Everything You Need to Know About Brachial Plexus Injuries.

Your brachial plexus is a network of nerves in your shoulder that branches into five major nerves in each arm. It carries signals from your spinal cord to your arms and hands, allowing you to move your arm, hands, and wrists. Sensory skin nerves are also part of the brachial plexus and allow you to feel temperature and other sensations.

There are several types of brachial plexus injuries, with many different causes. They also vary in severity, with some people healing completely on their own and others having permanent damage.

Read on to learn more about how brachial plexus injuries occur, what your treatment options are, and more.

What causes a brachial plexus injury?

The most common cause of a brachial plexus injury is some sort of trauma, such as:

• falls
• direct, blunt blows
• motor vehicle accidents, especially motorcycles
• penetrating wounds, such as gunshot or knife wounds

In some cases, the trauma itself will cause the injury, such as a nerve rupture on impact from a fall. In other cases, a brachial plexus injury can be secondary to another injury, such as:

• arm or shoulder fracture
• rib fracture
• traumatic brain injury
• spine fracture
• spinal cord injury

A newborn can also get a brachial plexus injury during childbirth.

Is a brachial plexus injury the same as a pinched nerve?

People often confuse a pinched nerve with a brachial plexus injury, but they’re not the same.

If you have a pinched nerve (aka cervical radiculopathy, nerve compression, or nerve entrapment), your nerve is compressed. This compression is usually due to inflammation or pressure. Doctors rarely use surgery to treat a pinched nerve, except in severe cases.

A brachial plexus injury is more severe and often requires surgery. It also occurs in a specific set of nerves. A pinched nerve can occur in many nerves.

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What are the types of brachial plexus injuries?

There are four main types of brachial plexus injuries.

Avulsion

An avulsion is the most severe type of brachial plexus injury. It’s when the root of your nerve separates from your spinal cord. These are usually due to severe trauma, such as a fall or motor vehicle accident.

Avulsion is often a permanent condition since surgery can’t usually reattach the nerve. Injuries at or near the spinal cord usually cause more severe pain.

Rupture

A rupture is also a tear in your nerve, but not at the spinal cord. It occurs when something causes your nerve to stretch to the point where it tears, either partially or fully.

It’s less serious than an avulsion but still more serious than other types of brachial plexus injuries. You’ll usually need surgery as soon as possible in order to recover.

Neurapraxia

Neurapraxia is when something stretches a nerve to the point of damage, but it doesn’t tear. It usually causes a burning or stinging sensation. Often called “burners” or “stingers,” these are the mildest kind of brachial plexus injury.

Neurapraxia is often due to compressing the root of your nerve. This can happen when something pushes your head to one side.

It may also be due to traction, which is when the nerve gets pulled down. This is more common in people who play contact sports.

Neuroma

An injured nerve may form scar tissue as it heals. This scar tissue, called a neuroma, can interfere with the function of your nerve by putting stress on it and blocking signals.

Neuromas can be very painful. Surgery is necessary to remove the scar tissue.

Who is at risk for brachial plexus injury?

Brachial plexus injuries are most common in males ages 15 to 25. This is likely due to the higher rates of participation in sports, accidents, and risk-taking among this age group.

Those most at risk for a brachial plexus birth injury include:

• large babies
• breech (feet first) babies
• babies born after a long labor
• babies of birthing parents with diabetes
• babies of birthing parents with uterine tachysystole (frequent contractions)
• babies of birthing parents who took oxytocin, a hormone used to induce labor

How common is brachial plexus injury during childbirth?

Brachial plexus injuries occur in about 1 to 3 births per 1,000. Approximately 20% to 30% of those injuries involve all five nerves.

Avulsion is the least common type of brachial plexus injury during childbirth, accounting for about 10% to 20% of cases.

What are the signs and symptoms of a brachial plexus injury?

Symptoms of a brachial plexus injury include:

• numbness or loss of feeling in your arm or hand
• weakness in your arm or hand
• an arm that hangs limply
• inability to move your shoulder, arm, wrist, or hand
• inability to control your shoulder, arm, wrist, or hand movement
• severe or sudden shoulder or arm pain
• burning or stinging sensation in your shoulder or arm

In newborns

Symptoms of a brachial plexus injury in newborns include:

• muscle weakness
• paralysis of the arm or hand
• decreased movement in the arm or hand
• decreased sensation in the arm or hand

Brachial plexus injuries in newborns usually don’t cause much pain.

When to contact a doctor

Contact a doctor if you have any of the above symptoms, especially after an injury or physical trauma. You should also contact a doctor if your shoulder, arm, or hand aren’t working as they should, even if you haven’t had a recent injury.

It’s best to get medical help as soon as possible after your symptoms start. Earlier treatment can lead to better outcomes, especially if you need surgery. The chance of a successful surgery decreases sharply if it isn’t done within 6 months of the injury.

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How do doctors diagnose a brachial plexus injury? 

Most doctors are able to diagnose a brachial plexus injury. For treatment, you’ll usually need an orthopedist, orthopedic surgeon, or neurosurgeon. If you need a referral, your primary care doctor can make one for you.

In addition to taking a medical history, a doctor may perform or order the following to diagnose a brachial plexus injury:

• Physical exam: A doctor will conduct a physical exam to check for mobility, range of motion, and loss of sensation in all areas that your brachial plexus nerves affect. They’ll also look for physical symptoms such as drooping eyelids.
• X-ray: An X-ray may help rule out other causes of your symptoms, such as rib fractures or herniated discs. They can also check for lung injuries.
• Computed tomography (CT) scan: According to the American Academy of Orthopaedic Surgeons, a CT scan is the best way to identify an avulsion. A CT scan should occur at least 3 to 4 weeks after the injury.
• Magnetic resource imaging (MRI) scan: A doctor may use an MRI instead of or along with a CT scan.
• Electrodiagnostic exams: A doctor may perform an electromyogram or nerve conduction velocity test to check your nerve function. These tests measure the electrical activity of your nerves to assess the amount of damage.

