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Orthopedic Surgery > TRAUMA
Brachial Plexus Injuries, Traumatic
Article Last Updated: Sep 26, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Mark R Foster, MD, PhD, FACS, President and Orthopaedic Surgeon, Orthopaedic Spine Specialists of Western Pennsylvania, PC
Mark R Foster is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Physical Society, Christian Medical & Dental Society, Eastern Orthopaedic Association, North American Spine Society, Orthopaedic Research Society, and Pennsylvania Orthopaedic Society
Coauthor(s):
Christopher Chaput, MD, Assistant Professor of Orthopedic Surgery, Texas A&M Health Science Center; Consulting Surgeon, Department of Orthopedic Surgery, Scott and White Memorial Hospital;
Robert A Probe, MD, Associate Professor of Orthopedic Surgery, Texas A&M University Health Science Center; Chairman, Department of Orthopedic Surgery, Scott and White Clinic and Memorial Hospital
Editors: Jeffrey L Visotsky, MD, Assistant Professor, Department of Clinical Orthopedic Surgery, Northwestern University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Author and Editor Disclosure
Synonyms and related keywords:
traumatic brachial plexus injury, lesions of the brachial plexus, supraclavicular injuries, upper plexus injuries, lower plexus injuries, shoulder injuries
History of the Procedure
The treatment of lesions of the brachial plexus has changed from shoulder fusion, elbow bone block, and finger tenodesis following World War II to far greater functional restoration by advances in nerve repair and microsurgery. The natural history of becoming "one handed" within 2 years has been replaced by early exploration, neurolysis, nerve grafting, neurotization, and free muscle transfers, as well as tendon transfers, for shoulder and elbow function and for wrist or hand prehension. Recent advances in diagnostic imaging, nerve transfers, electrophysiologic testing, nerve root repair, nerve rootlet replantation, and free muscle transfers make this a dynamic but highly specialized field.1, 2, 3
Related Medscape topics:
Specialty Site Orthopaedics
Orthopaedics CME and News
Related eMedicine topics:
Brachial Plexus Injuries, Obstetrical
Tendon Transfers
Problem
High-energy trauma to the upper extremity and neck can cause a variety of lesions to the brachial plexus. Most common are traction injuries, in which the head and neck are moved away violently from the ipsilateral shoulder; injuries may also be caused by compression between the clavicle and first rib, penetrating injuries, or direct blows. Recognition may be delayed by other injuries, particularly to the spinal cord and head.4, 5 Because this topic is complex, this article focuses primarily on traction injuries, the most common injuries in adults. Such injuries usually are catastrophic for the affected individual. Loss of useful function of the upper extremity is common, but early repair and reconstruction are providing far greater restoration than was possible a few years ago.
Related Medscape topic:
Resource Center Trauma
Resource Center Spinal Disorders
Related eMedicine topic:
The Polytraumatized Patient
Frequency
Reliable information on the incidence of traumatic brachial plexus injuries is difficult to find; the exact incidence is not known. Goldie and Coates suggested that 450-500 closed supraclavicular injuries occur each year in the United Kingdom.6 Young males are disproportionately affected, mostly between 15 and 25 years of age, as in other types of trauma.
Narakas developed his rule of "seven seventies " in his experience over 18 years with 1068 patients7:
- Approximately 70% were motor vehicle accidents (MVAs).
- Of the MVAs, 70% were motorcycles or bicycles.
- Of the cycle riders, 70% had multiple injuries.
- Of the multiple injuries in cycle riders, 70% were supraclavicular injuries.
- Of the supraclavicular injuries, 70% had at least one root avulsed.
- Of the avulsed roots, 70% were lower C7, C8, T1.
- Of the 70% avulsed roots, 70% of those were associated with chronic pain.
Etiology
The common mechanism for traction injuries of the brachial plexus is violent distraction of the entire forequarter from the rest of the body. These injuries usually result from a motorcycle accident or a high-speed motor vehicle accident. A fall from a significant height may also result in brachial plexus injury, either traction type or from a direct blow; penetrating injuries and low- or high-velocity gunshot wounds also are seen.
