Traumatic Brachial Plexus Injury

  • Symptoms can mimic those of a spinal cord injury
    • Essential to differentiate from spinal cord injury early
    • Assume it is a spinal cord injury until proven otherwise
  • Minor to moderate brachial plexus injuries are commonly referred to as “stingers” or “burners” which are transient, unilateral neuropraxias commonly seen in sporting injuries
    • These will resolve without intervention and should be differentiated from more severe and permanent brachial plexus injuries
  • Neurologic exam is critical to assess and document as the exam may change with time
    • Common root injury patterns have classic resting arm positions (see below) which may help clue providers into specific roots that are injured

  • Mechanism (often high energy)
    • Often forced arm abduction i.e. grabbing a tree limb while falling
    • “Stingers” are common sports injuries (often seen in football) and are unilateral and transient in nature (often paresthesias in deltoid and/or biceps)
  • Timing of injury
  • Other locations of injury or pain
  • Numbness and tingling
    • Variable distribution depending on the extent of injury (see physical exam)
  • Associated injuries:
    • Common: rib fractures, pneumothorax, clavicle fracture, closed head injuries, scapulothoracic dissociation
    • Horner's syndrome (ptosis, miosis, anhidrosis)
  • Anticoagulation? Last dose?
  • Last time the patient ate (NPO)
  • Hand dominance
  • Profession

  • Airway, breathing, circulation must be evaluated and stabilized with standard trauma evaluation guidelines
  • Commonly occurs in high energy/level trauma setting

  • Quick assessment of hemodynamic stability (heart rate, hypotension, etc.)
  • Vascular injury can occur with traction injuries or direct trauma

  • Assess the skin for lacerations, bruising, ecchymosis
  • Tenderness to palpation
    • Palpate the remainder of the upper extremity to assess for other injuries
    • Palpate cervical spine for tenderness or step off
    • Thorough secondary exam to assess for concomitant injuries

  • Preganglionic injuries
    • Horner's syndrome
      • Ptosis, miosis, anhidrosis
    • Winged Scapula
      • Long thoracic nerve palsy
    • Elevated hemidiaphragm
      • Phrenic nerve palsy
  • Postganglionic lesion
    • Involves peripheral nervous system (see below)
  • Careful exam to determine the extent of the injury and specific roots involved
    • Do not have to localize roots acutely
      • Document deficits in motion that you notice (for trending over time)
    • Common Root Injury Patterns
      • Complete involvement (C5-T1) - most common
        • Worse prognosis
        • Flaccid arm
        • Involves motor and sensory
      • C5-C6 upper trunk injuries
        • Adducted, internally rotated at shoulder, pronated and extended at elbow
        • Axillary nerve deficient (weak deltoid and teres minor)
        • Musculocutaneous deficient (weak bicep)
        • Suprascapular nerve deficient (weak supraspinatus and infraspinatus)
      • C8-T1 lower trunk injuries
        • Claw hand - wrist extended, hyperextended MCPs, flexion of IP joints in the hand
        • Ulnar and median nerve deficit (weak hand muscles)

Motor Exam (common peripheral nerve exam) :
  • Median Nerve/ Anterior interosseous nerve (AIN)
    • Opposition of the thumb
      • Opponens innervated by the median nerve - helpful to assess if concern for acute carpal tunnel syndrome
    • Flexion of wrist, fingers, thumb
    • “A-OK sign” = AIN
      • Tests flexion of thumb IP joint (FPL) and flexion of index DIP joint (FDP)
  • Radial nerve/ Posterior interosseous nerve (PIN)
    • Extension of wrist, fingers, thumb
      • Radial nerve palsy is common seen in humeral shaft fractures especially midshaft and distal third
    • “Thumbs up” = PIN
      • Tests extension of thumb IP and MCP joints (EPL))
    • Palm on flat surface and lifting/extending thumb off the surface is also a good test for PIN (tests extension of thumb MCP joint (EPL))
  • Ulnar nerve
    • Finger abduction (spread fingers, “peace sign”), finger adduction, cross fingers (“promise”)
Sensory Exam:
  • Use dermatomal distributions, especially if concerned for root injuries
  • Dermatomes
Vascular exam:
  • Radial artery, Ulnar artery
    • If having difficulty with palpation of radial artery, find a US doppler
    • Vascular injury can occur with traction injuries or direct trauma
  • Capillary refill to digits

