Brachial plexus injury

Background

Brachial plexus surrounding the brachial artery.

Anatomical illustration of the brachial plexus with areas of roots, trunks, divisions and cords marked.

Nerve roots that supply sensation to the upper extremities.

• Injuries can be penetrating, compression, or closed traction:
  • Supraclavicular (roots and trunks)
  • Infraclavicular (cords and terminal nerves)

Causes of Brachial plexopathy

• Idiopathic
• Post-infectious
  • Viral
    • Epstein-Barr, CMV, influenza, parvovirus, coxsackie, HIV, Polio
  • Bacterial
    • Lyme, Leptospirosis, TB, Salmonella
• Post-immunization
• Compressive
  • Neoplasm
    • Pancoast tumor
• Post-traumatic
  • Penetrating or blunt neck/shoulder trauma
  • Traction injury
  • Birth trauma
    • Erb's palsy
    • Klumpke's paralysis
• Connective tissue disorders
• Autoimmune disorders
  • Lupus
  • Polyarteritis nodosa
  • Temporal arteritis
• Iatrogenic
  • Post-surgical
  • Medication induced
  • Radiation
• Hereditary Neuralgic Amyotrophy
• Rotator Cuff Injury
• Adhesive capsulitis
• Calcific tendinitis
• Thoracic outlet syndrome
• ALS
• Poliomyelitis
• Parsonage-Turner syndrome

Anatomy

• Roots:
  • C5
  • C6
  • C7
  • C8
  • T1
• Trunks:
  • Upper
  • Middle
  • Lower
• Cords:
  • Lateral
  • Posterior
  • Medial
• Terminal Nerves:
  • Musculocutaneous
  • Median
  • Axillary
  • Radial
  • Ulnar

Clinical Features

Simulated mechanism of injury.

• Arm pain (constant, burning)
• C5 injury:
  • weakness of deltoid and infraspinatus causes adducted, internally rotated shoulder
• C6 injury:
  • weakness of biceps causes elbow extension
• C7 injury:
  • weakness of extensor muscles causes wrist and digit flexion

Differential Diagnosis

• Rucksack paralysis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

• Shoulder Dislocation
  • Anterior shoulder dislocation
  • Posterior shoulder dislocation
  • Inferior shoulder dislocation
• Clavicle fracture
• Humerus fracture
• Scapula fracture
• Acromioclavicular joint injury
• Glenohumeral instability
• Rotator cuff tear
• Biceps tendon rupture
• Triceps tendon rupture
• Septic joint

Nontraumatic/Chronic:

• Rotator cuff tear
• Impingement syndrome
• Calcific tendinitis
• Adhesive capsulitis
• Biceps tendinitis
• Subacromial bursitis
• Cervical radiculopathy

Refered pain & non-orthopedic causes:

• Referred pain from
  • Neck
  • Diaphragm (e.g. gallbladder disease)
• Brachial plexus injury
  • Rucksack paralysis
• Axillary artery thrombosis
• Thoracic outlet syndrome
• Subclavian steal syndrome
• Pancoast tumor
• Myocardial infarction
• Pneumonia
• Pulmonary embolism

Upper extremity peripheral nerve syndromes

Median Nerve Syndromes

• Carpal tunnel syndrome
• Pronator teres syndrome
• Anterior interosseous neuropathy

Ulnar Nerve Syndromes

• Ulnar neuropathy

Radial Nerve Syndromes

• Radial neuropathy at the spiral groove (ie. "Saturday night palsy")
• Posterior interosseous neuropathy

Proximal Neuropathies

• Suprascapular neuropathy
• Long thoracic neuropathy
• Axillary neuropathy
• Spinal accessory neuropathy
• Musculocutaneous neuropathy

Other

• Brachial plexopathy
  • Parsonage-Turner syndrome
• Cervical radiculopathy

Evaluation

• Clinically evaluate for concurrent phrenic nerve injury and diaphragmatic paresis
• MRI
• CT myelography
• EMG
• Surgical exploration

Management

• Early neurosurgical consultation
• PT / OT

See Also

• Spinal cord levels
• Neurologic Exam