In traction-type injuries, the crucial prognostic factor is whether the injury is proximal (preganglionic) or distal (postganglionic) to the dorsal root ganglion. A preganglionic root avulsion means that the cell bodies of the sensory nerves are pulled from the cord, diminishing the possibility of recovery or surgical reconstruction. These are differentiated from distal ruptures—postganglionic stretch injuries—in which cell bodies are still in continuity with their axons.
Pathophysiology
In traction-type brachial plexus injuries, the head and neck are moved away violently from the ipsilateral shoulder. Upper plexus injuries (C5 and C6) usually predominate if the arm is at the side because the first rib acts as a fulcrum to direct the traction forces preferentially in line with the upper plexus. When the arm is moved violently and abducted overhead, the lower elements (C8-T1) typically are injured, as the force is directed in line with C7. A lower plexus lesion predominates when the arm is raised because the coracoid acts as a fulcrum in a similar fashion. Lower plexus lesions may be more common, in part, because of the well-formed transverse radicular ligaments that help resist traction forces at C5, C6, and C7; C8 and T1 lack these ligaments. Traction forces can result in preganglionic or postganglionic injuries. Preganglionic injuries refer to lesions proximal to the dorsal root ganglion, which is in the spinal canal, and foramen. Preganglionic ruptures may be central or direct from the spinal cord or intradural. Preganglionic lesions do not cause wallerian degeneration or neuroma formation because the axons remain in continuity with the cell bodies in the dorsal root ganglion. Postganglionic lesions are defined as any lesions distal to the spinal ganglion and are physiologically similar to other peripheral nerve injuries.
Clinical
History The index of suspicion for a brachial plexus injury is much higher for severe shoulder girdle injuries, particularly motorcycle and motor vehicle accidents. The mechanism of injury should be considered, as these may occur in polytrauma. Other injuries requiring sedation indicate that detailed follow-up examination of the upper extremity may needed. The patient may present with the following symptoms:
- Pain, especially of the neck and shoulder. Pain over a nerve is common with rupture, as opposed to lack of percussion tenderness with avulsion
- Paresthesias and dysesthesias
- Weakness or heaviness in the extremity
- Diminished pulses, as vascular injury may accompany traction injury.
Physical examination The standard advanced trauma life support (ATLS) protocol should be followed. Abrasions to the head, helmet, or tip of the shoulder suggest supraclavicular injury. Ptosis (lid droop), enophthalmos (sinking of the eye into the orbit), anhydrosis (dry eye), and miosis (small pupil) or Horner syndrome suggest a complete lower plexus lesion (see Image 1), as the sympathic ganglion for T1 is in close proximity to the brachial plexus. Swelling about the shoulder can be dramatic. Diminished or absent pulses suggest vascular injury, and special consideration should be given to rupture of the subclavian vessels. Clavicle fractures often are palpable. Careful inspection and palpation of the axial skeleton may reveal concomitant injuries. Examine each cervical root individually for motor and sensory function as soon as circumstances allow. Some special considerations are warranted for the neurologic examination, as follows:
Related Medscape topics:
Resource Center Trauma
Resource Center Vascular Surgery Related eMedicine topics:
The Polytraumatized Patient
Horner Syndrome
Peripheral Vascular Injuries
Clavicle Fractures
Formerly, most brachial plexus lesions were treated conservatively. Patients were monitored over 12-18 months for recovery of significant voluntary motor control, and any residual deficit was pronounced permanent. Leffert suggested that after 9-12 months, any residual deficit at the level of the shoulder can be considered permanent.8 However, recovery of more distal function may occasionally be observed more than a year after injury. The customary treatments were shoulder fusion, elbow fusion, wrist and finger tenodesis and transhumeral amputation. The 3 crucial factors in restoration of upper arm function after brachial plexus injury are patient selection, timing of surgery, and prioritization of restoration. Open injuries from a sharp object may benefit most from immediate exploration and, if possible, direct, end-to-end repair. With an open injury from a blunt object, a 3- to 4-week delay in repair, after initial debridement and tagging, allows injured nerve ends to demarcate. Low-velocity gunshots injuries may be neuropraxic, and may be observed. High-velocity gunshot injuries need early exploration for significant soft-tissue damage.
Stretch injuries present the most complex issues. Early surgery may preclude opportunities for spontaneous recovery; delayed surgery may allow failure of end plates and reinnervation. Suspected avulsions may be explored at 3-6 weeks, and, generally, failure of adequate reinnervation may be explored at 3-6 months.
