Brachial plexus injury

Introduction

Brachial plexus injuries range in severity and cause. The effects may be mild or severe. Unfortunately traumatic incidences of BP injuries are on the rise, often leading to severe social and financial hardships, and greatly affecting quality of life QOL. This page outlines the main issues arising from BP injuries and the rational behind their management.[1]

Historical note : Homer (approx. 800 BC) depicted a battle in The Illiad which involved Hector striking Teucer over the clavicle with a rock and preventing him from wielding his bow.[2]

Brachial plexus in situ.jpg

Function

Brachial plexus is the network of nerves which runs through the cervical spine, neck, axilla and then into arm or it is a network of nerves passing through the cervico axillary canal to reach axilla and innervates brachium (upper arm), antebrachium (forearm) and hand.It is a somatic nerve plexus formed by intercommunications among the ventral rami (roots) of the lower 4 cervical nerves (C5-C8) and the first thoracic nerve (T1).
The brachial plexus is responsible for cutaneous and muscular innervation of the entire upper limb, with two exceptions: the trapezius muscle innervated by the spinal accessory nerve (CN XI) and an area of skin near the axilla innervated by the intercostobrachial nerve.

Clinical Anatomy

The plexus consists of roots, trunks, divisions,cords and branches.

1. ROOTS: These are consititued by the anterior primary rami of spinal nerves C5,6,7,8 and T1 with contributions from the anterior primary rami of C4 and T2. The origin of the plexus may shift one segment either upward or downward resulting in a PRE FIXED PLEUS or POST FIXED PLEXUS respectively. In a prefixed plexus, the contribution by C4 is large and in that from T2 is often absent. In a post fixed plexus, the contribution by T1 is large, T2 is always present, C4 is absent, and C5 is reduced in size.[3] The roots join to form trunks as follows:

                     Brachial-plexus-2.png


2.TRUNKS: Upper trunk is formed by C5 & C6

                   Middle trunk is formed by C7

                   Lower trunk is formed by C8 & T1

3. DIVISIONS OF THE TRUNKS: Each trunk divides into ventral and dorsal divisions (which ultimately supply the anterior and posterior aspects of the limb). These divisions join to form cords.

4. CORDS:  it forms 3 cords

  • The Posterior Cord is formed from the three posterior divisions of the trunks (C5-C8,T1)
  • The Lateral Cord is the anterior divisions from the upper and middle trunks (C5-C7)
  • The Medial Cord is simply a continuation of the anterior division of the lower trunk (C8,T1)

5. BRANCHES: The specific branches of each cord can be seen at this page

Mechanism of injury

Injury to brachial plexus can occur in many ways. These include the contact sports, road traffic accident, motor vehicle accident or during birth. Grossly, it can be divided into

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 from 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[4]. The former examples of events are caused by one of two mechanisms that remain constant during the injury.[5]. The two mechanisms that can occur are traction and heavy impact[6]. These two methods disturb the nerves of the brachial plexus and cause the injury[7].

TRACTION: Traction, also known as stretch injury, is one of the mechanisms that cause brachial plexus injury. The nerves of the brachial plexus are damaged due to the forced pull by the widening of the shoulder and neck.Traction occurs from severe movement and causes a pull or tension among the nerves. There are two types of traction: downward traction and upward traction. In downward traction there is tension of the arm which forces the angle of the neck and shoulder to become broader. This tension is forced and can cause lesions of the upper roots and trunk of the nerves of the brachial plexus. Upward traction also results in the broadening of the angle between the arm and chest as occurs when the arm and shoulder are forced upward, this time the nerves of T1 and C8 are torn away.[8][9]

IMPACT: Heavy impact to the shoulder is the second common mechanism to causing injury to the brachial plexus. Depending on the severity of the impact, lesions can occur at all nerves in the brachial plexus. The location of impact also affects the severity of the injury and depending on the location the nerves of the brachial plexus may be ruptured or avulsed. Some forms of impact that affect the injury to the brachial plexus are shoulder dislocation, clavicle fractures, hyperextension of the arm and sometimes delivery at birth.[10] During the delivery of a baby, the shoulder of the baby may graze against the pelvic bone of the mother. During this process, the brachial plexus can receive damage resulting in injury.This is very low compared to the other identified brachial plexus injuries.[11]

Classification of injuries

The various classifications of brachial plexus injury are as follows:

  1. Leffert classification of brachial plexus injury
  2. Millesi classification of brachial plexus injury
  3. Classification on anatomical location of injury

