Brachial Plexus Injury Analysis

Before discussing physical exam findings, different diagnoses, and follow-up plans of the brachial plexus injury treatment, it is important to examine its pathophysiology and clinical manifestations. According to R.D. Leffert’s classification, which takes into account the mechanism and the level of injury, BPI can be open and closed. The closed BPI is classified as a postganglionic lesion, which is divided into subclavian and supraclavicular lesions (Miller & Nikkhah, 2018). In this regard, a thorough examination and management plan are needed for the patients with the brachial plexus injury to provide the correct treatment.

According to the pathomorphological changes, several degrees of damage are distinguished: minimal, with the trauma of the myelin sheath—neuropraxia, with the damage to the axon and internal membranes—axonotmesis, and the most severe, with additional violation of the integrity of the epineuria—neurotmesis (O’Berry et al., 2017).

First of all, these pathological changes depend on the mechanism of injury. In the case of traction, which corresponds to neuropraxia or axonotmesis, there is the possibility of spontaneous regeneration (O’Berry et al., 2017). Complete rupture or the formation of scars along the nerve trunks block regeneration. In this case, scar tissue is removed with the help of surgery. When the nerve roots are separated from the spinal cord, nerve transfer is performed.

A detailed physical examination in most cases makes it possible to diagnose and determine the indications for surgical treatment (Kwon et al., 2019). The determination of the level and severity of the lesion is important during the clinical evaluation. When the general condition of the patient allows, a thorough clinical examination of the muscles is performed.

Physical examination findings help to understand whether the nerve roots are separated from the spinal cord and whether there is a possibility of regeneration of damaged structures. For example, heavily injured motorcyclists after a collision with a car, having total paralysis of the upper limb and hematomas in the supraclavicular fossa without fractures of the clavicle and scapula, most likely have the severe BPI with multiple detachments of the roots from the spinal cord (Miller & Nikkhah, 2018).

At the stage of diagnosis testing, the medical specialist should pay special attention to the presence of damage to the subclavian and axillary vessels, spinal cord, chest injury on the side of the faculty. Open injuries or operations in the projection of the main nerve trunks at shoulder or forearm level indicate the possibility of a two-level lesion.

Manual muscle testing is carried out by visual and palpation determination of the contraction of a single muscle or tension of its tendon. The measurement of the amplitude of active and passive movements in the joints is carried out using a goniometer. Maintaining the full volume of passive movements is a priority for all patients with BPI, regardless of the severity of functional disorders (Kwon et al., 2019). The presence of severe joint contractures in the early stages after damage is an unfavorable prognostic sign since the prolonged muscle anoxia can lead to necrosis.

An X-ray examination should be performed in all cases of BPI, regardless of the mechanism of injury, since it shows the localization of damage. The doctor should pay attention to the state of the diaphragm and the presence of rib fractures on the side of the brachial plexus lesion. MRI myelography allows visualizing the anterior and posterior roots of the spinal cord, localizing them by segments, and even noticing their partial separation (Kwon et al., 2019). All patients with suspected separation of the spinal nerve roots should undergo MRI myelography.

The management plan for the patients with BPI is controversial and requires consideration of many factors and causing some discussion among specialists who are involved in this pathology. From the first days after injury, it is necessary to carry out the passive movements in all joints of the limb. Physiotherapeutic procedures are selected taking into account the duration of the disease, the patient’s age, and concomitant pathology.

The electrical stimulation of the paralyzed muscles at all stages of treatment is also the most important moment of rehabilitation therapy (Miller & Nikkhah, 2018). It compensates for the functional deficiency of intrasegmental impulse, improving microcirculation in muscle tissue and nerve trunks, preserving the synaptic apparatus of denervated muscle, and preventing its atrophy (Miller & Nikkhah, 2018). The parameters of the currents used on denervated and reinnervated muscles differ and are selected individually.

The surgical operations in the BPI treatment include various complex microsurgical reconstructions, such as the restoration of the structures of the damaged substation and the surgery of the tendon-muscle apparatus, bones, and joints. The terms of surgical treatment for the BPI depend on the location and severity of the lesion. For example, with the help of neurolysis, scar tissue is removed from the outside of the nerves and the inside of the brachial plexus elements (Miller & Nikkhah, 2018).

Nerve transfers are another technique, which is widely used for the separation of roots from the spinal cord. In the cases of multiple separations of the spinal nerves with total paralysis of the limb, nerve transfer is the only alternative to amputation. It has become especially popular in recent years and has significantly improved the results of the surgical treatment of the BPI.

The use of the above techniques can significantly improve the function of the upper limb, even in cases of severe BPI. The result of the surgery is determined mainly by the choice of the correct combination of the treatment techniques. This choice is based on the most objective examination of the localization and prevalence of the damage, as well as the condition of brachial plexus elements. Therefore, a correct examination helps to avoid diagnostic errors in determining the localization of nerve damage, and also to choose the appropriate treatment tactics.


Kwon, S. H., Yeow, K. M., Chuang, D. C. C., & Chang, T. N. J. (2019). Role of Magnetic Resonance Imaging in Localization of Acute Brachial Plexus Injury. International Microsurgery Journal (IMJ).

Miller, R., & Nikkhah, D. (2018). The Importance of Clinical Examination in Traumatic Brachial Plexus Injuries. Journal of hand and microsurgery, 10(03), 178-179.

O’Berry, P., Brown, M., Phillips, L., & Evans, S. H. (2017). Obstetrical brachial plexus palsy. Current problems in pediatric and adolescent health care, 47(7), 151-155.

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