Surgical options include nerve (primary) and soft-tissue (secondary) reconstruction. External neurolysis alone may benefit a nerve in continuity that exhibits a nerve action potential (NAP). Postganglionic neuromas or ruptures may benefit from nerve grafting. From an overall perspective, such grafts include C5 for shoulder abduction, C6 for elbow flexion, and C7 for elbow and wrist extension.
Nerve transfers (neurotization) can be performed to accelerate recovery from preganglionic injuries.9 Such procedures, performed ideally within 6 months, reduce time to reinnervation by reducing the distance to the site of the nerve injury. Sources for transfer include the spinal accessory nerve, intercostal nerves, and the medial pectoral nerve.10, 11 The Oberlin transfer uses a fascicle of a functioning ulnar nerve, but the median nerve or others may also be used in specific cases.
Significant recovery after nerve grafting can take more than 18 months, and maintaining joint mobility, minimizing edema, and treating deafferentation pain during this period can make postoperative care challenging. The age of the patient also is important. The ability of nerve transfers to restore functional strength decreases dramatically with patient age. Therefore, many of the surgical options are reserved for younger patients.
The brachial plexus is formed from the spinal nerves or roots, the coalescence of the ventral (motor) and the dorsal (sensory) rootlets as they pass through the spinal foramen. The dorsal root ganglion contains the cell bodies of the sensory nerves; the cell bodies for the ventral nerves lie within the spinal cord.
Typically, the brachial plexus is formed from C5-T1; in some cases with there is a contribution from C4 (prefixed, 28-62%) or T2 (postfixed, 16-73%). All nerve supply to the upper extremity passes through this plexus. The brachial plexus starts at the scalenes, courses under the clavicle, and ends at the axilla. It is typically composed of 5 roots, 3 trunks, 6 divisions (2 from each trunk), 3 cords and terminal branches.
The 5 roots are named by the level with which they correspond. The C5-7 roots give off branches to form the long thoracic nerve, and the C5 root gives branches to form the dorsal scapular nerve. C5 and C6 gives branches to form the superior trunk, C7 the middle trunk, and C8 and T1 the inferior trunk. Each trunk has 2 divisions: 1 division of each of the trunks forms the posterior cord; the anterior division of the superior trunk and the anterior division of the middle trunk form the lateral cord. The anterior division of the inferior trunk forms the medial cord. The medial, lateral, and posterior cord designations describe their relationship to the axillary artery.
The superior trunk gives off the suprascapular nerve and a nerve to subclavius. The posterior cord has the upper and lower subscapular nerves, with the thoracodorsal nerve between them. The lateral pectoral nerve emanates from the lateral cord, and the medial pectoral nerve from the medial cord but with a connection between the pectoral nerves. The posterior cord then becomes the axillary and radial nerves.
The lateral cord continues as the musculocutaneous nerve; a branch from the medial and lateral cords becomes the median nerve; and a branch from the lateral branch joins the medial cord continuation as the ulnar nerve, after the medial cord gives off the medial brachial cutaneous and the medial antebrachial cutaneous nerves. The cords and branches are distal to the clavicle; the roots and trunks proximal. The plexus lies in close proximity to the axillary artery, which exits between the anterior and middle scalenes. Knowledge of this anatomy may allow localization of lesions from the physical examination. Many different approaches to the brachial plexus have been used. Surgeon preference is largely shaped by training and by the goals of a particular procedure. In any approach, the clavicle can be a barrier to visualization. Millesi described an approach using 3 anterior incisions with the patient in the supine position.12 He makes a sagittal incision on the lower neck and 2 transverse incisions more distally, following skin tension lines. By moving the clavicle and looking at the plexus from both a cephalad and a caudad direction, he is able to visualize upper, middle, and lower trunks of the brachial plexus and avoid osteotomy of the clavicle. The spinal nerves of the upper plexus can also be visualized with this approach.
Contraindications to surgery include the following:
- Joint contractures
- Severe edema
- Advanced patient age
- Lack of patient motivation or lack of patient understanding of surgical goals
Lab Studies
- Laboratory studies generally are not helpful for diagnosis, although they may be indicated in the routine evaluation of any trauma patient.
