The brachial plexus starts at the neck and symbols the upper chest to the armpit. Injury to this network of nerves often occurs when the arm is pulled or stretched forcibly.

Mild brachial plexus injuries can heal without treatment. More serious injuries may require surgery to regain function of the arm or hand.

Types of brachial plexus injuries

Brachial plexus birth injuries are often classified according to the type of nerve injury and the pattern of nerves involved. There are four types of nerve injuries.

• Stretching (neuropraxia)
• the nerve has been stretched but not broken
• the injury occurs outside the spinal cord
• most common way
• Usually affected nerves can heal on their own, usually within the baby's first 3 months of life.
• Breaking off
• The nerve is undecided, but not where it attaches to the spine.
• injury occurs outside of the spinal cord
• common way
• may require surgical repair
• Avulsion
• nerve roots are pulled from the spinal cord
• injury occurs in the spinal cord
• less common form (about 10 to 20 percent of cases)
• it cannot be surgically mended directly; damaged tissue must be surgically substituted (nerve transfers)
• It can damage the nerve of the diaphragm, causing difficulty in breathing.
• drooping eyelid on the affected side may indicate a more serious injury, such as Horner syndrome
• Neuroma

The nerve has tried to heal, but scar tissue has formed that presses on the injured nerve or interferes with nerve function.

may need surgical treatment with nerve rebuilding and / or secondary tendon transfers

Causes of brachial plexus injury

A brachial plexus birth injury is believed to be caused by an injury involving the child's brachial plexus during the birthing process. This injury can result in incomplete sensory and / or motor function of the affected arm.

Based on our published research, a brachial plexus injury was found to occur in 1.5 out of every 1000 live births.

Traumatic brachial plexus injuries can occur due to car accidents, bicycle accidents, ATV accidents, sports, etc. Nerve injuries vary in harshness from mild widening to tearing of the nerve root of the spinal cord.

Signs and symptoms

Nerve injuries can stop signals to and from the brain, preventing the muscles in the arm and hand from working properly and causing a loss of sensation in the area.

Diagnosis

"The test is used primarily to measure the degree of nerve injury and determine the location of the injury, and the resulting info is used to help understand the likelihood and degree of recovery," she explains. "The decision to perform surgery and the type of operation required will often depend on this information." He adds that the EMG test can also be used to monitor recovery.

The test involves stimulating the nerves with tiny electrical shocks and inserting tiny acupuncture-like needles into certain muscles. The test can last between 30 and 60 minutes, depending on the complexity of the injury and the amount of information the doctor requires.

Based on the surgeon's findings, adult patients can be diagnosed with any of the following conditions:

Neurapraxia: a stretched nerve

Neuroma: a condition in which scar tissue has grown around a damaged nerve.

Rupture: one or more nerves are torn, but not in the spinal cord

Avulsion - Nerve roots detach from the spinal cord. Multiple root avulsion is the most common diagnosis in high-energy traumatic brachial plexus injuries, such as occurs in a motorcycle or ATV accident.

Symptoms include numbness, inability to use the muscles in the shoulder, arm, and hand, and burning or crushing pain. Patients with a plain avulsion injury may also have tired eyelids, a phenomenon known as Horner syndrome.

Non-surgical treatment

Stretch neuropraxia patients can regenerate healthy nerve tissue. However, the recovery is unpredictable. In such cases, the orthopedic surgeon performs frequent and thorough examinations for the first three to six months after the injury and performs additional imaging and electro diagnostic tests as needed. If there is no retrieval, the patient is evaluated for interior nerve damage and surgery may be necessary.

 Surgical treatment

Although nerve grafts and repairs have been used in the past to reconstruct damaged nerves in the brachial plexus, these surgeries have had variable success and were often not adequate to restore function in severely injured patients.

For the past decade, HSS orthopedic surgeons have used nerve transfers, in addition to nerve grafts and nerve repair, to restore function in these complex cases. While the concept of nerve transfer is not new, pioneered in the 1900s, newer nerve transfer techniques have accelerated the rate and scope of recovery of shoulder and elbow function.

"The use of surgical nerve transmissions has revolutionized our method to these patients," explains Scott W. Wolfe, MD, Chief of Hand and Upper Extremity Service at HSS. "With the working microscope, we can transmission a part of an intact nerve from a working muscle and reattach it to the undamaged part of one nerve from another."

Previously, the surgeon removed healthy nerve tissue from an uninjured site on the arm or leg. Occasionally, nerves were removed from between the ribs and transferred to the arm. More recently, Dr. Wolfe and his colleagues have identified specific nerve transfer sites within the injured area that offer even better results than previously achieved with nerve grafts or chest wall grafts. The timing of surgery is essential. "Ideally, we repair the nerves within three to six months of injury," says Dr. Wolfe. "Surgery can still be done later with some improvement in function, although at 12 months and beyond, our results are much less predictable, as the muscles are less able to revive."

Some patients seeking treatment for a chronic injury year after their initial trauma may also benefit from surgery in which the muscles that work with their blood and nerve supplies are transferred from distant parts of the body. Read more about a patient's experience with brachial plexus injury repair in HSS.

