Brachial Plexus injuries in Adults

Kayakriti Plastic Surgery & Dental Center

Less than 1 year of injury – NERVE REPAIR/TRANSFERS

Complete Brachial plexus Injury-C5678T1

Partial Brachial plexus Injury-C56 or C567

More than 1 year of injury- MUSCLE/TENDON TRANSFERS

Complete Brachial plexus Injury-C5678T1

Partial Brachial plexus Injury-C56 or C567

Brachial Plexus injuries in Adults

Best Brachial plexus injury in adults surgery in India

Brachial plexus injuries are injuries related to the brachial plexus. Brachial Plexus is a network of nerves that sends signals from the spinal cord to the shoulder, arm and hand and controls the movement and sensations of the same. The brachial plexus begins at the neck and crosses the upper chest to the armpit. Usually, injury to the brachial plexus occurs when the arm is forcibly stretched, pulled or injured during an accident.

When these nerves that send and receive the signals are either compressed or stretched and sometimes even are torn or ripped apart, this may cause weakness, numbness or loss of movement in the shoulder, arm or hand. This can easily be understood when a person is unable to lift his/her hand from the elbow or shoulder joint, lose grip and is unable to hold objects. It is often seen more in men aged between 15-25 years.

Causes of Brachial Plexus Injury

Most common cause in adults is road traffic accidents, especially motorcycle accidents
Others are sports injuries
Fall from height
Gunshot or penetrating injury
Carrying a heavy backpack and inappropriate operative positioning.
Non-traumatic causes consist of tumors, irradiation, and congenital abnormalities such as cervical ribs.

Examination of Brachial Brachial Plexus Injury

Immediately after the accident, the patient must be thoroughly examined to rule out any fracture at the site of injury or injury to other parts of the body, such as the head, spinal cord or chest injury.
Level of consciousness of the patient after the accident should be inquired for and whether he/she was able/not able to lift his limb after the accident and had/ had not any sensation then, which can be a clue for planning management later.

Now the interesting part is - The patient should consult whom? A General physician? Surgeon? Orthopedician? Neurologist???????

Due to very less awareness, often patient roams around and reach the right person quite late after the injury. So, Plastic surgeons trained in the management of Brachial Plexus injuries are the ones who should be consulted for the management of such cases. Dr Amit Agarwal specializes and has the expertise of more than 11 years in the field of brachial plexus injury management and is well aware of all aspects of treatment.

After the patient has recovered from the other injuries, the patient will be advised for regular physiotherapy and explained to examine himself as per the features described below and follow-up is done every month. If no recovery is perceived, the patient will undergo a few diagnostic investigations. Chest radiographs, Magnetic Resonance Neurography of Brachial Plexus, Pulmonary function tests (PFT), Electromyography (EMG) and Nerve Conduction Studies (NCSs) are done to confirm the diagnosis, localize and characterize the nerve lesion.

Timing of surgery in Brachial Plexus injury

The next important factor is the time interval between the accident and surgical intervention. It is said that the "sooner the treatment, better the outcome" in brachial plexus injuries. The nerves are explored, repaired and transferred during the surgery.

In case of sharp open injury, immediate surgery is performed, and the zone of damage is explored/identified.
Otherwise, in blunt closed injuries which are more common, observation is done for the first 2-3 months, which gives the time for any spontaneous recovery and if present, we can wait for further 3 months.
If no recovery is seen after 3 months of the accident, nerve transfer surgery is done as early as possible.
Surgery can still be done for injuries within 9 months to 1 year of injury, but chances of recovery would be less when compared to surgery done early at 3 months.
If nerve transfer surgery is attempted after 1 year of the accident, it has been observed that chances of recovery would be very less as there's is not enough time left for nerve regeneration, so specific targeted muscle and tendon transfers are done instead of nerve transfer surgery beyond 1 year of the accident.

Types of Brachial Plexus Injuries

The brachial plexus is formed by five cervical nerves, C5, C6, C7, C8 and T1. Patients can relate their type of injury with the kind of symptoms and weakness they have. So the injury to these nerves can be divided into-

Partial brachial plexus injury - upper arm type (C5, C6 with or without C7 injuries)- Upper arm type injury will present with deficits in shoulder stability, abduction (outward movement), external and internal rotation, as well as in elbow flexion (bending of the elbow) and forearm supination (rotate forearm inward). If C7 is involved, there will be a variable weakness in elbow, wrist and finger extension (straightening of elbow, wrist and finger joints).
Partial brachial plexus injury - Lower arm type (C8, T1 injuries), very less common. Lower arm type injury will present with weakness of hand muscles and finger extension, along with loss of sensation in forearm and hand. The patient may notice a difference in the size of both eyes (meiosis), and a lowering of the upper eyelid (ptosis).
Complete brachial plexus injury (C5, 6, 7, 8, T1 injuries). Total arm type injury will have a complete loss of movements in hand, forearm and arm, with loss of sensation as well.

The upper brachial plexus (C5, C6) is more likely to stretch or rupture in the neck region, whereas the lower brachial plexus (C8, T1) avulse/detach from the spine.

The nerve regeneration occurs slowly at a rate of approximately 1 mm/day, recovery from a brachial plexus injury takes time, and patients may not experience results for several months even after successful surgery.

The patient is advised for regular physiotherapy, and TENS therapy (transcutaneous electric nerve stimulation).

A positive mindset and the support of family, friends, and healthcare professionals are important to recovery and rehabilitation.

The maximum result that a patient with full effort and physiotherapy gets in Complete brachial plexus injury after the surgery is that he can abduct (lift his arm away from the body) up to 90 degrees, flex the elbow (bend elbow towards the body) and mild grip in hand (just to hold any object). So that he can use his paralyzed hand as a supportive hand.

How we treat Brachial Plexus Injuries is dependent on the time that has elapsed since the accident.

If the time of intervention is less than one year of the accident, then nerve transfers or nerve repair are done. If more than one year has passed after the accident, then muscle or tendon transfers are advised.

The type of nerve or muscle procedure would further depend on whether the Brachial Plexus injury is either complete or partial.

A) Less than 1 year of Injury

If the time of intervention is less than one year of the accident, then nerve transfers or nerve repair is done. The type of nerve repair and nerve transfer would depend on whether the injury is complete or partial.

B) More than 1 year of Injury

If more than one year has passed after the accident, then muscle or tendon transfers are advised. The types of muscle and tendon transfer advised and done would depend on whether the injury is complete or partial.

Brachial Plexus injuries in Adults

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Dr Amit Agarwal

Best plastic surgeon, Dr. Amit Agarwal is an American Board Certified, extensively trained, and best Plastic & Aesthetic surgeon in Lucknow. He is the Chief Plastic Surgeon heading the Department of Plastic, Microvascular, and Craniofacial surgery at Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, U.P, India. He maintains a busy practice at Avadh and Nishat Hospital and his own center - Kayakriti Plastic Surgery & Dental Center. He was formerly a Consultant in the Department of Plastic Surgery and Burns at the prestigious SGPGI, Lucknow.

MS, DNB (General Surgery) MCh, DNB (Plastic Surgery),
MNAMS, FACS, FICS, FRCS (Edinburgh, UK)

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