- Electrophysiologic studies are crucial in the management of these injuries, but timing (eg, for Wallerian degeneration to occur) must be considered.
Imaging Studies
- Radiographic evaluation
- In anteroposterior (AP) chest radiography, specific attention should be directed to the distance between the spinous processes of the thoracic spine and the scapula. If the radiograph is not malrotated, an increase in this distance compared with the contralateral side may indicate scapulothoracic dissociation (see Image 3).
- AP and axillary lateral views of the shoulder reveal clavicle fractures, most scapular fractures, and most proximal humerus fractures.
- Cervical spine series including AP, lateral, and odontoid views are useful.
- Computed tomography (CT) scanning: Adequate plain radiographs may be difficult to obtain, especially of the odontoid and the cervicothoracic junction. A CT scan of the neck can often be obtained in conjunction with CT scanning that is a part of the evaluation of many trauma patients. Plain CT scanning is very helpful in evaluating any cervical fractures, and should be obtained if fractures are suspected based on plain radiographic findings. CT scanning of the chest may reveal subclavian vessel injuries, scapular fractures, humeral fractures, and thoracic spine fractures (see Image 4).
- Myelography: The most reliable indicator of root avulsion is an absent root shadow on plain myelography.13 A common sign of a root avulsion is a meningocele at the affected level; hence, myelography may best be delayed for 4 weeks so that any blood clot will not be dislodged by the study and the meningocele can be allowed to form.
- CT myelography (CTM): The literature is still inconclusive regarding the sensitivity and specificity of CTM, but CTM is being performed more often.14 Lower concentrations of contrast medium can be detected by CTM than by standard myelography. Burge states that CTM may be better able to reveal small meningoceles, but artifact from surrounding soft tissues may be problematic at the lower cervical levels.15
- Magnetic resonance imaging (MRI): MRI is the current criterion standard for visualizing spinal cord injuries, but reports of its utility in evaluating traumatic lesions of the brachial plexus are sparse. MRI is the only technique that can be used to visualize the postganglionic brachial plexus. While the impact of MRI on surgical decision-making is yet to be defined, it no doubt will play a larger role in the evaluation of the brachial plexus in the future.
- Angiography: Both conventional angiography and magnetic resonance angiography (MRA) are valuable tools in evaluating any suspected vascular disruption.
Other Tests
- Sensory nerve action potentials (SNAPs): SNAPs are very helpful in differentiating preganglionic from postganglionic injuries. If the injury is proximal to the dorsal root ganglion (DRG), no Wallerian degeneration occurs because the sensory axon is intact. Thus, a SNAP observed in a nerve with an anesthetic dermatome confirms a preganglionic lesion. SNAPs are not useful for C5 evaluation because C5 does not provide a significant contribution to a major peripheral sensory nerve.
- Electromyography (EMG): In the first week after injury, EMG cannot be used to exclude a complete nerve disruption unless voluntary motor unit action potentials are observed. If no signs of denervation are apparent in a paralyzed muscle by 3 weeks after injury, EMG can be used to confirm neuropraxia.
- Somatosensory evoked potentials (SSEPs): Intraoperative SSEPs are useful in brachial plexus surgery. The presence of SSEPs suggests continuity between the peripheral nervous system and the CNS via the DRG. SSEPs are absent in postganglionic or combined pre- and postganglionic lesions.
Medical therapy
Nonoperative treatment of brachial plexus lesions is complex and may best be addressed by an integrated multidisciplinary team that includes a skilled orthotist, occupational therapists, physical therapists, and physicians. Bracing often plays a role in preventing contractures while waiting for recovery after surgery or while waiting for recovery from neuropraxia.
Surgical therapy
Operative care of the brachial plexus is a highly specialized field that is limited to relatively few tertiary care centers. Wide variation exists in how these injuries are addressed surgically. The availability of subspecialists with experience in the operative management of these lesions is critical if operative management is considered. In general, the surgical options consist of nerve transfers, nerve grafting, muscle transfers, free muscle transfers, and neurolysis of scar around the brachial plexus in incomplete lesions. Advances in the field are likely to create more surgical options in the future. For example, Carlstedt obtained promising initial results with the repair of preganglionic lesions by replanting nerve rootlets directly into the spinal cord.16 This is a dramatic advance because preganglionic lesions were previously thought to be irreparable.
