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Brachial Plexus Injury

71 citationsUpdated Sep 2026

Overview¶

Brachial plexus injury management requires a multidisciplinary approach utilizing a broad range of complementary treatment modalities to optimize function, particularly in the growing child where pathology and glenohumeral joint dysplasia evolve [4]. Achieving a stable and dynamic shoulder girdle is a primary reconstructive goal [3]. In obstetric brachial plexus palsy, these combined procedures allow good functional recovery of a nondominant limb in 75% of cases [1]. Children with obstetric injury should be seen early by a hand surgeon specializing in brachial plexus injuries [5]. For traumatic injuries, reconstruction of elbow extension is a priority, particularly when hand function is preserved [11]. Most cases following shoulder dislocation carry a good prognosis for recovery, except for intrinsic hand muscles [7]. Patients with functional deficits after anterior shoulder dislocation require immediate referral to a specialist brachial plexus service for assessment, physiotherapy, and potential surgery [12].

Nerve transfers are replacing other techniques as the gold standard for brachial plexus and proximal peripheral nerve injuries, offering functional outcomes that surpass traditional nerve repair or tendon transfers [14]. These transfers have broadened reconstructive options and delivered more reliable results, with particular improvement in the reconstruction of the paralysed shoulder [15]. Specific techniques, such as the transfer of triceps motor branches of the radial nerve to the axillary nerve, provide antigravity shoulder abduction and should be considered in selected individuals with upper brachial plexus injuries [6]. In avulsion injuries, double neurotization from a single donor nerve provides favourable results for restoring shoulder abduction [31]. For total root avulsion, nerve transfer and functioning free muscle transplantation are the only reliable reconstructive options [41]. Nerve transfers for global brachial plexus avulsions have a validated effect based on objective MRC grading combined with patient self-assessments [17].

Outcome expectations vary by injury pattern and timing. Most obstetric patients with isolated absent or slowly recovering shoulder movements recover at least 90 degrees of abduction [10]. In delayed presentation of birth injury, reconstruction yields good functional recovery of elbow flexion and shoulder external rotation, but modest recovery of finger flexion and wrist extension [16]. Early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants [13]. An established protocol-based treatment plan has the potential to reduce the incidence of posterior shoulder subluxation in children with brachial plexus birth injury [42]. Various methods have been shown to be beneficial for rehabilitation [2]. Combined subclavian artery and brachial plexus injury from blunt trauma is rare but results in devastating functional disability [8]. In cases of axillary arterial entrapment and brachial plexus injury due to proximal humeral fracture, prompt release of the artery along with exploration and repair of the plexus is key to saving the limb and decreasing permanent neurological damage [9]. A brachial plexus injury may be encountered even when a cesarean section is performed, with increased risk for newborns with a birth weight over 4,500 g [18]. Since no successful treatment is available for radiation-induced brachial plexus neuropathy, restricted use of radiation therapy to the brachial plexus is warranted, especially when administered concomitantly with cytotoxic therapy [39].

Anatomy & Pathophysiology¶

Bony Anatomy¶

The proximal humerus comprises the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [61]. The articular head is spherical with a diameter of 37 to 57 mm [61]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [61]. Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [61]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [61]. The anatomic neck is located at the junction of the articular surface and the tuberosities [61], while the surgical neck represents the metadiaphyseal junction below the tuberosities but above the humeral shaft [61]. The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [61], whereas the lesser tuberosity serves as the attachment site for the subscapularis tendon [61].

The glenoid is a convex structure of shallow depth shaped like an inverted pear [61]. The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure that imparts stability to the shoulder girdle [61]. The scapula is attached to the axial skeleton by the acromioclavicular and sternoclavicular joints [63]. It is separated from the chest wall by thin gliding fibro-fatty tissue, allowing smooth excursion over the chest wall [63]. The lateral pillar connects the inferior border of the glenoid with the inferior angle of the scapula [63]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [63]. Together, these pillars form the basic load-bearing structure of the scapular body, known as the biomechanical body of the scapula [63]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa [63]. The weakest area of the circumference of the biomechanical body is the spinomedial angle, where the scapular spine connects to the medial border [63].

The clavicle is the first bone to ossify, occurring in the fifth week of gestation [64]. It is the only long bone to ossify by intramembranous ossification [64]. The medial (sternal) epiphysis of the clavicle is the last ossification center to fuse, at age 20 to 25 years [64]. The primary blood supply to the clavicle is periosteal, with no nutrient artery present [64]. The scapula has only one true diarthrodial articulation, the acromioclavicular joint [64]. Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [64]. Ossification of the scapular body begins at the eighth week of gestation [64]. The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [64]. The coracobrachialis muscle and the short head of the biceps tendon originate from the coracoid process [64]. The pectoralis minor muscle inserts onto the medial coracoid process [64].

The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [64]. The glenoid averages 5 degrees of retroversion in relation to the axis of the scapular body [64]. The proximal humerus has three centers of ossification: the humeral head, greater tuberosity, and lesser tuberosity [64]. The humeral head averages 19 degrees of retroversion and 41 degrees of inclination (neck-shaft angle) [64]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [64]. The terminal intraosseous portion of the anterior humeral circumflex artery enters the humeral head at the proximal aspect of the intertubercular groove as the arcuate artery [64]. The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [64]. The posterior sternoclavicular joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [64]. The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior translation of the clavicle [64]. The coracoclavicular ligaments are the primary stabilizers to superior vertical translation of the distal clavicle [64].

The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [75]. It is anteverted on the chest wall approximately 30 degrees relative to the body [75]. The glenoid is retroverted approximately 5 degrees relative to the scapular body [75]. Os acromiale results from incomplete fusion of secondary ossification centers, most commonly between the mesoacromion and meta-acromion [75]. The coracoid process serves as an attachment for the coracoacromial ligament, coracoclavicular ligaments, conjoined tendon, and pectoralis minor [75]. The suprascapular artery passes superior to the superior transverse scapular ligament, while the suprascapular nerve passes inferior to the ligament through the notch [75]. At the spinoglenoid notch, both the artery and nerve pass inferior to the inferior transverse scapular ligament [75]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency [75]. The acromial branch of the thoracoacromial artery runs on the medial aspect of the coracoacromial ligament [75].

The humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [75]. The anatomic neck of the humerus is located directly below the humeral head and serves as an attachment for the shoulder capsule [75]. The transverse humeral ligament is an important stabilizer of the biceps tendon [75]. The glenohumeral joint is a ball-and-socket joint with the greatest range of motion in the body [75]. The fibrocartilaginous glenoid labrum deepens the socket by 50% and provides a bumper to translation [75]. The sternoclavicular joint is a double gliding joint with an articular disc [75]. The posterior sternoclavicular ligament is the strongest and primary restraint to anteroposterior instability of the sternoclavicular joint [75]. The sternoclavicular joint rotates 30 degrees with shoulder motion [75]. The acromioclavicular joint is a plane/gliding joint with a fibrocartilaginous disc [75]. The posterior and superior acromioclavicular ligaments are considered the strongest stabilizers against anteroposterior displacement [75]. The trapezoid ligament is located approximately 25 mm from the acromioclavicular joint [75]. The conoid ligament is located approximately 45 mm from the acromioclavicular joint and is stronger than the trapezoid ligament [75].

