENS device and decide when to apply treatment. Because TENS may cause arrhythmia, it is contraindicated in patients with any advanced heart disorder or a pacemaker. It should not be applied over the eyes.

Cervical traction:

Cervical traction is often indicated for chronic neck pain due to cervical spondylosis, disk prolapse, whiplash injuries, or torticollis. Vertical traction (with patients in a sitting position) is more effective than horizontal traction (with patients lying in bed). Motorized intermittent rhythmic traction with 7.5 to 10 kg is most effective. For best results, traction should be applied with the patient’s neck flexed 15 to 20°. Generally, hyperextension of the neck should be avoided because it may increase nerve root compression in the intervertebral foramina. Traction is usually combined with other physical therapy, including exercises and manual stretching.

Massage:

Massage may mobilize contracted tissues, relieve pain, and reduce swelling and induration associated with trauma (eg, fracture, joint injury, sprain, strain, bruise, peripheral nerve injury). Massage should be considered for low back pain, arthritis, periarthritis, bursitis, neuritis, fibrositis, hemiplegia, paraplegia, quadriplegia, multiple sclerosis, and cerebral palsy. It should not be used to treat infections or thrombophlebitis. Only a licensed massage therapist should perform massage for treatment of an injury.

Acupuncture:

Thin needles are inserted through the skin at specific body sites, frequently far from the site of pain). Acupuncture is sometimes used with other treatments to manage chronic pain and to enhance rehabilitation after stroke.

What happens when the brachial plexus is injured?

The network of nerves is fragile and can be damaged by pressure, stretching, or cutting. Stretching can occur when the head and neck are forced away from the shoulder, such as might happen in a fall off a motorcycle. If severe enough, the nerves can actually avulse, or tear out of, their roots in the neck. Pressure could occur from crushing of the brachial plexus between the collarbone and first rib, or swelling in this area from injured muscles or other structures.

Injury to a nerve can stop signals to and from the brain, preventing the muscles of the arm and hand from working properly, and causing loss of feeling in the area supplied by the injured nerve. When a nerve is cut, both the nerve and the insulation are broken. Pressure or stretching injuries can cause the fibers that carry the information to break and stop the nerve from working, without damaging the cover.

When nerve fibers are cut, the end of the fiber farthest from the brain dies, while the insulation stays healthy. The end that is closest to the brain does not die, and after some time may begin to heal. If the insulation was not cut, new fibers may grow down the empty cover of the tissue until reaching a muscle or sensory receptor.

Some brachial plexus injuries are minor and will completely recover in several weeks. Other injuries are severe enough that some permanent disability involving the arm can be expected.

Sources: UBPN; Ninds

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