The brachial plexus is a complex network of nerve fibres that supplies the skin and musculature of the upper limb. It begins in the root of the neck, passes through the axilla, and enters the upper arm.

The brachial plexus is divided into Roots, Trunks, Divisions, Cords, and Branches. There are five "terminal" branches and numerous other "pre-terminal" or "collateral" branches that leave the plexus at various points along its length.

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Injury to the brachial plexus can be very problematic because the nerves branching off of the plexus provide innervation to the upper extremity. Clinical signs and symptoms vary with which area of the plexus is involved, and generally result in paralysis and/or anaesthesia.

Symptoms can range from transient nerve dysfunction to complete upper extremity paralysis. Because of the anatomical variants of the brachial plexus these injuries can be a challenge to diagnose.

Traumatic injury may arise from

  • High-speed vehicular accidents, especially motorcycle accidents
  • Blunt trauma
  • Stab or gunshot wounds
  • Inflammatory processes (brachial plexitis)
  • Compression (for example caused by a growing tumor)
  • Neuropathies
  • Radiation therapy & iatrogenic causes

Nerve injuries vary in severity from a mild stretch to the nerve root tearing away from the spinal cord and include the following

  • Neurapraxia - The nerve has been stretched and damaged but not torn
  • Neuroma - Scar tissue has grown around the injury site, putting pressure on the injured nerve and preventing the nerve from sending signals to the muscles
  • Rupture - The nerve is torn, but not at the spinal cord attachment
  • Avulsion - The nerve is torn away from its attachment at the spinal cord; this is the most severe type of injury

Operative care of the brachial plexus is a highly specialized field that is limited to relatively few tertiary care centers. Wide variation exists in how these injuries are addressed surgically. The availability of subspecialists with experience in the operative management of these lesions is critical if operative management is considered.

In general, the surgical options consist of the following

  • Nerve transfers
  • Nerve grafting
  • Muscle transfers
  • Free muscle transfers
  • Neurolysis of scar around the brachial plexus in incomplete lesions

 

Video

Brachial plexus avulsion injury. Reconstruction of shoulder abduction & elbow flexion.

* Patient consent was obtained for publication of figures