1. Leffert classification of brachial plexus injury[12]: It is based on etiology and level of injury and is as follows

  • I Open (usually from stabbing)
  • II Closed (usually from motorcycle accident)
  • IIa Supraclavicular
    • preganglionic:
      • avulsion of nerve roots, usually from high speed injuries with other injuries and LOC;
      • no proximal stump, no neuroma formation (neg Tinel's)
      • pseudomeningocele, denervation of neck muscles are common
      • horner's sign (ptosis, miosis, anhydrosis)
    • postgangionic:
      • roots remain intact;
      • usually from traction injuries;
      • there are proximal stump and neuroma formation (pos Tinel's)
      • deep dorsal neck muscles are intact, and pseudomeningoceles will not develop;
    • Infraclavicular Lesion:
      • usually involves branches from the trunks (supraclavicular);
      • function is affected based on trunk involved;
  • III Radiation induced
  • IV Obstetric
  • IVa Erb's (upper root) - waiter's tip hand;
  • IVb Klumpke (lower root)

2. Millesi classification of brachial plexus injury[13]:  It is mainly divided into 4
I: supraganglionic/preganglionic.

II: infraganglionic/postganglionic

III: trunk.

IV: cord.


3. Classification on anatomical location of injury[14][15]:

  • Upper plexus palsy (Erb’s palsy in the OBPI cases) involves C5-C6+/-C7roots.
  • Lower plexus palsy (Klumpke’s palsy) involves C8-T1 roots (and sometimes also C7)
  • Total plexus lesions involve all nerve roots C5-T1
  • Some authors have included a fourth type,an intermediate type that primarily involves the C7 root.[16][17]

Injuries

[18]

Injuries to roots, trunks and cords of the brachial plexus produce characteristic defects which are as follow[3]

ERB'S PARALYSIS:

Site of injury: The region of the upper trunk of the brachial plexus is called Erb's point. Six nerves meet here. Injury to the upper trunk causes Erb's Paralysis.

Causes of injury: Undue separation of the head from the shoulder, which is commonly encountered in 1)birth injury 2) fall on shoulder, and 3)during anaesthesia

Nerve roots involved: Mainly C5 and partly C6.

Muscles paralysed: Mainly - biceps, deltoid, brachialis and brachioradialis. Partly - supraspinatus, infraspinatus and supinator

Deformity

Arm: Hangs by the side, it is adducted and medially rotated

Forearm: Extended and pronated

The deformity is known as "Policeman's tip hand" or "Porter's tip hand".

Disability:

  • Abduction and lateral rotation of the arm (shoulder).
  • Flexion and supination of forearm.
  • Biceps and supinator jerks are lost.
  • Sensations are lost over a small area over the lower part of the deltoid.

For more information on Erb's paralysis , including physiotherapy see this page

KLUMPKE'S PARALYSIS:

Site of injury: Lower trunk of the brachial plexus.

Cause of injury: Undue abduction of the arm, as in clutching a tree branch with the hand during a fall from a height, or sometimes in birth injury.

Nerve roots involved: Mainly T1 and partly C8.

Muscles paralysed:

  • Intrinsic muscles of the hand (T1)
  • Ulnar flexors of the wrist and fingers (C8).

Deformity: (position of the hand): claw hand due to the unopposed action of the long flexors and extensors of the fingers. In a claw hand there is hyperextension at the metacarpophalangeal joints and flexion at the interphalangeal joints.

Disability:

  • Claw hand
  • Cutaneous anaesthesia and analgesia in a narrow zone along the ulnar border of the forearm and hand.
  • Horner's syndrome: ptosis, miosis, anhydrosis, enophthalmos and loss of ciliospinal reflex- may be associated. This  is because of injury to sympathetic fibres to the head and neck that leave the spinal cord through nerve T1.
  • Vasomotor changes: The skin areas with sensory loss is warner due to arteriolar dilation. it is also drier due to the absence of sweating as there is loss of sympathetic activity.
  • Tropic changes: Long standing case of paralysis leads to dry and scaly skin.The nails crack easily with atrophy of the pulp of fingers.
For more information on Klupmke's paralysis and physiotherapy see this pgae

INJURY TO LATERAL CORD:

Cause: Dislocation of humerus associated with others

Nerve involved: musculocutaneous, lateral root of median.

Muscles paralysed:

Deformity and disability:

  • Midprone forearm
  • Loss of flexion of forearm
  • Loss of flexion of the wrist
  • Sensory loss on the radial side of the forearm
  • Vasomotor and trophic changes.

INJURY TO MEDIAL CORD:

Cause: Subcoracoid dislocation of humerus

Nerves involved: Ulnar, Medial root of median

Muscles paralysed:

  • Muscles supplied bye ulnar nerve
  • Five muscles of the hand supplied bye the median nerve.

