eMedicine Specialties > Sports Medicine > Neurological

Brachial Plexus Injury

Thomas H Trojian, MD, Assistant Professor of Family Medicine, Fellowship Coordinator, Sports Medicine Fellowship Director, Department of Family Medicine, University of Connecticut School of Medicine; Team Physician, University of Connecticut, Department of Athletics
Federico E Vaca, MD, FACEP, Team Physician, Department of Emergency Medicine, University of California Irvine; Clinical Assistant Professor, University of California at Irvine School of Medicine; Oniel Young, BS, College of Osteopathic Medicine of the Pacific
Contributor Information and Disclosures

Updated: Sep 5, 2006

Introduction

Background

Peripheral nerve injuries are not common in noncontact sports. However, in contact and collision sports like football and rugby, brachial plexus injuries occur often. The greater incidence of brachial plexus injuries has been suggested to be the result of direct trauma from participation in contact sports.

The result of trauma to the brachial plexus can lead to the cervical "stinger" or "burner" syndrome, which is classically characterized by unilateral weakness and a burning sensation that radiates down an upper extremity. The condition may last less than a minute or as long as 2 weeks, with the latter duration described as a chronic burner syndrome.

Frequency

United States

Brachial plexus injuries are the most common peripheral nerve injuries seen in athletes. True rate of brachial plexus injuries is difficult to determine due to significant underreporting. Many stingers last briefly and players do not seek medical attention. Clancy et al reported that 33 of 67 college football players (49%) sustained at least 1 burner during collegiate play. Sallis et al surveyed Division III college football players and reported that 65% experienced brachial plexus injuries. In addition, Sallis reported an 87% recurrence rate in these individuals. Meeuwisse reported that 7.2% of all football injuries were brachial plexus injuries.

International

True measure of international occurrence of brachial plexus injuries is undetermined due to significant underreporting in athletes and lack of studies in rugby and hockey involving brachial plexus injuries.

Functional Anatomy

Injuries to the cervical spine are common. The common level of injury is at C5-C6. Damage to other areas of the spinal area can lead to an array of motor and sensory deficits. The following is a list of cervical nerve roots with the associated area of potential motor and sensory deficits:

• C4 - Trapezius; shoulder; top of shoulders
• C5 - Deltoid, rotator cuff; shoulder abduction; lateral upper arm or distal radius
• C6 - Biceps, rotator cuff; elbow flexion; lateral forearm and thumb
• C7 - Triceps; elbow extension; index and middle finger tips
• C8 - Extension of fingers; distal thumb; fourth and fifth fingers

Sport Specific Biomechanics

The following 3 mechanisms are common to brachial plexus injury:

1. Traction caused by lateral flexion of the neck away from the involved side (similar to the mechanism in birth trauma)
2. Direct impact to the Erb point causing compression to the brachial plexus (often associated with poor-fitting shoulder pads)
3. Nerve compression caused by neck hyperextension and ipsilateral rotation (The neural foramen narrows in this mechanism.)

Clinical

History

Commonly, the athlete may complain or describe burning and/or sensation of numbness in the proximity of the neck, shoulder, or upper extremity. The following symptoms usually follow a blow to the head, trapezius, or shoulder:

• "Dead arm"
• Pain in neck
• Burning sensation in neck
• Dysesthesias
• Affected extremity may feel weak or heavy
• Paresthesias

Symptoms can last anywhere from a few seconds to weeks, depending on the extent of injury. Numbness in both upper extremities should alert the physician to a possible cervical cord injury.

Physical

The physician should keep a high index of suspicion for potential cervical fracture and/or cord injury in the face of an athlete with any degree of altered level of consciousness. In the alert and awake athlete, a full neurological examination is warranted.

• Assessment of immediate mental status
• Cervical nerve root assessment (motor and sensory)
• Tenderness over Erb point
• Spurling test
  
  
  • This test is best performed once cervical spine and neurologic assessment has been completed and no risk of potential spine injury is present.
  • The test is performed by extending the cervical spine with the head rotated toward the affected shoulder while cautious, but firm, axial loading is administered.
  • The purpose of the Spurling test is to reproduce the symptoms of a brachial plexus injury by manipulation of the neck. A positive Spurling test successfully reproduces the patient's symptoms.
     
• On-field management and assessment of the injury is determined at the time of injury and should include the following:
  
  
  • Specific symptoms
  • Durations of symptoms
  • Cervical ROM within pain threshold when no suspicion of cervical fracture is present
  • Assessment for motor deficits
  • Grip strength
  • Early mobilization of the affected region
  • Icing of the affected region with care not to ice the peripheral nerve

Causes

Classically, burner syndrome occurs as a result of a blow to the side of the head, shoulder, and/or Erb point.

• Burners are typically classified as grade 1 or grade 2.
  
  
  • Grade 1 describes neurapraxia, which is interruption of nerve function associated with demyelination. Remyelination occurs within 3 weeks of the incident, and axonal integrity is preserved. Weakness in muscle strength may be initially present in the acute examination. This may quickly develop and resolve in minutes but can also have a delayed onset.
  • Grade 2 involves axonotmesis, which is axonal damage and Wallerian degeneration. Weakness in muscle strength is often present; persistent weakness or bilateral involvement should raise the suspicion of a higher-grade lesion and further diagnostic studies should be performed.

References

• Acromioclavicular Joint Injury
• Cervical Disc Injuries
• Cervical Discogenic Pain Syndrome
• Cervical Radiculopathy
• Cervical Spine Sprain/Strain Injuries
• Shoulder Dislocation
• Shoulder Impingement Syndrome
• Thoracic Outlet Syndrome

• Back, Ribs, Neck, and Head Center
• Sports Injury Center
• Shoulder and Neck Pain Overview
• Shoulder and Neck Pain Causes
• Shoulder and Neck Pain Symptoms
• Shoulder and Neck Pain Treatment
• Neck Strain Overview