The humeral shaft extends from the level of the insertion of the pectoralis major muscle proximally to the supracondylar ridge distally [62]. The upper portion of the humeral shaft is cylindrical and becomes more flattened in an anteroposterior direction as it proceeds distally [62]. Medial and lateral intermuscular septae divide the arm into anterior and posterior compartments [62]. The anterior compartment of the arm contains the biceps brachii, coracobrachialis, and brachialis muscles, along with the neurovascular bundle [62]. The posterior compartment of the arm contains the triceps brachii muscle and the radial nerve [62]. The glenoid cavity is a shallow socket approximately one-third the size of the humeral head [62]. The anatomic neck of the proximal humerus lies at the junction of the head and the tuberosities [62]. The surgical neck of the proximal humerus lies below the greater and lesser tuberosities [62]. The major blood supply to the humeral head is through the ascending branch of the anterior humeral circumflex artery, which penetrates the head at the bicipital groove and becomes the arcuate artery [62]. The brachial plexus and axillary artery are located anterior to the coracoid process of the scapula and humeral head [62]. The neck-shaft angle of the proximal humerus measures an average of 135 degrees [62]. The humeral head is retroverted an average of 30 degrees [62].

The rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles [62]. The teres major is not a rotator cuff muscle [62]. The rotator cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [62]. The infraspinatus and teres minor are external rotators of the humerus [62]. The subscapularis is an internal rotator of the humerus [62]. The deltoid and pectoralis major muscles, along with the rotator cuff, cause predictable displacement of fractures around the proximal humerus [62].

The formation of the humerus begins with the appearance of the cartilage anlage by the fifth week of gestation [68]. The primary ossification center for the humerus appears at about the sixth week of gestation [68]. By birth, the entire humeral diaphysis is completely ossified [68]. The proximal humerus is primarily cartilaginous at birth, with ossification centers detectable by ultrasonography as early as the 38th week of gestation [68]. The ossification center for the humeral head is usually present at birth [68]. The greater tuberosity ossification center appears by 1 to 3 years of age [68]. The lesser tuberosity ossification center appears by 5 years of age [68]. The proximal humeral ossification centers fuse by 5 to 7 years of age to form the humeral head [68]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [68]. Humeral retroversion averages 65 degrees in infants and young children, gradually decreasing to adult values by 11 years of age [68]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis [68]. The proximal humeral physis accounts for approximately 40% of the growth of the entire upper extremity [68]. Less than 75% of proximal humeral growth occurs before 2 years of age [68]. More than 85% of proximal humeral growth occurs by 8 years of age [68].

The capsule of the glenohumeral joint extends from the glenoid rim, progressing laterally toward the surgical neck of the humerus and blending with the tendons of the rotator cuff musculature [68]. The posteromedial metaphysis, a portion of the physis, and the epiphysis are intracapsular [68]. A large part of the proximal humeral physis is extracapsular, making it susceptible to traumatic injury [68]. The proximal humeral physis is irregularly shaped, with its apex located on the posteromedial portion of the proximal humerus [68]. The periosteum is thicker and stronger in the posteromedial portion of the proximal humerus compared to the anterolateral portion [68]. The subscapularis originates from the anterior scapula and inserts anteriorly onto the lesser tuberosity [68]. The greater tuberosity provides attachment superiorly and posteriorly for the supraspinatus, infraspinatus, and teres minor [68]. The deltoid forward flexes and abducts the shoulder, coursing from the clavicle and acromion superiorly into a common tendinous insertion onto the lateral upper third of the humeral shaft [68]. The pectoralis major powers adduction and internal rotation due to its tendinous insertion anteriorly onto the lateral wall of the bicipital groove [68]. The pectoralis major forms the roof of the distal continuation of the bicipital tunnel, a closed space extending proximally to the glenohumeral joint [68].

64% of the humeral head blood supply arises from the posterior humeral circumflex artery [68]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [68]. The scapula has shifted caudally from the cervical position in lower animals, freeing the shoulder from the head and neck [71]. The scapular index is defined by the relationship between the length measured along the base of the spine and the breadth measured from the superior to the inferior angle [71]. Broadening of the infraspinatus fossa has changed the vector of muscle pull from the axillary border of the scapula to the glenoid fossa [71]. This adaptation allows the infraspinatus and teres minor muscles to be more effective as depressors and external rotators of the humeral head [71]. The acromion has enlarged over time, reflecting the increasing role of the deltoid muscle in shoulder function [71]. The broader attachment of the deltoid on the acromion and its more distal insertion on the humerus have increased its mechanical advantage in shoulder motion [71]. The coracoid process has undergone an increase in size over time [71]. With the shoulder in 90 degrees of abduction, the coracoid extension over the glenohumeral joint can mechanically limit anterior translation of the humerus relative to the glenoid [71].

Joints and Ligaments¶

The superior shoulder suspensory complex provides a stable connection between the scapula and the axial skeleton [64]. It is composed of the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion [64]. The superior strut of the superior shoulder suspensory complex comprises the middle clavicle [64]. The inferior strut of the superior shoulder suspensory complex comprises the lateral scapular border and spine of the scapula [64]. The rotator cuff stabilizes the glenohumeral joint via joint compression [64]. Static stabilizers of the glenohumeral joint include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [64]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [64].

The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [64]. The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [64]. Laxity of the rotator interval results in inferior laxity, known as the sulcus sign [64]. Contracture of the rotator interval is seen with adhesive capsulitis [64]. The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [64]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [64]. The superior glenohumeral ligament, along with the coracohumeral ligament, forms a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [64]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45 degrees of abduction [64]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90 degrees of abduction and external rotation [64]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [64].

Classification¶

Anatomical Level Classification: Brachial plexus injuries are classified into four levels based on anatomical location: Level 1 (preganglionic root), Level 2 (postganglionic spinal nerve), Level 3 (trunks and divisions), and Level 4 (cords and terminal branches) [109].

Obstetrical Anatomical Classification: Obstetrical brachial plexus palsy is anatomically classified into four categories: upper plexus palsy (Erb’s palsy, C5-C6 and sometimes C7), intermediate plexus palsy (C7 and sometimes C8-T1), lower plexus palsy (Klumpke’s palsy, C8-T1), and total plexus palsy (C5-C8 and sometimes T1) [115].

Narakas Clinical Classification: Obstetrical brachial plexus palsy is clinically classified into five types according to Narakas, with Type I indicating relatively mild palsy and recovery usually complete or almost complete by 1–8 weeks [115].

Other Considerations: In a cohort of 111 patients, the predominant level of brachial plexus injury varied by etiology, with automobile accidents showing 42% supraclavicular root and 54% supraclavicular trunk involvement [95]. Motorcycle accidents were associated with 59% supraclavicular root and 34% supraclavicular trunk involvement in the same cohort [95]. Penetrating injuries and iatrogenic injuries in this cohort resulted exclusively in supraclavicular trunk level brachial plexus injuries [95]. There was no significant association between the etiologies of brachial plexus injury and the anatomical levels of injuries, with a P-value of 0.21 [95]. In this cohort, 81% of arms with pan root involvement and 73% of arms with pan plexus involvement were classified as 'severe' in nature [95].

Anterior dislocation of the glenohumeral joint is associated with concomitant brachial plexus or terminal branch palsy in 5.4 to 55% of cases [47]. In infraclavicular nerve injuries due to glenohumeral dislocation, the axillary, ulnar, median, radial, and musculocutaneous nerves are affected in that order of frequency [47]. The NAPTIME score can distinguish which infants with brachial plexus birth injury will meet criteria for reconstructive nerve surgery earlier than clinical decision-making allows [48].

