The brachial plexus begins in the spinal cord at the cervical and upper thoracic region (from C5-T1) and is a system of nerves that relays messages to and from the central nervous system to your shoulder, arm and hand.
It is a complex network that supplies the nerves to all the muscles in our upper limb apart from the trapezius (Greenwood et al. 2013; Mauk 2012). If this web of nerves is damaged, it can potentially have quite severe consequences for the individual.
Brachial Plexus Injuries
Often a brachial plexus injury will occur when these nerves are stretched, compressed or torn. Signs and symptoms of brachial plexus injuries are dependent on basically two factors: the severity of the injury and the location of the injury.
The less severe brachial plexus injuries are those that occur from accidents such as a sporting mishap.
The symptoms experienced from these less severe injuries range from only lasting for a few seconds or minutes, to lasting for a few days. People will often complain of a burning sensation or electric shock feeling down their arm and may also experience numbness and weakness in the affected arm (Mayo Clinic 2016).
The more severe brachial plexus injuries are generally those that are a result of a high level exertion of force such as those felt in a motor vehicle accident.
The brachial plexus roots can be ripped away from the spinal cord, and this is known as a total avulsion brachial plexus injury. As you can imagine, by severely damaging these nerves, the individual may be left with a paralysed arm and a significant loss of function, sensation, and severe pain (Mayo Clinic 2016).
Congenital Brachial Palsy
Another way in which these injuries can occur is during birth. This is called congenital brachial palsy and is thought to occur during the birthing process from trauma occurring to the brachial plexus.
The injury can occur to some or even all of the nerve roots of the brachial plexus, in which during this process they become stretched or ruptured.
Congenital brachial palsy will present in babies as weakness of shoulder elevation and external rotation, absent biceps, absent internal rotation of the shoulder, absent elbow extension, triceps weakness, decreased wrist extension and thumb weakness.
Congenital brachial palsy occurs in approximately 0.1%-0.4% of births and those considered more at risk are babies with a large birth weight, breech presentation, shoulder dystocia (obstructed labour where the anterior shoulder of the infant can’t pass), prolonged second stage or labour, when delivery is assisted by vacuum forceps, and in those with maternal diabetes (Mauk 2012).
For infants with congenital brachial palsy, recovery is determined by the severity of the injury and of the motor deficit. Those with a less severe motor deficit will be less likely to have permanent significant weakness. Infants with minor injuries will frequently have a spontaneous recovery with no interventions at all. Others may need interventions such as splinting and range of motion exercises in order to prevent contractures from occurring. Those with more severe injuries may need surgical interventions (Mauk 2012).
Brachial plexus injuries can also occur in neurological conditions such as when individuals have suffered from a stroke, however studies are inconclusive if this population of patients suffer from a brachial plexus injury or if the symptoms are more likely due to a cortical lesion (Kingery et al. 1993). Regardless of this, the patients with symptoms suggestive of brachial plexus injury are often those with severe hemiplegia. Often these individuals will have a more prolonged recovery then those without this group of symptoms and require more extensive rehabilitation focusing on their upper limb weakness (Kaplan et al. 1977).
Other situations in which people are at risk of experiencing a brachial plexus injury include if they are undertaking radiation treatment to the area, the presence of tumours in the area that can put pressure on the nerves, or even inflammation, which can then cause damage to the brachial plexus (Mayo Clinic 2016).
Treatment of Brachial Plexus Injuries
In both infants and adults, the underlying treatment principles remain the same, with the main goal of treatment for patients being to return to their previous level of function and to prevent any potential further disability.
Rehabilitation is an important component of treatment for someone with a brachial plexus injury, especially those with a severe injury. An important factor not to be overlooked in their rehabilitation treatment is the patient’s willingness to participate in their treatment program. Therefore, to ensure patient engagement, they must be well informed on their condition and their chances of regaining back their strength, increasing their level of function, and to what degree their level of function is anticipated to be following this injury.
Physiotherapists are very important in this process in order to help the individual develop increased strength and coordination, and overcome disability and deformity. Occupational therapists also have an important role with assisting the individual with functional training and looking at areas such as range of motion, stamina, power and the need for any adaptive devices (Greenwood et al. 2013).
It is important that rehabilitative treatment is sought immediately following the injury. With any injury involving nerve and muscle, delayed treatment can lead to contractures forming and further disability for the individual (Greenwood et al 2013).
Surgical treatments can be used for those with severe brachial plexus injuries. These treatments cannot reconstruct the original nerve pathways, however they can help regain function by transferring and repairing nerves. These surgical repair treatments include nerve grafting, nerve transfers or a combination of both treatments, as well as musculoskeletal reconstructions (Ali et al. 2015; Fraiman et al. 2016). But, like most treatment strategies, these interventions are more viable during certain time frames from when the injury occurred, and even with these surgeries, the individual will most likely not regain all lost function from the injury (Franzblau et al. 2015).
Brachial plexus injuries can be quite debilitating for the individual. Nurses caring for these patients need to ensure they are informed of their condition and support them in becoming active participants in their care. Without this engagement, treatment can fail, leading to increases in disability for the individual and having a multitude of effects on all areas of their life.
- Ali ZS, Heuer, GG, Faught, R, Kaneriya, SH, Sheikh, UA, Syed, IS, Stein, SC & Zager, EL 2015, ‘Upper brachial plexus injury in adults: Comparative effectiveness of different repair techniques’, Journal of Neurosurgery, vol. 122, no. 1, pp. 195-201, viewed 10 May 2017, http://thejns.org/doi/full/10.3171/2014.9.JNS132823
- Fraiman, D, Miranda, MF, Erthal, F, Buur, PF, Elschot, M, Souza, L, Rombouts, SARB, Schimmelpenninck, CA, Norris, DG, Malessy, MJA, Galves, A & Vargas, CD, 2016, ‘Reduced functional connectivity within the primary motor cortex of patients with brachial plexus injury’, NeuroImage: Clinical, vol 12, pp. 277-284, viewed 10 May 2017, http://www.sciencedirect.com/science/article/pii/S2213158216301280
- Franzblau, LE, Maynard, M, Chung, KC & Yang, LJS 2015, ‘Medical treatment decision making after total avulsion brachial plexus injury: A qualitative study’, Journal of Neurosurgery, vol. 122, no. 6, pp. 1412-1420.
- Greenwood, RJ, Barnes, MP, McMillan, TM, Ward, CD (eds) 2013, Handbook of Neurological Rehabilitation, 2nd edn, Psychology Press, New York.
- Kaplan, PE, Meredith, J, Taft, G & Betts, HB 1977, ‘Stroke and brachial plexus injury: A difficult problem’, Archives of Physical Medical Rehabilitation, vol 58, no. 9, pp. 415-418.
- Kingery, WS, Date, ES, Bocobo, C 1993, ‘The absence of brachial plexus injury in stroke’, American Journal of Physical Medicine and Rehabilitation, vol. 72, no. 3.
- Mauk, KL 2012, Rehabilitation Nursing: A Contemporary Approach to Practice, Jones & Bartlett Learning, Sudbury.
- Mayo Clinic 2016, Brachial Plexus Injury, viewed 10 May 2017, http://www.mayoclinic.org/diseases-conditions/brachial-plexus-injury/symptoms-causes/dxc-20127374