What is the treatment for a brachial plexus injury? 

Minor brachial plexus injuries may heal on their own, although this can take months. Nerves regenerate at a rate of about 1 inch per month.

Babies with brachial plexus injuries and adults with neuropraxia are more likely to heal on their own.

If a doctor thinks your injury might heal on its own, they may monitor you for a few months. They may also recommend nonsurgical treatments, such as:

• physical therapy to help prevent stiffness and restore strength
• occupational therapy to restore functionality
• steroid creams or injections to manage pain
• splints or braces to support your arm or joints
• compression sleeves to prevent swelling

If you don’t start to improve during that time, they may move forward with surgery.

Surgical options

Some brachial plexus injuries require timely surgical treatment to prevent permanent loss of function. This is especially true of avulsions and ruptures. Surgery should take place within 3 to 6 months.

Depending on the type of brachial plexus injury, a doctor may recommend a specific surgery:

• Neurolysis: If you have a neuroma, the surgeon will remove the scar tissue around your nerve.
• Nerve repair: The surgeon reconnects two torn edges of a ruptured nerve.
• Nerve graft: A healthy nerve from elsewhere in your body acts as a graft, connecting and supporting the two ends of a ruptured nerve as they grow back together. This doesn’t work for an avulsion, because the nerve needs to be connected to your spine. According to a 2019 study, nerve grafts have a success rate of about 69%, though it depends on which nerves are damaged.
• Nerve transfer (aka Oberlin transfer): If your damaged nerve isn’t connected to your spine, the surgeon can take a healthy donor nerve and connect it to the injured nerve. A 2020 review noted that success rates for this procedure range from 75% to 93%.
• Tendon and muscle transfer: If you have a severe injury or wait too long for treatment, a surgeon may need to reconstruct the affected tendon or muscle. They’ll take a functioning tendon or muscle from elsewhere in your body and connect it to the affected area to help restore function.

Surgeries for brachial plexus injuries typically involve an incision above your collarbone. There may be a second incision at the front of your shoulder.

You’ll likely need physical therapy for several months after surgery.

Talk with a doctor to see if you’re a candidate for surgery.

Brachial plexus injury treatment options for newborns

Most brachial plexus injuries in newborns will heal on their own, often within the first 3 to 12 months. According to a 2019 review, experts agree that conservative treatment is the best option. This may include:

• physical and occupational therapy
• electrostimulation
• splints
• botulinum toxin (Botox) injections

If symptoms don’t improve within 3 months, a doctor may consider surgery.

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What does recovery look like for people with brachial plexus injuries? 

Recovery from a brachial plexus injury can take a long time. Minor injuries can take weeks or months to heal on their own. Even with surgery, you may not see results for at least a few months.

Occupational and physical therapy after surgery — or even if your injury is healing on its own — can help you regain strength and function. Depending on what level of motor function you have and how much you’ve lost, you may do exercises to build back your muscle strength and increase mobility or practice daily tasks such as writing.

As you recover, you should continue to see a doctor so they can check your progress. They can also help you manage pain with medication, therapy, and splints.

What are the complications of a brachial plexus injury?

Without proper treatment, a brachial plexus injury can cause lasting damage. You may not ever have full use of your arm or hand, or you may have chronic pain. If you don’t regain feeling in your arm or hand, it can lead to other injuries. For example, you may not recognize if you’re holding something hot enough to burn you.

Depending on which nerves are damaged, you or your child may experience a related condition. These include:

Erb’s palsy

Erb’s palsy, also known as brachial plexus birth palsy, occurs when the upper branches of the brachial plexus are damaged during childbirth. It’s one of the most common neurological birth injuries. It’s usually due to traction of the baby’s neck during childbirth.

It’s rare for Erb’s palsy to result in permanent disability. About 10% to 30% of infants have permanent issues due to the condition.

Klumpke’s palsy

Klumpke’s palsy occurs when the lower branches of the brachial plexus are damaged. It’s not common in newborns because it’s usually due to upward force on the arm or shoulder. It can affect the function of your hand and wrist.

Complete palsy

Complete or pan-plexus palsy is damage in all five brachial plexus nerves. This will affect your entire arm. It will be limp and without sensation.

Horner’s syndrome

A brachial plexus injury can also lead to Horner’s syndrome. That’s when there’s damage to the nerves in your sympathetic nervous system. Horner’s syndrome can cause:

• a drooping eyelid (ptosis)
• a small pupil (miosis)
• decreased sweating on one side of your face

Horner’s syndrome is usually a sign of a more serious brachial plexus injury.

How can I prevent a brachial plexus injury?

The best way to prevent a brachial plexus injury is to keep yourself safe from injuries or events that can cause a brachial plexus injury. For example:

• Always drive safely and wear your seatbelt.
• Wear protective gear when riding a motorcycle.
• If you play sports, always wear protective equipment and warm up properly.

Takeaway

Brachial plexus injuries are usually the result of trauma, including falls, wounds, or car crashes. While this can be a very serious injury, it’s treatable. Many people will need surgery to heal their brachial plexus injury.

Brachial plexus injuries can also affect newborns during childbirth. These injuries usually heal on their own, but more severe cases may require surgery.

If you or your child have a brachial plexus injury, don’t be discouraged if it heals slowly. This is typical. With proper treatment, whether nonsurgical or surgical, you should regain function and mobility.