Clinical Presentation¶

General Assessment and Diagnosis¶

The diagnosis of brachial plexus injury is often elusive, and resultant delay can negatively impact timely referral for specialized treatment [90]. Ideally, the diagnosis is made in the emergency department [90]. A good neurologic examination should be attempted in the emergency department, even if the patient is confused, sedated, or unconscious [86]. If an adequate neurologic examination cannot be performed preoperatively, this limitation must be explicitly noted in the medical record [86]. The clinical record should document individual muscle strength, sensory examination, and deep tendon reflexes rather than using general terms like "neurovascularly intact" [86]. A detailed neurologic evaluation of the upper extremity can be performed on a coherent patient in a relatively short time, even in the presence of shoulder dislocation or proximal humeral fracture [86].

The mechanism of injury, specifically the position of the neck and arm relative to the body during trauma, needs to be evaluated to support diagnosis [90]. A thorough primary and secondary assessment should identify concomitant injuries to the head, chest, vessels, long bones, pelvis, and spine [90]. Multitrauma is common in brachial plexus injury, and more critical injuries may receive attention while other potentially significant injuries are missed [90]. Detailed neurologic testing reveals deficits that affect a discrete pattern [90]. Diagnostic information should include whether the injury is complete or incomplete, whether it involves the supraclavicular or infraclavicular region, and whether it is preganglionic or postganglionic [90].

Imaging and Electrodiagnostics: * Plain radiographs: Might reveal an elevated diaphragm from a phrenic nerve injury [90]. * Angiography: Should be performed if vascular injury is suspected, especially when acute brachial plexus injury is present with an expanding hematoma, first-rib fracture, widened mediastinum, or upper limb pulse abnormality [90]. * Electrodiagnostic studies: Are most useful about 3 weeks after the injury to further localize the lesion and assess the degree of neural involvement [90]. * CT-myelography: Should be performed when a supraclavicular lesion has been diagnosed and a preganglionic injury is being considered [90]. * MRI: Of the brachial plexus is rapidly improving but has not yet been found to be as helpful as CT-myelography in identifying root avulsions [90]. MRI should typically be performed before making a treatment decision to examine the brachial plexus for any discontinuity or kinking [52].

Preganglionic Injury Indicators: Features suggesting a preganglionic injury include deafferentation pain, Horner syndrome, weak rhomboids or serratus anterior muscles, or the absence of Tinel’s sign in the neck [90]. Electrical studies showing fibrillations in paraspinal muscles or rhomboids, or preserved sensory nerve action potentials in an anesthetic hand with absent motor nerve action potentials, suggest preganglionic injury [90]. An elevated hemidiaphragm or associated cervical fractures on radiographs, and pseudomeningoceles or absent nerve rootlets on myelography, suggest preganglionic injury [90].

For closed injuries, patients are typically observed for spontaneous improvement over the first several months [90]. It is difficult to preoperatively determine which axonotmetic lesions (Sunderland grades II to IV) will recover spontaneously despite differing prognoses [90]. Sunderland grade II axonotmetic lesions are associated with good spontaneous recovery, while grade IV has a poor prognosis [90]. Patients should receive physical therapy for range of motion to prevent soft tissue contractures and to strengthen working muscles [90]. Neuropathic pain should be managed by a specialist, especially when refractory to first-line medications, as is often the case with deafferentation pain [90]. The proposed wearable technology is a sensitive and reliable tool for objective outcome evaluation of brachial plexus injury and its biomechanical consequences [37].

Obstetric Brachial Plexus Injury¶

Children with obstetric brachial plexus injury (OBPI) should be seen early by a hand surgeon dealing with brachial plexus injuries [5]. Obstetric brachial plexus injuries require a multidisciplinary approach and a broad range of treatment modalities to optimize function in the growing child [4]. The changing pattern of pathology and glenohumeral joint dysplasia in obstetric brachial plexus injuries necessitates a broad range of treatment modalities [4]. At best, only 45% of patients with OBPI were referred to multidisciplinary care in a publicly funded, universal healthcare system [35]. The timing of referral to a multidisciplinary center is important as it provides coordinated education for guardians and assessment by specialized physicians and therapists [35]. A 1-month time point is considered conservative for referral designation because a proportion of OBPI is neuropraxic and may resolve spontaneously by this time [35]. Approximately 35% of OBPI cases (95% CI 23%-48%) may resolve spontaneously by one month [35]. Primary care providers for newborns often lack the familiarity and expertise to educate guardians and monitor for patient recovery [35]. Recovery of OBPI is often overestimated, and residual impairment is not characterized [35].

Prevention of neonatal brachial plexus palsy has not been possible by any individual physician or groups of physicians, and the injury occurs independent of physician experience [24]. Even when a cesarean section is performed, a brachial plexus injury may be encountered, with an increased risk for newborns with a birth weight over 4,500 g [18]. Incidence of obstetric brachial plexus injury has been estimated as 1 to 2 per 1000 births [49]. Some babies have a transient paralysis of the upper limb that resolves fully within the first month or two with no long-term sequelae [49]. In general, those with persisting paralysis after 2 months will have some permanent limitations [49].

Glenohumeral abduction contracture is a very common finding in patients with upper neonatal brachial plexus injury, affecting approximately three-quarters of these patients [21]. The frequency of glenohumeral abduction contracture decreases substantially in complete palsies compared to upper neonatal brachial plexus injury [21]. Both passive glenohumeral extension and active shoulder extension angles can be measured reliably with a clinical exam [20]. At least 10 degrees of shoulder extension is necessary to perform the hand-to-spine Mallet task [20]. The results suggest that more emphasis should be placed on shoulder internal rotation in treatment strategies for children with Narakas Group 2 brachial plexus birth palsy [30]. In the delayed presentation of brachial plexus birth injury, brachial plexus reconstruction results in good functional recovery of elbow flexion and shoulder external rotation [16]. In the delayed presentation of brachial plexus birth injury, brachial plexus reconstruction results in modest functional recovery of finger flexion and wrist extension [16]. Brachial plexopathy with a prolonged neurological deficit can occur in infants who have septic arthritis and osteomyelitis [56]. The NAPTIME score might distinguish which infants will meet the criteria for reconstructive nerve surgery earlier than when the decision can be made clinically [48].

Adult Traumatic Brachial Plexus Injury¶

Patients with AT-BPI are often seen in situations involving significant trauma, where the patient may be confused, incoherent, sedated, or unconscious [86]. Injuries to the adult brachial plexus can be devastating to the patient and are difficult for the patient and family to comprehend [26]. Even in severe pan-plexal injury, treatment options offer patients the ability to obtain elbow flexion, limited shoulder abduction with shoulder stability, and hope for limited but potentially useful hand function [26].

Neuropathic pain is common in adult traumatic brachial plexus injury (AT-BPI), with more than half of patients experiencing it [26]. Pharmacologic options for neuropathic pain in AT-BPI consist primarily of anticonvulsants (gabapentin, pregabalin) and antidepressants (amitriptyline, duloxetine) [26]. For intractable neuropathic pain unresponsive to pharmacologic intervention, dorsal root entry zone ablation, spinal cord and deep brain stimulation may be considered [26]. Pain rehabilitation with behavioral medicine techniques may be effective for long-term management of chronic pain after AT-BPI [26]. The pain of preganglionic injury of the brachial plexus is not relieved by amputation [23].

Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently [45]. In 5.4 to 55% of anterior glenohumeral dislocations, concomitant palsy of the brachial plexus or one of its terminal branches may occur [47]. The risk of permanent nerve damage in glenohumeral dislocation depends on the delay of reduction [47]. Initial physical examination of patients suffering from glenohumeral dislocation should primarily focus on neurological lesions [47]. All infraclavicular brachial plexus terminal branches may be affected by glenohumeral dislocation, including the axillary, ulnar, median, radial, and musculocutaneous nerves [47]. If brachial plexus palsies from glenohumeral dislocation are incomplete in the majority of cases, several terminal branches are most commonly involved, corresponding to cord lesions [47]. Prompt release of the axillary artery injury along with exploration and, if possible, repair of the adjacent brachial plexus is key in saving the limb and decreasing the probability of permanent neurological damage [9].

Delayed fixation of clavicle fractures, especially between two and four weeks after injury, carries a small but significant risk of iatropathic brachial plexus injury [19]. Iatrogenic nerve injuries remain an inherent risk in shoulder surgery, with positioning and specific surgical steps placing nerves at risk [29]. Systematic physical examination and knowledge of anatomy are critical for prevention and recognition of iatrogenic nerve injuries in shoulder surgery [29].

Specific Nerve and Muscle Examination¶

Radial, median, and ulnar nerve function can all be assessed by a thorough evaluation of the hand and wrist, which should take less than 1 minute [86]. It is possible to flex the elbow strongly with the action of the brachioradialis without having any function of the biceps [86]. Loss of radial nerve function should make the examiner look closely at axillary nerve function because both nerves are derived from the posterior cord [86]. Loss of median nerve function might affect the musculocutaneous nerve if the lesion is in the lateral cord [86]. The condition of the medial and lateral pectoral nerves can be assessed by individually testing the strength of each of the major portions of the pectoralis major [86].

The deltoid can be assessed even in the case of a painful proximal humeral fracture or glenohumeral dislocation [86]. Some patients are able to abduct the shoulder through a full arc of motion by using either just the supraspinatus or the deltoid in the face of complete paralysis of either of them [86]. Ensuring muscle contraction is a critical element in examining shoulder abduction [86]. Visualizing and palpating the scapula are a necessary part of the examination, especially when there is possible dysfunction [86]. Patients with winged scapulae due to weakness of the serratus anterior or trapezius may have difficulty abducting the arm fully without the scapula stabilized and may compensate with trick motions [86]. A useful test for serratus anterior function that can be applied even in a patient with a complete brachial plexus lesion is to stabilize the inferior pole of the scapula while the patient pushes the arm forward [86]. Patients unable to perform the scapular stabilization test would not be able to perform the more standard push-off test with the arms extended against a wall [86].

The inability of a patient to externally rotate the arm or perform the lift-off test might represent a neurologic lesion affecting the infraspinatus or subscapularis, a rotator cuff tear, or both [86]. A patient who is feigning paralysis in the upper limb for secondary gain issues cannot voluntarily stop the latissimus dorsi from contracting while coughing [86].

Cervical radiculopathy is a common cause of pain in the shoulder accompanied by motor weakness and sensory loss in the upper extremity [86]. In cervical radiculopathy, flexion and extension of the cervical spine or Spurling’s maneuver might reproduce or exacerbate the patient’s symptoms [86]. Upper motor neuron lesions can result in shoulder weakness, with deep tendon reflexes that may be hyperreflexic, pathologic reflexes that may be present, and tone that may be increased [86]. The clinical examination should exclude referred pain as a possibility, because cardiac and other intrathoracic as well as intraabdominal complaints may manifest as shoulder pain [86].

Investigations¶

Clinical Assessment and Referral¶

Patients with functional deficits resulting from brachial plexus injury in anterior shoulder dislocation require immediate referral to a specialist brachial plexus service for assessment, physiotherapy, and surgical evaluation if indicated [12]. Careful neurological and vascular examination must be performed at presentation and repeated after relocation of the shoulder into joint for isolated traumatic anterior shoulder dislocation with brachial plexus injury [130]. Systematic physical examination and anatomical knowledge are critical for preventing and recognizing iatrogenic nerve injuries in shoulder surgery [29]. Both passive glenohumeral extension and active shoulder extension angles can be measured reliably with a clinical exam, with at least 10 degrees necessary to perform the hand-to-spine Mallet task [20].

Imaging¶

The purpose of shoulder imaging is to establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition to the patient [44]. Standardized plain films are almost always sufficient for shoulder evaluation [44]. The first key radiographic view is the anteroposterior (AP) view in the plane of the scapula, taken so that the x-ray beam passes through the glenohumeral joint [44]. The second key view is the axillary view, taken with the arm in the functional position of elevation in the plane of the scapula and oriented so that both the spinoglenoid notch and scapular neck are visible [44]. This axillary view is referred to as the “truth view” because it demonstrates glenohumeral relationships in the functional position of elevation [44]. Standardized AP and axillary views indicate cartilage space thickness, relative positions of the humeral head and glenoid, presence of osteophytes, degree of osteopenia, and extent of bony deformity and erosion [44]. The axillary truth view can show posterior subluxation or “functional decentering” that is not evident in images taken with the arm at the side [44].

Initially, all patients are usually asked to have AP and lateral plain radiographs of the shoulder related to their chief report [85]. Patients presenting with shoulder instability and dislocations are initially imaged with standard radiographs to provide an overview of bony anatomy, orientation of the humeral head in relation to the glenoid, and initial assessment for both bony Bankart and Hill–Sachs lesions [89]. In patients who are able to abduct the arm, an axillary view must be obtained to evaluate for anterior or posterior humeral head subluxation or dislocation [89]. If the patient is unable to abduct their arm due to the acuity of injury, a scapular “Y” view must be obtained to evaluate the relationship of the humeral head to the glenoid [89]. In a systematic review of posterior shoulder dislocations, a missed initial diagnosis was reported in 73% of patients due to the lack of an axillary view, Y view, or computed tomography imaging [89]. When the axillary or Y-view radiographs were made subsequently in this systematic review, the diagnosis of posterior dislocation was confirmed in 100% of patients [89].

The standard shoulder series should include orthogonal views of the shoulder, including a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [87]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration [87]. The axillary view is necessary in evaluation of glenohumeral joint instability and enables determination of the humeral head position in the glenoid fossa [87]. The scapular Y view provides visualization of the coracoacromial arch and can reveal coracoacromial spurs [87]. The acromiohumeral distance is normally 7 to 14 mm [87]. The width of the glenohumeral joint space should be symmetric superiorly and inferiorly [87]. The coracoclavicular distance is normally 1.1 to 1.3 cm [87]. Type III acromial morphology has been shown to have a correlation with the presence of rotator cuff disease, although no direct causal relationship has been demonstrated [87]. The classification of acromial morphology has shown relatively poor interobserver reliability [87].

Magnetic resonance imaging (MRI) is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [85]. Traditional MRI is utilized for evaluation of soft tissues, which can be performed with high contrast and spatial resolution [82]. Magnetic resonance accuracy in identifying labral and rotator cuff tears in the literature ranges from 70% to 100% [82]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance arthrograms to provide a more detailed picture of the joint surfaces [85]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [85]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [85]. MR arthrography increases the sensitivity for detecting tears and other lesions by distending the joint capsule, outlining the cartilage, ligaments, and labrum with contrast [82]. In a meta-analysis of the diagnostic test accuracy of MRA compared to MRI for the detection of glenoid labral injuries, MRA had a sensitivity of 88% and specificity of 93%, compared to MRI sensitivity of 76% and specificity of 87% [82]. Abduction and external rotation (ABER) of the arm is an alternative position utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury [82]. The sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than that of the MRA in neutral position and more effective in identifying Perthes lesions [82]. When MRI or MR arthrography is contraindicated, CT arthrography is indicated [85].