Related eMedicine topic:
Wound Healing, Nerve
Preoperative Details
Patient selection is key, as these injuries are very complex and vary widely. Other preoperative considerations are timing of intervention, which can be critical, and planning of the repair versus reconstructive nature of specific procedures.17
Initial evaluation centers on examination, particularly sensation and remaining motor function, but electrodiagnostic studies and imaging are integral to planning for any proposed procedure.
Physical therapy may be important in the prevention of contractures during the period of preoperative observation. However, surgery may proceed without observation if examination and imaging demonstrate the absence of potential for spontaneous recovery.
Immediate exploration with possible end-to-end repair may be indicated in some cases of open injury caused by a sharp object. Unfortunately, blunt-force and avulsion-type injuries are more common; if such an injury is open, nerves may be tagged at debridement, but call for 3-4 weeks for demarcation for delayed repair.
Although timing is controversial for stretch injuries, a period for spontaneous recovery should be allowed. However, too lengthy a delay may result in motor end-plate failure, which typically occurs at 3-6 months.
Reconstruction details are really a matter of planning, as the variety of procedures is large and reconstruction may need to be staged. Many surgeon prioritize the elbow and then the shoulder for reconstructive procedures. The principle considerations are the root level involved and the specific deficits, particularly hand sensibility, wrist extension, finger flexion, wrist flexion, finger extension, and intrinsic function of the hand.18
Examples of nerve grafting include cable grafts of sural nerve with C5 to target shoulder abduction, C6 for elbow flexion, and C7 for elbow and wrist extension.
Intraoperative Details
Primary procedures are repair procedures; secondary procedures are reconstructive.
Open injuries, particularly high-velocity gunshot wounds, call for debridement and immediate repair when possible, or tagging of nerves for delayed repair. External neurolysis should be performed for intraoperative monitoring and electrical studies, or neurolysis alone for nerves in continuity that exhibit a nerve action potential (NAP). The NAP can demonstrate preserved axons or significant regeneration, and potential for further recovery; a neurapraxic lesion shows no NAP, as opposed to axonometric lesions (positive for NAP). Otherwise (no intraoperative NAP) nerve grafting can be done for postganglionic neuromas or neural ruptures.
Somatosensory evoked potentials (SSEPs) demonstrate continuity between the CNS and the peripheral nervous system via a dorsal root ganglion (DRG). Postganglionic lesions do not have SSEPs.
Nerve grafting or nerve transfers (neurotization) may be performed for preganglionic injury (ie, intact cell bodies in DRG) or to reduce reinnervation time, usually within 6 months of the trauma.
Postoperative Details
Expectations after surgery are not for immediate recovery, but instead for a slow process requiring significant patient and family education and involvement. Physical therapy is critical to safely maintain joint motion and suppleness, as well as supports for protection. Electrical stimulation is controversial but may at least have psychological benefit.
Follow-up
Follow-up should be prolonged, as neural recovery time is lengthy, with a regeneration rate of 1 mm per day (1 inch per month). Tendon and free muscle transfers as well as arthrodeses may be critical to restoring some function; even marginal improvements may be functionally significant.
Physical therapy and bracing often are used over the prolonged postoperative period to prevent contractures, to keep joints supple after surgery, and to reinforce the need for patience from patient and family.