  • Assess active motor function of the joints in the affected extremity
    • May have motor deficits and be unable to move certain muscle groups

  • PA/Lateral Chest
    • Look for rib trauma and paralyzed diaphragm
  • Cervical spine radiographs AP/L/Oblique/Odontoid view
    • Transverse process fractures can indicate root avulsion
  • Shoulder radiographs AP/L/Scapular Y/Axillary lateral vs. Velpeau
    • Axillary lateral vs. Velpeau of shoulder
      •
      • Important to rule out concomitant shoulder dislocation which may not always be apparent on AP
        • Axillary
          • Beam directed into the axilla
          • Requires patient to abduct which might be painful in the setting of proximal humerus fracture
        • Velpeau
          • Superoinferior view looking down upon shoulder
          • Does not requires patient to abduct arm
    • Consider Grashey view if concerned for intraarticular extension
      • AP of the glenoid - possible to see fracture line exit into the glenoid
      • Patient rotated 35-45 degrees and his or her back (scapular body) up against the imaging detector.
  • CT myelography - Not acutely ordered
    • Gold standard for nerve root injury definition
    • Perform 3-4 weeks after injury
  • MRI - Leave to discretion of orthopaedics to order
    • Useful for imaging injuries distal to nerve roots and can visualize much of the plexus

     Medical Decision Making

Traumatic Brachial Plexus Injury due to :
  1. Sharp penetrating trauma (excluding GSW)
  2. Iatrogenic injuries
  3. Open injuries
  4. Progressive neurologic decline
  5. Expanding hematoma or vascular injury
*** is a *** y/o ***R/L hand-dominant ***M/F presenting with pain to the ***R/L shoulder which occurred while ***mechanism, found to have a scapular fracture. The patient was neurovascularly intact and had no poke holes or punctate wounds. There was tenderness to palpation about the shoulder girdle and tenderness to palpation ***other locations. Imaging revealed ***. On ***velpeau/axillary lateral the glenohumeral joint was concentrically aligned. The patient was immobilized with a sling and will follow up with orthopedic surgery in a week.
Traumatic Brachial Plexus Injury due to/with:
  1. Closed injuries
  2. Traction injuries
  3. Signs of neurologic recovery
  4. GSW without vascular injury
*** year-old R/L***-hand dominant M/F*** with a history of *** presenting with R/L*** upper extremity injury following mechanism*** . There is *** motor deficit, and *** sensory deficit. There is/is not associated ***ptosis/ miosis/ anhidrosis. Associated injuries include ***. On examination the patient’s neurologic exam shows deficient ***C5/C6/C7/C8/T1. Vascular assessment shows a ***perfused hand with ***intact/deficient radial and ulnar pulse. Radiographs of the *** show ***. The injury is closed. Given the history, exam and imaging findings, a traumatic ***pre/post ganglionic brachial plexus injury is suspected on the ***R/L extremity involving *** nerve roots. Plan for immobilization in sling for comfort and close outpatient follow up with hand surgery in one week.

If Traumatic Brachial Plexus Injury due to :
  1. Sharp penetrating trauma (excluding GSW)
  2. Iatrogenic injuries
  3. Open injuries
  4. Progressive neurologic decline
  5. Expanding hematoma or vascular injury
  • Consult orthopaedic surgery
  • NPO, preop labs (type and screen, INR, aPTT, CBC, BMP)
  • If concern for associated vascular injury- Consult vascular surgery immediately
All other traumatic brachial plexus injuries:
  • WB status: WBAT injured upper extremity, sling for comfort
  • Diet: Regular
    • Analgesia: short course of narcotic pain medication, tylenol (scheduled)
  • Ex: 5mg oxycodone q4 - 25 pills
  • Immobilization
    • Sling immobilization
  • Disposition: Home with follow up in hand surgery clinic in 1 week


Common ICD-10 Codes Brief Description
S14.3 Injury of brachial plexus