Computed tomography (CT) is helpful for planning fracture surgery and shoulder joint replacement [78]. CT imaging is frequently used to evaluate fractures of the shoulder, to assess for bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [85]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [87]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary truth view [44].

Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [78]. Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [85]. Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [85]. Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [85].

MRI should typically be performed before making a treatment decision to examine the brachial plexus for any discontinuity or kinking in cases of brachial plexus injury after a displaced clavicle fracture [52]. Unless a specific research protocol is in place, the temptation to “overimage” should be resisted, obtaining only the scans or reconstructions that are necessary for the care of the patient [44].

Electrophysiology and Pathology¶

The spinal accessory to suprascapular nerve transfer is typically undertaken via an anterior approach, which may miss injury to the suprascapular nerve about the suprascapular notch [59]. In 7 of 20 explorations after high-energy trauma using a posterior approach, abnormalities at the level of the suprascapular ligament were identified that would not have been identified with an anterior approach [59]. These abnormalities included two ruptures, two neuromas-in-continuity, and three cases of scar encasement necessitating neurolysis [59]. Nerve transfer could be undertaken distal to the suprascapular notch, bypassing the site of injury in cases where abnormalities were identified at the notch [59].

Treatment¶

Non-Operative¶

Many traumatic brachial plexus injuries, particularly mild and blunt cases, recover spontaneously over weeks to months [84]. Consequently, surgical intervention is indicated only for patients without the likelihood of spontaneous or further recovery [84]. Rehabilitation protocols aim to explore the potential contributions of various methods to brachial plexus injury rehabilitation and provide a concise overview of beneficial interventions [2]. The role of hand therapy is critical following brachial plexus injuries, including pre- and postoperatively, as well as in cases managed conservatively [33]. Various journal articles have elucidated the role of orthoses in maximizing upper limb function, preventing secondary contractures, and optimizing postoperative rehabilitation following brachial plexus injuries [33]. The purpose of dynamic assist orthosis is to facilitate and optimize muscle reeducation following brachial plexus injury [33]. An established protocol has the potential to reduce the incidence of posterior shoulder subluxation in children with brachial plexus birth injury [42]. Early application of passive shoulder repositioning into Sup and ER may improve outcomes in function of the arm in infants with birth-related brachial plexus injury [104].

Operative¶

Indications: The major absolute contraindications to brachial plexus reconstruction are a patient’s unwillingness to undergo surgery or having unrealistic goals [84]. Relative contraindications include severe elbow or shoulder contracture, advanced age, medical comorbidities, and traumatic brain injury or cervical spinal cord injury [84]. Isolated C8-T1 brachial plexus injuries are a relative contraindication to reconstruction because more predictable results may be achieved with distal nerve and/or tendon transfers [84]. Patients with functional deficits from brachial plexus injury in anterior shoulder dislocation should be immediately referred to a specialist brachial plexus service for assessment, physiotherapy, and the option of surgery if indicated [12].

Timing of Intervention: The time from injury to presentation determines if nerve grafting or nerve transfers can be performed [84]. Irreversible changes to the motor end plate occur without reestablishment of nerve continuity, confounded by the slow regeneration of a nerve (1 mm/d) and the time it takes to reach the motor end plate [84]. Nerve surgery is recommended within 6 months of injury [84]. When nerve root avulsions (preganglionic injuries) are suspected, surgical intervention is typically recommended within 3 to 6 weeks after injury [84]. When a postganglionic injury (eg, rupture, stretch injury) is suspected, delay in treatment (typically, 3-6 months after injury) may allow some recovery of injured nerves [84]. Nerve transfers (neurotization) or nerve grafting has worse outcomes in patients presenting between 6 and 12 months after injury than in early or routine cases [84]. After 12 months from injury, tendon transfers or free-functioning muscle transfers are considered [84]. After 1 year, direct nerve transfer or nerve grafting may not be advisable due to motor end plate issues [84]. Alternative treatments such as free-functioning muscle transfers (FFMTs) or tendon transfers about the shoulder should be considered after 1 year [84]. Shoulder arthrodesis can be considered after 1 year [84].

Acute and Vascular Management: Sharp, penetrating injuries (eg, knife wounds) to the brachial plexus should be explored and repaired acutely [84]. Vascular injuries associated with blunt trauma should be explored, and vessels should be repaired or reconstructed [84]. Nerve roots should be tagged for future identification and reconstruction in acute vascular injuries, if applicable [84]. Gunshot wounds should be observed because they typically are neurapraxic in nature [84]. Combined subclavian artery and brachial plexus injury as a result of blunt trauma results in devastating functional disability of the upper limb [8].

Nerve Reconstruction Techniques: Current surgical treatment focuses on the restoration of motor function and protective sensation [84]. The priorities of treatment, in order of importance, are elbow flexion, shoulder stability (with abduction and external rotation), hand sensibility, wrist extension/finger flexion, wrist flexion/finger extension, and intrinsic function [84]. Overall nerve transfers have broadened reconstructive options and delivered more reliable results for some patterns of injury to the brachial plexus, with a particular improvement in outcome for reconstruction of the paralysed shoulder [15]. Nerve root avulsions cannot be repaired surgically because achieving functional continuity between the rootlets and the spinal cord is not currently possible [84]. For nerve root avulsions, it is necessary to provide alternative methods of transferring functional motor nerves to the affected terminal nerve branches distal to the injury [84]. Postganglionic injuries (ruptures or stretch injuries) can be repaired surgically by nerve grafting using sural nerve cable grafts or by direct coaptation, if a focal lesion exists [84]. In obstetrical brachial plexus injury, nerve transfer is associated with improved shoulder external rotation and a lower rate of secondary shoulder surgery compared to nerve grafting for suprascapular nerve reconstruction [101]. Use of the transfer of triceps motor branches of the radial nerve to the axillary nerve should be considered in selected individuals with upper brachial plexus injuries [6]. The transfer of the branch to the long head triceps brachii of the radial nerve to the anterior branch of the axillary nerve can provide shoulder abduction and shoulder extension [32]. In brachial plexus injury reconstruction, achieving a stable and dynamic shoulder girdle is a primary goal [3]. This study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients' self-assessments [17].

Musculoskeletal and Soft Tissue Reconstruction: Modern approaches for obstetrical brachial plexus injury combine early microsurgical repair with subsequent musculoskeletal reconstruction to optimize the final functional outcome [22]. The different procedures for treatment of obstetrical brachial plexus palsy are complementary and allow in 75% of cases a good recovery of function of a nondominant limb [1]. Isolated lower trapezius transfer is considered an effective option with promising results in cases of sequelae of obstetric brachial plexus injury for restoration of shoulder external rotation as well as abduction [99]. Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury [38]. All patients stated that shoulder fusion had improved the function of their limb, with active abduction ranging from 50 to 80 degrees [40]. The findings provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with brachial plexus birth injury [13]. Arthroscopic release effectively improves both shoulder mobility and bone deformity, with few complications in young children with brachial plexus birth injury [100]. An elbow joint with an incongruent ulnohumeral joint and limited passive motion will continue to have limited motion after reconstruction of the biceps [84]. It is important to anatomically reconstruct injured joints and long bones in the setting of associated osseous injuries [84]. Large soft-tissue defects and traumatic muscle loss may preclude reinnervation of the nerves to the affected muscles [84]. Loss of the biceps muscle will preclude reinnervation of the musculocutaneous nerve, and alternative treatments must be considered [84]. Vascular reconstruction is necessary to provide optimal blood flow to the extremity, but it may preclude surgical procedures requiring vascular anastomoses in the area of reconstruction (eg, free-functioning gracilis transfers) [84].