Contractures related to certain types of incisions have been reported. In some exposures, the spinal accessory nerve is at risk and should be protected. More specific complications are variable and depend on the exact type of procedure performed. Deafferentation pain can be one of the most difficult problems for the clinician to treat after brachial plexus injuries. This pain syndrome may occur after surgical repair or with conservative treatment of brachial plexus lesions. When the nerve roots are avulsed in preganglionic lesions, the cells in the dorsal column are robbed of their nerve supply. Shortly after the injury (days to weeks), spontaneous signals are generated in these cells. These spontaneous signals can result in intractable pain for the patient. Patients often report severe burning in the extremity, and they may describe the pain as shooting or crushing. Typically, the pain is severe and has a paroxysmal component. Treatment of deafferentation pain begins with conservative measures. A pain management team should be involved early, and admission is often helpful to allow for initiation of treatment with a multidisciplinary approach.19 Antidepressants, anticonvulsants, and narcotics all may have a role, and treatments must be customized to the character of the pain and to the patient. As with other types of neurogenic pain, gabapentin has met with some success in the treatment of deafferentation pain. Transcutaneous nerve stimulation (TNS) can be considered. TNS may work by preventing the cells in the dorsal column from sending abnormal signals proximally. TNS must be used for a prolonged period, and maximum benefit from the device may not occur for several months. For a total brachial plexus lesion (C5-T1), the stimulators are placed on the front of the chest (C3-C4 dermatome) and on the inner arm (T2 dermatome). Acupuncture, hypnosis, biofeedback, and various desensitization protocols have been tried with mixed results. Advances in surgical technique have renewed interest in surgical procedures to disrupt the signals generated in the dorsal reentry zone (DREZ) of the dorsal columns. Thomas and Sheehy documented good pain reduction (75% relief) in about half of the patients in their series.20 Most surgeons reserve such invasive procedures for long-standing severe pain that is refractory to conservative measures.
The prognosis is highly variable. It depends not only on the nature of the injury but also on the age of the patient and the type of procedure performed. Doi et al reported achieving reliable grasping of the hand and voluntary control of the shoulder and elbow after complete avulsion of the brachial plexus.21 They achieved these impressive results using a double free muscle transfer technique. Kandenwein et al presented 134 cases that were treated surgically for traumatic brachial plexus lesions.22 In this group, the percentage of patients with grade 3 or better motor strength progressed from 2% preoperatively to 52% postoperatively, an enormous improvement over historical results; graft reconstruction performed better than neurotization.
Clear consensus regarding surgical timing and surgical indications is lacking. However, sural nerve grafting has been shown to be better than neurotization, and surgery between 3 and 6 months has become more common and preferred, with better outcomes. There is some difficulty in obtaining a significant series of comparable patients. More research is needed to demonstrate the efficacy of most of the procedures currently available. The future may bring further advances in nerve rootlet replantation for preganglionic injuries and in free muscle transfer techniques. Research into growth factors that promote nerve regeneration may make nerve grafting and transfers more appealing in the future.
For a further review of adult traumatic brachial plexus injuries, see Shin et al.1
Plexopathy.
American College of Radiology. 2006. 13 pages. NGC:005539
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Brachial plexus injuries, traumatic. This patient has ptosis and myosis of his right eye secondary to a complete lower brachial plexus lesion. |
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Brachial plexus injuries, traumatic. This is a human cadaveric dissection of the right brachial plexus. The clavicle and some soft tissues have been resected. The nerve roots are exiting their respective foramen at the right-hand border of the picture. The uppermost nerve root observed is C5, and C6, C7, and C8 are also visible. The cords of the plexus can be observed at the left-hand margin of the picture. Note the axillary artery at the bottom of the picture. |
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Brachial plexus injuries, traumatic. This is the initial anteroposterior chest radiograph of a patient involved in an accident with an 18-wheeled truck. The clavicle fracture observed on the initial chest radiograph was important in signaling the need for further evaluation of the injury because he was intubated and unresponsive secondary to a closed head injury. Scapulothoracic dissociation was suspected on close review of a CT scan of the chest, and a brachial plexus injury was noted once the patient became responsive. |
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Brachial plexus injuries, traumatic. This is a plain CT scan obtained during the initial workup of the same patient as in Image 3. A fracture of the right scapula is visible, as is a right pulmonary contusion and significant periscapular swelling. Scapulothoracic dissociation was suspected based on the patient's clavicle fracture, scapula fracture, brachial plexus palsy, and high-energy mechanism of injury (ie, accident with an 18-wheeled truck). The CT scan is oblique, so a high-quality anteroposterior chest radiograph demonstrating lateral displacement of the right scapula was obtained later to confirm the diagnosis. |
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- Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg. Oct 2005;13(6):382-96. [Medline].
- Blaauw G, Muhlig RS, Vredeveld JW. Management of brachial plexus injuries. Adv Tech Stand Neurosurg. 2008;33:201-31. [Medline].
- Rovak JM, Tung TH. Traumatic brachial plexus injuries. Mo Med. Nov-Dec 2006;103(6):632-6. [Medline].