Deformity and disability

  • Claw hand
  • Sensory loss on the ulnar side of the forearm and hand
  • Vasomotor and tropic changes as a bone.

Physiotherapy treatmentRehab equipment.png

Physiotherapy treatment for BP injury varies significantly according to the type and severity of the injury. In mild cases physiotherapy and rehabilitation will assist recovery, in more severe cases surgery and bracing may be needed.[19] Always the goal stays constant ie to return to previous level of function and preventing potential disability.

Physiotherapists treatment is aimed at

  1. Development of strength, flexibility, stamina and co-ordination
  2. Maintaining ROM via passive movements, exercise therapy, splinting and positioning and protection of denervated dermatomes.[20]
  3. Functional training and adoption adaptive devices if needed.[21]
  4. Pain control via acupuncture and TENS
  5. Managing chronic oedema via education, compression garments and massage therapy.[20]

The video clips below highlight the scope of treatment that may be undertaken due to the variance of injuries.

The following video shows treatment methods that may be employed after a Vespa scooter accident.

[22]

The next video is a treatment approach for an infant with a traction injury to the brachial plexus.

[23]

The next video shows treatment that may occur following a simple over stretching of the brachial plexus.

[24]

The next video is demonstrating BP neuromobility stretches could be used in the rehabilitation of eg sporting BP injuries. Neuromobilty places an important role in eliminating pain and restoring function.

[25]

Physiotherapy following surgery for Brachial Plexus injury

Surgery is an option for severe brachial plexus injuries, and to be viable should occur within certain timeframes. Surgery aims to regain function by surgical repair. This can take the from of nerve grafts, nerve transfers or both, and possible musculoskeletal reconstructions.[21]

Physiotherapists are crucial in the rehabilative phase post surgery in the restoring of function via strength, co-ordination, flexibility, ROM, power and use of splinting if needed. The client needs to be aware that the rehabilitation phase will be year(s) not weeks.[21]

The video clips below are examples of use of allografts and autografts. These complex procedures will need intensive physiotherapy after to resore the arm to the most optical outcome.

[26]
[27]

Medical Management - implications for Physiotherapy

Pain management is often a major issue. Significant pain occurs with root avulsions, causing neuropathic pain. Severe pain will also exhaust the client and if not treated appropriately will hinder the physiotherapy rehabilitation. This is when drugs should be used eg. NSAIDs and opioid drugs during the first stages (but not with neuropathic chronic pain). Neuropathic pain requires careful use of anti epileptic drugs (gabapentin and carbamazepine) or antidepressants such as amitriptyline. Still however less than a third of clients reports significant pain relief with this approach.[1]

Pain med.jpg

Physiotherapy may offer an additional source of pain relief with use of TENS, biofeedback, acupuncture and pain neuroscience education PNE. [1]

Dorsal Root Entry Zone (DREZ) operation is an option for persistent pain. The operation aims to destroy the nerve signal transmission from the secondary central sensory centrally.

Spinal Cord Stimulator (SCS) used to mask pain signals before they reach the brain, similar to TENS, but involves a small device and wires being inserted under the skin.[28]  Cervical SCS can be an effective treatment form of treatment for patients with neuropathic pain from brachial plexus avulsion[29].

Psychological Management

Psychological problems and a lack of cooperation by the patient may limit rehabilitation effects and increase disability.[8]

Fun fact.jpg Funny Fact........What are armies for? To hang your handy's from!

see also Nerve Injury Rehabilitation Physiotherapy

Resources

http://www.ubpn.org/

http://brachialplexussurgery.com/


Recent Related Research (from Pubmed)