Pain Management: Surgery for the restoration of motor function does not address the severe neuropathic pain associated with avulsion injuries [84]. Neuropathic pain is common in adult traumatic brachial plexus injury and more than half will experience neuropathic pain [26]. Pharmacologic options for neuropathic pain consist primarily of anticonvulsants (gabapentin, pregabalin) and antidepressants (amitriptyline, duloxetine), both providing some degree of pain relief [26]. Pain rehabilitation with behavioral medicine techniques may also be effective for long-term management of chronic pain after adult traumatic brachial plexus injury [26].

Complications¶

Obstetric brachial plexus injuries are associated with glenohumeral joint dysplasia [4]. Glenohumeral abduction contracture affects approximately three-quarters of patients with upper neonatal brachial plexus injury [21]. The frequency of glenohumeral abduction contracture decreases substantially in patients with complete palsies compared to upper neonatal injuries [21]. Shoulder extension impairment is a residual deficit in neonatal brachial plexus injury, requiring at least 10 degrees of extension to perform the hand-to-spine Mallet task [20]. Brachial plexus birth palsy can result in permanent neurological injury [107]. Clavicle fracture during shoulder dystocia is associated with a higher incidence of brachial plexus birth palsy compared to cases without fracture [107]. Brachial plexus injury may occur even when a cesarean section is performed, with increased risk for newborns with a birth weight over 4,500 g [18]. Brachial plexopathy with prolonged neurological deficit can occur in infants who have septic arthritis and osteomyelitis [56].

Iatrogenic and Surgical Complications¶

Delayed fixation of clavicle fractures between two and four weeks after injury carries a small but significant risk of iatropathic brachial plexus injury [19]. Iatrogenic nerve injuries are an inherent risk in shoulder surgery due to positioning and specific surgical steps [29].

Neurological and Pain Complications¶

Neuropathic pain is common in adult traumatic brachial plexus injury, affecting more than half of patients [26]. Pharmacologic options for neuropathic pain include anticonvulsants such as gabapentin and pregabalin, and antidepressants such as amitriptyline and duloxetine [26]. For intractable neuropathic pain unresponsive to pharmacologic intervention, dorsal root entry zone ablation, spinal cord stimulation, and deep brain stimulation may be considered [26].

Vascular Complications¶

Combined subclavian artery and brachial plexus injury following blunt trauma results in devastating functional disability of the upper limb [8]. Prompt release of axillary artery injury along with exploration and repair of the adjacent brachial plexus is key in saving the limb and decreasing the probability of permanent neurological damage [9].

Recovery¶

Other Considerations: In 75% of cases, complementary treatment procedures for obstetrical brachial plexus palsy allow a good recovery of function of a nondominant limb [1]. Nerve transfers offer functional outcomes surpassing those obtained from traditional nerve repair or tendon transfers for brachial plexus and other proximal peripheral nerve injuries [14]. Nerve transfers have delivered more reliable results for some patterns of injury to the brachial plexus, with a particular improvement in outcome for reconstruction of the paralysed shoulder [15]. Early neurotisation of the suprascapular, and if possible the axillary nerve offers the best outcome for shoulder reanimation in posttraumatic brachial plexus paralysis [54]. Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury and successful restoration of shoulder motion by previous nerve transfers [38]. The technique of transferring the branch to the long head triceps brachii of the radial nerve to the anterior branch of the axillary nerve can provide shoulder abduction and shoulder extension [32]. Deterioration of shoulder function during follow-up was observed in a study of latissimus dorsi transfer in obstetrical brachial plexus injury [60].