- Akita S, Wada E, Kawai H. Combined injuries of the brachial plexus and spinal cord. J Bone Joint Surg Br. May 2006;88(5):637-41. [Medline].
- Webb JC, Munshi P, Saifuddin A, Birch R. The prevalence of spinal trauma associated with brachial plexus injuries. Injury. Sep 2002;33(7):587-90. [Medline].
- Goldie BS, Coates CJ. Brachial plexus injury: a survey of incidence and referral pattern. J Hand Surg [Br]. Feb 1992;17(1):86-8. [Medline].
- Narakas AO. The treatment of brachial plexus injuries. Int Orthop. 1985;9(1):29-36. [Medline].
- Leffert RD. Green's Operative Hand Surgery. 4th ed. New York, NY:. Churchill Livingstone;1999:1557-1587.
- Rohde RS, Wolfe SW. Nerve transfers for adult traumatic brachial plexus palsy (brachial plexus nerve transfer). HSS J. Feb 2007;3(1):77-82. [Medline].
- Moiyadi AV, Devi BI, Nair KP. Brachial plexus injuries: outcome following neurotization with intercostal nerve. J Neurosurg. Aug 2007;107(2):308-13. [Medline].
- Suzuki K, Doi K, Hattori Y, Pagsaligan JM. Long-term results of spinal accessory nerve transfer to the suprascapular nerve in upper-type paralysis of brachial plexus injury. J Reconstr Microsurg. Aug 2007;23(6):295-9. [Medline].
- Millesi H. Brachial plexus injuries. In: Chapman MW, Szabo RM, Mann RA, et al, eds. Chapman's Orthopaedic Surgery. Philadelphia, Pa:. Lippincott Williams & Wilkins;2001:1703-1720.
- Boome RS. The hand and upper extremity. In: Boome RS, ed. The Brachial Plexus. Vol 14. Philadelphia, Pa:. WB Saunders Co;1997:1-18.
- Amrami KK, Port JD. Imaging the brachial plexus. Hand Clin. Feb 2005;21(1):25-37. [Medline].
- Burge P. Diagnostic investigations. In: Boome RS, ed. The Brachial Plexus. Vol 14. Philadelphia, Pa:. WB Saunders Co;1997:19-29.
- Carlstedt TP. Spinal nerve root injuries in brachial plexus lesions: basic science and clinical application of new surgical strategies. A review. Microsurgery. 1995;16(1):13-6. [Medline].
- Jivan S, Kumar N, Wiberg M, Kay S. The influence of pre-surgical delay on functional outcome after reconstruction of brachial plexus injuries. J Plast Reconstr Aesthet Surg. May 15 2008;[Medline].
- Ahmed-Labib M, Golan JD, Jacques L. Functional outcome of brachial plexus reconstruction after trauma. Neurosurgery. Nov 2007;61(5):1016-22; discussion 1022-3. [Medline].
- Parry CB. Management of Deafferentation Pain. In: Boome RS, ed. The Brachial Plexus. Vol 14. Philadelphia, Pa:. WB Saunders Co;1997:165-168.
- Thomas DG, Sheehy JP. Dorsal root entry zone lesions (Nashold's procedure) for pain relief following brachial plexus avulsion. J Neurol Neurosurg Psychiatry. Oct 1983;46(10):924-8. [Medline].
- Doi K, Muramatsu K, Hattori Y, et al. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results. J Bone Joint Surg Am. May 2000;82(5):652-66. [Medline].
- Kandenwein JA, Kretschmer T, Engelhardt M, Richter HP, Antoniadis G. Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases. J Neurosurg. Oct 2005;103(4):614-21. [Medline].
- Birche R. Surgical Disorders of the Peripheral Nerves. 1st ed. Churchill Livingstone:1998:157-207.
- Miller MD. Review of Orthopedics. 3rd ed. Philadelphia, Pa:. WB Saunders Co;2000:519-527.
- Tavakkolizadeh A, Saifuddin A, Birch R. Imaging of adult brachial plexus traction injuries. J Hand Surg [Br]. Jun 2001;26(3):183-91. [Medline].
Brachial Plexus Injuries, Traumatic excerpt Article Last Updated: Sep 26, 2008
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