References

  1. 1.0 1.1 1.2 Sakellariou VI, Badilas NK, Stavropoulos NA, Mazis G, Kotoulas HK, Kyriakopoulos S, Tagkalegkas I, Sofianos IP. Treatment options for brachial plexus injuries. ISRN orthopedics. 2014 Apr 14;2014. (last accessed 12.3.2019)
  2. Luo TD, Li Z. Brachial Plexus Injuries. [Updated 2018 Dec 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482305/ (last accessed 13.3.2019)
  3. 3.0 3.1 B.D Chaurasia.Human Anatomy.Vol.1.Fourth Edition.
  4. American Society of Surgery of Hand. Available from www.assh.org/Public/HandConditions/Documents/Web_Version_PDF/BrachPlex.pdf
  5. Midha, Rajiv, MD. "Neurosurgery." Epidemiology of Brachial Plexus Injuries in a Multitrauma Po... :. Congress of Neurological Surgeons, June 1997. Web. 29 Jan. 2013.
  6. Narakas, A.O. "The Treatment of Brachial Plexus Injuries." Link.springer.com. International Orthopaedics, June 1985. Web. 28 Jan. 2013.
  7. Hems, TE.; Mahmood, F. (Jun 2012). "Injuries of the terminal branches of the infraclavicular brachial plexus: patterns of injury, management and outcome.". J Bone Joint Surg Br 94 (6): 799–804.
  8. Coene, L.N.J.E.M. "Mechanisms of Brachial Plexus Lesions." ScienceDirect.com. Clinical Neurology and Neurosurgery, 25 Mar. 2003. Web. 29 Jan. 2013.
  9. Orthoinfo. Brachial Plexus injuries. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/brachial-plexus-injuries/ (last accessed 12.3.2019)
  10. Jeyaseelan, L.; Singh, VK.; Ghosh, S.; Sinisi, M.; Fox, M. (Jan 2013). "Iatropathic brachial plexus injury: A complication of delayed fixation of clavicle fractures.". Bone Joint J 95–B (1): 106–10.
  11. Joyner, Benny, Mary Ann Soto, and Henry M. Adam. "Brachial Plexus Injury." Brachial Plexus Injury. Pediatrics in Review, 1 June 2006. Web. 29 Jan. 2013.
  12. Clifford R. Wheeless.Wheeless' Textbook of Orthopaedics.Duke's Orthopaedics.
  13. Andrew Hodges.A-Z of Plastic Surgery.Oxford University Press.
  14. Dodds SD et al.Perinatal Brachial Plexus Palsy. Curr Op Pediat 12: 40-47, 2000.
  15. Kay SPJ. Obstetrical Brachial Palsy. Br J Plastic Surg 51: 43-50, 1998.
  16. Al-qattan MM. Self-mutilation in Children with Obstetric Brachial Pexus Palsy. J Hand Surg Br 24B; 5: 547-549, 1999
  17. Shenaq SM et al. Brachial Plexus Birth Injuries and Current Management. Clin Plast Surg 25; 4: 527-536, 1998
  18. Hospital for special surgery. What is a brachial plexus injury. Available from: https://www.youtube.com/watch?v=BnAJNnhC5EY (last accessed 10.3.2019)
  19. Richmond Rehab. The Brachial plexus. Available from: https://www.richmondrehab.com.au/blog/category/the-brachial-plexus (last accessed 10.3.2019)
  20. 20.0 20.1 Sakellariou VI, Badilas NK, Stavropoulos NA, Mazis G, Kotoulas HK, Kyriakopoulos S, et al. Treatment options for brachial plexus injuries. ISRN Orthop. 2014:314137. doi: 10.1155/2014/314137. Available from:  Sakellariou VI, Badilas NK, Stavropoulos NA, Mazis G, Kotoulas HK, Kyriakopoulos S, et al. Treatment options for brachial plexus injuries. ISRN Orthop. 2014:314137. doi: 10.1155/2014/314137.(last accessed 11.3.2019)
  21. 21.0 21.1 21.2 Ausmed. Brachial Plexus Injuries. Available at: https://www.ausmed.com/cpd/articles/brachial-plexus-injuries (last accessed 10.3.2019)
  22. Mayo clinic. Treatment of Brachial plexus injuries. Available from: https://www.youtube.com/watch?v=KwgHgg3Vfx4 (last accessed 10.3.2019)
  23. rAnn and Robert H. Lurie. Childrens hospital of Chicago. Available from: https://www.youtube.com/watch?v=bvKrUEehkKc (last accessed 10.3.2019)
  24. Ask Dr Jo. Bracial plexus injury stretches and exercise. Available from: https://www.youtube.com/watch?v=oVWfYUk4vOA (last accessed 10.3.2019)
  25. COR. Brachial plexus neuromobility. Available from: https://www.youtube.com/watch?v=F3tKQG8IUrI (last accessed 10.3.2019)
  26. Hand surgery internation 2015. BP surgery in 3 minutes. Available from: https://www.youtube.com/watch?v=6YzHsisOFtw (last accessed 11.4.2019)
  27. Phoenics Children's Hospital. Dylan's story. Available from: https://www.youtube.com/watch?v=A8h3LgbVTMU (last accessed 11.4.2019)
  28. Mayfeild Brain and Spine. Spinal Cord Stimulation. Available from: https://mayfieldclinic.com/pe-stim.htm (last accessed 13.3.2019)
  29. Samer Abdel-Aziz, Ahmed H. Ghaleb; Cervical Spinal Cord Stimulation for the Management of Pain from Brachial Plexus Avulsion, Pain Medicine, Volume 15, Issue 4, 1 April 2014, Pages 712–714, https://doi.org/10.1111/pme.12313 (last accessed 13.3.2019)