The results of nerve transfer surgery can be dramatic, especially with respect to shoulder and elbow function, according to Dr. Wolfe. “What is amazing is the degree of redundancy within the peripheral nervous system that allows us to separate a portion of a functioning nerve without causing a loss of strength or sensation, but then reconnect the same nerve elsewhere and regain function. muscle loss in a matter of months,” he explains.

Common examples include the use of a single bundle of ulnar nerve fibers to reactivate the biceps muscle of the arm, or a portion of the triceps muscle nerve to restore energy to an atrophied deltoid muscle in the shoulder. While some advancement in the forearm and hand is on the horizon, it is important for patients to realize that sensation and function below the elbow, if injured, may remain limited. Additionally, patients should understand that the first signs of muscle recovery may not be apparent until 6 to 12 months after surgery; This is followed by a gradual return to strength and mobility.

Treatment

Observation

Most brachial plexus injuries heal on their own. Your doctor will monitor your child closely. Many children improve or recover between 3 and 12 months of age. During this time, ongoing exams should be done to monitor progress.

Physical therapy or occupational therapy

Therapy is recommended to help maximize use of the affected arm and prevent muscle and joint strain. With the teaching and guidance of therapists, parents learn to perform range of motion (ROM) exercises at home with their child several times a day. These exercises are important so that the joints and muscles move as normally as possible.

Botox® injections

Botox® (primarily for the shoulder) can be used to help with joint movement, rebalance the muscles, or prevent shoulder contractures and dislocations.

The surgical options for brachial plexus injury

Children who continue to have problems 3 to 6 months after birth can benefit from surgical treatment. Your child's doctors have several surgical options to treat congenital brachial plexus palsy, including:

Microsurgery (10 to 20 percent of all surgeries for brachial plexus injuries)

Microsurgery is recommended to repair or reconstruct injured nerves if recovery is still inadequate 3 to 6 months after birth. This surgery generally consists of a combination of nerve grafts and nerve transfer procedures. It is best done between 3 and 9 months of age and is generally not beneficial for children older than 1 year.

Osteotomy

An osteotomy is a procedure in which bones are cut and reoriented to improve upper limb function by better positioning the hand and arm. It is most often done on the humerus (upper arm bone) or forearm.

Tendon transfers

Tendon transfers involve detaching the tendon from its normal attachment and repositioning it in a new location. This procedure, which is usually performed between the first year and adulthood, allows a healthy muscle to help a weaker or injured muscle return to its desired function. Tendon transfers are usually done around the shoulder to improve the ability to lift the arm, but can be done in the forearm, wrist, or hand. Children are usually in a cast for four to six weeks after surgery.

Open reduction of the shoulder joint (capsulorraphy)

Open reduction of the shoulder joint, performed through a surgical incision or arthroscopically, reduces (placing the humeral head back into the joint) and surgically tightens the loose tissue around the shoulder joint. The procedure is necessary when persistent muscle weakness has caused instability or dislocation of the shoulder joint. It is often done in conjunction with other surgical procedures.

Free muscle transfers

A free muscle transfer is an extensive surgery, generally using the muscles in the legs, requiring reconnection of blood vessels and nerves under the microscope. It is performed only when there are no local muscles in the arm or hand to replace the dysfunctional muscles.

Risk factor's

Participation in contact sports, particularly soccer and wrestling, or being involved in high-speed car accidents increases the risk of brachial plexus injury.

Complications

Given enough time, many brachial plexus injuries in both children and adults heal with little or no lasting damage. But some injuries can cause temporary or permanent problems, such as:

Stiffness in the joints. If you experience paralysis of your hand or arm, your joints may stiffen. This can make movement difficult, even if you eventually regain use of the limb. For that reason, your doctor will likely recommend continued physical therapy during your recovery.

Pain. This is due to nerve damage and can become chronic.

Numbness. If you lose feeling in your arm or hand, you risk getting burned or injured without knowing it.

Muscular atrophy. Nerves grow back slowly and can take several years to heal after an injury. During that time, lack of use can cause affected muscles to break down.

Permanent disability. How well you recover from a serious brachial plexus injury depends on several factors, including your age and the type, location, and severity of the injury. Even with surgery, some people experience permanent muscle weakness or paralysis.

Prevention

Although damage to your brachial plexus often cannot be prevented, you can take steps to reduce the risk of complications once an injury has occurred:

For you. If you temporarily lose the use of your hand or arm, daily range of motion exercises and physical therapy can help prevent joint stiffness. Avoid burns or cuts, as you may not feel them if you experience numbness.

If you are an athlete who has suffered injuries to the brachial plexus area, your doctor may suggest that you use specific padding to protect the area during sports.

For your son. If you are the parent of a child with brachial plexus palsy, it is important that you exercise your child's functional joints and muscles every day, starting when your baby is only a few weeks old. This helps prevent joints from becoming permanently stiff and keeps your child's active muscles strong and healthy.

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