Key Evidence¶

[L5] The different procedures for treatment of obstetrical brachial plexus palsy are complementary and allow in 75% of cases a good recovery of function of a nondominant limb. [1] (10.1016/b978-0-444-52910-7.00014-3)
[L5] The purpose of this article is to explore the potential contributions of various methods to brachial plexus injury rehabilitation and to provide a concise overview of the interventions that have been shown to be beneficial. [2] (10.3389/fneur.2023.1084223)
[L4] In brachial plexus injury reconstruction, achieving a stable and dynamic shoulder girdle is a primary goal. [3] (10.1097/prs.0b013e3181881fc5)
[L5] Obstetric brachial plexus injuries require a multidisciplinary approach and a broad range of treatment modalities to optimize function in the growing child due to the changing pattern of pathology and glenohumeral joint dysplasia. [4] (10.1111/sae.12003)
[L4] Children with OBPI should be seen early by a hand surgeon dealing with brachial plexus injuries. [5] (10.4103/0970-0358.90805)
[L4] Use of this technique should be considered in selected individuals with upper brachial plexus injuries. [6] (10.1007/s11552-012-9398-0)
[L4] Most cases of brachial plexus injury after shoulder dislocation have a good prognosis for recovery except for intrinsic muscles of the hand. [7] (10.1016/j.injury.2009.05.015)
[L5] Combined subclavian artery and brachial plexus injury as a result of blunt trauma is a rare occurrence, but results in devastating functional disability of the upper limb. [8] (10.1016/s0020-1383(98)00064-3)
[L5] Prompt release of the axillary artery injury along with exploration and, if possible, repair of the adjacent brachial plexus is key in saving the limb and decreasing the probability of permanent neurological damage. [9] (10.1016/j.injury.2013.05.010)
[L3] Most obstetric brachial plexus injury patients with isolated absent or slowly recovering shoulder movements recover at least 90 degrees of abduction. [10] (10.1177/17531934251327083)
[L4] In patients with traumatic injuries of the brachial plexus, reconstruction of elbow extension is worthwhile and should be viewed as a priority, particularly if hand function is preserved. [11] (10.1177/1753193408101466)
[L4] Such patients should be immediately referred to a specialist brachial plexus service for assessment, physiotherapy, and the option of surgery if indicated. [12] (10.1177/1753193421993088)
[L4] The findings provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI. [13] (10.1016/j.jse.2023.06.016)
[L4] Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries, offering functional outcomes surpassing those obtained from traditional nerve repair or tendon transfers. [14] (10.1016/j.injury.2020.04.015)
[Paper] Overall nerve transfers have broadened reconstructive options and delivered more reliable results for some patterns of injury to the brachial plexus, with a particular improvement in outcome for reconstruction of the paralysed shoulder. [15] (10.1007/s12593-011-0031-1)
[L4] In the delayed presentation of brachial plexus birth injury, brachial plexus reconstruction results in good functional recovery of elbow flexion and shoulder external rotation but modest functional recovery of finger flexion and wrist extension. [16] (10.1016/j.jhsa.2022.11.003)
[L4] This study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients' self-assessments. [17] (10.1016/j.injury.2012.02.006)
[L3] Even when a cesarean section is performed, a brachial plexus injury may be encountered, with an increased risk for newborns with a birth weight over 4,500 g. [18] (10.1159/000049410)
[L4] Delayed fixation of clavicle fractures, especially between two and four weeks after injury, carries a small but significant risk of iatropathic brachial plexus injury. [19] (10.1302/0301-620x.95b1.29625)
[L4] Both passive glenohumeral extension and active shoulder extension angles can be measured reliably with a clinical exam, with at least 10 degrees necessary to perform the hand-to-spine Mallet task. [20] (10.1016/j.jse.2023.03.036)
[L3] Glenohumeral abduction contracture is a very common finding in patients with upper neonatal brachial plexus injury, affecting approximately three-quarters of these patients, while the frequency decreases substantially in complete palsies. [21] (10.1177/17531934211045509)
[L5] Modern approaches combine early microsurgical repair with subsequent musculoskeletal reconstruction to optimize the final functional outcome. [22] (10.1016/s0749-0712(21)00269-9)
[L4] The pain of preganglionic injury of the brachial plexus is not relieved by amputation. [23] (10.1016/0020-1383(93)90123-n)
[L5] The paper concludes that prevention of neonatal brachial plexus palsy has not been possible by any individual physician or groups of physicians, and the injury occurs independent of physician experience. [24] (10.1080/01443610802295880)
[L5] [26] (10.5435/jaaos-d-18-00433)
[L4] Iatrogenic nerve injuries remain an inherent risk in shoulder surgery, with positioning and specific surgical steps placing nerves at risk; systematic physical examination and knowledge of anatomy are critical for prevention and recognition. [29] (10.5435/jaaos-21-12-717)
[L3] The results suggest that more emphasis should be placed on shoulder internal rotation in treatment strategies. [30] (10.1177/1753193420964768)
[L4] The technique of double neurotization from a single donor nerve provides favourable results in restoring shoulder abduction in avulsion brachial plexus injuries. [31] (10.1177/1753193416680725)
[L4] This technique can provide shoulder abduction and shoulder extension, which are the functions of the posterior deltoid muscle. [32] (10.1016/j.jhsa.2022.04.022)
[L5] [33] (10.1055/s-0038-1642068)
[L4] [35] (10.3171/2015.6.peds14703)
[L4] The proposed wearable technology is a sensitive and reliable tool for objective outcome evaluation of brachial plexus injury and its biomechanical consequences. [37] (10.1016/j.jse.2020.10.025)
[L4] Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury, and with successful restoration of shoulder motion by previous nerve transfers. [38] (10.1016/j.jhsa.2015.01.038)
[L2] Since no successful treatment is available, restricted use of RT to the brachial plexus is warranted, especially when administered concomitantly with cytotoxic therapy. [39] (10.3109/02841869009096384)
[L4] All patients stated that shoulder fusion had improved the function of their limb, with active abduction ranging from 50 to 80 degrees. [40] (10.1016/0020-1383(91)90004-x)
[L5] Different degrees and levels of brachial plexus injury require different reconstructive strategies, with nerve transfer and functioning free muscle transplantation being the only reliable options for total root avulsion. [41] (10.1055/s-0030-1253242)
[L2] The established protocol has the potential to reduce the incidence of posterior shoulder subluxation in children with brachial plexus birth injury. [42] (10.1177/17531934211056998)
[L4] Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently. [45] (10.1016/j.jhsa.2021.09.009)
[L4] [47] (10.1016/j.injury.2020.08.005)
[L2] The NAPTIME score might distinguish which infants will meet the criteria for reconstructive nerve surgery earlier than when the decision can be made clinically. [48] (10.2106/jbjs.24.00561)
[L4] [49] (10.1177/17531934231166824)
[Case_report] MRI should typically be performed before making a treatment decision to examine the brachial plexus for any discontinuity or kinking. [52] (10.1186/s12891-022-05601-5)
[L4] Early neurotisation of the suprascapular, and if possible the axillary nerve offers the best outcome. [54] (10.1016/j.injury.2009.09.009)
[Case_report] Brachial plexopathy with a prolonged neurological deficit can occur in infants who have septic arthritis and osteomyelitis. [56] (10.2106/00004623-199601000-00014)
[L4] [59] (10.1177/17531934211039698)
[L4] Disappointing in our study was the deterioration of shoulder function during followup. [60] (10.1097/bth.0b013e318176b32f)
[L4] [95] (10.1016/j.injury.2012.07.182)
[L4] Isolated lower trapezius transfer is considered an effective option with promising results in cases of sequelae of obstetric brachial plexus injury for restoration of shoulder external rotation as well as abduction. [99] (10.1186/s12891-024-08048-y)
[L4] This systematic review showed that arthroscopic release effectively improves both shoulder mobility and bone deformity, with few complications in young children with brachial plexus birth injury. [100] (10.1016/j.jse.2020.12.021)
[L1] In obstetrical brachial plexus injury, nerve transfer is associated with improved shoulder external rotation and a lower rate of secondary shoulder surgery. [101] (10.1177/15589447211030691)
[L3] [104] (10.1007/s11552-014-9625-y)
[L2] [107] (10.1016/j.jhsa.2018.11.006)
[L4] [109] (10.1016/j.injury.2008.05.012)
[L5] [115] (10.1016/j.injury.2013.01.020)
[L5] Careful neurological and vascular examination should be performed at presentation and repeated postrelocation of the shoulder into joint. [130] (10.1136/bcr-2015-213497)

References¶

[1] Obstetrical brachial plexus palsy. Handbook of Clinical Neurology. 2013. DOI: 10.1016/b978-0-444-52910-7.00014-3

[2] Review of rehabilitation protocols for brachial plexus injury. Frontiers in Neurology. 2023. DOI: 10.3389/fneur.2023.1084223

[3] Evaluation of Single-, Double-, and Triple-Nerve Transfers for Shoulder Abduction in 90 Patients with Supraclavicular Brachial Plexus Injury. Plastic and Reconstructive Surgery. 2008. DOI: 10.1097/prs.0b013e3181881fc5

[4] Management of Shoulder Problems Following Obstetric Brachial Plexus Injury. Shoulder & Elbow. 2014. DOI: 10.1111/sae.12003

[5] Obstetric brachial plexus injury. Indian Journal of Plastic Surgery. 2011. DOI: 10.4103/0970-0358.90805

[6] Transfer of Triceps Motor Branches of the Radial Nerve to the Axillary Nerve with or without other Nerve Transfers Provides Antigravity Shoulder Abduction in Pediatric Brachial Plexus Injury. HAND. 2012. DOI: 10.1007/s11552-012-9398-0

[7] Recovery of brachial plexus injury after shoulder dislocation. Injury. 2009. DOI: 10.1016/j.injury.2009.05.015

[8] Combined subclavian artery and brachial plexus injury following blunt trauma to the shoulder. Injury. 1998. DOI: 10.1016/s0020-1383(98)00064-3

[9] Axillary arterial entrapment and brachial plexus injury due to proximal humeral fracture. Injury Extra. 2013. DOI: 10.1016/j.injury.2013.05.010

[10] Spontaneous recovery of shoulder abduction in obstetric brachial plexus injury patients with less than horizontal abduction at 3 months. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251327083

[11] Lower Trapezius Muscle Transfer for Reconstruction of Elbow Extension in Brachial Plexus Injuries. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408101466

[12] Functional deficits as a result of brachial plexus injury in anterior shoulder dislocation. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/1753193421993088

[13] Surgery for internal rotation contracture in infancy may obviate the need for brachial plexus nerve reconstruction: early experience. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.06.016

[14] Nerve transfers in the upper extremity: A review. Injury. 2020. DOI: 10.1016/j.injury.2020.04.015

[15] Nerve Transfers for Traumatic Brachial Plexus Injury: Advantages and Problems. Journal of Hand and Microsurgery. 2011. DOI: 10.1007/s12593-011-0031-1

[16] Long-Term Results of Microsurgical Brachial Plexus Reconstruction in Late-Presenting Cases of Brachial Plexus Birth Injury. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.11.003

[17] Functional outcome of nerve transfers for traumatic global brachial plexus avulsion. Injury. 2013. DOI: 10.1016/j.injury.2012.02.006

[18] Shoulder Dystocia and Brachial Plexus Injury: A Population-Based Study. Gynecologic and Obstetric Investigation. 2002. DOI: 10.1159/000049410

[19] Iatropathic brachial plexus injury. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b1.29625

[20] Shoulder extension impairment with residual neonatal brachial plexus injury. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.03.036

[21] Glenohumeral abduction contractures after residual neonatal brachial plexus injury. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211045509

[22] A MANAGEMENT APPROACH FOR SECONDARY SHOULDER AND FOREARM DEFORMITIES FOLLOWING OBSTETRICAL BRACHIAL PLEXUS INJURY. Hand Clinics. 1995. DOI: 10.1016/s0749-0712(21)00269-9

[23] Brachial plexus injury: when to amputate?. Injury. 1993. DOI: 10.1016/0020-1383(93)90123-n

[24] Newborn brachial plexus palsy. Journal of Obstetrics and Gynaecology. 2008. DOI: 10.1080/01443610802295880

[26] Adult Traumatic Brachial Plexus Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00433

[29] Iatrogenic Nerve Injuries in Shoulder Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/jaaos-21-12-717

[30] Relative importance of factors affecting activity and upper extremity function in children with Narakas Group 2 brachial plexus birth palsy. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420964768

[31] Restoration of shoulder abduction in brachial plexus avulsion injuries with double neurotization from the spinal accessory nerve: a report of 13 cases. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416680725

[32] Posterior Deltoid Function After Transfer of Branch to the Long Head Triceps Brachii of the Radial Nerve to the Anterior Branch of the Axillary Nerve. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.04.022

[33] The Use of Dynamic Assist Orthosis for Muscle Reeducation following Brachial Plexus Injury and Reconstruction. Journal of Hand and Microsurgery. 2068. DOI: 10.1055/s-0038-1642068

[35] Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system. Journal of Neurosurgery: Pediatrics. 2016. DOI: 10.3171/2015.6.peds14703

[37] A novel instrumented shoulder functional test using wearable sensors in patients with brachial plexus injury. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.10.025

[38] Polyester Tape Scapulopexy for Chronic Upper Extremity Brachial Plexus Injury. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.01.038

[39] Radiation-Induced Brachial Plexus Neuropathy in Breast Cancer Patients. Acta Oncologica. 1990. DOI: 10.3109/02841869009096384

[40] Arthrodesis of the shoulder following brachial plexus injury. Injury. 1991. DOI: 10.1016/0020-1383(91)90004-x

[41] Brachial Plexus Injury: Nerve Reconstruction and Functioning Muscle Transplantation. Seminars in Plastic Surgery. 2010. DOI: 10.1055/s-0030-1253242

[42] A protocol-based treatment plan to improve shoulder function in children with brachial plexus birth injury: a comparative study. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211056998

[44] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > Radiographic Evaluation.

[45] Patterns of Nerve Injury and Recovery Rates of Infraclavicular Brachial Plexus Lesions Following Anterior Shoulder Dislocation. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.09.009

[47] Endoscopic brachial plexus neurolysis in the management of infraclavicular nerve injuries due to glenohumeral dislocation. Injury. 2020. DOI: 10.1016/j.injury.2020.08.005

[48] Early MRI Can Predict the Indication for Surgery in Brachial Plexus Birth Injury. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.00561

[49] Obstetric brachial plexus injury in Scotland: incidence over 16 years. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231166824

[52] Conservative treatment for brachial plexus injury after a displaced clavicle fracture: a case report and literature review. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05601-5

[54] Shoulder reanimation in posttraumatic brachial plexus paralysis. Injury. 2010. DOI: 10.1016/j.injury.2009.09.009

[56] Septic Arthritis Associated with Brachial Plexus Neuropathy. A Case Report. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199601000-00014

[59] Pathological findings identified during the posterior approach to the spinal accessory nerve after high-energy trauma. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211039698

[60] Results of Latissimus Dorsi Transfer in Obstetrical Brachial Plexus Injury. Techniques in Hand & Upper Extremity Surgery. 2008. DOI: 10.1097/bth.0b013e318176b32f

[61] Rockwood And Matsen S The Shoulder. Shoulder and Elbow Specialty Clinic Workers’ Survey > ANATOMY.

[62] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > SHOULDER AND ARM INJURIES.

[63] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Applied Anatomy Related to Scapular Fractures.

[64] Aaos Comprehensive Orthopaedic Review 3. Anatomy of the Shoulder, Arm, and Elbow > I. Shoulder.

[68] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > FRACTURES OF THE PROXIMAL HUMERUS.

[71] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > Development of Individual Regions.

[75] Miller S Review Of Orthopaedics. Genetics of musculoskeletal conditions and abnormalities are summarized in Table 1.27 > UPPER EXTREMITY > SHOULDER.

[78] Apley And Solomon S Concise System Of Orthopaedics And Trauma. INVESTIGATION.

[82] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Magnetic Resonance Imaging and Arthrography.

[84] Aaos Comprehensive Orthopaedic Review 3. Traumatic Brachial Plexus Injuries > V. Treatment Decisions.

[85] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Shoulder Anatomy and Biomechanics, Clinical Evaluation, Imaging > Clinical Evaluation > Imaging.

[86] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > CLINICAL EVALUATION.

[87] Aaos Comprehensive Orthopaedic Review 3. Imaging of the Shoulder and Elbow > I. Shoulder.

[89] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Radiography.

[90] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > Diagnosis.

[95] Traumatic brachial plexus injury: Electrodiagnostic findings from 111 patients in a tertiary care hospital in India. Injury. 2012. DOI: 10.1016/j.injury.2012.07.182

[99] Lower trapezius transfer to infraspinatus in cases of sequelae of obstetric brachial plexus injury. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08048-y

[100] Effect of arthroscopic shoulder release on shoulder mobility and bone deformity following brachial plexus birth injury: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.12.021

[101] Nerve Transfer Is Superior to Nerve Grafting for Suprascapular Nerve Reconstruction in Obstetrical Brachial Plexus Birth Injury: A Meta-Analysis. HAND. 2021. DOI: 10.1177/15589447211030691

[104] An Early Shoulder Repositioning Program in Birth-Related Brachial Plexus Injury: A Pilot Study of the Sup-ER Protocol. HAND. 2014. DOI: 10.1007/s11552-014-9625-y

[107] The Association of Clavicle Fracture With Brachial Plexus Birth Palsy. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.11.006

[109] Brachial plexus reconstruction based on the new definition of level of injury. Injury. 2008. DOI: 10.1016/j.injury.2008.05.012

[115] Obstetrical brachial plexus palsy: Lessons in functional neuroanatomy. Injury. 2013. DOI: 10.1016/j.injury.2013.01.020

[130] Anterior humeral circumflex artery avulsion with brachial plexus injury following an isolated traumatic anterior shoulder dislocation. BMJ Case Reports. 2015. DOI: 10.1136/bcr-2015-213497

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